Need for Psychiatrists

[amynet]

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Why is there a dire need for psychiatrists, particulary child psychiatrists? And why are psychiatrists treated as 2nd class citizens by other MDs?

 

[chameleonknight]

The first is geograhic (at least partially). No shortage of psych docs in Boston or NYC. Central Nebraska however....

The second is more difficult to answer; it is worth noting that psychiatrists are not treated like that everywhere. And as time goes by, and we get more and more scientific, prejudices from other specialties will dim quite a bit.




^^ all just my opinion, fwiw

 

[Doc Samson]

The first is geograhic (at least partially). No shortage of psych docs in Boston or NYC. Central Nebraska however....

The second is more difficult to answer; it is worth noting that psychiatrists are not treated like that everywhere. And as time goes by, and we get more and more scientific, prejudices from other specialties will dim quite a bit.




^^ all just my opinion, fwiw

I think relying on being "scientific" to diminsh prejudice is something of a false promise (and certainly a part of what got us into our current big pharma debacle). Our colleagues value us if we're useful, not if we have reams of EBM data supporting our choice of Celexa over Paxil.

 

[strangeglove]

I think relying on being "scientific" to diminsh prejudice is something of a false promise (and certainly a part of what got us into our current big pharma debacle). Our colleagues value us if we're useful, not if we have reams of EBM data supporting our choice of Celexa over Paxil.

I agree. I think that we as a field are guilty of using science as a means to soothe our collective insecurity about relying on talking to both diagnose and treat illness. Science is useful in so much as it helps us help our patients, rather than helping us feel like real doctors. What makes us doctors is not how scientific we are, but the comprehensive way in which we take responsibility for our patients' wellbeing. Remember, when you are treating someone who wants to commit suicide, you are saving a life in a way that is more tangible than any other doctor can boast doing. This may not be "scientific," but it is life-saving.

 

[masterofmonkeys]

lets not confuse being scientific with being reductionistic. The idea that without characterizing receptor subtypes, binding affinities, etc, we cannot be scientific is just plain silly.

This attempt to distill the life of the mind down to chemical miscellania is just plain silly. The brain is too complex, its interactions with the environment are too complicated, for us to make it as simple as many demand we do. A complex system needs a complex model.

And the more complex the system, the less justice an overly simplistic model can do for it. You can program a MIDI synthesizer to play a violin concerto, but it still sounds better when played by a human on a 19th century violin.

Reductionism is a disservice to both our profession and our patients.

 

[HMSPSYCH]

In my opinion, the docs with the mindset “I’m a psychiatrist, I don’t need to know basic medical sciences” are one of the main reasons why the other services may not respect psychiatry. To treat patients comprehensively and do it well, one needs to know a good amount of general medicine principles in addition to psychodynamics and other biological treatment modalities, ie., ect/tms, psychopharmacology. The other major reason is that many psychiatrists are rather strange birds, some even narcissistic.

Pediatric psychiatry is a difficult subspecialty to train and practice for various reasons. Many MSIVs who enter residency with the intent to pursue this field end up pursuing other fellowships or practice general psychiatry due to their experiences as residents on child and adolescents wards. A good number returns to adult or other fields of psychiatry even after they have completed their child fellowship and/or practice for a few years.

Psychiatrists are in high demands because the US population has increased and mental illnesses have received more social acceptance over the years. Like it or not, for psychiatry to become even more ‘respected’ amongst our medical/surgical colleagues, we need to incorporate/discover more scientific data into how we diagnose and manage patients. Without sound medical/scientific knowledge to go along with strong psychodynamic principles, we’re no better than LICSWs, psychologists, or psychDs.

 

[Faebinder]

In my opinion, the docs with the mindset "I'm a psychiatrist, I don't need to know basic medical sciences" are one of the main reasons why the other services may not respect psychiatry. To treat patients comprehensively and do it well, one needs to know a good amount of general medicine principles in addition to psychodynamics and other biological treatment modalities, ie., ect/tms, psychopharmacology.

Yes, sadly some dont care to understand this huge flaw. 👍

The other major reason is that many psychiatrists are rather strange birds, some even narcissistic.

Sadly true.

Child Psychiatry is not a pretty specialty. You end up fighting with the parents who usually want to medicate the kid while you are telling them the child does not need the medication. That generally makes unhappy parents who disagree with you at everything. Worse, a lot of child psychiatry is hard to treat. There is no drug to fix the majority of the behavioral problems in children such borderlinish behavior of a 10 year old. A lot of times telling the parents that they are the reason the child is that way will result in the loss of a customer and a bad taste in your mouth if not a punch in the face or a lawsuit. Adults are easier... no parents to deal with and many times the families are estranged and drugs actually work on many diseases.

 

[whopper]

IMHO, since Internal Medicine doctors dominate most of the exposure residents & students get, they get the opinions of those doctors--who tend to not like psychiatrists as much. Think about it, most of the rotations in medical school are with IM.

But in hindsight, at least from my perspective, several fields of medicine really have their love & hates with other fields.

IM docs from my experience consider PCPs wimps (yes, I know IM docs can be PCPs, I'm talking the IM docs that do mostly inpatient). PCPs from my experience really value psychiatrists since they as a whole are usually the first line that encounters someone with a possible mental health problem which they will either try to handle themselves or refer to a psychiatrist. In fact PCPs prescribe more psychotropics than psychiatrists. (A fact that that the Scientologists don't seem to get, I don't see them waging war on Family Practitioners).

IM docs have also considered surgeons the "plumbers" of medicine.

As for the first 2 years of medical school, that too is dominated by those who chose not to go into mental health, and let their prejudices be known, which in time I didn't find surprising because docs in general I've found have big egos, so of course they're going to pick on others, especially the person in the field they do not understand well.

Another factor also maybe that psychiatry residency in general (and I have seen several exceptions) is less brutal in terms of the hours spent on call. I've seen several surgery & Ob-Gyn programs really push their residents to the brink, even over the maximum allowable hours. I've rarely seen that with psychiatry. I recall my fellow IM residents working 6 days a week, often times getting over the 80 hr limit, while I was putting in about 50 hrs. Well hey, don't blame me if my program director believes that a program shouldn't be treating me like an indentured servant.

Being out of medical school for a few years, but still green in several ways being a new attending, I've seen several FPs, pediatricians, police officers, the court system among several others very appreciative of psychiatrists. I've had several IM docs talk with me in the doc's lounge, telling me about a case they got where there's a mental health issue, we chat, and they are very appreciative for my input.

In my opinion, the docs with the mindset "I'm a psychiatrist, I don't need to know basic medical sciences" are one of the main reasons why the other services may not respect psychiatry.

Unfortunately true. I've met several psychiatrists that forget medicine to the point where its disgraceful. I don't mind a psychiatrist not remembering everything about medicine, but I have seen some that forget to order BUN/Cr & lithium levels on patients on lithium.
However I've seen this sort of laziness in all doctors. I've locked horns with 3 IM docs at my current hospital because IMHO they were not adequately treating a patient I had with a history of pulmonary embolisms. I had to bring it all the way up to the top doctors in the administration. I had to spend about 12 hrs on that specific issue on that 1 patient when I'm not even supposed to be treating their internal medicine issues.

 

[nancysinatra]

In fact PCPs prescribe more psychotropics than psychiatrists. (A fact that that the Scientologists don't seem to get, I don't see them waging war on Family Practitioners).

Whopper, or anyone else who might know the answer to this--since family practice doctors often treat whole families, do they consider it ethical to treat multiple members of the same family for, say, depression, or anxiety? A psychiatrist wouldn't treat two family members like that, would they, unless there were no other alternatives? I realize that a PCP is going to refer out a case that gets complicated and also wouldn't be doing formal psychotherapy, but still, it's just a question I had--hope not to take the thread way off topic or anything. Thanks.

 

[Doc Samson]

In my opinion, the docs with the mindset “I’m a psychiatrist, I don’t need to know basic medical sciences” are one of the main reasons why the other services may not respect psychiatry. To treat patients comprehensively and do it well, one needs to know a good amount of general medicine principles in addition to psychodynamics and other biological treatment modalities, ie., ect/tms, psychopharmacology. The other major reason is that many psychiatrists are rather strange birds, some even narcissistic.

Pediatric psychiatry is a difficult subspecialty to train and practice for various reasons. Many MSIVs who enter residency with the intent to pursue this field end up pursuing other fellowships or practice general psychiatry due to their experiences as residents on child and adolescents wards. A good number returns to adult or other fields of psychiatry even after they have completed their child fellowship and/or practice for a few years.

Psychiatrists are in high demands because the US population has increased and mental illnesses have received more social acceptance over the years. Like it or not, for psychiatry to become even more ‘respected’ amongst our medical/surgical colleagues, we need to incorporate/discover more scientific data into how we diagnose and manage patients. Without sound medical/scientific knowledge to go along with strong psychodynamic principles, we’re no better than LICSWs, psychologists, or psychDs.

Couldn't agree with you more about psychiatry requiring a medical foundation (I'm a CL doc after all), but would echo MoM's point about reductionism. Psychiatry is medicine plus a broader view (existential, behavioral, psychodynamic, whatever) but it's that broader view that makes us psychiatrists and not just internists with a limited pharmacopeia. Our colleagues couldn't care less whether we can point to some pixels on an fMRI and claim that that's where schizophrenia lives - they care whether we can help them effectively care for the patient. Not to minimize the importance of research to advace the field - but in terms of day to day results, our colleagues will take empiric success over evidence based mediocrity every time.

I would also stress that in my experience the number of strange birds/narcissists in psychiatry is comparable to (and in some cases far exceeded by [yes surgery and pathology, I'm looking at you]) other specialties.

 

[whopper]

Very much agree with Doc Samson.

This is one field where you need to try to fundamentally understand why the patient has their particular mental health problem. Often times just diagnosing an Axis I & giving the specific medication for it is too simple.

Often times I've found a comorbid medical cause that was worsening the psychaitric illness. I've found medical problems the IM & ER doc overlooked that was causing the psychiatric problem. I've seen patients with extreme guilt trips that made them look psychotic-the person is curled in a ball & keeps muttering over & over how she's made mistakes. I've seen one patient dissociate so badly that everyone thought she was psychotic at first glance. Her attending gave her an antipsychotic and it didn't help. He just kept trying more & more antipsychotics without trying to fundamentally understand what was going on with her. Then about 3 weeks later, she gets some very good news, and snap, she was out of the dissociation. Then 1 day later, the good news turned out not to be true and she was back into dissociation mode.

Having a good understanding of Internal Medicine will allow a psychiatrist to understand fundamental causes of the psychiatric problem on a more profound level than just memorizing the DSM.

since family practice doctors often treat whole families, do they consider it ethical to treat multiple members of the same family for, say, depression, or anxiety?

I would allow family treatment for more than 1 family member only if all members of the family were comfortable with it, believed such a treatment would be beneficial for all involved, and after a thorough review of the case, I saw no reason to believe it could cause problems. When I say thorough, I mean thorough. I've had plenty of cases where the family members all say they are comfortable, but they truly are not due to whatever cultural or idiosyncratic family dynamics. Worst case I had was a family wanted me to commit someone in the family for being suicidal in the ER, but everytime they talked to the patient (they were all in the ER), they kept painting it as if I was trying to commit her and they were against it. They were splitting, and being quite histrionic with it, yelling and screaming at me for wanting to commit the patient, then 5 minutes later yelling and screaming at me in a different room for not doing enough to commit the patient. They even went to go as far as to very dramatically demand to put in writing in front of the patient's prescence that the patient should not be committed which was very much complicating the case because putting that document in the chart would confuse anyone reading it. They then told me in private that everything they were saying in front of the patient was only an act. I told the family that as the patient's doctor, it is my ethical & legal duty to be honest with that patient, including answering to her if the family was not acting consistent if she asked. They flipped, and started screaming telling me it was my duty to do what they told me to do. I told them to just drop the act, just tell me what they honestly felt, and try to leave it that to not make the case more complicated than they were making it. It didn't get to the point, but I was considering having hospital security remove them from the hospital if they kept up the drama. It was getting that bad. I also considering haldolling them, but only didn't do so out of legal concerns. I'm not kidding. Hospital guidelines say yelling & screaming are considered agitation, and I got the duty to treat agitation. They were yelling & screaming in the ER in a very disruptive manner, which can cause major disruption to people who could be in a life threatening situation.

They were of a culture where this dynamic happens, and the hospital translator who was of the same culture kept muttering to me "geez doc, I'm really sorry, they're making me ashamed to be of this culture".

 

[Faebinder]

I will point out that when it comes to IM view of psychiatry you have to take into account the number of non-US trained physicians. I have met several FMGs who are in IM that hardly rotated in psychiatry in medical school. They swing by with 2 weeks of psych and 4 weeks of neurology labeled "psych" for example.

Mental health in many other countries is a shamble and not nearly as advanced as here due to the lack of funding. Many applicants from outside the US don't realize that psychiatry in the US has better hours than IM for equivilant if not better pay. There are many out there pretty much clueless as to what we do in psych because of this lack of exposure. You can tell by the number of inappropriate consults in our institution (although this is an n=1 experience).

 

[whopper]

You'll find less than 50% of the consults truly needing a psychiatrist. Its usually a nurse who doesn't want to deal with the problem and calls up the IM attending asking for a psyche consult. The attending who doesn't want to be bothered, okays it.

Then you do the consult and realize the person was upset becuase the Eagles lost a football game, but since the nurse didn't want to deal with it--now you are, and because its a consult you have to shlept for about 1.5 hrs, asking the nurse what happened (and its a new shift with a new nurse who doesn't know what's going on), calling up the attending who doesn't call back for 1/2 an hour and you got to sit at the nurse's station waiting for him to call, and calling up the person's family if need be, and asking the person if they feel depressed--half the time with them upset that the hospital would think they're "depressed" or "psychotic".

Happened at our hospital Faebinder, but I've noticed it happens at a heck of a lot of other places too. Ask Dr. Zwil who's worked at several (U Penn, Dartmouth, the VA.....)

 

[Regnvejr]

The first is geograhic (at least partially). No shortage of psych docs in Boston or NYC. Central Nebraska however....

Or western.. Only one there.

The second is more difficult to answer; it is worth noting that psychiatrists are not treated like that everywhere. And as time goes by, and we get more and more scientific, prejudices from other specialties will dim quite a bit.

Personal experience: I'm in a small community health center with FP's and FP residents. They all seemed REALLY happy when I started here.

Child psychiatrists get paid more. But we go through residency 1-2 years longer, have to endure specialty boards, deal with children and their families in the light of very little FDA approval of anything we do.

However, job security is fantastic per chronic shortage. Residencies are never filleu up throughout the nation, and the field is chronically only covered with 35-45% of the C&A Psychiatrists needed.

So there is work enough for you to end up doing whatever you care to do.

 

[Regnvejr]

Unfortunately true. I've met several psychiatrists that forget medicine to the point where its disgraceful. I don't mind a psychiatrist not remembering everything about medicine, but I have seen some that forget to order BUN/Cr & lithium levels on patients on lithium.

Bad stereotypes, resulting in PCP/IM not listening to the patient. "They are psych, it must all be in their head." Severely mentally ill patients die of preventable diseases. And often you as their psychiatrist is the only one who lays eyes on them. So you better be up on recognizing stuff if not treat.

Not as urgent with a 6-year kid, but a 55-year, homeless patient with mixed bipolar disorder? You are REALLY lucky if the last doc didn't spend the lat clinic visit mainly figuring out how to get him out of the clinic in a hurry.

Other stuff is managed well by Primary care, though. Most SSRI's are prescribed by PCP, not psychiatry (new development since the old tricyclics).

 

[Regnvejr]

Whopper, or anyone else who might know the answer to this--since family practice doctors often treat whole families, do they consider it ethical to treat multiple members of the same family for, say, depression, or anxiety? A psychiatrist wouldn't treat two family members like that, would they, unless there were no other alternatives? I realize that a PCP is going to refer out a case that gets complicated and also wouldn't be doing formal psychotherapy, but still, it's just a question I had--hope not to take the thread way off topic or anything. Thanks.

I treat families. Not a lot of psychiatrists around. It is also a comfort level. You treat the son's ADHD and it works, and soon the older son is brougt in because he is almost flunking out of Senior year. Then Dad. Then mom per the stress of living with 3 ADHD males.

It is as much a matter of comfort in the patients. You can suggest referrals, and make it clear to the family members that treatment is not wholesale licence to spy on each others quirks. But sometimes you're it, there simply are nobody else (confounded by our clinic as the only place in town that providing sliding scale ).