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No fine line b/w Psychiatic illness and Neurological illness? Really?

Discussion in 'Neurology' started by BrianUM, Apr 20, 2007.

  1. BrianUM

    BrianUM Future M.D
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    Hey everyone

    The other day I was surfing the web when I came across this website of the University of Colorodo Health Sciences Center:

    mhtml:http://www.uchsc.edu/psychiatry/residency/NeuroPsychiatricSlides/1_Intro_and_Historical_Overview.mht!1_Intro_and_Historical_Overview_files/frame.htm

    Apparently, in describing this new fellowship known as "Behavioral Neurology and Neuropsychiatry," it is said that advances in imagining and electrophysiology have allowed one to interpret psychiatric illness as a brain illness and, as such, there is no fine line in between. Moreover, the website goes on to state that psychological factors are appreciated yet interpreted as affecting brain functioning. If all this is correct, couldnt a Neurologist trained in this fellowship theoretically treat a spectrum of disorers ranging from Epilepsy and MS to schizophrenia and depression?

    I, myself, am very intereted in both psychiatry and neurology. If all this is true, then would it make sense to pursue a Neurology residency, a neuropsych fellowship and obtain licensing in Electrodiagnostic medicine from the AANEM? It seems to me that this development has recieved little to no public attention.

    Thanks!
     
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  3. neurologist

    neurologist En garde
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    Sure. It's called "general neurology." Neurologists treat run-of-the-mill depression all the time; so do family practitioners for that matter. You don't need a neurobehavioral fellowship to do that. Neurologists also treat psychiatric complications/comorbidities of dementia and other neurodegenerative conditions all the time (psychosis, anxiety, etc). I think a neurobehvioral fellowship is optional unless you want to make this your primary sub-subspecialty or be an academic researcher in the field.

    Even though both "psychiatric" and "neurologic" disease are "of the brain," I think when you get into stuff like frank primary schizophrenia, dissociative disorders, refractory depression, etc, just about all neurologists would punt to psych.
     
  4. BrianUM

    BrianUM Future M.D
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    Hey Thanks for the response, thats good to know

    I guess what I am trying to say is would a Neurologist trained in this fellowship be so competent when it comes to psychiatric disorders that they wouldnt even need to refer his or her patient to a psychiatrist, even if the disoder is considered primarily psychiatric. After all, the philosophy of the fellowship is that all psychiatric illness is neurological illness and that the distinction b/w the 2 specialties is arbitrary.

    My mom is a psychotherapist, and I respect her work a great deal. I hear all the time , however, how difficult and tedious it is for a psychiatrist to run a private practice (esp. nowadays w/ managed care) where psych docs are basically forced to cut their sessions short due to time contraints placed upon them by managed care. I was thinking that perhaps a Neurologist trained in this fellowship would be able to work in a more objective fashion w/o neccesarily giving therapy, expand his/her repetoir to all diseases affecting the nervous system, and make more money via procedures such as eeg, emg...i guess time will tell
     
  5. ChildNeuro

    ChildNeuro Junior Member
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    A large amount of the difference between Neurology and Psychiatry is a pragmatic one, remember that neurology and psychiatry can into being a long time ago, relatively speaking. A neurologist would take care of those problems that were obviously based in a metabolic or what have you more anatomic disorder i.e. epilepsy, stroke, and a psychiatrist would deal with people who were delusional, psychotic, etc . . . You can see how this work from a practical standpoint i.e. if you are running a hospital the doctors called psychiatrists deal with patients coming in who are psychotic, have schizophrenia, etc. . . and neurologists see stroke, epilepsy and other diseases. Back then, you choose what specialty you wanted based on what type of patients you wanted to take care of, if you like talking to depressed patients and helping them more than stroke patients than voila you are a psychiatrist, and back in the day all psychiatry had was unproven (and still debated) complex thought based models of psychiatric illness, a la Freud. It didn't make sense for a neurologist back then to see psychiatrically ill patients, because they had no experience with them, and would have to learn psychiatry all over.

    Zoom ahead 50 years or what have you. In the 21st Century we know that SSRIs can help depression, we know the biological basis of depression, most cases of depression are treated by family practice doctors or non-psychiatrists. What do psychiatrists do? They deal with acutely psychotic patients, patients with schizophrenia because they have the expertise and experience to help these severly mentally ill patients. A neurologist can't walk onto a psychiatry floor and start treating schiozphrenia and bipolars as well as a board-certified psychiatrist who has been doing it for many years, to do this well (or perhaps even legally) you would need board certification in psychiatry and neurology. There are alot of nuisances in psychiatry that you would miss if you had only a neurology residency and jumped into seeing schizophrenic patients and bipolar patients, and presumably you wouldn't treat them as well and might do some damage. Likewise, a psychiatrist can't start seeing seizure patients and prescribe anti-convulsants for seizure disorders or take care of other complex neurological disorders. Yes, both neurology and psychiatry focus on what is now believed to be biologic diseases of the brain, but because the populations of patients seen by psychiatry and neurology vary to a great extent, they are separate fields, separated for practical reasons.

    In the future could you train someone in say "Clinical Neuroscience" which may involve a lengthy 5 or 6 years residency who can see psychiatric and neurologic patients? Sure, even now you can get a dual board certification in both Neurology and Psychiatry. But, from a healthcare cost standpoint it makes sense to break up the patient workload, i.e. it may too much of a strain and education to train someone to be both a psychiatrist and neurologist for non-academic reasons. You could try to dabble in psychiatry as a neurologist, but this would likely have devastating consequences for your patients, . . . three years of psychiatry residency is the requirement for a reason.

    In terms of psychotherapy, that is a different ballgame, some psychiatrists seek extra training in psychotherapy, and people who are non-MD can seek training in psychotherapy. However, in today's fast paced world, when you can pop an SSRI, instead of spending time on a couch to work out your problems, why not just take the quick fix?
     
  6. ChildNeuro

    ChildNeuro Junior Member
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    Looking more closely on the fellowship in Neuropsychiatry and Behavioral Neurology, the premise of this fellowship appears to dance around the semantics of the difference between psychiatry and neurology. Obviously, to anyone familiar with neurology there are neurologic conditions that involve an affective component or an impairment in emotion, and likewise in psychiatry there are psychiatric illness with a well-defined neurobiological etiology.

    However, it is important to realize the reason for the split between Neurology and Psychiatry which occurred way before the introduction of PET scans and receptors modulating drugs. It came down to the types of patients that neurologists and psychiatrists were seeing. Obviously, there are clear cut distinctions, i.e. a patient with only schizophrenia, and a patient who is post-stroke. However, these distinctions are more historical than based on gross differences in etiology, i.e. both neurologists and psychiatrists deal with abnormal processes in the brain. All this fellowship appears to really do is to help psychiatrists care for patients with complex disease processes that do not fit cleanly into the rubric of psychiatry or neurology which are abitrary to begin with. Therefore, the "joining" of neuropsychiatry and behavioral neurology is not a groundshattering paradigm shift, but really just a re-adjustment of the type of medical training required for certain patients.

    For example, take a modern day epidemic which is relatively new, HIV/AIDS, some 30 or so years ago nobody knew what HIV/AIDS was. But now, since every medical student in the US has helped to care for a patient with HIV/AIDS, which will unfortunately become more a health problem in the developing world in the future, we developed a need for HIV/AIDS specialists to treat these patients. So you have fellowships in HIV/AIDS, and even a Neuro-HIV fellowship for neurologist. In the same manner, alot of psychiatric illnesses, i.e. schizophrenia have been re-discovered by some very smart neurologist and psychiatrists to have a biological basis, as well as the more "psychiatric" or affective and behavioral complexities of certain formerly pure neurologic disorders have been discovered, therefore, the perceived need to create super-psychiatrists trained to treat so-called neuropsychiatric disorders, which are really just older disorders that have been further elucidated.

    Over the past century medicine has become increasingly specialized, and specializations within specializations have been created, usually with great benefit for the patient because these specialists have the ability to perfect their art in a given area, in some cases psychiatrist and neurologists are much more specialized than in the past, such as a patient on the psychiatry service with neurologic symptoms will be referred to the neurology service. Of course, if your primary care doctor was a specialist in everything then you would get the best care possible, but this is clearly impossible. Some patients, however, have complex issues, and for a team of neurologists and psychiatrists to treat these patiensts is less efficient than having a neuro-psychiatric specialist treat them. For example, in child neurology, we seek training in both pediatrics and neurology to able to treat children with disorders too complex for a general pediatrician, and with pediatric issues too complex or foreign to a general neurologists or a general neurologist with child neurology fellowship. In this instance does a child need a child neurologist. A child with one simple febrile seizure does not need to see us. Same way as a patient with a thoroughly investigated case of clinical depression does not need to see a neuro-psychiatric specialist.
     
  7. BrianUM

    BrianUM Future M.D
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    Hey thanks a lot for the input. I have a LONG time to go before settling in on a specialty (I will start med school this fall), but I can't help but think about what I may be interested in. Currently, I am most interested in neurology and psychiatry. Both are very interesting. I envision myself practicing in a manner similar to a Neurologist, w/o giving therapy, reading images, eeg's, etc but expanding my pt pop to those w/ neuro disoders, psych disorders and neuropsych disorders. My major in college was psychology and I am fascinated by psychopathology.

    According to the ABPN, neurologists are supposed to be competent in evaluating and treating psych disorders (just not at the level of a psych doc). Perusing through the Neuropsychiatry fellowship program, it says that Neurologists can pursue the fellowship as well, not just psychiatrists. So what does this all mean? Could a neurologist w/ this fellowship also be competent in dealing w/ psych pts. I would have interest in a combined neuro/psych program esp since they have one in Miami, but I hear that they are supposedly dying out.
     
  8. ChildNeuro

    ChildNeuro Junior Member
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    OK, there are two scenarios, one is getting doubled boarded in psychiatry and neurology, and the other is doing a fellowship in neuropsychiatry, however, remember if you do a fellowship in neuropsychiatry coming from either neurology or psychiatry you are NOT given privelege to practice the complementary field, but are qualified to do research in neuropsychiatry. For example if you do a neurology residency and then a fellowship in neuropsychiatry you would have a hard or probably impossible time convincing HMOs and hospitals that you should be given privelege to practice as a psychiatrist. Remember, positions in hospitals and HMOs for psychiatrists everywhere look for BE/BC, meaning board certified/board eligible in psychiatry, which you can only get by completing a psychiatry residency. It would be ill-advised for a hospital to have a neurologist with a neuropsychiatry fellowship (really specialized research training in new imaging modalities) to be allowed to practice psychiatry.

    However, if you want to practice psychiatry and neurology you should apply for a double-board residency in neurology and psychiatry, however, you will not have the background to do research in neuropsychiatry, but you will of course be allowed to see both psychiatric and neurology patients.

    Therefore if you are a neurologist and do neuropsychiatric fellowship you are NOT eligible for board certification in psychiatry. Of course, as a neurologist you probably would know more than a Family Practicioner or Internist about psychiatry, but that alone doesn't give you the privilege to see psychiatric patients. A fellowship in neuropsychiatry is a pathway to doing research into neuropsychiatry disorders in an academic setting, not core training in psychiatry necessary to see psychiatric patients.

    Likewise a psychiatrist with a fellowship in neuropsychiatry would probably not be given hospital privileges to see neurologic patients, i.e. patients with stroke, or round on patients in a neuro-intensivist setting.

    I would guess that a person who is board certified in psychiatry and neurology would be highly sought after in strictly clinical employment settings, as they could oversee inpatient psychiatry services, see psychiatric patients and basically do a neuro-consult themself if needed, and be able to educate psychiatric residents concerning certain neurologic disorders better than a person who is just BC/BE in psychiatry. However, research-wise the double-board certification might not necessarily help in terms of getting grants for neuropsychiatric research, this is what the fellowship is for.
     
  9. ChildNeuro

    ChildNeuro Junior Member
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    Also, way back in the day, physicians would do what is called "rotating internship" and get experience in everything from ob/gyn to peds to internal medicine, and such General Practice physicians would basically do what they felt comfortable doing, later on residencies were established to force physicians to seek specialist training and to become competent in it. For example, an ob/gyn might known some about care of neonates, but they can not expand their patient population to moonlight in the NICU.

    Similarly, you can't as a neurologist decide on your own that you want to expand your practice to psychiatric patients seen by psychiatrists. First of all, who would refer patients to you? No physician would refer a patient with a severe mental illness like schizophrenia to a neurologist who wants to branch out and see severely mentally ill patients but has no experience clinically managing these patients. No hospital would want to have a neurologist manage an inpatient ward of psychiatric patients or see patients admited for psychosis, because what if one of those patients committs suicide? It might be because you don't have the psychiatric training to pick-up the warning signs or clinical skills that a psychiatrist has and you and the hospital would be rightfully sued by a lawyer.

    Bottom-Line: It is extremely important to know when you are in over your head in medicine and need to consult a specialist. Likely you could attempt to manage maybe 75% of patient that psychiatrists see on an inpatient setting, but for the others you would not have the required training. Remember, psychiatry is more about just knowing the biologic pathophysiology of a psychiatric disease and what med to prescribe, but, having years of experience with severly mentally ill patients is not something that you can learn overnight. I.e. is this bipolar patient a danger to themselves, how long do I keep them in the hospital during this manic episode? What sort of follow-up do I need? Is the patient responding to this medication as planned? Do I need to switch medications? You only get the answers by seeing the number of patients that a psychiatry residents sees.
     
  10. ChildNeuro

    ChildNeuro Junior Member
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    Sorry for the long post, but lastly, yes a neurologist should be aware of the manifestations of psychiatric diseases and how they are treated, of course, but they should not be treating psychiatric patients with serious disorders by themselves. The reason is that the best specialist knows not only their own field, but also alot about other fields as well. For example, if you know alot of psychiatry as a neurology resident then you can figure out when to refer to psychiatry, how to write a good psychiatry consult, etc. . . this is just part of being a good doctor. For another example, say I am an internist, and that I did well in surgery rotation in med school, and read general surgery articles in New england journal of medicine, conversed with surger colleges, then when I get a patient with abdominal pain I can think like a surgeon and decide whether or not I need to consult a general surgeon, do an imaging procedure, etc . . . Some of the worst doctors know little to nothing about fields other than their own and thus don't make correct decisions about when to refer to a specialist.

    For example, if as a psychiatrist you have a patient with psychotic symptoms, but also this patient has Kaiser-Fleischer rings, whoops!, the patient may have Wilson's disease, and you need to consult a medicine specialist quickly to treat this condition. Is Wilson's disease a strictly psychiatric disorder? No. Does it have psychiatric manifestations? Yes. Are patients with Wilson's disease sometimes mistaken for patients with schizophrenia and keept in a psychiatric ward? Yes. So you see, yes, neurologist need to known alot about psychiatric disorders to make sure their neurology patients don't have depression, i.e. pseudo-dementia in the elderly which is really depression. Does this mean neurologists know how to manage a patient with schizophrenia once they are diagnosed? No.
     
  11. BrianUM

    BrianUM Future M.D
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    Thanks so much for your responses, basically the gist of it is: combined neuro, psych good in practice, Neuropsych good for research.

    I was wondering though if you think it would be possible as a Neurologist with a Neuropsych fellowship to establish your own private practice in which you see Neurological pts, Neuropsych pts and non severe psych pts. If a pt is out of the realm of my competence, I could then refer them to a psychiatrist. My feeling is that my mom is a psychotherapist and she could refer me pts and if I establish myself, others would refer me cases. Do you need to be certified in Psychiatry to bill for a psych consult?

    Bottom line is, ill prob switch specialty interests. However, Neuro-Psych residencies sound really appealing. Of course, there are rumors that Psychiatry itself will morph into a more objective form of Neuropsychiatry in which more neurological procedures, brain scans, etc are used. In that case, I may just opt for psychiatry. Thanks a lot!
     
  12. ChildNeuro

    ChildNeuro Junior Member
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    Hi, glad I could be of some help. If your Mom is a psychotherapist she could refer patients to you I would suppose. Depression can be treat with either psychotherapy or pharmacotherapy i.e. pscyhotropic medications like SSRIs or perhaps a best combination is using both psychotherapy and pharmacologic therapy.

    Most physicians who treat depression are basically family practice types who treat people who only have depression. However, you have to be able to distinguish depression from certain other types of psychiatric diseases like Bipolar and schizophrenia. While it can be rewarding working with people with depression, you wouldn't really be able to do and see alot of the other patients that psychiatrists see. Alot of psychiatry is very different from what people believe it is i.e. listening to someone talk sitting on a couch, or a overly technical view of someone listening to someone and using a battery or sophisticated tests and imaging for a patient. Alot of psychiatrists work with patients who are severely mentally ill i.e. bipolar, schizophrenia, who are in and out of mental institutions their whole life, and deal with multifaceted social and legal issues, you will see this when you do a psychiatry rotation. I did clinical rotation on a psychiatry admission ward at a place that used to be large asylum for mental patients. Alot of psychiatry work is legally related i.e. petitioning patients you have to talk to a judge on a daily basis. So if you are not a psychiatrist then you don't belong getting involved in more complex cases.

    So, if you just see patients with stable depression, or multiple episodes of depression you are really limiting yourself to what most psychiatrists see. Any physician can talk to a patient and see that they are depressed and prescribe SSRI and see if it helps. Most psychiatrists I believe can't bill for psychotherapy because they are not trained in it, so you wouldn't have 45 minutes to talk to a depressed patient, just 10 minutes to prescribe an SSRI, the only care you can be justified in providing, yes you could talk to them for 45 minutes at your own expense, but I am not sure you could bill for something that you haven't trained in.

    I do not believe that psychiatry will ever have alot (or any) procedures. Psychiatrists give meds for patients who are acutely ill and treat acutely ill patients on a psychiatry ward, and on a chronic basis in a clinic. There are new imaging modalities that might help psychiatrists choose which SSRI to presribe based on which might be more effective, better patient care yes, but getting an insurance company to pay for you to do MRIs or PET on each of your 30 patients you are following on a psychiatry ward and whom have an average stay of 2 weeks is impractical. Currently, if a patient does not improve clinically then you switch the SSRI (they are all different) or try a different medication. Classically, how it is divided is that neurologists see what is traditionally thought of as more "organic" based disorders for previously alluded to reasons, and do lumbar punctures etc . . . If you want to do some procedures and use imaging alot (which neurologists do) then you should perhaps go for neurology. Remember, neurologists get to talk alot with patients too, probably about as much as a psychiatrist on an inpatient ward who only has maybe 15-20 minutes per patient/day to see if patient is less psychotic etc . . .

    Bottom Line: You could probably see patients with clinical depression who are stabilized, taking their medications, and observe their improvement. But you will not be allowed to work-up patients in severe depression presenting with psychotic symptoms, you can't committ a person to a hospital for their own safety, you probably shouldn't be seeing bipolar patients and patients with schizophrenia, and you can't round on your patient when they are in acute-inpatient psychiatric care units. Basically, psychiatric care is tightly regulated so that just psychiatrists treat these patients for obvious legal reasons and you would be barred from doing alot of this.
     
  13. ChildNeuro

    ChildNeuro Junior Member
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    In addition, I don't why anyone would refer you cases (except maybe Mom!) because why would a Family Practicioner refer a patient to a non-psychiatrist for depression, which they could treat as well as you (probably better if they have been in FP a while and know the patient).

    Also, no hospital would give you privileges to round on their psychiatric patients, or work in their psychiatric outpatient clinics because you wouldn't be a psychiatrist. Once you are BE/BC in psychiatry then you could setup a private clinic or work in emergency psychiatry. I don't think you could advertise well in a newspaper for patients either, i.e. stating you are a non-psychiatrist neurologist who is looking to help only patients with depression. It would be impossible to earn a reputation being a specialist in depression, but not be a psychiatrist, as so many physicians treat depression. It would be the same as being a Family Practice graduate, and some how advertising yourself as a depression specialist, which could potentially get lawsuits filed against you being a nonpsychiatrist.

    Now, being a neurologist you would be able to setup a clinic and get patients referred to you for neurologic problems. If you for some reason want to see both, best to be double-board in psych, and neurology, that way you would get referrals and would be legally allowed to see different types of patients. (There are alot of sublties of psychiatry that you learn in psychiatry residency that are essential for really caring for these patients). This would open up some interesting opportunities in academia as well as in a hospital environment where you could walk between two worlds.

    I am pursuing double board certification in pediatric and neurology via the Child Neurology residency because I want to be able to properly care for children with neurologicaly disorders, which alot believe requires a solid foundation in Pediatrics i.e. two years pediatric residency (which I would love to do anyway), as well as the three years neurology training, then I would be BE/BC in BOTH pediatrics and neurology with the special competency in child neurology. You can try to care for pediatric neurology cases by doing a fellowship after an adult neurology residency, but you wouldn't have the basic pediatrics residency background, and similarly a pediatrician can care for most/common seizure d/o, but they do not have the neurologic training to care for most complex/difficult cases. Basically, what residency you do dictates what type of patients you can safely care for.
     
  14. ChildNeuro

    ChildNeuro Junior Member
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    Here is another analogy, you have both cardiologist and cardiothoracic surgeons who both know alot about the heart and treat basically only heart disease. Who would you want to do a heart bypass? The surgeon of course. And who would you want to manage a patient with acute CHF in a coronary care unit with medication? The cardiologist of course.

    Now, could a cardiologist just decide one day to do a heart transplant? No. They would have to do a gen. surgery residency, then do a CT fellowship. There are some blurring of the lines such as invasive cardiologist doing some surgical procedures i.e. cardiac cath, but they really can't manage the pre-op, op, and post-op of a patient that needs a congenital heart surgery.

    Also, a cardio-thoracic surgeon might not be uptodate on the most current pharmacologic treatment of patients in a cardiac care unit, so no, they just can't walk in there and start taking care of those patients.

    It seems to me that you wish that the field of psychiatry had alot of procedures and imaging techniques, (probably will have alot of imaging techniques in the future), if you are interested in expanding the horizons of psychiatry then a fellowship in neuropsychiatry might be right up your alley, in such research situations you have the funds to use PET etc . . . to elucidate underlying psychiatric pathophysiology etc . . . Realize that most psychiatrists today (including many in teaching institutions and residency directors) are not uptodate on current imaging modalities and personalized psychopharmacology, as there is no proven benefit to this yet and no one will pay for it yet. Maybe in 10-15 years there will be a use for MRI/PET in helping to decide what meds to use for certain patients with depression, but remeber that Neuroradiologists and radiologists will actually read those studies and report the results to you, so you will not be trained now or in the forseable future to interpert these new head scans.
     
  15. ChildNeuro

    ChildNeuro Junior Member
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    One more tidbit, when Family Practice doctors were created, it was hoped that they would become "super doctors" and be able to care for basic ob/gyn, surgical, internal medicine, and pediatric cases. I.e. such super-doctors would be able to do Laproscopic Cholecystectomies, do a large number of labor and deliveries, and basically everything for their patients. This didn't work out as much as hoped, as the field did not expand as espected, one adult medicine specialist told me recently that they wished that the whole field of Family Practice was abolished. The reason behind this thinking is that a "jack of all trades" is "master of none." For example, an ob/gyn doctors trains many years in residency seeing multiple different types of pregnancies and may do a fellowship in high-risk pregnancy, or fetal-matneral medicine etc . . . so if you have patient who has a high risk pregnancy i.e. gestational diabetes or maybe past hx of pre-eclampsia you want them to see the real thing, the ob/gyn with the training. So the role for Family Practice there is diminished. Similarly, I have seen Family Practicioners examine and care for pediatric patients, but they do not have the knowledge or perhaps focus of pediatricians, and their exams and care is often superficial and they miss important things that a pediatrician would pick-up on. I would want my child to be seen by a pediatrician, not a family practice doctor, and then by an internal medicine doctor when older. The training in family practice is very much outpatient oriented, and misses some of the more intensive training that pediatricians and internists get, some of that residency is spent doing ob/gyn and general surgery too, so that dilutes the training. Don't get me wrong, I am considering FP too, but it such a large information base to keep up on. I think a neurologist trying to keep up with neurology (which is very medicine based) and psychiatry (which requires you to see alot of psych patients in a psych residency to do well) might be like a Family Practice doctor trying to specialize in everything.
     
  16. BrianUM

    BrianUM Future M.D
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    Thanks so much for your time.

    If things remain the same, I think I will prob try to go for the combined psych-neuro, esp the one at UM as that's where I'm going for med school. If not, I think I may opt for a neuro residency followed by a Behavioral Neuro/Neuropsych fellowship. Of course I will keep my options open and may end up doing something completely different like surgery!

    Once again, thanks and best of luck in the future.
     
  17. nala56

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    I am a junior in college majoring in psychology and I am also interested in psychology and neurology. I was wondering if it was possible to participate in a dual residency in neurology and psychiatry, become board-certified in neurology and psychiatry in order to become a behavioral neurologist. Or is participating in a dual residency in neurology and psychiatry will make you a neuropsychiatrist? What is the difference between a neuropsychiatrist and behavioral neurologist?:(
     
  18. neurologist

    neurologist En garde
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    1. There are joint neurology/psychiatry residencies (usually 6 years long, I think)

    2. If you do one you can be board certified in both neuro and psych as separate specialties. You would have to take 2 separate examinations to do this (although they are both handled by the same board -- the American Board of Psychiatry and Neurology)

    3. A behavioral neurologist is a neurologist who has done a behavioral neurology fellowship -- they usually deal with dementia and cognitive complications of other diseases (parkinsons, neuro-infection, etc). They are NOT psychiatrists although they generally have a pretty good handle on psychiatry and use many of the same medications that psych uses for depression, psychosis, etc.

    4. I have to admit I'm not 100% sure what a "neuropsychiatrist" is. I've always assumed it's a psychiatrist with particular interest in the neurobiology of psychiatric disease.
    I kind of look at it like this: a behavioral neurologist is a neurologist who is interested in the psychiatric aspects of neurology, and a neuropsychiatrist is a psychiatrist who is interested in the neurologic aspects of psychiatry. Sort of two sides of the same coin.

    Hope this was helpful. Maybe someone else can clarify further. Or you can try posting on the Psych forum as well.
     
  19. ChildNeuro

    ChildNeuro Junior Member
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    For a more in-depth definition check out:

    http://en.wikipedia.org/wiki/Neuropsychiatry

    I was pleased to see that it re-iterated my comments in this thread that psychiatrists and neurologists see different patient populations and pragmatically it would be hard to have a 3 year neuro-psychiatry residency, and the route to competency in both remains a dual psychiatry-neurology residency.

    From above website:

    "

    [edit]
    Summary of the arguments for neuropsychiatry

    Diseases of the body have a physical manifestation that can often be caused by internal factors, external factors, or a combination of the two. Mental disorders should be no different and when together neurology and psychiatry's aim was to show that this was the case. Psychiatry departed the union preferring ideology over empiricism, including very environmentally-based aetiology as well as espousing that the mind was something fundamentally different to the brain. Neurologists, however, finding no physiopathology for certain disorders left them to the psychiatrists, whilst themselves pursuing the diseases with clear physiopathology.

    However, the cleavage between mind and brain and the causal dichotomies are argued not to be veridical. Psychiatric disorders are increasingly showing organic manifestation and demonstrate causation from something as distant as culture. Thus the reasons for the initial division are argued not to be useful or real ones. The two specialties are both dealing with disorders of the same system. Biological psychiatry and behavioural neurology show how the boundaries are being blurred. It is argued that there can be no objection to a reunion on philosophical or scientific grounds. However, there may be reasons to question whether neuropsychiatry would be practically possible. The differences in patient management, knowledge base and skill competency between neurology and psychiatry mean that being proficient in both may be impossible."
     
  20. nala56

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    I printed out the information on the website and it explained the meaning of neuropsychiatry. Do you believe that a dual residency in neuro/psych is a waste of time?:)
     
  21. ChildNeuro

    ChildNeuro Junior Member
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    No, I don't believe that a dual residency in neurology and psychiatry is a waste of time for those people who want to practice both neurology and psychiatry, or wish somehow to push forward the more academic aspects of the interface between neurology and psychiatry. There are many combined residencies, that people pursue for a variety of reasons. For example, a combined IM/EM, combined IM/Neurology. But I would say that psychiatry and neurology are different fields, and the respective practicioners see different patient populations.
     
  22. nala56

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    Is it harder to get accepted into a combined residency program than a surgery residency program? I know that this question may be a little far-fetched, but would you associate migraines and headaches with neuropsychiatry?
     
  23. llogg

    llogg New Member
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    I don't understand your first question. It's not all that difficult to get into a general surgery residency. If you meant neurosurgery then that makes a little more sense, although the motive behind the question still puzzles me.
     
  24. ChildNeuro

    ChildNeuro Junior Member
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    I would guess from comments on this message board that combined residency programs are easy to get into, probably because they are longer than traditional residencies. All general surgery residencies are a fixed amount of time, so if you want to do surgery you have to go this route. Headaches are routinely evaluated by neurologists, as well as by Family Practice practicioners for any red flaggs that might warrant a more in-depth workup. As far as I know, there is no/very limited psychiatric, i.e. affective component of the headache itself that would benefit the input of a pscyhiatrist, i.e. psychiatrists aren't called to evaluate headaches. A family practice doctor would probably better manage a headache than a psychiatrist.
     
  25. nala56

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    My first question was if you (or anyone) think that acceptance into a combined residency is less competitive than, say, a surgical residency. Also, there is NO motive behind it the question. I just wanted to ask this question because I was curious.:laugh:
     
  26. BrianUM

    BrianUM Future M.D
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    Hey childneuro,

    Thanks so much for the info! I was wondering if you knew whether or not there is a financial benefit for doing the combined residency and whether it is possible to establish a niche as a double boarded neurologist and psychiatrist. I'm asking because it is a rather huge commitment. I'm hoping that in med school I'll get a better idea of what I like. Right now I am interested in a lot of things but mostly psychopathology from a biological perspective. However, I dont think I would enjoy therapy or the psychiatrists' approach and would rather make use of objective measures. Do you think the combined program would make sense for me?
     
  27. ChildNeuro

    ChildNeuro Junior Member
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    I think that practically all double-board residents do it because they really love two fields and what to be competent in both or practice both of them. When you are in third year you will get a good idea of what you want to practice, i.e. some people find out that they love internal medicine and head off to do that. More important in the long term is to do what you will enjoy doing day in and day out. I am not sure about the financial incentive of doing a double-board residency, I think the lure is that you get to live in two worlds and perhaps have more research options available to you. For example, some emergency medicine doctors want to be double boarded in internal medicine just to have that background/knowledge/skill. Reading about psychiatry in a textbook is different from seeing what psychiatrists do on an actual basis, your theoretical grasp of medical specialties may change greatly in medical school. Psychiatrists do prescribe medications, fill out paper work for committing patients, and track the improvement of seriously mentally ill patients, their "approach" is the most scientific and ethical way to care for these patients that technology allows. Not many psychiatrists do the group therapy part, and if so it is only a couple times a week, alot of it is figuring which medications work for a given patient. Psychiatrists use the bio/psycho/social model to evaluate a patient and do know alot about the biology of various psychiatric disorders. You can not, however, make psychiatry more "objective" by also being a neurologist, this just means you can see neurologic patients on consults, which is a whole different patient population. I.e. because you know the more defined pathophysiology of Parkinson's doesn't mean that you can sit down with a psychotic patient for three minutes and come to a more "objective" evaluation of their risk to themselves or others, on the contrary, psychiatrists may see 25 very mentally ill patients a day and make a decision about who is safe to release, who isn't, who needs a medication change, being a neurologist won't somehow transform you into a more "objective" psychiatrist at all. I hope this helped. When you rotate through psychiatry your questions will be answered fairly quickly and will know whether or not you want to do psychiatry longterm.
     
  28. nala56

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    I was interested in learning more about the combined neuro/psych residency because I wanted to become a neuropsychiatrist. Do you know anybody who is a neuropsychiatrist?:idea:
     
  29. ChildNeuro

    ChildNeuro Junior Member
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    There are neuropsychiatry fellowships post psychiatry, which from what I have read are research oriented, i.e. psychiatrists who want to understand the biologic basis of psychiatric disorders, often using new imaging technologies, so:

    1. Psychiatry resideny -> Neuropsychiatry fellowship -> Research opportunities in neuropsychiatry plus can practice as a Psychiatrist.

    A combined resident in psychiatry and neurology means that you are both a psychiatrist and neurologist.

    2. Combined Neurology/Psychiatry residency -> You are Neurologist and Psychiatrist. You could do a fellowship after this like neuropsychiatry, epilepsy that would lead to research opportunities.

    You can see, I hope, that the neuropsychiatry fellowship is very different from a combined residency. Why spend years a neurologist residency seeing stroke, headache, etc. . . if you want to neuropsychiatry fellowship post psychiatry residency? If you do a combined residency you are a neurologist and psychiatrist i.e. can be Board Certified in both, however, if you just want the neuropsychiatry fellowship which is *highly* specialized you can do this after either a psychiatry residency or neurology residency. I could give you better advice if you could describe what you want to do, i.e. neuropsychiatric research (also people with PhDs can do this) or if you want to practice Neurology AND Psychiatry. There is a big difference from someone who is a psychiatrist and does a neuropsychiatry fellowship from someone who is board certified in both fields, the former is training to do highly specialized research, the later can legally, ethically see both neurology and psychiatry patients. Being doubled board in both Neurology and Psychiatry does not give you some sort of special view on your psychiatry patients, it just means you have extra training to evaluate patients with pure neurological disorders. Neuropsychiatry fellowship, in my opinion, allows you to compete for funding for neuropsychiatric research projects on which many types of people PhDs, MD, neuroradiologists, may collaborate.

    I am not an expert on this, so please do a google search for neuropsychiatry, here is something I found about Brown's program, note that the director is a psychiatrist and neurologist by training:

    Combined Neurology-Psychiatry Residency
    Overview
    The fields of neurology and psychiatry have been brought closer together by advances in basic neuroscience, genetics, pharmacology, and imaging. Each field offers unique perspectives for understanding diseases of the brain and central nervous system. The Combined residency training in neurology and psychiatry is designed for physicians who plan on a clinical or research career in the clinical neurosciences and who have determined that completing clinical training in each specialty will provide them with the best background to meet their career goals.

    Mission
    The mission of the Brown University Combined Residency Program in Neurology and Psychiatry is to provide solid clinical training in both neurology and psychiatry for future leaders in clinical neuroscience. At the completion of training combined residents are eligible for board certification in both neurology and psychiatry.

    The Brown University Combined Training Program began in 1995. The combined residency was certified by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Psychiatry and Neurology (ABPN) in 1996. The first combined resident graduated in 2001. We are currently one of a small group of combined programs who are certified by the ABPN and ACGME.

    Brown Medical School offers an excellent environment for combined training in neurology and psychiatry. The residency programs in neurology and psychiatry are both well developed, and the departments enjoy a close working relationship. There is also a close working relationship with the Department of Neurosurgery and a growing collaboration with the campus department of neuroscience, which is quite strong in brain/behavior research. The program is small enough that residents are able to develop close mentoring relationships with an outstanding group of faculty in the Medical School. Neuropsychiatric research is a major theme for a large number of faculty in the School of Medicine.

    The Neuropsychology program at Brown has a strong national reputation. There are mature neuropsychiatric research programs in movement disorders, dementia, geriatric psychiatry, mood and anxiety disorders, stroke, epilepsy and pediatric neurology.

    Program Direction
    Stephen Salloway, M.D., M.S. is the Director of the Combined Training Program. Dr. Salloway is an Associate Professor of Clinical Neurosciences and Psychiatry, and Human Behavior. He graduated Stanford Medical school and completed residency training in neurology and psychiatry at Yale University. His research focuses on developing new treatment for vascular dementia and Alzheimer's disease. He is a past President of the American Neuropsychiatric Association and he writes lectures widely on neurobehavioral disorders. A Training Committee made up of Janet Wilterdink, M.D., Director of Neurology Training and Timothy Mueller, M.D., Director of Psychiatry Training, and the Combined Residency Director oversees the Combined Training Program. The Training Committee meets annually to review the curriculum and the progress of each resident.
     
  30. nala56

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    What I want to do is to become a clinical neuropsychiatrist. However, I am thinking about becoming a neurologist and psychiatrist.
     
  31. ChildNeuro

    ChildNeuro Junior Member
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    Hi, since this slightly out of my experience here is a post by Anasazi23

    whom posted not that long ago, maybe you should PM him/her to get more info about what a neuropsychiatrist does. I think in your case if you want to be able to *clinically* see some overlap patients your best bet IS to do the combined neurology/psychiatry residency. You could potentially research neuropsychiatrists in your area to find a good shadowing experience and maybe even some research experience. For the description below if you want to manage seizure meds and do neuro exams you best bet is to do the neurology residency in addition to psychiatry. Good Luck!

    >>>Copies and Posted from old thread:

    --------------------------------------------------------------------------------

    I've worked with a couple neuropsychiatrists [closely], and have had exposure to many others.

    Their practices were similar. The both did private practice along with hospital-based medicine. In many cases, the hospital practice fed their private practice.

    They tended to specialize in diseases and syndromes that overlap the so-called boundaries between neurology and psychiatry. A common day was to do rounds on patients on the floors in the AM, and in one case, run rounds on the geri psych unit after regular rounds, which normally occurred on the medical floors, neuro floor, psych floor, and all of the above.

    When going to the practice, we'd see patients such as post TBI patients, parkinson's patients, huntington's, post-concussive syndromes, more conventional neuro patients, and conventional psych patients, which would include everything from addiction to anorexia. At night, we'd go to the house where we'd read both emg's and eegs that were done by the techs during the day.

    In the case of one practice, we'd spend some time doing botox injections for muscle tension headaches and similar problems. Both docs tended to see lots of seizure disorder/psych patients as outpatients. They would manage anti-seizure meds and conduct neuro exams, while dealing with concomitant psychiatric manifestations of the disease [I did lots of reading on the epileptoid personality].

    >>>
     
  32. nala56

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    Thank you so much for the information!!:)
     

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