docpsych

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I Am A Pgy-1 Psych Resident. I Originally Applied For Medicine But Before Starting Medicine Residency I Switched Into Psych. I Am Fairly Satisfied With My Decision To Go Into Psych, And Hopefully Into A Pain Fellowship. However The Lack Of Respect From Other Specialities Is Disturbing. For Example, I Was On Call Seeing A Pt In The Er For Psych Eval And Found That He Had Blood Glucose Level Of 350, So I Ordered 40units Insulin 70/30. The Er Doc Was Surprised I Was Confident Enough To Order It Without Consulting Him, And It Being The Appropriate Course Of Action. He Actually Said To Me, "looks Like Your On The Ball, Why Are You Doing Psychiatry". This Is Just One Of Many Comments I Seem To Get On A Weekly Basis, Not Kidding. Is This Something I Can Expect The Rest Of My Career? It Is Important To Me To Be Respected Among My Peers. Does Anyone See A Change In The Future Of Psych To Be More Respected As A Medical Specialty.

Anyone Have Any Advice For Obtaining A Pain Fellowship Through Psych. According To Frieda One Program Exists At Cleveland Clinic. I Am In A University Psych Program, Does This Make Me A More Formidable Candidate For This Fellowship.
 

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docpsych said:
He Actually Said To Me, "looks Like Your On The Ball, Why Are You Doing Psychiatry".
Response: "Well, I'm doing it because I have the potential to make 3 times the money that you do, with 10 times better lifestyle."



That's my standardized answer to the medical residents that make similar comments to me. Good job.
 

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I agree, it doesn't really matter what the hell anyone else thinks. The fact is, I'll be making at least as much money and probably more than medicine hospitalists, live wherever I want because there are so many crazy people and so few docs, and I will have my life to enjoy.
 

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docpsych said:
I Am A Pgy-1 Psych Resident. I Originally Applied For Medicine But Before Starting Medicine Residency I Switched Into Psych. I Am Fairly Satisfied With My Decision To Go Into Psych, And Hopefully Into A Pain Fellowship. However The Lack Of Respect From Other Specialities Is Disturbing. For Example, I Was On Call Seeing A Pt In The Er For Psych Eval And Found That He Had Blood Glucose Level Of 350, So I Ordered 40units Insulin 70/30. The Er Doc Was Surprised I Was Confident Enough To Order It Without Consulting Him, And It Being The Appropriate Course Of Action. He Actually Said To Me, "looks Like Your On The Ball, Why Are You Doing Psychiatry". This Is Just One Of Many Comments I Seem To Get On A Weekly Basis, Not Kidding. Is This Something I Can Expect The Rest Of My Career? It Is Important To Me To Be Respected Among My Peers. Does Anyone See A Change In The Future Of Psych To Be More Respected As A Medical Specialty.

Anyone Have Any Advice For Obtaining A Pain Fellowship Through Psych. According To Frieda One Program Exists At Cleveland Clinic. I Am In A University Psych Program, Does This Make Me A More Formidable Candidate For This Fellowship.
do you always type like that?
 

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http://forums.studentdoctor.net/showthread.php?t=160140

#6.

I'm not sure what you mean by changing at the last minute, but it sounds like you may have had reservations from the beginning.

As for ordering 40 U of 70/30 as an intern without consulting, that seems fairly bold for an intern in any specialty. I would take the statement as a compliment and a joke and be happy with my performance. Part of the stigma against psychiatrists arises from taking of stigma too seriously.

I think you should do what Anasazi said and keep up the great work! :laugh:
 

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While physicians are generally bright people, that doesn't mean that they're secure. I'm sure we have all heard a physician belittle an MD in another field. If you haven't, you will.

While psychiatrists seem to be on the receiving end more than the average MD, at least in my experience so far, I think that has something to do with the fact that psych is so specialized. It's unlike many other fields within medicine or surgery, and often over time psychiatrists lose touch with traditional medical and surgical topics since they don't use that knowledge base as much - just like a language. This, coupled with the fact that the brain and psychiatry as a field are more of a black box compared to other organ systems/fields, leads some to take shots at the field.

The increased understanding of the biological underpinnings of psychitaric pathology, along with increased understanding of psychopharmacological mechanisms that will come with research, particularly genetics, may change this to a degree. What will surely not change is the fact that some people are insecure and feel the need to be critical of others.

At the risk of sounding like Oprah :eek: , do what you enjoy and find rewarding.
 

meisteckhart

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First off, I think the perception of psychiatry varies depending on where you are in the country and what hospital you are at. I know that when I rotated at Mass General, psychiatry seemed very well respected. On the other hand, I worked at a community hospital where psych was looked down upon, and unfortunately the rep there was somewhat deserved. Second, I think that if we want to change the perception of psychiatry as a specialty and actually deserve the prescribing rights we seem to want to keep from psychologists, we need to be good physicians in all respects. To me, that means giving our patients insulin when they need it, knowing our basic medicine, and not consulting medicine every time our patient has a cold. I had the same thoughts you did when I was deciding on my specialty, but I ultimately decided I love psych too much to let it bother me. So I'm planning on going into consult to keep closer to my medicine roots and to help keep up on my medicine. If you prove to your colleagues that you are a competent and caring physician, I think they will respect you no matter what specialty you are in.
 

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To clarify, I meant "consult" as in "run it by" the primary attending or upper level resident.

Also, I am not clear whether the intern was on the psychiatry consult or ED service, and therefore, whether or not this ED attending was the intern's attending.

I agree consulting medicine is out of range here. ;)
 

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#1) Unfortunately lots of psychiatrists out of sheer laziness forget their medicine. Some of this reputation is earned by psychiatrists as a whole because there's so many that forget their stuff

2) but on the other hand in most cases they're not actively required to manage diabetes. In many hospitals, the psychiatrists aren't supposed to touch medical management.

I've already been told many times not to touch a psychiatric patient with medical management. I think a large part of it has to do with the fact that my attending is responsible for any mistakes I may make and he's been out of touch with medicine for some time. Some of it is also I believe that psychiatrists are covered by the hospital for medical liability, but are for psychiatric liability.
 

Teufelhunden

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meisteckhart said:
Second, I think that if we want to change the perception of psychiatry as a specialty and actually deserve the prescribing rights we seem to want to keep from psychologists, we need to be good physicians in all respects. To me, that means giving our patients insulin when they need it, knowing our basic medicine, and not consulting medicine every time our patient has a cold.
I applaud your desire to maintain your general medical knowledge, and agree with you that it is important for psychiatrists to recognize their role as physician, first and foremost. However, how legally defensible would it be for a psychiatrist to be writing orders for insulin? Most psychiatry attendings I've worked for would not give even consider writing an rx for an abx for a URI...with the general feeling that it wasn't their role, especially since they don't keep up w/ literature re: tx of infx dz, etc. (even something as 'simple' as treating URIs).

I think the field of medicine gains something from the fact that all of us share common roots, i.e. we all attend medical school, most of do an internship w/ rotations in a variety of settings. Realistically though, I think that most specialists do indeed have to let go of a lot of information, and that's not necessarily a bad thing.

In the hospital setting, I do think it's appropriate to consult medicine for all non-psychiatric issues. Why not allow the most-appropriately-trained individual to manage diabetes in the hospital setting? I wouldn't want an internist managing schizophrenia any more than I want an orthopod treating an arrhythmia.

Again, it's not a matter that a psychiatrist can't give insulin orders...I'm just saying that he/she shouldn't if someone more qualified (and they ARE more qualified in terms of experience/training) is available, i.e. an internist.
 

doc05

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what's the sense in doing a psych residency if you're planning on a pain fellowship? you'll have zero facility when in comes to procedures/anatomy, which is very important for pain. anesthesia is the way to go. or even neurology.
 

meisteckhart

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Teufelhunden said:
I applaud your desire to maintain your general medical knowledge, and agree with you that it is important for psychiatrists to recognize their role as physician, first and foremost. However, how legally defensible would it be for a psychiatrist to be writing orders for insulin? Most psychiatry attendings I've worked for would not give even consider writing an rx for an abx for a URI...with the general feeling that it wasn't their role, especially since they don't keep up w/ literature re: tx of infx dz, etc. (even something as 'simple' as treating URIs).

I think the field of medicine gains something from the fact that all of us share common roots, i.e. we all attend medical school, most of do an internship w/ rotations in a variety of settings. Realistically though, I think that most specialists do indeed have to let go of a lot of information, and that's not necessarily a bad thing.

In the hospital setting, I do think it's appropriate to consult medicine for all non-psychiatric issues. Why not allow the most-appropriately-trained individual to manage diabetes in the hospital setting? I wouldn't want an internist managing schizophrenia any more than I want an orthopod treating an arrhythmia.

Again, it's not a matter that a psychiatrist can't give insulin orders...I'm just saying that he/she shouldn't if someone more qualified (and they ARE more qualified in terms of experience/training) is available, i.e. an internist.
I think you make a good point. An internist is more qualified in many cases to give medical treatment when waranted, and I certainly think that psychiatrists should consult medicine, ob, surgery, neurology, or any other service when they are needed. However, there is a line between ordering a useful consult and just consulting for any problem that isn't directly psychiatry related. To comment on your example, no I would not expect an internist to be managing schizophrenia. But what about a patient with a mild depression? It is certainly ok for an internist to start an SSRI and never even consider calling a psychiatrist. Would the psychiatrist be better at choosing a medication for the patient? Perhaps, but no one is going to fault the internist for trying something out and then ordering a consult if the patient doesn't improve. In non-urgent and non-emergent medical situations, I don't see why it can't be the same for a psychiatrist. I wouldn't be able to manage DKA, but I don't have a problem giving a little insulin to a non-symptomatic diabetic with a mildly elevated glucose. I think you order a consult when you feel like the problem is beyond your own ability to diagnose or treat effectively.

There is one other comment I would like to make. There is always the fear of your own liability if something should go wrong. I would certainly not want to be sitting in a witness stand being asked by a lawyer when it was that I completed my medicine residency. Oh yeah, never. However, I think there is way too much focus on avoiding litigation in general at the expense of patient care and increasing health care costs. It is known that the strongest predictor of whether you will be sued is your relationship with your patients, not whether you do everything right or not. I think if you are confident, but not overconfident in your abilities and you recognize your limits, you can manage minor medical issues and be just fine.
 

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I too would like to be able to take care of the basic health care needs of my psych patients--I figure that some of them might have medical issues (minor) that they would not seek treatment for in a real world situation due to money, disorganization--whatever. I do think that we have a lot of resources at our disposal (med school classmates, books, journals, web) that are there to help us make informed and up to date basic medical decisions if we feel our training is out of date. I think the key to covering yourself is doing the basic things any physician would (good PE when needed, great documentation including your resources etc.) For something like an OCP etc., it is a bit crazy to think that it is not okay to prescribe for a stable patient with KNOWN medical Hx--make sure they have follow up....We are all doctors. Be aware of your limits and do what you feel you could be responsible for.
 

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it's interesting during my interviews one of the comments amde was that they were looking for people who weren't 'running away from medicine' and indeed all the case studies they gave me were actualyl medical probelsm mascarading as psychiatric- i.e. the 40 y.o business man in a bookstore who suddenly starts acting odd and then drops into unconciousness. Often a psychiatrist may be the only doctor a patient sees so why not manage their (minor) medical conditions or at least remain open to the possibility.

On the other track of this post have you had the 'but your aptients are going to kill/assault you' commetns yet? i get that one all the time. And itnerestingly I've not had a psychaitry patient threaten me yet, I think going to the pub is more dangerous.
 

PsychMD

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I do not mean to start a huge controversy in here, but you will find that increasingly in the "real world", the first-line responder (and at times the only realistically available responder) to a requested consult for an Internal Medicine or Neurology or Cardiology (etc.) colleague is in fact a Physicians' Assistant, not an MD colleague. So it's good for everyone to hone their "medical skills" and keep them updated, because on the inpt. unit you are in fact the main "captain of the ship" (with all the responsibility and liability incurred). Also, it is good for everyone to familiarize themselves with the variability and differences in training and experience of graduates from various PA schools. We will increasingly work in teams with midlevel providers, even if it's just because there just aren't enough available MD's at this time who are still motivated or interested to do any hospital based work (including consults), and even at the outpatient level, there is a lot of fragmentation and variability in the real accessibility to a specialist consultant, especially for psychiatric patients who in general have "limited" types of insurance or means to afford such access. Streamlined access to "optimal" or "text-book"-like healthcare is becoming an increasingly difficult proposition for a fairly large patient population (especially more so at the level of the psychiatric patient population), so lots of psychiatrists will also need to learn how to "navigate" various systems of care in order to be in a position to advocate for their patients in lots of circumstances, and at times even pick up some slack/responsibility. This goes with the turf.

Regardless of my own "feelings" re. general aspects of accesibility to care in this current overburdened and strained health-care system (and which one isn't pretty much anywhere in the world at this time?!), this is, IMHO, yet just another quite "practical" and de-mistifying aspect (beyond the other perfectly valid idealistic, historical, or theoretical ones) re. why most psychiatrists in the more recent era are fairly firmly rooted and anchored in their MD professional identity, and are also (hopefully!) fairly well trained across the board during their residencies to wear "lots of hats" in a responsible and appropriate manner, including being aware of their limitations and also of their knowledge, etc.

So I agree, at the most basic level, no one should ever pursue a psych. residency because "they are running away" from other types of clinical specialties!

It is quite interesting for me to observe that, according to the latest match figures, it seems that Psych. matched at record levels this year, and this trend seems to have been going this way pretty strongly in the last decade. This, IMHO, doesn't solely reflect the "desire for lifestyle", but also that the profession itself is probably doing a better job at educating medical students about itself in a clear and de-mistifying manner. (As an aside tidbit, in Europe, Psychiatry had already been one of the more competitive specialties for even longer than here in the US, but I guess that is natural, since that's where the roots of "modern era" psychiatry, as a professional specialty field, seem to have originated anyway.)
 

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tangents said:
I think the key to covering yourself is doing the basic things any physician would (good PE when needed, great documentation including your resources etc.)
I think the PE would be a bad idea. I was always under the impression that psychiatrists should strictly avoid any physical contact with patients, including therpeutic/clinical contact, as it would certainly muddy the transference waters, so to speak. Am I wrong in this thinking?

(This issue first came up to me in an Osteopathic journal/magazine article that dealt with D.O. psychiatrists' use of OMT. Now for those of you who aren't familiar with the osteopathic insanity that runs amok in the D.O. ivory tower, they always try to encourage practicing D.O.s in every specialty to use OMT. So, I was actually a bit shocked that this article admitted that it was not a good idea for D.O. psychiatrists to perform OMT on their patients, citing the transference issues as the main problem.)
 

tangents

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Not an ivasive PE, but I found doing a basic heart lungs, HEENT exam on inpatient units--required of med students for their patients--was really a good thing for getting to know your patients and having them trust you more (lots of time to talk, learn their med issues). I don't ever think it is crossing boundaries to whip out a stethoscope or an opthalmoscope in your psych practice. I think the key is informing the patient about your intent, and asking their permission. Example-Pt. in your outpt. office who has chest pain and SOB...sort of negligent to not take a listen before sending them off somewhere.
I did not mean the kind of exam where a gown is required, or any major personal space is violated. To each his own in this arena. Also depends on the patient and the situation...and on what kind of psych you are practicing...analysis vs. inpatient etc
 

meisteckhart

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Teufelhunden said:
I think the PE would be a bad idea. I was always under the impression that psychiatrists should strictly avoid any physical contact with patients, including therpeutic/clinical contact, as it would certainly muddy the transference waters, so to speak. Am I wrong in this thinking?
No PEs at all? I suppose I can understand wanting to be aware of transference and coutertransference issues in relation to patient contact, but I think avoiding a PE because you are concerned about touching a patient is a little too cautious. I think you should do a PE on any patient that you think needs it. Say a patient comes to you for acute onset of severe anxiety, hasn't seen a primary doctor before coming to you, and has a family history of thyroid problems. Shouldn't you do a physical exam and send off some thyroid function tests? Sure you will send them to an internist anyway to get checked out, but what if they have new onset afib secondary to thyroid toxicity? Your physical exam is the difference between sending them to an internist in the next two days and sending them to the ER in the next two minutes. I'm not saying these things happen on a regular basis, but I've heard enough anecdotal stories from attendings to believe that it is at least worth your time to do a quick chest and abdominal exam if the situation warrants it.
 

Teufelhunden

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meisteckhart said:
No PEs at all? I suppose I can understand wanting to be aware of transference and coutertransference issues in relation to patient contact, but I think avoiding a PE because you are concerned about touching a patient is a little too cautious. I think you should do a PE on any patient that you think needs it. Say a patient comes to you for acute onset of severe anxiety, hasn't seen a primary doctor before coming to you, and has a family history of thyroid problems. Shouldn't you do a physical exam and send off some thyroid function tests? Sure you will send them to an internist anyway to get checked out, but what if they have new onset afib secondary to thyroid toxicity? Your physical exam is the difference between sending them to an internist in the next two days and sending them to the ER in the next two minutes. I'm not saying these things happen on a regular basis, but I've heard enough anecdotal stories from attendings to believe that it is at least worth your time to do a quick chest and abdominal exam if the situation warrants it.
Good points. I'm curious about this issue. Does the APA have a stance on this? How much clinical contact is acceptable?

Truth is - I have never seen a psychiatrist perform any portion of a physical exam - in any setting (not even on the C/L service). I'd like to get a straight answer on all this. Granted, I know there's going to be opposing opinions, but I wonder what the 'official' stance on this is.
 
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docpsych

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not to do a PE, i think that is crazy. say your on the wards, and somebody complains of abdo pain. are you going to consult with only a chief complaint of abdo pain. this is why psych will not be respected. do a PE, and present the case like a MD should.
ex cc: abdo pain
hpi XXXX
PE: abdo soft or rigid, tenderness location? scars? bowel sounds?, etc.
Present a case like this, somwhat of a crude example, other med specialities will take you seriously.

i appreciate all the replies and would like to point out a comment which other attendings have told me as well. sometimes psychiatrists are the only docs pts go to. so it is in the best interests of your pt to be able to manage basic medical problems--otitis, uri, uti and have them follow-up if needed with internist. we do 4-8 months of medicine for a reason.

maybe i'm wrong in saying this. i am only a pgy-1, maybe not realistic practicing basic internal med with the potential litigation that may arise. seems we are taught to practice preventive medicine, instead its defensive medicine.
 

mdblue

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docpsych said:
not to do a PE, i think that is crazy. say your on the wards, and somebody complains of abdo pain. are you going to consult with only a chief complaint of abdo pain. this is why psych will not be respected. do a PE, and present the case like a MD should.
ex cc: abdo pain
hpi XXXX
PE: abdo soft or rigid, tenderness location? scars? bowel sounds?, etc.
Present a case like this, somwhat of a crude example, other med specialities will take you seriously.

i appreciate all the replies and would like to point out a comment which other attendings have told me as well. sometimes psychiatrists are the only docs pts go to. so it is in the best interests of your pt to be able to manage basic medical problems--otitis, uri, uti and have them follow-up if needed with internist. we do 4-8 months of medicine for a reason.

maybe i'm wrong in saying this. i am only a pgy-1, maybe not realistic practicing basic internal med with the potential litigation that may arise. seems we are taught to practice preventive medicine, instead its defensive medicine.
In OP, PEs are rare because of the setting and non-availability of time(10/15 min medck). And if a pt has HTN, the PCP should be knowing and managing about this, not me.
OTOH, in inpt and CL service PE/NE is essential and routinely done during adm.
 

meisteckhart

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Teufelhunden said:
Good points. I'm curious about this issue. Does the APA have a stance on this? How much clinical contact is acceptable?

Truth is - I have never seen a psychiatrist perform any portion of a physical exam - in any setting (not even on the C/L service). I'd like to get a straight answer on all this. Granted, I know there's going to be opposing opinions, but I wonder what the 'official' stance on this is.
I am not sure if the APA has a stance on the issue of physical exams, but I decided to go back to the medical school text I read while in my third year psychiatry rotation. The book is "Clinical Psychiatry for Medical Students" by Alan Stoudemire for those who would like to know the reference. In the chapter on psychiatric evaluation, they comment on a psychiatrist's physical exam. Here are some excerpted sections:

"The physical exam currently is included in 0-11% of outpatient psychiatric evaluations and in 4-40% of inpatient evaluations. Ideally, all psychiatric patients should receive a physical examination. Unfortunately, many psychiatrists, like other medical specialists, logically focus their examination on areas related to their specialty. Few 'primary' psychiatric diagnoses can be confirmed by positive findings on the physical examination; thus, it is often bypassed altogether."

..."Unlike many subspecialties in medicine, psychiatry deals with clinical presentations that frequently have as their origin a primary medical disorder that causes the patient's symptoms. The list for major depression alone includes diseases from most organ systems. To exclude an underlying medical disorder as a cause of the patient's symptoms, a systematic evaluation that traditionally has included a physical examination is required."

It continues, but I will paraphrase some of the interesting points that are made:

1) The physical examination confirms, denies, or narrows the differential diagnosis based on history in 30% of patients in a primary medical setting. (Hampton et al 1975)

2) The PE uncovers unexpected, important findings that lead to a diagnosis not related to the chief complaint in 7.5% of patients. (Hampton et al 1975)

3) A study of 224 consecutively examined psychiatric inpatients found similar results to the numbers above. (Chandler and Gerndt 1988)

And since we have been talking about it, here is the section on the affect of PE on the therapeutic relationship:

"Koranyi (1980) showed that physical examination did not adversely affect the therapeutic realtionship in over 2000 psychiatric outpatient evaluations, although it was not clear if breast and genital examinations were completed on all patients, or if there was any effect caused by the gender of the examiner and the gender of the patient. Those who claim transference and countertransference problems due to the physical examination may be creating imaginary dragons because the psychoanalytic/psychodynamic process involves working through these and other psychological conflicts. More likely, those who suggest this reason for avoiding the physical examination are merely rationalizing their dislike of or lack of skill in doing them. In many outpatient settings, however, it may be more realistic for the psychiatrist to insist that a physical exam be performed by a family physician or internist..."

I think that another good point was also made on this thread, and that is that we are sometimes the only doctor our patient's see. Even if a patient comes to an inpatient unit throught the ED, I know I have personally seen several ED docs do a quick once over of a patient because they are "psych" and not even do a good exam. Sometimes that chest pain isn't because the alcoholic is drunk and complaining, or because the schizophrenic is totally psychotic. Sometimes its real and if we don't take it seriously, sometimes no one else will.

Sorry for the long post folks. Guess I got a little carried away.
 

nortomaso

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"Those who claim transference and countertransference problems due to the physical examination may be creating imaginary dragons because the psychoanalytic/psychodynamic process involves working through these and other psychological conflicts. "

I'm baffled that that psychodynamic babble is even allowed into this argument by the author of a psychiatric textbook, much less members of this forum. How is it that a theory and applied therapy that has no evidence to support its efficacy [at best limited evidence that it has equivalent efficacy to CBT and IPT in a few studies, in others clearly inferior] dominates psychiatric vocabularly to the point that it drives a discussion on whether or not to examine our patients? I think that psychoanalytic witchcraft is the major tarnish on other specialties' perception of psychiatry and I think it is justified: medicine should be driven by evidence wherever possible and where not possible we should at least avoid turning it into a religion.
 

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meisteckhart said:
It is certainly ok for an internist to start an SSRI and never even consider calling a psychiatrist. Would the psychiatrist be better at choosing a medication for the patient? Perhaps, but no one is going to fault the internist for trying something out and then ordering a consult if the patient doesn't improve.
This is an example of where numerous PCPs have gotten into trouble. They see a pt with depression, prescribe an SSRI, and then don't follow up soon enough since they know that it will take some time for the medication to "take effect". The avolitional aspects resolve first with treatment, and if there is an underlying SI that was not discovered by the PCP...disaster. Too late for a consult.

As someone else has already said, we need to know our limits, but that's hard to appreciate often times. All the more reason for us to respect the roles we all have to play in patient care.
 
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nortomaso said:
" I think that psychoanalytic witchcraft is the major tarnish on other specialties' perception of psychiatry and I think it is justified: medicine should be driven by evidence wherever possible and where not possible we should at least avoid turning it into a religion.
i cannot agree with you more.
 

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Nor me!! I have to say that psychiatrists are getting a bad wrap lately, and part of it is their own fault and part of it is BS. As a psychologist, I will always covet a relationship with a good psychiatrist. My interest is to see my patients get well.
Sometimes I need the help of a psychiatrist, and if we have mutual respect for each other then only good things can happen for our patients. Fear, backbiting, ignorance etc.. only lessens our effectiveness as mental health clinicians. :D
 

meisteckhart

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nortomaso said:
I'm baffled that that psychodynamic babble is even allowed into this argument by the author of a psychiatric textbook, much less members of this forum. .
Well, I agree that psychodynamic and psychoanalytic psychotherapy are not particularly efficient ways to treat patients, nor is there much evidence, other than anecdotal, to support their use with a few exceptions. I should note also that there are studies ongoing which are attempting to work on just that question. However, regardless of your opinion on the subject of analytic therapies, I do not think there is any reason to dismiss discussion about it outright. The author of a textbook is obligated to look at the field as a whole and address issues which may be of importance to many different psychiatrists with many differing opinoins. In addition, I do think issues of transference and countertransference are important beyond just the application of psychodynamic or analytic therapies. Psychiatry has a very rich history which still permeates much of what we do and where our profession came from. If you dismiss some of these ideas and theories as pure unfounded witchcraft, I think you risk missing out on some very useful ideas that may help you to understand and better treat your patients whether you specifically choose to practice these therapies or not.
 

nortomaso

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meisteckhart said:
Well, I agree that psychodynamic and psychoanalytic psychotherapy are not particularly efficient ways to treat patients, nor is there much evidence, other than anecdotal, to support their use with a few exceptions. I should note also that there are studies ongoing which are attempting to work on just that question. However, regardless of your opinion on the subject of analytic therapies, I do not think there is any reason to dismiss discussion about it outright. The author of a textbook is obligated to look at the field as a whole and address issues which may be of importance to many different psychiatrists with many differing opinoins. In addition, I do think issues of transference and countertransference are important beyond just the application of psychodynamic or analytic therapies. Psychiatry has a very rich history which still permeates much of what we do and where our profession came from. If you dismiss some of these ideas and theories as pure unfounded witchcraft, I think you risk missing out on some very useful ideas that may help you to understand and better treat your patients whether you specifically choose to practice these therapies or not.
Zeal is often self-defeating and my use of the word "witchcraft" was a little unwise. I think a better analogy is Chinese medicine. While I'm loathe to accept the opaque and heuristically useless theory behind it (chi), I acknowledge that there are many practices associated with it (though not logically DEDUCED from it) which are testable. The differences of course being that Chinese medicine has a much longer tradition, its many practices are not attributable to a small handful of theoreticians, and it has actually born useful empirical fruit.

I reject the notion that psychiatry should be faithful to its own history and traditions. In my mind the only sacrosanct tradition is "first do no harm". Perhaps psychoanalytic ideas are useful. Some study should be run to determine whether psychiatrists receiving analytic training are more effective clinicians. Until then I have no reason to think so and will avoid any residency program where undue time is devoted to psychoanalysis at the expense of real science. Furthermore, psychotherapy is a treatment just like medication. We should not assume that it is at it's worst ineffective-- it can do harm. An example is debriefing of victims of traumatic experience which is shown to increase the rates of PTSD.

The textbook that was recommended to me for my core psychiatry rotation was Cutler and Marcus's Psychiatry. The authors spend about 3 times as much ink on psychoanalytic theory as opposed to other psychopathologic explanations. Worse, they use psychoanalytic jargon in general sections as if this were not just one school of thought, but the definintive way to practice. Fortunately, my preexisting interest in psychiatry pushed me to look past these flaws. Many of my classmates, however, undoubtedly dismissed the entire specialty of psychiatry as a load of bull based on this limited exposure. I think this cuts to the core of the original poster's concern. There is so much good we can do and so much we can explain, all in language understandable to our medical colleagues and to lay people. Why shroud ourself in obscure, vocabulary and untested practices just because others have done so for the past 80 years?
 

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I think the appropriate term here is that there is more than one way to skin a cat. I think that all of us are in it to do a good job and provide the best patient care possible. We all differ in what we believe, from psychopharm issues to psychotherapy to faith based medicine-there are camps out there who support EVERYTHING and anything. Just do your thing. I am betting that there are plenty of folks to fall on each side of the psychanalysis debate--psychanalysis is here, and serves many purposes for many people. I think you are well within your right to not practice it, and it is good that you are looking at other types of training programs. To each his own. Just keep in mind that however you feel, it is likely that someone with a lot more training than you who feels otherwise, and you are going to have to hear about psychanalysis and its terms no matter how biological your practice is......do some studies of your own if you feel there is a need for it out there. Please remember that demeaning a whole field without a lot of education about it is not really that weighty in an intellectual debate.
I have no plans to be an analyst, but found the insight of long term analysts to be impressive-at least on the interview trail--they were the best interviewers IMHO. I think there is a lot you can take from their techniques, even if it is a matter of doing a good interview, and asking the right questions. (This is not a debate I care to start by the way, just thought I'd share--I am not invested in analysis enough to make further observations even)
 

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tangents said:
I think the appropriate term here is that there is more than one way to skin a cat. I think that all of us are in it to do a good job and provide the best patient care possible. We all differ in what we believe, from psychopharm issues to psychotherapy to faith based medicine-there are camps out there who support EVERYTHING and anything. Just do your thing. I am betting that there are plenty of folks to fall on each side of the psychanalysis debate--psychanalysis is here, and serves many purposes for many people. I think you are well within your right to not practice it, and it is good that you are looking at other types of training programs. To each his own. Just keep in mind that however you feel, it is likely that someone with a lot more training than you who feels otherwise, and you are going to have to hear about psychanalysis and its terms no matter how biological your practice is......do some studies of your own if you feel there is a need for it out there. Please remember that demeaning a whole field without a lot of education about it is not really that weighty in an intellectual debate.
I have no plans to be an analyst, but found the insight of long term analysts to be impressive-at least on the interview trail--they were the best interviewers IMHO. I think there is a lot you can take from their techniques, even if it is a matter of doing a good interview, and asking the right questions. (This is not a debate I care to start by the way, just thought I'd share--I am not invested in analysis enough to make further observations even)
I don't think "just do your thing" is good advice, nor encouragement for those having doubts about the seriousness of the profession. Do what works, what has been proven to work, what you are quite sure won't hurt.

You also wrongly assume that by criticising psychoanalysis, I'm taking a purely biological/psychopharm stance. Far from it. If you had read my post carefully, you would have seen that I think therapy should be taken just as seriously as medication and that I do not understand why psychoanalysis is emphasized at the expense of other psychotherapies [whereas in psychology PhD programs, I think the problem is an overemphasis on CBT and the theoretical primacy of cognitions, though this is somewhat more justified and it roils me that psychologist are by and large more empirically inclined than MD psychiatrists].

I do not think that I am "demeaning a whole field without a lot of education about it". I'm clear about the limited extent of my exposure to psychiatry. I am a student, I'm starting to explore options for residency and have trouble understanding the prevalence of psychoanalytic thought and the amount of devoted training time in prestigious institutions such as Columbia and UCSF. Whenever I have confronted anyone in the field about it, they have either shared my frustration or defended psychoanalysis with vague anecdotes (such as your experience with interviewers) or arguments of authority (such as your "there is likely that someone with a lot more training than you who feels otherwise"), but no one has given me a satisactory evidence supported defense of the current academic state of affairs. In no other field of medicine (or even psychology!) would that be acceptable.
 

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Just jumping into the discussion here....

As a clinical psychologist, I am a bit baffled by the emphasis placed on psychodynamic/psychanalytic schools of thought within psychiatry. I am currently on internship at a major academic medical school, and have become friendly with several of the residents here. They get 3 long years of psychodynamic theory and supervision, and only 1/2 year of didactics and 1 year of supervision in CBT. On the other hand, the psychology interns come in with several years of didactics, training, and supervision in CBT and (to varying extents) other "empirically-supported treatments" such as IPT, DBT, BCT, etc. Moreover, the internship and post-doc programs strongly emphasize this EST approach. Putting differences in training aside (obviously psychiatry has to address biomedical issues that we don't spend time on) I just don't get the theoretical discrepancy between the two disciplines - esp. when the training programs are housed within the same institution.

There is an enormous body of literature supporting the use of CBT, either alone or in combination with pharmacoptheray, in the reduction of symptoms for several disorders. Moreover, there is some evidence to suggest that CBT may even outperform meds in the treatment of certain disorders (e.g., panic) and that relapse rates are often lower in CBT arms of intervention studies. Finally, there is an interesting body of research emerging that demonstrates similar changes in functional brain imaging from pre- to post-Tx for patients in pharmacotherapy and CBT (without meds) for disorders such as major depression and OCD. [ETA: Perhaps we're "invested" in it because the literature supports its use - but that is not to say that psychology has abandoned treatment development research due to reification of CBT. In fact, new treatments are being developed for empirical scrutiny all the time - just do a search on NIH CRISP and you'll see]

But I do honestly think that if training programs in psychiatry provided a stronger emphasis on CBT, that it would serve your field well. I consistently get referrals from people specifically seeking out CBT, and noting that they had difficulty finding someone in the community who specializes in this treatment. So there is clearly a demand - to combine CBT with pharmacotherapy would allow psychiatrists to be in a very competitive position.

And contrary to popular opinion (at least among my psychiatry resident friends), CBT is not "boring." :D
 

nortomaso

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LM02 said:
Just jumping into the discussion here....

As a clinical psychologist, I am a bit baffled by the emphasis placed on psychodynamic/psychanalytic schools of thought within psychiatry. I am currently on internship at a major academic medical school, and have become friendly with several of the residents here. They get 3 long years of psychodynamic theory and supervision, and only 1/2 year of didactics and 1 year of supervision in CBT. On the other hand, the psychology interns come in with several years of didactics, training, and supervision in CBT and (to varying extents) other "empirically-supported treatments" such as IPT, DBT, BCT, etc. Moreover, the internship and post-doc programs strongly emphasize this EST approach. Putting differences in training aside (obviously psychiatry has to address biomedical issues that we don't spend time on) I just don't get the theoretical discrepancy between the two disciplines - esp. when the training programs are housed within the same institution.

There is an enormous body of literature supporting the use of CBT, either alone or in combination with pharmacoptheray, in the reduction of symptoms for several disorders. Moreover, there is some evidence to suggest that CBT may even outperform meds in the treatment of certain disorders (e.g., panic) and that relapse rates are often lower in CBT arms of intervention studies. Finally, there is an interesting body of research emerging that demonstrates similar changes in functional brain imaging from pre- to post-Tx for patients in pharmacotherapy and CBT (without meds) for disorders such as major depression and OCD. [ETA: Perhaps we're "invested" in it because the literature supports its use - but that is not to say that psychology has abandoned treatment development research due to reification of CBT. In fact, new treatments are being developed for empirical scrutiny all the time - just do a search on NIH CRISP and you'll see]

But I do honestly think that if training programs in psychiatry provided a stronger emphasis on CBT, that it would serve your field well. I consistently get referrals from people specifically seeking out CBT, and noting that they had difficulty finding someone in the community who specializes in this treatment. So there is clearly a demand - to combine CBT with pharmacotherapy would allow psychiatrists to be in a very competitive position.

And contrary to popular opinion (at least among my psychiatry resident friends), CBT is not "boring." :D
Thanks for your intervention, LMO2. "Baffle" is the word that also always comes to my mind when I consider this. I don't understand why the MD culture is so far behind the clinical Phd culture here (kind of like comparing the economies of Uganda and Japan). Hopefully the two will converge over the next several years.
 

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Paendrag said:
Yup. I'm also a clinical psychologist and have noticed a similar trend in my dealing with psychiatrists. At the academic medical center I did my internship at, the psychiatry rounds were hilarious with all the analytic mumbo jumbo flying around. What I found most amazing is how much time was spent discussing the psychiatrists' feelings about their patients. Under the rubric of analytic theory it makes sense, but. . . wow.
Before we all jump on the “death to psychodynamics” bandwagon lets get a little historical perspective.

First of all, the body of research supporting psychodynamic and psychoanalytic approaches to therapy is substantially larger than that supporting CBT. True, there are issues (some irresolvable) involving studying a dynamic therapy rather than a prescriptive therapy, but the fact remains that psychoanalytic and psychodynamic approaches have withstood the intense and often critically biased attention of science for over a hundred years. To suggest that these treatments have “no” support depends upon a fairly narrow view of the literature.

Second, recent literature does provide quite a bit of support for the effectiveness of psychodynamic approaches to therapy. The meta-analysis found in the December (I think) issue of the Archives of General Psychiatry is an example of such support. Early comparative studies that did find significant differences favoring CBT were flawed largely because they were conducted by proponents of CBT. The psychodynamic comparison groups in these studies were little more than straw men.

Third, so-called “empirically-supported therapies” suffer from their own empirical shortcomings. Don’t agree? Then demonstrate the existence of an cognitive-emotional schema and prove the role its activation serves in psychopathology.

Finally, many of the ESTs draw upon (or are reformulations of) psychodynamic therapies. A personal favorite of mine is IPT. IPT was originally designed as a manualization of an object relations/interpersonal approach to psychotherapy. After a manual was created and preliminary results indicated that it was superior to CBT in the treatment of depression, CBT theorists decided that IPT wasn’t actually a psychodynamic treatment at all. In fact, since the approach worked they decided that IPT must actually be CBT in disguise! How Orwellian.

This is not to say that there is anything wrong with CBT. I like CBT and use it when my client seems likely to benefit from the approach. But I also use psychodynamic approaches and feel quite comfortable that the research supports this choice as well.

Sorry for the long post
 

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You have some good points! I always felt that therapies fit the doctor using them in some synergistic way. I like CBT because I work with kids mainly in medical settings where quick results are needed, but also because I am a pragmatic, slightly methodical type person who gets real squirmy with big picture concepts and conceptualization of a person's whole psyche. I would be a bad psychodynamic therapist. See my point?

:cool:
 

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I agreee... you have some good points! I'll try to respond, in turn.

psychgeek said:
Before we all jump on the “death to psychodynamics” bandwagon lets get a little historical perspective.

First of all, the body of research supporting psychodynamic and psychoanalytic approaches to therapy is substantially larger than that supporting CBT. True, there are issues (some irresolvable) involving studying a dynamic therapy rather than a prescriptive therapy, but the fact remains that psychoanalytic and psychodynamic approaches have withstood the intense and often critically biased attention of science for over a hundred years. To suggest that these treatments have “no” support depends upon a fairly narrow view of the literature.
I’m not certain if you are referencing my post directly, but at no point have I suggested that there is “no support” for psychodynamic therapy. However, as you reference above, there are serious issues in the empirical study of these therapies (there are often built-in tautologies) and very little standardization across studies for purposes of meaningful comparison.

Moreover, it’s hard to say that the literature “supporting” these therapies outweighs the literature supporting CBT. I’ll be the first to agree that there is a larger literature on psychodynamic therapy, but quantity is not always quality - historically many of these studies (not all) utilize non-randomized treatment designs, lack adequate comparison groups, etc.

Second, recent literature does provide quite a bit of support for the effectiveness of psychodynamic approaches to therapy. The meta-analysis found in the December (I think) issue of the Archives of General Psychiatry is an example of such support. Early comparative studies that did find significant differences favoring CBT were flawed largely because they were conducted by proponents of CBT. The psychodynamic comparison groups in these studies were little more than straw men.
It is noteworthy that the meta-analysis in the December Archives covers the years spanning 1970-2004, yet the authors were only able to include 17 studies in their analysis. Only 17 studies in 34 years? Yes, they used rather strict criteria for inclusion, but those criteria are considered the “Gold Standard” of psychotherapy research and are routinely utilized in CBT research. I think the paper provides some preliminary and intriguing evidence, but I think we need to see more of this.

Third, so-called “empirically-supported therapies” suffer from their own empirical shortcomings. Don’t agree? Then demonstrate the existence of an cognitive-emotional schema and prove the role its activation serves in psychopathology.
I initially put that expression in quotes for a reason – you are absolutely correct to say that the studies examining the ESTs suffer from methodological shortcomings. In fact, that is why they are called “empirically-supported” and not “empirically-validated.” Nonetheless, there is research demonstrating that dysfunctional attitudes and cognitions (measured by interview, self-report and by using information processing paradigms) do change post-Tx and do predict long-term outcome. I don’t think that “proves the existence” of a cognitive schema, but it certainly provides some support for the underlying theoretical foundation.

Finally, many of the ESTs draw upon (or are reformulations of) psychodynamic therapies. A personal favorite of mine is IPT. IPT was originally designed as a manualization of an object relations/interpersonal approach to psychotherapy. After a manual was created and preliminary results indicated that it was superior to CBT in the treatment of depression, CBT theorists decided that IPT wasn’t actually a psychodynamic treatment at all. In fact, since the approach worked they decided that IPT must actually be CBT in disguise! How Orwellian.
I’m in full agreement – up to a point. I believe that we have benefited from the early conceptualizations of psychotherapy and can use some of these ideas in our current practice. We work in an evolving field, so of course ideas build on themselves. I have, in fact, been trained in IPT (and IPSRT) and am aware of its early connections to object relations. But the treatment, as it is currently manualized, looks quite different from object relations therapy. Where I disagree with you is your interpretation of how CBT folks responded to the TDCRP – being that my clinical specialty is in depression research and treatment (and I have worked with some big names), I don’t think that anyone would ever claim that IPT is another form of CBT. In fact, as IPT is manualized, you are strictly directed to NOT address cognitions in any way. I think that most CBT-oriented psychologists have a lot of respect for IPT as its own treatment.

This is not to say that there is anything wrong with CBT. I like CBT and use it when my client seems likely to benefit from the approach. But I also use psychodynamic approaches and feel quite comfortable that the research supports this choice as well.
To sum up, when it comes to psychotherapy, my attitude is: “show me the money.” First and foremost, I describe my theoretical orientation to be that of “empiricist.” If I can empirically justify using a particular therapy with a particular patient, then I feel that I am doing my job. As it stands now, psychodynamic therapy is working to catch up with the rest of the field – and perhaps it will. In the meantime, given my empirical leanings, I plan to follow the research.

Given that there is some general support for psychodynamic approaches, I wouldn’t suggest that they be tossed out of practice nor out of psychiatry training programs. However, where I continue to remain stumped is on the issue of the relative imbalance these approaches receive within psychiatry training programs. CBT at least deserves as much attention as psychodynamics – a 1/2 year training course does not cut it.


Sorry for the (equally) long post. :)
 

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LM02 said:
I agreee... you have some good points! I'll try to respond, in turn.



I’m not certain if you are referencing my post directly, but at no point have I suggested that there is “no support” for psychodynamic therapy. However, as you reference above, there are serious issues in the empirical study of these therapies (there are often built-in tautologies) and very little standardization across studies for purposes of meaningful comparison.

Moreover, it’s hard to say that the literature “supporting” these therapies outweighs the literature supporting CBT. I’ll be the first to agree that there is a larger literature on psychodynamic therapy, but quantity is not always quality - historically many of these studies (not all) utilize non-randomized treatment designs, lack adequate comparison groups, etc.



It is noteworthy that the meta-analysis in the December Archives covers the years spanning 1970-2004, yet the authors were only able to include 17 studies in their analysis. Only 17 studies in 34 years? Yes, they used rather strict criteria for inclusion, but those criteria are considered the “Gold Standard” of psychotherapy research and are routinely utilized in CBT research. I think the paper provides some preliminary and intriguing evidence, but I think we need to see more of this.



I initially put that expression in quotes for a reason – you are absolutely correct to say that the studies examining the ESTs suffer from methodological shortcomings. In fact, that is why they are called “empirically-supported” and not “empirically-validated.” Nonetheless, there is research demonstrating that dysfunctional attitudes and cognitions (measured by interview, self-report and by using information processing paradigms) do change post-Tx and do predict long-term outcome. I don’t think that “proves the existence” of a cognitive schema, but it certainly provides some support for the underlying theoretical foundation.



I’m in full agreement – up to a point. I believe that we have benefited from the early conceptualizations of psychotherapy and can use some of these ideas in our current practice. We work in an evolving field, so of course ideas build on themselves. I have, in fact, been trained in IPT (and IPSRT) and am aware of its early connections to object relations. But the treatment, as it is currently manualized, looks quite different from object relations therapy. Where I disagree with you is your interpretation of how CBT folks responded to the TDCRP – being that my clinical specialty is in depression research and treatment (and I have worked with some big names), I don’t think that anyone would ever claim that IPT is another form of CBT. In fact, as IPT is manualized, you are strictly directed to NOT address cognitions in any way. I think that most CBT-oriented psychologists have a lot of respect for IPT as its own treatment.



To sum up, when it comes to psychotherapy, my attitude is: “show me the money.” First and foremost, I describe my theoretical orientation to be that of “empiricist.” If I can empirically justify using a particular therapy with a particular patient, then I feel that I am doing my job. As it stands now, psychodynamic therapy is working to catch up with the rest of the field – and perhaps it will. In the meantime, given my empirical leanings, I plan to follow the research.

Given that there is some general support for psychodynamic approaches, I wouldn’t suggest that they be tossed out of practice nor out of psychiatry training programs. However, where I continue to remain stumped is on the issue of the relative imbalance these approaches receive within psychiatry training programs. CBT at least deserves as much attention as psychodynamics – a 1/2 year training course does not cut it.


Sorry for the (equally) long post. :)

Screw it. I didn’t want to work on my dissertation today anyway :)

I don’t mean to suggest that CBT suffers from any paucity of support. I am merely trying to point out that psychodynamic therapies have persisted in what has been a hostile research environment for quite some time. At no point has any competing theory been able to demonstrate a stable, clinically significant superiority relative to psychodynamic treatment. Perhaps this will change; until it does we might want to avoid hasty conclusions based upon research that remains in its infant stages. (After all, according to the 1950s empiricists we were all going to be practicing pure behaviorism by now.)

It is true that there is not as much current research devoted to psychodynamic treatments and thus the clinical research that supports PD treatments seems somewhat unsophisticated by current standards. Current CBT research will seem hopelessly naïve in 50 years too. Unfortunately the best minds in psychodynamic theory have traditionally been uninterested in clinical research regarding basic outcomes and processes. Fortunately, I think this traditional stance will change.

I think your answer to the cognitive schema question demonstrates my basic point. Nobody can prove the existence of schemas. You can only demonstrate that observed outcomes match predicted outcomes according to the model. This is the same sort of proof that can be generated for psychodynamic models. For both, ultimately, the only “empirical“ proof available for the core theoretical models is that they predict. (I actually work with a pretty big-name CBT theorist now and it drives him crazy when I make this argument.)

I know most reasonable IPT practitioners recognize that the approach is not actually CBT, but this is not necessarily the case for CBT researchers. I took this argument from another (very poorly done) review published in Psych Science in the Public Interest in 2002. I would actually disagree that IPT looks terrifically different from object relations therapy as it is currently practiced. It is time-limited but so is OR in our current managed-care climate. There is perhaps more latitude given to OR practitioners in the structuring of their intervention and the degree to which they wish to involve developmental issues. IPT seems to give a little more latitude regarding how active the clinician may be in session. Other than these differences the practice of the two seems pretty similar.

I completely agree that psychiatrists should be exposed to more than just psychodynamic theory in the course of their training. This seems to be a general problem with psychology/psychiatry. People end up pigeon-holed in one discipline or orientation which leads them to discount the value of other perspectives.

Sorry. This will be my last thread hijacking post. I promise :D
 

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Unfortunately the best minds in psychodynamic theory have traditionally been uninterested in clinical research regarding basic outcomes and processes.
I tend to think that it's also a matter of the research funding process/system.
 

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Personally, I think it's okay to manage some medical issues up to a point. However, who is better at optimally managing Diabetes? An internist or Psychiatrist? So, I think it's our job to make sure the patient is stable and not going into DKA, untill Medicine can give their input. It's not like Surgery, OB/GYN, Ortho, etc never consult for simple Diabetes management, right? I think it's in the best interest of the patients to have Medicine on board in management. I know in my internship so far, if there is a medicine patient that has ANY remote Psychiatric component they will consult Psych. Can you imagine seeing medicine prescribing antipsychotics or Lithium, etc? Yeah, they can write scripts for some SSRI's, but it's pretty difficult to kill somebody with those. Regardless, in my experience Medicine doesn't feel comfortable dealing with even minor Psych issues and it's probably better for the patients that their Psych issues are optimally managed by a Psychiatrist. So, IMHO, I think it's best for our patients for us to take a big gulp and swallow our pride and do what is best for patient management. That doesn't mean we give up medicine all together, but I still think most medical issues should be managed by those who optimally manage those problems. Liability is another issue if you get sued you're screwed for practicing outside your scope of practice. Even a simple ACE could get you in hot water. e.g. A inpatient attending psychiatrist I'm working with right now is getting sued for prescribing Lisinopril and the patient had an allergic reaction to the drug. That could happen to an internist, but the defense will be much more difficult since she's a Psychiatrist and technically is practicing outside the scope of her specialty. Sad, but true.
 

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One must keep in mind that depending on your eventual practice goals, only some or even none of your patients will be difficult-to-treat psychiatric inpatients. The truth is that some patients are LOOKING for a more analytical, theoretical approach to their problems, relationship patters, destructive habits, and the like.

To dismiss psychodynamics outright is to neglect a mode of thinking that can help you approach a patient, understand their background and make predictions about their future behaviors, IF you're analytically minded and have good abstraction and extrapolation capabilities.

I consider myself very heavily biologically oriented, but am cognisant of psychodynamic constructs when they present themselves.

Most of Freud's critics haven't read Freud. While much of the theory seems nonsensical or irrelevant, having some of the knowledge in the background helps you create a more complete picture of patients in a variety of ways.

Keep science at the forefront of your practice, and certainly in your documentation. But, try not to dismiss entirely, psychodynamic understandings of your patients. Not all that is helpful or interesting is replicable in double blind placebo-controlled studies. Much is the case with theoretical physics. To me, it's simply a mode of thought, of thinking - about your patients, about yourself and can even help both.
 

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docpsych said:
The Er Doc Was Surprised I Was Confident Enough To Order It Without Consulting Him, And It Being The Appropriate Course Of Action. He Actually Said To Me, "looks Like Your On The Ball, Why Are You Doing Psychiatry".
Did you ask him what he meant by this statement? :D
 

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docpsych said:
not to do a PE, i think that is crazy. say your on the wards, and somebody complains of abdo pain. are you going to consult with only a chief complaint of abdo pain. this is why psych will not be respected. do a PE, and present the case like a MD should.
ex cc: abdo pain
hpi XXXX
PE: abdo soft or rigid, tenderness location? scars? bowel sounds?, etc.
Present a case like this, somwhat of a crude example, other med specialities will take you seriously.

i appreciate all the replies and would like to point out a comment which other attendings have told me as well. sometimes psychiatrists are the only docs pts go to. so it is in the best interests of your pt to be able to manage basic medical problems--otitis, uri, uti and have them follow-up if needed with internist. we do 4-8 months of medicine for a reason.

maybe i'm wrong in saying this. i am only a pgy-1, maybe not realistic practicing basic internal med with the potential litigation that may arise. seems we are taught to practice preventive medicine, instead its defensive medicine.

I agree with you totally, if I were a physician and had someone call and say 'I've got a patient with abdo pain' and they hadn't done even the briefest exam or history you'd be royal peeved. At the same time how many times have you had they 'this patient needs a psych consult' telephoen call but when you ask them what they want to know, why they think the patient needs you or what question they wanted answered they jsut look at you with this the patient is crazy and you need to fix them look. (and often the 'crazy' is just PD and whata re you going to do anyway...)
 

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psychgeek said:
psychodynamic therapies have persisted in what has been a hostile research environment for quite some time. At no point has any competing theory been able to demonstrate a stable, clinically significant superiority relative to psychodynamic treatment. Perhaps this will change; until it does we might want to avoid hasty conclusions based upon research that remains in its infant stages. (After all, according to the 1950s empiricists we were all going to be practicing pure behaviorism by now.)
A few things. One, the fact that something has persisted in the face of research doesn't prove anything at all. We have tons of people running around saying that vaccines cause autism, when many studies have shown there is no link.

Two, just because other theories have flaws, this does not make them inherently worse or better than any given theory.

Third, I'm mostly behavioristic. I would say that if someone practiced with my population and he or she was NOT largely behavioristic, they would be bordering on malpractice; that's what my population responds to (severe developmental disabilities). I know many behaviorists who plot behaviors on a graph, and intervene as such.

Fourth, I train psychology students and we do developmental screening. I want to strangle them when they yap on about 'good breast bad breast' crapola. I wish they wouldn't teach this anymore, since research has demonstrated that babies are interested in the external world, are capable of having relationships, etc.

I think we could do a lot better if we publicly stated that we are jumping on the evidence-based practice bandwagon. I'm not saying we shouldn't continue to research psychodynamic theory. I'm self-psych oriented at times. But I also practice parsimony, and if I have to wrap myself around an axel to make the relational aspect of psychopathology sound plausible, then it's most likely not the right answer. ;)