New sub-specialty: Interventional Psychiatry

[Extralong]

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So I somehow stumbled upon a medscape article (at the most recent annual APA meeting) with "Drs. Edward M. Kantor and Nolan R. Williams about the emerging new field of interventionalist psychiatry and their initiative to develop a training program"

There was discussion about a new psychiatry sub-specialty in the works called Interventional Psychiatry. It was not exactly clear what that would entail but my guess would be ECT, TMS, VNS, DBS, tDCS and EpCS.

They discussed how there was some exploring of this topic during the AADPRT meeting.

Lastly, they made a good point, they would prefer(as I would) "avoid mistakes of an earlier era and to make sure that psychiatrists are the ones to perform the procedures, rather than other specialists who are clinically unfamiliar with the psychiatric disease management"


Anyways, here is the article, and let me hear your thoughts.


http://www.medscape.com/viewarticle/804826


P.S. I'm all for this, because I believe that even though currently our field is lacking in procedures, our specialty is unique in the way we treat a person as a whole. Let me know all of your thoughts.

-E

 

[Yoyomama88]

How does this fellowship change anything? Can't any psychiatrist perform these techniques without a fellowship anyways? I guess it just gives psych a monopoly?

 

[notdeadyet]

There was discussion about a new psychiatry sub-specialty in the works called Interventional Psychiatry. It was not exactly clear what that would entail but my guess would be ECT, TMS, VNS, DBS, tDCS and EpCS.

They discussed how there was some exploring of this topic during the AADPRT meeting.

Lastly, they made a good point, they would prefer(as I would) "avoid mistakes of an earlier era and to make sure that psychiatrists are the ones to perform the procedures, rather than other specialists who are clinically unfamiliar with the psychiatric disease management"

I like interventional psychiatry. It's basically just a fancy term for a collection of some services that few psychiatrists do or are even trained to do.

But in fairness, if you look at the list above (bolded), you'll find it's pretty much a collection of procedures that either a) psychiatrists are already capable of doing independently but no one else wants to do or b) psychiatrists can not do independently.

ECT and TMS are psych's domain and no one is pushing for them. DBS and VNS will never be done by psychiatry alone due to the surgical component and the surgeons will always own the surgery while we fiddle with dials.

I'm not complaining. That's how it should be. We can be a procedural specialty only so far as they are non-invasive procedures (a la TMS, for however long folks will keep beating that horse). Once a scalpel comes up, we're going to be sitting in the back seat.

 

[OldPsychDoc]

..I'm not complaining. That's how it should be. We can be a procedural specialty only so far as they are non-invasive procedures (a la TMS, for however long folks will keep beating that horse). Once a scalpel comes up, we're going to be sitting in the back seat.

Guess we shouldn't have given up our ice picks. 😱

 

[Extralong]

I think that we do have the potential to treat patients that need invasive procedures. Just look, we do have a pain fellowship available to us...its 1 year, that 1 year includes heavy OR time. So I would not prefer to take a back seat, but actually accelerate our residency to include ice picks if necessary. 🙂

Of note, cardiologists were reading ECGs forever (gross simplification, and am not trying to piss off the cardiologists) until they just decided that they should start doing invasive stuff..or radiologists that said, hey we are experts in anatomy, so we should do procedures too because we can tell where the dye is flowing(again, I'm not trying to piss anyone off, and am simplifying things). I think you get the point.

This invasive psychiatry is a good start at maybe one day taking over some of our own procedures that should be done by us. Maybe there should be many more years of fellowship training beyond just the basic 4 years, maybe we should allow our field to evolve that direction and maybe this is not for everyone.

Don't get me wrong, I love talking to my patients, doing psychotherapy, discussing their stories, etc, but I am all for there progression of psychiatry to involve all aspects of care.

 

[MacDonaldTriad]

I think the American Board of Psychiatry and Neurology has been fairly clear that they are not ready to add more subspecialty boards in psychiatry. After sleep, they came out against an emergency psychiatry certification because “we need to leave something in the domain of general psychiatry”. I think it is wonderful if people want advanced training in device based therapy, but I don’t think we should make it even harder to be able to do. ECT is hard enough to find already.

 

[nitemagi]

I'd find this all the more interesting if it incorporated Brief therapies intended to target refractory cases (my own niche), as another form of "intervention."

 

[Extralong]

I think the word "intervention" is broad, and for right now, could be a way to at least categorize our current techniques

 

[nancysinatra]

If this really moves forward I will be so embarrassed. This field is already imploding upon itself. For one thing all of medicine is overspecialized. But at least there's a reason fields like cardiology have interventional subspecialties. I would not want a regular cardiologist to insert a catheter into my coronary arteries, ok? With ECT, I'd be more worried about the anesthesia part. There's no danger in ECT!!! Isn't that what we tell patients?? Good grief if there are no life threatening risks to rattle off on the consent form why would anyone need a "fellowship?"

Oh wait let me offer an idea for a new fellowship. Let's call it the Abilify fellowship. To give Abilify you now have to do an extra year of training. Another great idea from the world of psychiatry.

 

[vistaril]

If this really moves forward I will be so embarrassed. This field is already imploding upon itself. For one thing all of medicine is overspecialized. But at least there's a reason fields like cardiology have interventional subspecialties. I would not want a regular cardiologist to insert a catheter into my coronary arteries, ok? With ECT, I'd be more worried about the anesthesia part. There's no danger in ECT!!! Isn't that what we tell patients?? Good grief if there are no life threatening risks to rattle off on the consent form why would anyone need a "fellowship?"

Oh wait let me offer an idea for a new fellowship. Let's call it the Abilify fellowship. To give Abilify you now have to do an extra year of training. Another great idea from the world of psychiatry.

agree with the post in entirety(well except that non-interventional cards does do dx caths)....

But yeah, with all these things the procedural/interventional part is done by other specialties(as they should be)....so it would be ridiculous to label it interventional psychiatry.

 

[michaelrack]

I With ECT, I'd be more worried about the anesthesia part. There's no danger in ECT!!! Isn't that what we tell patients?? Good grief if there are no life threatening risks to rattle off on the consent form why would anyone need a "fellowship?"

I think danger/risk isn't that relevant. After all there is less risk in doing sleep studies (even a cpap study) than ECT, and sleep is a fellowship because of the complexities of the field aren't fully covered during a standard psych/IM/neuro residency.

ECT is a complex procedure (ie, setting the electical parameters)- but it is one that should be fully covered during residency- I think that competency in ECT should be a requirement for completion of a psychiatric residency/board certification.

 

[vistaril]

Nancy did you decide to keep on working in psych now or go back and get training in a more medical specialty as you indicated you might?

 

[Extralong]

If this really moves forward I will be so embarrassed. This field is already imploding upon itself. For one thing all of medicine is overspecialized. But at least there's a reason fields like cardiology have interventional subspecialties. I would not want a regular cardiologist to insert a catheter into my coronary arteries, ok? With ECT, I'd be more worried about the anesthesia part. There's no danger in ECT!!! Isn't that what we tell patients?? Good grief if there are no life threatening risks to rattle off on the consent form why would anyone need a "fellowship?"

Oh wait let me offer an idea for a new fellowship. Let's call it the Abilify fellowship. To give Abilify you now have to do an extra year of training. Another great idea from the world of psychiatry.

So the reason for a fellowship is to have that much more training in a specialized area in your field. I would absolutely not be embarrassed that psychiatry wants to move forward like other medical fields, but rather excited. I think that having additional training in a variety of procedures that are already available for psychiatrists is great. And further, create ones that we can manage ourselves would be very valuable.

I am not sure what you mean by stating that psychiatry is imploding on itself, but I think that we have to evolve as a field, have options available to us to better manage patients that we can follow with a good continuity of care.

I do agree that some interventions are just not practical, and I am not running for the scalpel here, but most general psychiatry training programs do not expose you to thorough ECT and TMS training. Also, how about VNS and DBS programming? I'm sure there are many more types, but my point is, these fall in the category of "interventional psychiatry." This is not one specific thing, like your abilify example, but rather a cluster of interventions that are available to the field of psychiatry.

 

[vistaril]

Possible rotation schedule for 'interventional psychiatry' fellowship:

July- practicing electrode positions in unilateral ECT

August- practicing electrode positions in bilateral ECT

September- watching surgeons put in VNS devices

October- watching surgeons put in DBS devices

November- watching crnas prep/do anesthesia for ect while co-fellow practices electrode positions

December- practicing fitting TMS device on patients

January- What in the world is EpCS?.......

 

[Extralong]

Possible rotation schedule for 'interventional psychiatry' fellowship:

July- practicing electrode positions in unilateral ECT

August- practicing electrode positions in bilateral ECT

September- watching surgeons put in VNS devices

October- watching surgeons put in DBS devices

November- watching crnas prep/do anesthesia for ect while co-fellow practices electrode positions

December- practicing fitting TMS device on patients

January- What in the world is EpCS?.......

So again, I'm not here promoting using a scalpel. As for a fellowship schedule, I think that it should be done by someone, or a group of people, experienced/educated in the field enough to lay out time frames, goals, objectives, etc.
Also, technology is advancing, thus there may be newer techniques that we have not heard of yet.
Lastly, watching surgeons, I'm sure is not the intention, I think the intention is to understand the technique, understanding how to adjust what is needed post op, how to communicate what has happened to the patient, how to promote proper care, how to actually manipulate the devices properly, and to have safe patient followup. And of course this is a start, and maybe there will be minimally invasive VNS and DBS techniques that can be done in the office many years done the line, and maybe we should be doing them. Just a thought.

epidural cortical stimulation (EpCS).

 

[strangeglove]

So again, I'm not here promoting using a scalpel. As for a fellowship schedule, I think that it should be done by someone, or a group of people, experienced/educated in the field enough to lay out time frames, goals, objectives, etc.
Also, technology is advancing, thus there may be newer techniques that we have not heard of yet.
Lastly, watching surgeons, I'm sure is not the intention, I think the intention is to understand the technique, understanding how to adjust what is needed post op, how to communicate what has happened to the patient, how to promote proper care, how to actually manipulate the devices properly, and to have safe patient followup. And of course this is a start, and maybe there will be minimally invasive VNS and DBS techniques that can be done in the office many years done the line, and maybe we should be doing them. Just a thought.

epidural cortical stimulation (EpCS).

Sure, but why would you need a fellowship to do this? This stuff is not that hard, unless we see ourselves as less capable of assimilating new technologies than other specialties. I would say that the only "interventions" in psychiatry that would merit fellowship training are psychotherapies, which actually take time and skill to learn and can cause harm if done improperly. On top of this, most residencies do not teach this in much depth, and there is definitely a "market" for these interventions, although not really an insurance-based one.

 

[nancysinatra]

Sure, but why would you need a fellowship to do this? This stuff is not that hard, unless we see ourselves as less capable of assimilating new technologies than other specialties.

You got it, dead on. Takes us 4 years to learn what I'm guessing is less than half the knowledge they learn in neuro. I keep waiting for someone to explain this to me and since no one can, I have concluded that the rate limiting step in our training must be us. This applies not only to "procedures" but to psychopharm. We have like 35 meds and our residency is 4 years long. Go figure... (This rule does not apply to therapy. Therapy really does take time to learn.)

 

[nancysinatra]

Possible rotation schedule for 'interventional psychiatry' fellowship:

July- practicing electrode positions in unilateral ECT

August- practicing electrode positions in bilateral ECT

September- watching surgeons put in VNS devices

October- watching surgeons put in DBS devices

November- watching crnas prep/do anesthesia for ect while co-fellow practices electrode positions

December- practicing fitting TMS device on patients

January- What in the world is EpCS?.......

You need to add a few months of professionalism and boundaries in there. Preferably about 12. And at the end you need a self congratulatory graduation ceremony.

Also remember that not everyone learns at the same pace. Some people may need extra time.

 

[nancysinatra]

So the reason for a fellowship is to have that much more training in a specialized area in your field.

Well then back to my suggestion for an Abilify fellowship. This sounds really exciting too. After that you could do a Geodon fellowship. And an Ambien fellowship.

I would absolutely not be embarrassed that psychiatry wants to move forward like other medical fields, but rather excited.

Neither would I but anyone who has taken college physics knows that you don't measure speed alone, but also direction. You need to be moving forward before you can "move forward like other fields." The last time I saw an innovative, novel development in psychiatry that implied forward momentum was... oh wait I've never seen one. And don't get me started about TMS, etc.

I think that having additional training in a variety of procedures that are already available for psychiatrists is great.

I bet a lot of program directors would think that the cheap labor is "great."

I am not sure what you mean by stating that psychiatry is imploding on itself, but I think that we have to evolve as a field, have options available to us to better manage patients that we can follow with a good continuity of care.

Right -- I would call that "doing what's expected so as to justify our existence as a specialty." However I don't see us lowering rates of disease, definitively curing illnesses, developing many novel treatments, or discovering the causes of maladies. I for one still can't even tell who really has bipolar disorder and nothing in 4 years of training helped me learn. I'm still at step one. But maybe you are ahead of me.

I am not running for the scalpel here,

Good because that would require a 5 year fellowship known as a surgery residency.

but most general psychiatry training programs do not expose you to thorough ECT and TMS training. Also, how about VNS and DBS programming?

This is called "a failure" on the part of training directors and "poor planning" by the ACGME or the ABPN, whoever it is that makes money making the rules.

 

[nancysinatra]

I think danger/risk isn't that relevant. After all there is less risk in doing sleep studies (even a cpap study) than ECT, and sleep is a fellowship because of the complexities of the field aren't fully covered during a standard psych/IM/neuro residency.

ECT is a complex procedure (ie, setting the electical parameters)- but it is one that should be fully covered during residency- I think that competency in ECT should be a requirement for completion of a psychiatric residency/board certification.

This is a good point. But sleep and ECT are very different. There is a whole science surrounding sleep medicine. ECT may have some nuances, but not enough to justify it as a subspecialty. I agree it should be fully covered during residency.

 

[notdeadyet]

I bet a lot of program directors would think that the cheap labor is "great."

I agree with nancy here. I am a little uncomfortable with a few of the non-recognized psychiatry fellowships that seem to basically take what is a first year of employment, toss in some didactics, and call it a fellowship. If folks want to do it, that's perfectly fine, but there is an element of exploitation.

For something like interventional psychiatry, all the acronyms are great, but the big bulk will be ECT, which a strong residency program will have enough training in for privileges if the resident devotes some fourth year elective time. After that, you'll likely have TMS that the program really wants to use (with arguable efficacy at best) and you'll get exposure to some of the experimental stuff.

If you managed the psych side of every DBS case at a given psych program, you'd be spending less time than most folks spend reading the paper.

 

[Extralong]

I'm not sure why nancysinatra is so sarcastic, but, in response, feel free to read my original statement as to why I think that paralleling this to an "abilify fellowship" is invalid.

As to make statements such as "The last time I saw an innovative, novel development in psychiatry that implied forward momentum was... oh wait I've never seen one" or "I don't see us lowering rates of disease, definitively curing illnesses, developing many novel treatments, or discovering the causes of maladies" I think are also invalid, and kind of insulting to the field. I think the field of psychiatry has done great and amazing things. Feel free to start another thread with those comments and I would love to debate this topic forever, but I would not prefer to have this thread hi-jacked by this topic.

As for cheap labor, totally. Program directors would love it, though, they would have to teach or find someone to teach, the specifics on ECT,TMS,VNS, DBS, tDCS and EpCS. Aside from ECT and TMS, I really don't know if I know enough to just go out there and start..or even read about it and feel comfortable dealing with that technology.

 

[vistaril]

I'm not sure why nancysinatra is so sarcastic, but, in response, feel free to read my original statement as to why I think that paralleling this to an "abilify fellowship" is invalid.

As to make statements such as "The last time I saw an innovative, novel development in psychiatry that implied forward momentum was... oh wait I've never seen one" or "I don't see us lowering rates of disease, definitively curing illnesses, developing many novel treatments, or discovering the causes of maladies" I think are also invalid, and kind of insulting to the field. I think the field of psychiatry has done great and amazing things. Feel free to start another thread with those comments and I would love to debate this topic forever, but I would not prefer to have this thread hi-jacked by this topic.

As for cheap labor, totally. Program directors would love it, though, they would have to teach or find someone to teach, the specifics on ECT,TMS,VNS, DBS, tDCS and EpCS. Aside from ECT and TMS, I really don't know if I know enough to just go out there and start..or even read about it and feel comfortable dealing with that technology.

I did a google search just putting in 'EpCS in psychiatry' and I get basically nothing. At all. The idea that this needs to be a core part of a fellowship is laughable.

 

[vistaril]

Right -- I would call that "doing what's expected so as to justify our existence as a specialty." However I don't see us lowering rates of disease, definitively curing illnesses, developing many novel treatments, or discovering the causes of maladies. I for one still can't even tell who really has bipolar disorder and nothing in 4 years of training helped me learn. I'm still at step one. But maybe you are ahead of me.

here is how I tell if someone has bipolar d/o:

1) Are they on a mood stabilizer? 1 point for yes
2) Are they on Seroquel as well? Add 2 points


If your final score is 3 pts, they *definately* have Bipolar. If the final score is 1 point, they may or may not have bipolar.

 

[notdeadyet]

... ECT,TMS,VNS, DBS, tDCS and EpCS. Aside from ECT and TMS, I really don't know if I know enough to just go out there and start..or even read about it and feel comfortable dealing with that technology.

That's why the fellowship idea is a bit before it's time. DBS and (to a lesser extent) VNS are so rarely done that you won't see these cases except at certain centers, and with an emphasis on research. There's no point in having a fellowship for procedures and technology you won't see outside of your fellowship.

At this point, I would think interventional psychiatry would be best served by a research fellowship focusing on clinical.

 

[michaelrack]

I would say that the only "interventions" in psychiatry that would merit fellowship training are psychotherapies, which actually take time and skill to learn and can cause harm if done improperly. .

The above is true of ECT: it takes time and skill to learn, and can cause harm if done improperly (cognitive impairment).

While I agree with most on this thread that ECT should not be a separate fellowship; I don't think it does justice to our profession to call this a simple procedure. ECT is complex, takes dedicated time to learn properly, and should be an integral component of every psychiatry residency. It is not letting anesthesia do their thing and then merely pressing a button.

 

[michaelrack]

x

 

[michaelrack]

At this point, I would think interventional psychiatry would be best served by a research fellowship focusing on clinical.

Agree

 

[Extralong]

I did a google search just putting in 'EpCS in psychiatry' and I get basically nothing. At all. The idea that this needs to be a core part of a fellowship is laughable.

pubmed: EpCS in treatment resistant depression; relatively new stuff

http://www.ncbi.nlm.nih.gov/pubmed/19819427

 

[Extralong]

That's why the fellowship idea is a bit before it's time. DBS and (to a lesser extent) VNS are so rarely done that you won't see these cases except at certain centers, and with an emphasis on research. There's no point in having a fellowship for procedures and technology you won't see outside of your fellowship.

At this point, I would think interventional psychiatry would be best served by a research fellowship focusing on clinical.

Yeah, maybe too early, though very interesting; having the skills to deal with these types of treatments would be awesome!

I totally agree that these would be likely fellowships at research centers and would require very specific research centers too. I noticed that UCSF is looking for an interventional pscyhiatrist to hire. They have some quailifications, but very broad because I am sure its a big grey area. Here is the link:

http://psych.ucsf.edu/careers.aspx?id=5773

 

[Extralong]

Found an article written by Dr. Adam Philip Stern, M.D; Harvard Longwood Psychiatry Residency Training Program, Boston.

Its from 2011, look at page 3-5(Harvard Psychiatrists), then page 7 (Psychiatrists from Emory). Written to discuss "Interventional Psychiatry"

http://psychiatryonline.org/data/Journals/AJP/4334/October2011-ResidentsJournal.pdf

 

[digitlnoize]

here is how I tell if someone has bipolar d/o:

1) Are they on a mood stabilizer? 1 point for yes
2) Are they on Seroquel as well? Add 2 points


If your final score is 3 pts, they *definately* have Bipolar. If the final score is 1 point, they may or may not have bipolar.

Please tell me you're joking...if so, it's kinda funny. Haha. If not, smh.

 

[neurodoc]

Most of the "interventions" discussed seem to involve more than prescribing psych meds...e.g. mag-stim, ECT, electrical neurostimulation, etc.. This would seem to be more in the purview of those who view themselves as "medical" doctors, such as neurologists. For better or for worse, the psychiatric profession has been distancing itself from general medicine and neurology, to the point that (as I've posted previously) that psychiatrists have become very reluctant to deal with the "medical" problems of their patients, including even the "medical" side effects of their prescribed psychotropic meds...

Were this not the case (and it certainly is the case),I'd not have any qualms about psychiatrists seeking to develop a program of "interventional psychiatry" as a defined psychiatric subspecialty. 🙁

 

[vistaril]

Most of the "interventions" discussed seem to involve more than prescribing psych meds...e.g. mag-stim, ECT, electrical neurostimulation, etc.. This would seem to be more in the purview of those who view themselves as "medical" doctors, such as neurologists. For better or for worse, the psychiatric profession has been distancing itself from general medicine and neurology, to the point that (as I've posted previously) that psychiatrists have become very reluctant to deal with the "medical" problems of their patients, including even the "medical" side effects of their prescribed psychotropic meds...

Were this not the case (and it certainly is the case),I'd not have any qualms about psychiatrists seeking to develop a program of "interventional psychiatry" as a defined psychiatric subspecialty. 🙁

all fair points...

 

[splik]

I don't think that ECT should be a core competency for psychiatry residency. I think all residents should have the opportunity to learn this, but:

a) there are many residency programs where there is no ECT program
b) some residents believe ECT is unethical. Im not interested in debating the validity of this, but as it is not an essential or even core part of general psychiatric practice, it is hard to argue that every should do ECT
c) whilst ECT may be a core part of geriatric psychiatry (most ECT patients are geriatric), it would be hard to argue that ECT is a key part of psychiatry in general. why for example should psychiatry residents have training in ECT and not in say eating disorders management (which most psychiatry residents do not get training in)?

as for these interventional procedures - this is an incredibly small, almost entirely research based aspect of psychiatry. these procedures are typically not covered by insurance companies, have little to no evidence supporting their use, are extremely costly, and are limited to the most highly refractory patients who do not make up even 1% of the typical patients seen by psychiatrists. it is hard to argue that this should be a part of psychiatry residency or a clinical fellowship. I am all for people learning this, but the vast majority of psychiatry programs would not be able to offer this sort of training. there aren't even 100 psychiatric patients having DBS a year in the US, and these are all in academic settings treated by researchers.

 

[notdeadyet]

a) there are many residency programs where there is no ECT program[
b) some residents believe ECT is unethical. Im not interested in debating the validity of this, but as it is not an essential or even core part of general psychiatric practice, it is hard to argue that every should do ECT
c) whilst ECT may be a core part of geriatric psychiatry (most ECT patients are geriatric), it would be hard to argue that ECT is a key part of psychiatry in general. why for example should psychiatry residents have training in ECT and not in say eating disorders management (which most psychiatry residents do not get training in)?

The argument to support only training residents in what is the "key part of psychiatry in general" only holds water as long as we're talking about the minimal requirements for a program to keep its license. You're throwing out any requirements for exposure to ECT, MAOI, even TCAs, etc. Decent psych programs will give you exposure to all of this.

And I would respectfully disagree with the ECT / eating disorders analogy. Eating disorders are much more the domain of CAP than ECT is Geri. I've probably worked with a couple dozen ECT patients so far and only a sizable handful have been over 65. It may be a regional difference, but the days in which patients had to show symptoms refractory to treatment for 40 years are long gone.

 

[michaelrack]

I don't think that ECT should be a core competency for psychiatry residency. I think all residents should have the opportunity to learn this, but:

a) there are many residency programs where there is no ECT program
b) some residents believe ECT is unethical. Im not interested in debating the validity of this, but as it is not an essential or even core part of general psychiatric practice, it is hard to argue that every should do ECT
c) whilst ECT may be a core part of geriatric psychiatry (most ECT patients are geriatric), it would be hard to argue that ECT is a key part of psychiatry in general. why for example should psychiatry residents have training in ECT and not in say eating disorders management (which most psychiatry residents do not get training in)?

.

a. those residencies should be required to either start an ECT program (or have their residents rotate somewhere that does) or close down.

b. Please briefly describe an ethical arguement against modern ECT, that doesn't also apply to psychiatry or psychotropics in general. I wouldn't be opposed to some type of moral/ethical exception, similar to the OB/GYN abortion opt-out.

c. Training in eating disorders (not necessarily a dedicated rotation, this could be part of outpt year), should be a part of every psychiatric residency. I received training in eating disorders during residency, including didactics, without a dedicated one month rotation. If I could get this training as a med/psych resident, there is no reason a straight psych resident couldn't. Are you saying that many psych residents see and treat no eating d/o patients during their inpt and outpt rotations?

 

[splik]

And I would respectfully disagree with the ECT / eating disorders analogy. Eating disorders are much more the domain of CAP than ECT is Geri. I've probably worked with a couple dozen ECT patients so far and only a sizable handful have been over 65. It may be a regional difference, but the days in which patients had to show symptoms refractory to treatment for 40 years are long gone.

i admit it's not a fair comparison as ECT is at least used to treat the bread and butter of psychiatry, and I think everyone should be familiar with use, be able to refer appropriate patients, understand its use and counsel patients etc, but I don't think you necessarily have to be proficient in doing ECT during residency. i have a done a 360 in this regard because I used to think it was important to learn how to do it, in fact everything, and whilst I personally will elect to do further ECT training in residency, I don't think it should be a requirement. I see that as different to being exposed to patients undergoing ECT etc...

 

[toothless rufus]

You got it, dead on. Takes us 4 years to learn what I'm guessing is less than half the knowledge they learn in neuro. I keep waiting for someone to explain this to me and since no one can, I have concluded that the rate limiting step in our training must be us. This applies not only to "procedures" but to psychopharm. We have like 35 meds and our residency is 4 years long. Go figure... (This rule does not apply to therapy. Therapy really does take time to learn.)

Yeah. Why is psych residency four years long? Three I can see, but not four. Bet you could even get by with two if you studied really hard and had outpt exposure.

 

[michaelrack]

Yeah. Why is psych residency four years long? .

Because other non-generalist specialties are at least 4 years long.

 

[michaelrack]

Sorry for going off on a tangent, but I wish there was more exposure to hypnosis in psychiatric residencies. Also wish there was a way for me to cheaply learn it as a private practice attending.

 

[shan564]

a. those residencies should be required to either start an ECT program (or have their residents rotate somewhere that does) or close down.

b. Please briefly describe an ethical arguement against modern ECT, that doesn't also apply to psychiatry or psychotropics in general. I wouldn't be opposed to some type of moral/ethical exception, similar to the OB/GYN abortion opt-out.

c. Training in eating disorders (not necessarily a dedicated rotation, this could be part of outpt year), should be a part of every psychiatric residency. I received training in eating disorders during residency, including didactics, without a dedicated one month rotation. If I could get this training as a med/psych resident, there is no reason a straight psych resident couldn't. Are you saying that many psych residents see and treat no eating d/o patients during their inpt and outpt rotations?

Yes, agree with all of the above. One of the problems with many psych residency programs is that they don't take advantage of the learning opportunity offered by the 4-year length. A good program should require us to rotate in ECT, eating disorders, geriatrics (independently of ECT), C/L, drug/alcohol, child/adolescent, teaching/supervision, and research, and still have plenty of elective time. Some of us won't like some of those things (there are at least two things on that list that I'm really not looking forward to), but the experience will help me be a better psychiatrist.

 

[nancysinatra]

Because other non-generalist specialties are at least 4 years long.

Then why not make the surgical residencies four years if what matters in medical training is adherence to some arbitrary policy?

 

[michaelrack]

Then why not make the surgical residencies four years if what matters in medical training is adherence to some arbitrary policy?

I agree it is arbitrary, and notice I used the words "at least"- All of the surgical specialties are at least 4 years long.

edit: I am including internship year in calculating length, even if the intern year is separate from residency.

 

[nancysinatra]

I agree it is arbitrary, and notice I used the words "at least"- All of the surgical specialties are at least 4 years long.

edit: I am including internship year in calculating length, even if the intern year is separate from residency.

Oh yeah, I saw that about "at least." I was being kind of sarcastic. I just finished a four year residency where I feel like I was being exploited for about half of it. I doubt anyone in a position of authority is going to seek to change a system that is awash in so much cheap labor. But what really bothered me wasn't the exploitation itself, it was the puffed up, self-aggrandizing euphemistic rhetoric about the importance of developing "clinical skills" that accompanied it.

But here's a question: why doesn't pediatrics restyle itself as a "specialty" and make their residency 4 years? There's a gold mine of cheap labor to be tapped that way, and pediatricians could then gain some additional bragging rights.

 

[nancysinatra]

a. those residencies should be required to either start an ECT program (or have their residents rotate somewhere that does) or close down.

b. Please briefly describe an ethical arguement against modern ECT, that doesn't also apply to psychiatry or psychotropics in general. I wouldn't be opposed to some type of moral/ethical exception, similar to the OB/GYN abortion opt-out.

c. Training in eating disorders (not necessarily a dedicated rotation, this could be part of outpt year), should be a part of every psychiatric residency. I received training in eating disorders during residency, including didactics, without a dedicated one month rotation. If I could get this training as a med/psych resident, there is no reason a straight psych resident couldn't. Are you saying that many psych residents see and treat no eating d/o patients during their inpt and outpt rotations?

I saw no bona fide eating disorder patients in my entire psychiatry residency. (Even though an ED rotation in med school was my inspiration for going into psychiatry.) We also had almost zero exposure to ECT. Over and over we were reminded about what a great "clinical education" we were getting. Personally I think any program that fails to teach ECT or eating disorders should be shut down ASAP.

 

[billypilgrim37]

I think part of the reason for four years is that few would be willing to do another two years for a child fellowship. One extra year is enough. Not that people don't do 4+2 now, but there'd be a significant drop off in child. Not saying that's a good reason, just a reason.

I can't speculate as to the value of the 4th year as my 4th year was really valuable, as it was the first year of a child fellowship! I imagine at some programs with tons of specialty electives there can be a lot of benefit from a 4th year, but without those intensive experiences available, it does seem questionable.

 

[splik]

Yeah. Why is psych residency four years long? Three I can see, but not four. Bet you could even get by with two if you studied really hard and had outpt exposure.

Interesting in the ACGME guidelines for psychiatry:

Programs should meet all of the Program Requirements of Residency Education in Psychiatry. Under rare and unusual circumstances one or two year programs may be approved, even though they do not meet the above requirements for psychiatry. Such oneor two year programs will be approved only if they provide some highly specialized educational and/or research program. These programs may provide an alternative specialized year or two of training, but do not provide complete residency education in psychiatry. The traditional program time and the specialized program must ensure that residents will complete the didactic and clinical requirements outlined in the program requirements.

 

[MacDonaldTriad]

If you ask psychiatric educators if they see PGY-IVs as more skilled than PGY-IIIs, the answer would be almost universally “yes”. Of course there is variability in skill and looking over graduates at the end of training some are more ready than others. Hopefully, all are ready enough and all practitioners continue to learn after training.
Shortening training may attract a few more applicants into a field that is very undersupplied, but I would wonder if the cost in quality of training would justify it. A fourth year of training is what you make of it. Electives are of variable quality and variable usefulness. If you choose to cruise through it, you probably can. Fortunately, few do this from what I see.

 

[notdeadyet]

There is a big move in residency education towards competency-based training and EPAs. It'll be interesting if this translates to more varied residency lengths...