So many great answers here and will try not to just parrot others, but some advice from someone finishing residency who has had similar thoughts at times along the way:
I often see patients coming in with the alphabet soup diagnoses “patient has a history of MDD GAD ADHD DMDD PTSD” when I see that, I immediately think, this is a traumatized patient with a personality disorder and some psychiatrist out there calls it MDD and gives the patient Zoloft with no real effect because the primary issue with the patient is personality, but the issue with treating personality is that it takes time, effort and addressing genuine catastrophic thought processes which are indeed super valuable but do not make economical sense to do as insurance doesn’t reimburse well for therapy.
Keep in mind how common co-morbidities with many of these disorders are. The endless alphabet soup is often a bad sign, but I have had a couple of patients where as we peeled away the onion layers new, legitimate diagnoses kept emerging. Example: patient legit MDE is stabilized then turns out they have PTSD, then turns out they've had GAD since before any of their traumas, then turns out all of that is well-controlled, but they also very likely have ADHD. This was an actual therapy patient of mine who I initially saw for depression/anxiety treatment after d/c from inpatient. I believe he ended up on Duloxetine + Wellbutrin, and Prazosin and was doing pretty well when I last saw him.
2. You can go into academics, community mental health, hospital based practices, etc. Each sector prioritizes different things. Usually the private practices are production based, "turn and burn" conveyor belt psychiatry (from my experience so far). Community mental health they get funding through other sources (im in this setting) and we have access to things like ACT team, substance abuse groups, supported employment, etc. I had a patient today, when i first saw him, was on 16 psych meds. I have him down to 3. Hes doing amazing. He had severe TD from all the antipsychotics they through on him, just from peeling away his meds and adding austedo his QOL has drastically improved. Some of the hospital systems seem to prioritize quality as well, each setting has its own pros and cons. Community setting will be your higher/possibly highest acuity setting in outpatient, as I definitely see the sickest of the sick
I will say that the bolded can vary significantly between practices/facilities within the same area. One of the CMHCs we rotated through (which our program dropped) was absolutely awful and it was a 3-4 month wait just for a case manager, and only thing they would get before CM was assigned was med appointments. Pretty awful set up.
but be ready to navigate offering what you can (accept what you can't) and accept the limited progress of patients that you know could have achieved so much more. You can't do it all, and you can't "fix" 'em all.
You are correct that treating personality takes time and effort. However, that time and effort must come from the patient not the psychiatrist.
I definitely don’t know what I don’t know and maybe that’s what I’m struggling with. Maybe it’s an ego thing for me to actually want to “help” the patient.
Quoting these because they reflect the best advice I got during 3rd year which I repeat on here regularly. "You should not be working harder than your patient is." For a while I felt like if I couldn't help that I was failing or at least not meeting my own expectations. It's important to realize that there are some people you just can't help because they don't really want to
BE better, they just want a magic pill to
FEEL better. There are also times when everyone is working their butts off, but because of social factors you just can't get them the help they need. The best way to address that is to know what the local resources are and know how to get your patients to them. For some, that will do far more good than you ever could.
Why are axis II not reimbursed? The quality of mental health care and actually efficiency at our jobs would greatly increase if we had sensible diagnoses such as “current major depressive episode secondary to underlying cluster B personality disorder/traits”
So that the patient and all providers reading can work on the patient’s actual problem which would be DBT focused interventions.
Admittedly, I am very cynical nowadays with my diagnostic approach and I am quick to believe really the majority of what I see is behavioral/personality issues that medications don’t fully address.
Again, remember that co-morbidities are common and that it's often easier to play the game (insurance and meds) by just listing MDD and BPD as separate diagnoses as long as they're meeting criteria. That should not change your recommended treatment for the personality/behavioral components, but it keeps things simple for non-psychiatrists and can easily be clarified in formulation.
Maybe at this stage in the game, I really see a ton of BPD and I get so frustrated because I am still mainly in the inpatient/ED/CL portions of my training and I feel so useless because I’ll spend time really talking to these patients and all of their destructive thought processes unravel in front of me and I see so much space to really work
At this point you do not have the experience to understand the pros and cons of what different practice options are out there, which might be better suited for your personality and interests, and to what extent you have the power to tailor them to your own choosing.
It would be like you're doing a research paper and struggling to write your conclusion before the data has even come in.
Orgone answered it perfectly, but to add an N to the sample size, there were a lot of things I didn't realize until I was actually rotating in our outpatient clinics. ED/Inpt/CL it's usually not difficult to figure out what a patient actually needs (meds, therapy, CM, housing resources, etc) if you spend enough time with them, but actually making that happen is very, very different. We're pretty spoiled with having great SW/CM on our inpatient unit who make a lot happen for our patients at d/c. When I rotated through our CMHC during 3rd year, it was very eye opening. Resources that seem basic and should be easy for patients to obtain may not exist. At the same time, in other clinics you'll see patients who are very motivated, have the means and access to resources, and genuinely get better thanks to your help and a little nudge in the right direction.
I do wish I could go back to my 2nd year and even 3rd year to give myself some advice on various settings and situations, but if you're at a decent program with good exposure, you'll get there as you progress.
Comparing doctors who have 5 minute OP follow-ups with the rare IP doctors with 30 minutes to talk to each patient is an apples and oranges comparison. I'm sure you have seen IP docs spend < 5 minutes with a patient. The goal of these short-term, acute-care IP facilities isn't to address the root cause of the patient's suffering. It's to stabilize them just enough that they can go out and get the outpatient treatment.
Agree, and to go a step farther it's important to keep in mind the purpose of the setting you're working in. In the ER, I'm basically just triaging patients to see where they go next and providing them with basic resources if we're discharging them. Our inpatient unit is more acute, so we're there to stabilize them, help develop safety plan and basic coping skills, and ensure they've got a safe plan for d/c with f/up. In our academic outpt clinic our patients are a bit higher functioning than the CMHC, so we're really "practicing" psychiatry and working to get them better utilizing meds, performing therapy, and collaborating with the rest of their outpt team and therapists. At the CMHC I was at it was basically the wild west, so we were mostly trying to ensure SPMI patients were taking their meds and remaining stable or just preventing them from needing to go inpatient. I also went a step farther and made sure their CM knew what resources they needed if anything new came up in the appointments.
Trying to do meaningful and in-depth psychotherapy on an acute psych inpt unit isn't very realistic, just like making med changes to their primary meds in the ER isn't usually a good idea. Know your role for your setting and it may help keep some of the things you're stressing out about in context.
I think it’s important to reality check my self. I’ll be sure to reflect on this.
This is great insight. Good for you for actually exploring these thoughts and seeking advice. Sounds like you're at least on the right path for personal growth.