Psych a stable specialty?

[scubadoc78]

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Hi guys, first time poster/long-time benefactor of SDN. Looking to choose a specialty and found psych to be by far the most fascinating and rewarding rotation I did this year and would love to pursue this as a career. However, I have "cold feet" for a few reasons which, in sum, make me wonder why this specialty could not be performed by non-physicians.

1. In my region (midwest) psych is GROSSLY underrepresented. In my state, they are so desperate for psych docs they're actually flying residents to areas of the state to moonlight for enormous amounts of money. Historically, I understand this has been THE argument for non-MDs being given the authority to diagnose/treat as MDs (see NPs/PAs/medical psychologists).

2. The psychiatrists I worked with had almost entirely lost their medical diagnostic skills. Basic skills like performing physical exams or interpreting labs (not just listening to heart/lungs or reading a creatinine level). These are skills I see as distinguishing a physician and non-physician and frankly support opinion from non-opinion (we order labs to defend our hypothesis of disease, right?). I know many PAs/NPs who, regrettably, I would consider more competent in these areas than many psychiatrists I've met. A psychiatrist I worked with seeing a newly referred patient (teenage girl for dizzy spells) actually didn't think to ask about recent trauma until I raised the question and then I had to explain to her (the psychiatrist!) about vertebrobasilar insufficiency which the girl turned out to have when she was referred to peds at my urging! I will admit that episode REALLY discouraged me about psych.

3. Again on my rotation, a psychiatrist I worked with said the specialty is particularly open to diagnostic disagreement (psychologists routinely disagreed with the psychiatrists diagnosis) because the diagnoses are
"soft" relative to other fields. Psychologists at the VA I work at routinely disagree with psychiatrists based on their testing and subsequently question the drugs being used.

4. It seems to me (again, just my opinion) that the only legitimate claim psychiatrists have is that they're experts at using psych meds. However, is this really so large a skill that it can't be learned by a non-physician? Again, it doesn't seem to require PE skills, keen lab skills or hard diagnostic abilities which others can't learn. There are many FPs in my area who practice child psych simply because they read up on the psych meds and still have the PE/Labs skills to go with it.

So, 1. enormous pressure need (and a public outcry for solutions!) + 2. seemingly less medical skills required + 3. 'soft' diagnoses = a future of non-MDs diagnosing/treating mentally ill patients? Don't get me wrong, I REALLY do want to believe psychiatry is a healthy field and I understand every specialty to some extent is going through similar defense of territory. I just feel that so much about psych is uniquely "less physician" than any other field and many streamlined, non-MD fields are quite good at "cutting to the chase" in their training these days.

Please tell me I'm wrong!!! Thanks for your time and wisdom...

 

[kugel]

1. In my region (midwest) psych is GROSSLY underrepresented. I understand this has been THE argument for non-MDs being given the authority to (prescribe).

2. The psychiatrists I worked with had almost entirely lost their medical diagnostic skills.

3. Again on my rotation, a psychiatrist I worked with said the specialty is particularly open to diagnostic disagreement

4. It seems to me (again, just my opinion) that the only legitimate claim psychiatrists have is that they're experts at using psych meds.

1. That was the primary argument in New Mexico and Louisiana. I don't know, but I'm guessing that the vast majority of psychologists seeking prescribing rights practice in large urban areas, not in the rural hinterland where access to psychiatrists is worst. No psychologist in any of the public health arenas where I've worked is hoping to have the extra work and responsibility of prescribing.

2. As specialists age it is common for them to lose touch with some parts of medicine that they don't often use. That's not an excuse, just a fact. Many long-practicing FPs I know don't really know anything about newer psych meds nor much about newer ortho techniques. It's also true (unfortunate but true) that many docs who couldn't get matched in other residencies ended up in psych.

3. Since we work in a field that is still in the "syndromic diagnostic" stage of development, there is plenty of room for disagreement. That doesn't make it better or worse, it just is. I'm actually quite happy to work a field that is not rife with cookie-cutter treatment standards. And I've known plenty of specialists in other fields who disagree with each other very regularly. In my own health problems last year, the surgeon disagreed with the pulmonologist who disagreed with the cardiologist who disagreed with the nephrologist who disagreed with the infectious disease specialist - and the poor internist had to put up with all of them and me

4. psych meds are NOT all that difficult to learn (though I still see a lot of misuse), but that's not the only reason for psychiatrists. Every day, I make decisions about how to use psych meds on particular patients based on all I know about other fields of medicine, interaction with non-psych meds, exactly how much drug/alcohol withdrawal illness I can safely treat in a stand-alone psych facility (vs being sent to the ED), which psych and non-psych meds I can eliminate or temporarily hold in order to better understand what's really going on here, and what symptoms/history should prompt me to be searching for a non-psychiatric cause.

I don't see my job going away anytime soon. And there's no psychologist clamoring to do it.

Plenty of room for you if you're interested.

 

[BobA]

All specialists lose general medical knowledge.

That said, some psychiatrists will be better than others. I just finished interviewing, and saw that there was a wide variety in the amount of "medicine" that psych docs were exposed to. At places like Johns Hopkins, Michigan, Harvard-Longwood, Duke, and I'm sure many many others residents do some serious medicine. If that's important to you, you'll be able to find it.

 

[Anasazi23]

I think a bad example of a medical specialty will make the specialty look bad no matter what. You'll find similar experiences in family practice, IM, and other subspecialties, (rheumatology, etc).

Learning the basics of psychiatric meds is easy. Getting good at it is hard, and cannot be learned to the same degree or manner in PA, NP, or certainly prescribing school.

Seek out more experiences in psychiatry - preferably something more academic, and not overrun horribly by lack of docs, which often force them to focus on volume, and not quality.

 

[scubadoc78]

Thanks for the respones. I'm 70/30 psych over family med. I'm probably overthinking it but I'm just concerned that after all this education/training/loans I'll get into practice in a few years and legislation will suddenly open up the field to non-physicians because of the desparate need. I'd love to be 100% altruistic and not worry about income potential, but I've got a baby girl and wife who've have largely put their lives on hold for me to get through school/residence!

 

[OldPsychDoc]

Thanks for the respones. I'm 70/30 psych over family med. I'm probably overthinking it but I'm just concerned that after all this education/training/loans I'll get into practice in a few years and legislation will suddenly open up the field to non-physicians because of the desparate need. I'd love to be 100% altruistic and not worry about income potential, but I've got a baby girl and wife who've have largely put their lives on hold for me to get through school/residence!

Family med is equally, if not more, vulnerable with continued expansion of NP and PA roles in providing primary care. I wouldn't worry about psychologist prescribing cutting our income significantly, at least not as a factor isolated from other larger scale changes in health care funding.

 

[medium rare]

As both a clinical psychologist and psych NP, I comment from a non-physician perspective. I don't see psychiatry going anywhere and believe that reports of "the death of psychiatry" are unfounded. Well-trained psychiatrists bring a unique and needed perspective to mental health treatment. Yes, I have seen my share of piss-poor psychiatrists, but I have also worked with several great ones. I have also seen my share of psychologists I wouldn't trust with my dog. Same goes for NPs and any other type of professional.

In my practice, I handle all the cases I am comfortable managing but still refer to psychiatry on a regular basis. It is my opinion that wide-spread psychologist prescribing, as well as a continued proliferation of psych NPs, will occur, but I also believe that this will not supplant the need for good psychiatrists.

 

[scubadoc78]

Thanks Medium, I particularly appreciate your input. I'm sure the largest factor is I'm simply insecure of my role this early in training. I look forward to asking more psych questions...thanks guys!

 

[anesthesiarocks]

Hi guys, first time poster/long-time benefactor of SDN. Looking to choose a specialty and found psych to be by far the most fascinating and rewarding rotation I did this year and would love to pursue this as a career. However, I have "cold feet" for a few reasons which, in sum, make me wonder why this specialty could not be performed by non-physicians.

1. In my region (midwest) psych is GROSSLY underrepresented. In my state, they are so desperate for psych docs they're actually flying residents to areas of the state to moonlight for enormous amounts of money. Historically, I understand this has been THE argument for non-MDs being given the authority to diagnose/treat as MDs (see NPs/PAs/medical psychologists).

2. The psychiatrists I worked with had almost entirely lost their medical diagnostic skills. Basic skills like performing physical exams or interpreting labs (not just listening to heart/lungs or reading a creatinine level). These are skills I see as distinguishing a physician and non-physician and frankly support opinion from non-opinion (we order labs to defend our hypothesis of disease, right?). I know many PAs/NPs who, regrettably, I would consider more competent in these areas than many psychiatrists I've met. A psychiatrist I worked with seeing a newly referred patient (teenage girl for dizzy spells) actually didn't think to ask about recent trauma until I raised the question and then I had to explain to her (the psychiatrist!) about vertebrobasilar insufficiency which the girl turned out to have when she was referred to peds at my urging! I will admit that episode REALLY discouraged me about psych.

3. Again on my rotation, a psychiatrist I worked with said the specialty is particularly open to diagnostic disagreement (psychologists routinely disagreed with the psychiatrists diagnosis) because the diagnoses are
"soft" relative to other fields. Psychologists at the VA I work at routinely disagree with psychiatrists based on their testing and subsequently question the drugs being used.

4. It seems to me (again, just my opinion) that the only legitimate claim psychiatrists have is that they're experts at using psych meds. However, is this really so large a skill that it can't be learned by a non-physician? Again, it doesn't seem to require PE skills, keen lab skills or hard diagnostic abilities which others can't learn. There are many FPs in my area who practice child psych simply because they read up on the psych meds and still have the PE/Labs skills to go with it.

So, 1. enormous pressure need (and a public outcry for solutions!) + 2. seemingly less medical skills required + 3. 'soft' diagnoses = a future of non-MDs diagnosing/treating mentally ill patients? Don't get me wrong, I REALLY do want to believe psychiatry is a healthy field and I understand every specialty to some extent is going through similar defense of territory. I just feel that so much about psych is uniquely "less physician" than any other field and many streamlined, non-MD fields are quite good at "cutting to the chase" in their training these days.

Please tell me I'm wrong!!! Thanks for your time and wisdom...

An NP or PA who has worked a long time in medicine(especially if they do some inpt work) will know 20x what a psychiatrist will about renal failure, heart disease, and other "mediciny" stuff. The idea that you are surprised by this is a little odd...what did you expect? I tell everyone this- if you want to deal with things like "vertebrebasilar insufficiency" and whatnot, psych is NOT the field for you. Pick something else.

The people you will see in your practice as a psychiatrist will be schizophrenics, schizoaffectives, bipolar pts, mdd and panic d/o patients....thats your bread and butter. If you want to treat someones syncope(outside from making sure a drug you rx'ed doesnt cause it), you best be going into some other field.

 

[anesthesiarocks]

I think a bad example of a medical specialty will make the specialty look bad no matter what. You'll find similar experiences in family practice, IM, and other subspecialties, (rheumatology, etc).
.

I don't know of any attending internists(or subspecialties of medicine) who dont know how to properly analyze(and initiate management) after being given the abg of a typical copder having an attack.

Some of the best psychiatrists I've known couldn't. Wouldnt even know where to start. Why? Because they dont have to.

 

[BobA]

I don't know of any attending internists(or subspecialties of medicine) who dont know how to properly analyze(and initiate management) after being given the abg of a typical copder having an attack.

Some of the best psychiatrists I've known couldn't. Wouldnt even know where to start. Why? Because they dont have to.

There is no way that your average Opthalmologist, Dermatologist, or Radiologist would know where to start with a COPDer's abg.

 

[pingumd]

Well one thing to consider is that the psych meds often have pretty serious side effects and that even well trained internists are hesitant to deal with some of the drug interactions.

Especially now in with the aging population where people are routinely on 10-15 drugs the potential for interactions is huge. Delirium, falls from altered mental status, renal damage, liver damage, metabolic syndrome, and the list goes on and on.

One of the psychopharm gurus at our academic hospital just shakes his head when he sees the combination of drugs people are routinely maintained on. Needless broken bones, years feeling "out of it", alleged dementia that was just a drug side effect, syncope from hypotension due to adrenergic interactions are just a few of the more common scenarios. I have heard more than one patient say something akin to "this is the first time I have felt okay in years".

So I think it might be easy to do a subpar job in psych but to really be a healer in psych you do have to really know what you are doing and you have to know medicine.

 

[scubadoc78]

An NP or PA who has worked a long time in medicine(especially if they do some inpt work) will know 20x what a psychiatrist will about renal failure, heart disease, and other "mediciny" stuff. The idea that you are surprised by this is a little odd...what did you expect? I tell everyone this- if you want to deal with things like "vertebrebasilar insufficiency" and whatnot, psych is NOT the field for you. Pick something else.

*****Really? Is hoping an attending psychiatrist can rule out (read: rule out, not treat) serious conditions, particularly textbook cases involving circulation to the brain, so 'odd'?

The people you will see in your practice as a psychiatrist will be schizophrenics, schizoaffectives, bipolar pts, mdd and panic d/o patients....thats your bread and butter.

*****Isn't part of a specialty recognizing symptoms that aren't within your scope of practice? Not zebras, but maybe a horse or two.

If you want to treat someones syncope(outside from making sure a drug you rx'ed doesnt cause it), you best be going into some other field.

*****Again, I'm looking for a rule out, not treatment. Incidentally, I don't think having an interest in general medicine precludes you from going into ANY specialty, I think it makes you better at what you do...

 

[Faebinder]

Lack of good internal medicine skills is dangerous for a psychiatrists. The older psychiatrists know this and try to stick to medications and treatment therapies they are comfortable with. ALL specialists will lose their strength in managing medical conditions because the management has changed drastically and they dont do it often enough or read about it. Hence the specialization.

Still...

If you can't read EKGs, then how will you tell the QTc prolongation from the antipsychotics or when the panic attack is actually a real heart problem and it's time to call medicine?
If you don't know when the thyroid needs addressing then what will you do when Lithium kicks in?
Do you know how to work up delirium and how to reverse it?
When is the psychosis possibly from Hyperparathyroidism/Syphilis or the anxiety from Adrenaloma?

The more you know medicine, the more you are able to tell when someone does not have schizophrenia, bipolar or depression and that is a very critical skill to have cause that is what other medical fields want from you.

 

[OldPsychDoc]

I don't know of any attending internists(or subspecialties of medicine) who dont know how to properly analyze(and initiate management) after being given the abg of a typical copder having an attack.

Some of the best psychiatrists I've known couldn't. Wouldnt even know where to start. Why? Because they dont have to.

There are a lot of pretty damn good internists out there who would be intimidated as hell by florid psychosis or active suicidality, too.

 

[ronin12]

I am quite surprised that based upon one rotation in underserved midwestern rural area you are basing your opinion about a medical speciality. These kind of examples can be found for evey speciality and professions,including np's PA's and psychologists.

In my personal opion in order to be a good psychiatrist first you have to be a good physician . In my practice On several occasions I picked up, alcohol withdrawal lablelled as Bipolar dx by Er physicians and treated by NP's as bipolar dx, Consulted for conversion disorder, turned out to be Delirium/seizures disorder, How to manage COPD pt with anxiety and panic attacks,Pregnant woman with psychiatric illnesses.I can go on and on with examples of daily practice in which I not only manage psych issues but also keep an eye on medical aspects and on occasions referred them back to medicine for unnoticed medical issues.The best asset a psychiatrist or any other physician have is medical school and MD degree. No other profession, Np's, Pa's or psychologists will be able to learn skills, confidence and competence without going through medical school. Patients are eventually referred to Psychiatrist to sort out the mess of polypharmacy and other crude mistakes made by " Mid level providers" ( please take no offence ) but this is the reality which I saw in my residency and continue to experience at my current job and by the way I do not work in academic settings.

Psychiatry is evolving and will continue to evolve into more scientifically spophisticated profession . You can choose to be a Good psychiatrist or not so good one, but personally good old ways and good old days are long gone.if you want to be a good psychiatrist be a good physician first.

lastly money is a non issue I do not forsee any challenge to monitary aspects of psychiatry. I guess Once you are an MD you are a necessity, not a luxury and it is true in all specilities including Psychiatry.

 

[Regnvejr]

Psychiatrists are physicians, not more but certainly not less. The brain and its quirks don't exists absent from the rest of the body, and all physicians are really treating the whole patient, whether they focus on the whole or not.

Doing a full workup of patients and knowing all potential causes of symptoms is necessary. Any physician who completely or deliberately ignore issues outside of their confined field are ineffective.

On the other hand, you do more in your specialty, and the claim leveled here is unrealistic, unfair and extremely one-sided. Go ask your cardiologist to treat your psoriasis and see what response you get.

 

[whopper]

There are a lot of pretty damn good internists out there who would be intimidated as hell by florid psychosis or active suicidality, too.

I refused a surgeon's request to transfer a post surgical patient to the psyche unit. Guy was in 70s & ranting about how he wanted Bush to personally put him in Afghanistan and how he was going to kill the Taliban, and how he was going to start on his war within a few hours. The guy had no history of mental illness, his WBCs were elevated and he had a fever.

I recommended that the infection be treated first since the guy seemed delirious before any consideration was taken to transfer the pt to psyche. The surgeon didn't know what I was talking about and he & the surgical team were claiming to never had heard of such a thing.

The bottom line is every field starts to forget medicine outside their specialty, and IMHO all doctors should keep their primary medical skills honed.

 

[michaelrack]

I don't know of any attending internists(or subspecialties of medicine) who dont know how to properly analyze(and initiate management) after being given the abg of a typical copder having an attack.

.

I know of several who would have trouble doing this. I am an internal medicine subspecialist (board certified in sleep medicine through the American Board of internal medicine); I guess in a pinch I could initiate treatement for a copd attack, though I would be relying on a respiratory therapist to translate my vague orders for albuterol/atrovent nebulizer into a proper dose. I guess I could figure out a steroid dose and could pick out a couple of abx- but my choice of abx would probably be different from the current recs. I am losing my general medical skills very quickly; 10 years from now I probably wouldn't be able to handle a COPD'er.
One thing I could do expertly for a copd'er is initiate and adjust BiPaP therapy for those who needed noninvasive ventilation.

 

[OldPsychDoc]

I refused a surgeon's request to transfer a post surgical patient to the psyche unit. Guy was in 70s & ranting about how he wanted Bush to personally put him in Afghanistan and how he was going to kill the Taliban, and how he was going to start on his war within a few hours. The guy had no history of mental illness, his WBCs were elevated and he had a fever.

I recommended that the infection be treated first since the guy seemed delirious before any consideration was taken to transfer the pt to psyche. The surgeon didn't know what I was talking about and he & the surgical team were claiming to never had heard of such a thing.

The bottom line is every field starts to forget medicine outside their specialty, and IMHO all doctors should keep their primary medical skills honed.

Yeah, but how in Hades does a surgeon forget about delirium and post surgical infections???? 🙄

 

[Regnvejr]

Yeah, but how in Hades does a surgeon forget about delirium and post surgical infections???? 🙄

Here is a joke told by my past surgery instructor at the VA:

In a non-descript VA in the Midwest, two best friends, a surgeon and a psychiatrist are riding in an elevator when a patient stumbles in and yells "Help me. Oh, please help me," clutches his chest and falls down.

The psychiatrist, a bit stunned, checks the patient, hits the alarm, starts CPR and keeps the patient stable until helps arrives. The patient is taken away to the ICU. The psychiatrist steps back, takes a deep breath and then excitedly turns around and talks to his friend: "Wow, did you see that? I can't believe that I remembered all that, it was amazing."


He then pauses and looks closer at his friend. The surgeon stand pressed up against the back wall of the elevator, pale and sweaty, shaking. "What's wrong my friend?" the psychiatrist asks. The surgeon replies: "Oh, my God, that was horrible. For a moment, I thought I was going to have to talk with a patient."

 

[Tradewind]

At the risk of being slaughtered, in defense of the surgeons, postoperatively, patients often have a low grade fever and demargination of white blood cells, producing elevated total WBC count. But, yes, I agree with above posts that it's good to be wary. Getting a WBC differential, making sure the temperature and WBC are not markedly elevated and looking at the patient are all great ideas to rule out infection or other complicating medical factors.

 

[Tradewind]

Ronin's & Regnvejr's posts:

 

[espaceLumiere]

1. In my region (midwest) psych is GROSSLY underrepresented. In my state.

I'm from the same region too, and I had the same fears as you had. I think because it is underrepresented, the training sometimes can be less than stellar out here in my state. Which is why I want to train somewhere else

2. The psychiatrists I worked with had almost entirely lost their medical diagnostic skills.

I encountered that often. I think part of it is that you do forget a lot of this stuff. It also can be the culture of the program as well. The outpatient attendings knew far less than the inpatient attendings in my opinions. If you love psych but want to retain your IM knowledge, consultation-liason psych maybe for you.

3. Again on my rotation, a psychiatrist I worked with said the specialty is particularly open to diagnostic disagreement

I saw that all the time and it is a worry. But psych isn't always as clear-cut like IM can be, so naturally psychiatrists can disagree with the diagnosis and treatment. That's what makes it interesting, but at the same time, it can make treatment frustrating.

However, is this really so large a skill that it can't be learned by a non-physician? There are many FPs in my area who practice child psych.

I personally believe that psych is more than just medically managing it- a little therapy can go a long way. And these drugs are easy to prescribe, but hard to master in difficult situations. I've seen plenty of psych patients who get referred from FP when Prozac and xanax fails, when the basics fail. I think it's more comfortable for a pt. to go to a FP rather than a psychiatrist for mental health issues. Less stigma. But still, most people tend to avoid crazy people, so I think we'll be OK. An FP may deal with some depression, but schizophrenia? I don't think so.