any thoughts?
yeah, one: stop the separation of psychiatry from "general medicine"
**RANT ALERT**
Step 1: disband public departments of mental health and separate psychiatric hospitals.
The assumption that psychiatrists are outside the industry of health, and the assumption that psychiatric patients cannot be permitted in the same clinic as other medical departments are the two of the largest factors maintaining stigma within the medical establishment. Psychiatric wards are no more different from Med/Surg wards than the ICU is.
There is such a huge duplication of bureaucracies that I believe 20% of all public mental health budgets are wasted on it. Staff, managers, supervisors, directors, buildings, maintenance, vehicles, phone systems, copiers, duplication of charts, etc., etc. Almost all the decisions about what treatments/services to deliver are made without recognition of any evidence for efficacy. They are made on the basis of what other bureaucracies and agencies "like" to fund - not about what works for patients. There is zero accountability regarding patient outcomes. If a surgical suite has an infection rate obviously higher than average, the hospital will likely shut it down until the cause is identified and the problem removed. No so in public mental health.
Step 2: expect psychiatrists to practice in ways similar to other depts.
Psychiatrists expectations of their "lifestyle" is possibly the largest contributor to the stigma in "general medicine" against psychiatry. Most psychiatrists that I know who practice in a hospital or in a public clinic believe (to the point of quitting) that they should never have to be at work past 4:30, never have to work on a weekend, never have to cover ER call duty, etc. I have not seen a large general hospital where psychiatrists were as active as most depts in medical staff committees (though I'm sure they exist). In many psych hospitals, patients rarely get discharged on the weekends because the "weekend doctors" don't know the patients and are not held accountable. Psychiatrists are not held accountable for properly documenting the reasons for continued inpatient care. It is common for public psychiatric hospitals to get denied for 40-50% of all the inpatient care provided in a given year because the physician documentation did not clearly identify the necessity of continued inpatient care. Psychiatrists who fall below that (very low) bar, do not have their decisions questioned; they are taught how to use magic phrases that reviewers like.
Step 3: make psychiatry part of the core competencies of medical school.
Given that many more patients are started on psychiatric medication by primary care providers than psychiatrists, psychiatric diagnosis/treatment should be taught as a core portion of general medical care. FPs, Peds, Internists will be seeing psychiatric problems every day of their careers, but the education is relegated to a "vacation rotation" of 3-4 hours/day on the wards, no call, few expectations. It's common for the total psychiatry rotation in medical school to be 3-4 weeks, while surgery is more like 16.
The pre-clinical psychiatry courses are often taught by non-MDs. This is not a dig at those professionals, but medical students take a lesson from that. In my own case, those non-MD professionals talked almost exclusively about family relations, abuse, and sociology. I learned more in my pre-clinical years about treating psychiatric disorders from the pharmacology prof than I ever did from the psychologists (non-practicing by the way) who taught our pre-clinical courses. I learned Nothing about non-pharmacotherapies in medical school.
Primary care residencies (FP, Internal Med, Peds, ObGyn) should probably have at least 1 month of psychiatry in each year of training, that's still only 1/12th of the time.
