splik

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One of the med students in the psych forum asked me if I would do this, and I am happy to answer questions.
***Though you can find info on:
-how to beef up your application here,
-my thoughts for newly matched psych residents here,
-key readings here and here,
- psych fellowships here,
-my reflections on psych residency here,
-my thoughts on what I don't like about psych here,
- psych clinician educator jobs here, and
- contract negotiations here. ***


About me: junior faculty at an academic medical center, trained on the west coast, I do a mix of forensics, neuropsychiatry, and consultation-liaison psychiatry and have been heavily involved in medical education, residency selection, and on med student/resident national awards committees. Happy to answer any questions I can, especially about these sub specialties which med students do not get much exposure to, career opportunities, and controversies in the field etc.
 

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halfwaycrooks

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Thanks for doing this, would you come forward if an emergent medical situation developed on an airplane?
 
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- Do you ever miss more physical medicine?
- What other fields did you consider?
- Would you still recommend psych to medical students considering it?
- Do you have any concerns about how effective you are in actually treating people?
 

Mad Jack

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But my serious question- how much does a neuropsych fellowship help if I am a DO psychiatrist looking to go academic?
 
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splik

splik

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Thanks for doing this, would you come forward if an emergent medical situation developed on an airplane?
Great question! Yes. I have not had to do so as a psychiatrist [happened in my previous life], but I know several psychiatrists who have. If someone was more experienced or appropriate to the situation then of course I would let them handle it. But most inflight medical "emergencies" are trivial and often psychiatric in origin - e.g. flight anxiety, panic attack, whereas others are basic than any physician would have a simple grasp of how to respond (e.g. sx caused by hypoglycemia). for more serious emergencies you are going to be directed by someone experienced on the ground and the real decision is whether you need to land the plane or not (e.g. suspected ACS, or acute abdomen, stroke etc). Psychiatrists are physicians first and foremost and would generally know enough to respond in these situations, especially since there is ground support available, as well having a moral obligation to do so. Depending on years of practice and the setting of practice, psychiatrists' knowledge of general medical issues can be variable. For example in some inpatient settings psychiatrists manage the basic medical comorbidities of their patients, whereas in others this is done by an internist or NP. I know some psychiatrists who try to stay abreast of some of this stuff by doing regular courses in disaster medicine and keeping up to date with their ACLS etc though that is unusual.


- Do you ever miss more physical medicine?
I sometimes miss the diagnostic aspects of medicine, and do miss not doing some basic procedures which I found satisfying as a resident. Also, sometimes other physicians assume I don't know much "real medicine" because I'm a psychiatrist or I'm mistaken for a psychologist, but in general, I have quite satisfied with what I do. Especially since my clinical work is in consultation-liaison psychiatry and neuropsychiatry I have close collaborative relationships with medicine, surgery, and neurology as well as treating psychiatric manifestations of neurological and other diseases, or treating somatization and conversion disorders. I also catch things that others miss. For example, I picked up a case of autoimmune limbic encephalitis (due to voltage gated potassium channel antibodies) that was dismissed as "psychiatric" by neurology and internal medicine. The patient would have died otherwise. I dx a patient who had been misdiagnosed with hashimoto's encephalitis by neurology with functional neurological disorder which meant they were able to get off all the unnecessary drugs, and the patient dramatically improved with treatment with hypnotherapy and short-term dynamic therapy I provided. I dx a patient who had been misdiagnosed with progressive supranuclear palsy with creutzfeldt-jakob disease (sadly a worse dx), but meant that an appropriate care plan could be put in place. I dx a patient who had been misdiagnosed with meth psychosis with lupus cerebritis and sent to rheum....

I also pick up mistakes in overtreatment - had a patient receiving coumadin with a dubious dx of antiphospholipid syndrome based on a borderline antibody test, with all the risks entailed. The patient never had any VTEs, and sx misdiagnosed as stroke were really pseudoneurological symptoms in a pt with somatization disorder.... I could go on...

- What other fields did you consider?
I went into med school thinking I would do psych, but I actually started off in IM. If I didn't do psych, I would have likely done infectious diseases. I also considered EM, pediatrics, family medicine, occupational medicine, and preventive medicine/public health. When I was doing IM (which I was pretty good at) I would spend too long talking to pts and fascinated by delirium and addressing the psychosocial issues going on with patients. I really liked the interface of medicine and psychiatry (for example how personality disorders, trauma, behaviors, family dynamics and so on lead to abnormal illness behavior and maladaptive health service utilization, how early childhood experiences shape how people respond to illness, and medical presentations of psychological distress in the form of somatization and conversion).

- Would you still recommend psych to medical students considering it?
Obviously psych isn't for everyone. It takes a certain type of student. However if you like building meaningful relationships with people, want to have more time with each patient, enjoy listening to the stories of your patients, like neuroscience and psychopharmacology,are interested in psychosocial and cultural aspects of health, are committed to social justice and humanitarianism, enjoy working with and advocating for some of the most marginalized and disadvantaged groups, are interested in what makes people the way they are and why people do the things they do, then psychiatry might be a good fit for you.

Other attractive aspects of the field include the favorable lifestyle, plenty of part time work, no after hours or weekend work if you choose to practice that way, an excellent job market (you can essentially settle down and practice where you like), significantly increasing reimbursement/salaries in recent years, lowest risk of malpractice of any clinical specialty, lots of potential for academic/research careers, and one of the last vestiges of solo practice for physicians. While in other specialties physicians are increasingly becoming employed, there are plenty of opportunities to start your own practice, including private pay and practicing medicine to provide the high quality care your patients deserve. It's easy to switch jobs and settings or to work in multiple settings/jobs at the same time to keep things interesting.


- Do you have any concerns about how effective you are in actually treating people?
Of course! Did you know in the 1940s psychiatrists were more highly respected than other physicians? This was because medicine and surgery were not at the stage where they could do much for patients, and psychotherapy and psychoanalysis was in vogue and could treat some patients, particularly those returning from the theatres of war. Since then of course there have been rapid advances in medicine and surgery with curative interventions and procedures that have revolutionized those fields. Unfortunately, things have somewhat stagnated in psychiatry and many of our interventions are not as effective as we would like. That is also why it is so exciting as new treatments and innovations are being developed.

In addition, all fields of medicine have a good proportion of patients that we cannot cure. There are quite a few disorders in psychiatry that are very curable: phobias, panic disorder, PTSD, and conversion disorder are all eminently curable in many cases and highly satisfying to treat. For the most part you have to be able to tolerate smaller successes over a longer period of time to be a good fit for psychiatry. But we sometimes see dramatic and astonishing improvements quite quickly too. For example catatonia (which can be lifethreatening) often responds dramatically to benzodiazepines and/or electroconvulsive therapy. I have also treated patients with brief psychotic disorder with total resolution of their psychosis.

Psychiatry has its fair share of chronic problems, but it can be extremely rewarding working with people to make small wins. For example I've treated patients who are in the hospital 5-10 times in the past year until they start therapy and other appropriate treatment with me and though they continue to struggle no longer have a single hospitalization. That is a big deal to patients.

Even though we can't cure many of the more severe illnesses, manic-depressive illness and other psychotic illnesses often respond very dramatically to medications and can be controlled effectively in many cases.

Finally, psychiatry isn't just about treatment. We also provide education to other healthcare professionals, to families, to schools, to the courts, and the wider public. We act as advocates for our patients so they receive appropriate medical care. As a forensic psychiatrist I provide a service to the courts by determining whether or not defendants are competent to stand trial so that individuals who don't know what is going on are not unjustly thrown into court proceedings without treatment; I help make determinations on whether someone was criminally responsible, or if their mental illness meant they could not know the wrongfulness of their actions; I help in sentencing mitigation if a mental disorder substantially contributed to criminal behavior and make treatment recommendations. Conversely, some people try to game the system and fake (malinger) mental illness, and I make that determination so they do not get away with it etc.

In the medical setting I provide expertise to my medical colleagues on ethical and medico-legal issues and opine on whether someone is competent to make medical decisions or for placement, or to choose physician assisted dying etc. I can help resolve impasses and communication breakdowns between patients and families, or the medical team etc. I can help educate nurses and physicians how to manage "difficult" patients with personality disorders etc.
 
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But my serious question- how much does a neuropsych fellowship help if I am a DO psychiatrist looking to go academic?
Not sure what your question is. Do you want to be a neuropsychiatrist (i.e. specialize in dementia, functional neurological symptoms, and psychiatric manifestations of neurological disease)? Do you want to have a research career? Do you mean academic as in researcher/PI or academic as in working as a clinician educator in an academic medical center. I don't see the point in doing a fellowship unless you want to additional clinical or research training in that particular field. Many neuropsych fellowships are aimed at training researchers to get K-awards, whereas others are more clinically focused. If neuropsych is not your jam, then it is not going to help you.

If you attend a decent allopathic residency program, no one cares about you being a DO, particularly if you want a clinician-educator job at an academic center. You are mainly disadvantaged for research because you didn't attend a proper medical school with lots of research activity, but you may be able to join a research track in a residency program to rectify this. T32 research fellowships post-residency are not competitive at all, and again if you attend a halfway decent allopathic residency it would be a non-issue that you went to a DO school. Also please note that psych fellowships in general are not competitive and plenty of DOs end up doing fellowships at top programs. The further you get from your medical school years, the less relevant it becomes. What we care about is whether you do excellent work as a psychiatrist, not the letters after your name.

If you specifically want to be a neuropsychiatrist, there are actually some highly regarded DOs in the field, including David Baron at USC, well known in the TBI field, and Michael Schrift at Northwestern.
 

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Seeing the stats for psychiatry applicants over the past few years, do you think the field will become significantly more competitive in the future like EM? What is the most important factor for landing a psych residency other than not having red flags in your app? Board scores? LORs?

On the education side, what are the best learning resources for someone entering a psych residency other than the DSM?
 

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If you specifically want to be a neuropsychiatrist, there are actually some highly regarded DOs in the field, including David Baron at USC, well known in the TBI field, and Michael Schrift at Northwestern.
The latter is going to be an interesting position in the next few years (until he decides to retire I guess). I believe he's hired at NWMH officially as a geropsych director, but is more or less creating a neuropsych-focused geri fellowship for his fellows down there (from what people have told me it probably isn't going to be much different from his previous neuropsych fellowship at UIC).

Psych generally isn't the type of specialty where people get too hung up on DOs, though I'm also in the midwest. Your experience on the coasts could be different. And the main reason to do a neuropsych fellowship is if you want to do neuropsych. If you want to go into academics, the main requirement is willingness to take a pay cut. :D
 
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sunflower18

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I thought I was for sure going to go into peds (and it's definitely still on the table), but I LOVED my psych rotation and am now seriously considering child psych, although I haven't had any significant exposure to it. I just know that I love talking with patients and their families and getting to know them on a deeper level than what was emphasized in my other rotations such as IM -- I really appreciated that psychiatry is all about what the patient says and how they feel and how they are acting rather than ignoring the patient to focus solely on labs and imaging (which is unfortunately what I've seen in other fields sometimes). Communication and good physician-patient relationships are very important to me, and super-short 15 minute primary care peds visits don't provide a lot of opportunities for true connection with patients and families, so child psych seems like a better avenue for that type of interaction. However, I don't know that I'm super passionate about ADHD and autism and ODD, which I know is the bulk of child psych (though I find eating disorders, depression, anxiety, bipolar disorder, and psychosis fascinating).

Do you have any advice/wisdom that might help me decide between peds (probably with fellowship in cardiology, but not sure on that front yet) and psych-->child psych? How should I go about getting exposure to the field if I can't do a formal rotation in it until fourth year (and by then, it's about time to apply!)?

Thanks! Sorry that this isn't a very well-formulated question. Really, anything you have to say about child psych would be stellar :)
 
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splik

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Do you have any advice/wisdom that might help me decide between peds (probably with fellowship in cardiology, but not sure on that front yet) and psych-->child psych? How should I go about getting exposure to the field if I can't do a formal rotation in it until fourth year (and by then, it's about time to apply!)?
I'm not a child psychiatrist. I would highly recommend you meet with the child psychiatry faculty at your medical school. Child psychiatrists usually love teaching and will be thrilled to hear of your interest. Many medical schools (including UCLA) have a special program for medical students to learn more about the field (Current Grantees) and you should try to do an elective or some shadowing at the earliest opportunity. AACAP has medical student awards (Medical Students Awards) and you may be interested in attending their annual meeting.

Also if you match into peds, you can start as a PGY-2 in psychiatry if you decide it's not for you (either after intern year or later). In my program we had someone who switched into psych after completing a peds residency, and someone who switch into peds after deciding they didn't like adult psych (which you will have to do almost 2.5 years of). So its common for students to choose between the two! One of my students applied to both specialties (which you can totally do if you really can't decide). There are also triple board programs (which allow you to get boarded in peds, general psychiatry, and child psychiatry) but the trade off is you won't really learn much psychotherapy, which is an important skill for psychiatrists.

I think you might find ADHD and autism more interesting if you learnt more about them and had more exposure to them! But child psychiatrists work in many different settings and if you were working on an inpatient adolescent unit for example you would see more eating disorders, early psychosis, mood disorders and so on. Bear in mind that ADHD and autism are usually comorbid with other disorders including epilepsy, tourette's syndrome, OCD, depression and so on. There are also issues at the interface of the legal and educational systems which child psychiatrists may be directly involved in.

You might be interested in pediatric consultation-liaison psychiatry. These are child psychiatrists who work with children and their families in medical settings. For example a child who becomes seriously demoralized or depressed because they've been in the hospital for months, or a teen with anorexia nervosa necessitating hospitalization for refeeding, or a child who presents with medically unexplained symptoms because he's being sexually abused, or a child with cognitive and behavioral difficulties because of a brain tumor or autoimmune disease, or a child who becomes traumatized following an invasive procedure etc. This requires understanding how illness affects the family system (for example, a sibling might resent the sick brother for getting all the attention, and start acting out), how illness/hospitalization affects normal child development, helping children and their families cope with medical illness (which in turn improves outcomes) etc. It also requires a good understanding and appreciation of the ethical and medicolegal issues, as well as the complexities of various pediatric diseases and interventions.

I think it's a personal decision which field to choose. One thing to think about is whether you have any interest in treating adults. child psychiatrists are trained to treat adults as well. Some child psychiatrists see patients who come to them as kids through their adult life! Some people really value being able to work with patients over many years. additionally, sometimes patients you saw as kids might call you many years later (as adults) to ask for your help. or you could focus on transitional age or college aged kids.

Some books:
Dibs in Search of Self
Why Love Matters
The Curious Incident of the Dog in the Nighttime
Driven to Distraction
 
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Seeing the stats for psychiatry applicants over the past few years, do you think the field will become significantly more competitive in the future like EM?
the "stats" remain comparatively poor. psychiatry is still one of the least competitive specialties. by the stats, only FM fares worse and this remains unchanged. board scores have increased for everyone, the reason its more notable in psych is mainly because they were so low to begin with. There has certainly been an increase in people applying to psych. That includes some very good people, but more often it not so good people. As demonstrated by this thread (which has been pretty dead) psychiatry just does not appeal to most students. I do think we have seen some people become interested because of the lifestyle and the significant (25-50%) increase in pay we've seen in psych over the past 5 yrs. Srsly only 61.7% of those who matched were US allopathic students (same in 2009). 7.4% were DO students (7.8% in 2013). Given that some US students went unmatched, they were so bad that IMGs were ranked and matched instead.

What is the most important factor for landing a psych residency other than not having red flags in your app? Board scores? LORs?
showing an interest, commitment and aptitude for a career in psychiatry.

board scores not as important except that if you have poor board schools you better have a compelling case for why you're interested in psych. if you've CV is all derm or something and you have poor board scores then you're screwed. otherwise we take into account the totality of the application. board scores, medical school of origin, clerkship grades (for USMD students) are all important in the interview selection.

LORs should be from people who know you well and can give concrete, specific examples of what is so good about you. Ideally most (if not all) letters should be faculty at an allopathic medical school (if you want to do an allopathic residency). Letters from some random person in the community are of less value because for all I know they're terrible.


On the education side, what are the best learning resources for someone entering a psych residency other than the DSM?
my 100 papers. (see above)
Fish's Clinical Psychopathology (the older 2nd edition by Max Hamilton)
stahl's essential psychopharmacology (both are good)
maudsley prescribing guidelines
the psychiatric interview in clinical practice (any old edition will suffice)
 
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WiseOne

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What do you think about the use of psychedelics in treating psychiatric problems? Do you think you'll ever see them start being used in your lifetime? One thing I find very interesting about them is that they do not seem to need chronic treatment and yet the therapeutic benefits from them seem to be long lasting. Unfortunately due to the stigma surrounding these substances it has taken a long time for them to be taken seriously, but current studies on MDMA (already in phase 3 trials) and psilocybin are showing a lot of promise.
 
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seeinghowitgoes

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Sorry for the length of this...

How do you envision patient demand for the field changing over the next x number of years (I guess buried in that is a question about how you think insurances will reimburse mental health services in the future as coverage sometimes drives demand)?

Concerning the here-and-now, is it really as easy to get a job in psych after residency as everybody suggests (aka there are that many psych jobs out there)? Does this hold for academic positions as well?

How close is the field to being able to implement some of the genetic and imaging advancements for patient care as opposed to just research (for example, I've read a bit about some work looking at getting large amounts of genetic data for schizophrenic patients in the hopes of better targeting therapies)?

Are there roles in administration, or in industry, for psychiatrists? Being frank, I guess I'm curious about your opinion about whether psychiatrists are at a disadvantage compared to higher-reimbursed specialties (i.e. Surgical subspecialists) or broader specialties (i.e. Internal medicine) when they try to jump to hospital leadership or other admin/non-clinical work later on in a career?

What are some of the stronger neuro/biological-based residencies for psychiatry? Any programs you see residents come from that you feel on the whole seem particularly well prepared, or, more to the point, any psych residencies you think do a really great job of training future psychiatrists?

Thanks for doing this, @splik!
 
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psychMDhopefully

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Do you guys think the gravy train is going to end in psychiatry soon? Like some guy (or committee) who decides how much physicians get paid for each service says " Why are we paying psychiatry so much, does the stuff they do even work?"


Second, on average how many hours a week do you guys really work? I see most psychiatrist work less, like 36-40hrs a week.
 

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Are there any papers or book chapters you can recommend on performing and documenting a psychiatric exam (judging affect, mood, thought process, etc.)?
 
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splik

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Your steps in a psychiatric evaluation
not sure what you're asking. depends on setting, context, reason and type of eval. psychiatric evaluation involves everything from record review and patient observation, to full interview, collateral, neurobehavioral mental status examination, neuropsychological testing, neuroimaging, genetic testings, neurophysiology, labs and csf studies etc. The key as in any other area of medicine is observation, observation, observation and careful listening to what the patient is telling you.

Tips for calling a good psychiatric consult
I am always happy to be consulted, whatever the question. Please don't call psych to try and turf a patient with no active medical or acute psychiatric needs. It is infinitely more difficult to place a patient from a psych ward than from some other service and psych wards can be dangerous places, particularly for vulnerable LOLs who don't need to be there.

As with any consult, please tell me who you are, what your question is, and if relevant, the name of the patient, the attending, the MRN, your pager number, where the pt is, and a brief spiel about the patient and what you want to know. For curbside consults, please don't tell me the name of the pt just ask a generic question, e.g. can TCAs and SSRIs be combined, and if so what do I need to look out for? etc (it is not longer a curbside, if you reveal any identifying patient details contrary to popular belief). I especially like consults related to unexplained medical symptoms, abnormal illness behavior, psychological reactions to illness/hospitalization, decisional capacity in patients who have mental illness (no indication to call psych if the pt is not mentally ill), suicide risk assessment, violence risk assessment, patient needs mental health follow up, medicolegal/risk management issues, ethical dilemmas, family systems issues, end of life issues, complex psychopharm questions, factitious disorders and Munchausen's.

What do you think about the use of psychedelics in treating psychiatric problems? Do you think you'll ever see them start being used in your lifetime?
I have always been very fascinated by the therapeutic potential for psychedelics and am delighted to see the research base flourishing in this area. As you may be aware the reason for the stigma is mostly related to what happened at Harvard with Timothy Leary and colleagues. Incidentally Leary received LSD from Sandoz (who happen to make clozaril lol) even thoguh he was a psychologist and not an MD, because he was at harvard. The whole episode was a huge scandal and terribly embarassing for harvard and put a dent on any future psychedelic research. Also some of the early research was bad or showed worse outcomes (for example the Oak Ridge studies of psychopaths in Canada). Enough time has passed we are seeing these drugs being used.

Although ketamine is still experimental a growing number of academic medical centers and private practice psychiatrists are using it in the treatment of depression and other mental disorder. For better or for worse, it is quite lucrative. It is also popular on some military bases. I know some psychiatrists who are rxing an intranasal preparation (rather than IV infusions).

It has long been known that stimulants including MDMA can facilitate psychotherapy in traumatized individuals and I think we will be seeing more of this for PTSD treatment in the future.

There is a growing evidence base for psilocybin in the treatment of cluster headaches, existential anxiety, and possibly depression. Previously it was hoped to be a treatment for alcoholism and I think it could potentially facilitate spiritual experiences in some that may help them with their psychic pains including enhance spirituality for addictions.

LSD is a bit more controversial.

These drugs are not benign and of course can have significant and serious adverse effects. However they should definitely be available at least experimentally for patients who have not responded to other therapies and in the future may become more widely available, depending on the evidence.
 
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How do you envision patient demand for the field changing over the next x number of years (I guess buried in that is a question about how you think insurances will reimburse mental health services in the future as coverage sometimes drives demand)?
There really high demand for services for mental health (not necessarily from psychiatrists). Indeed, 1 in 3 people seeking help for mental health problems does not have a mental disorder! As for psychiatry, there is unfortunately a strong demand for psychoactive drugs from the general public and this is not going away anytime soon.

Who knows what will happen to demand or reimbursement in the future, but many plans provide truly crappy mental health coverage tantamount to no coverage at all (because the coverage provided is simply unusable). However history tells us these things ebb and flow; insurance companies find ways to cut and physicians find ways to game the system or circumvent restrictions, which the insurance companies will again react to!

Concerning the here-and-now, is it really as easy to get a job in psych after residency as everybody suggests (aka there are that many psych jobs out there)? Does this hold for academic positions as well?
It is very easy to get a job in psych. Does that mean you can get any job you want? No, of course not.
What do you mean by academic positions? If research, (i.e. academic faculty) then you will obviously have to have a strong track record and be in a position to obtain grants. If you mean a non-academic position in an academic institution (i.e. clinical faculty), it's become easier in recent years as departments are hemorrhaging faculty as they fail to compete salary wise, and demand more and more while offering less and less. If you want to obtain a faculty position at a top academic medical center, your best bet is to complete your residency training at one.

If you can't find a job you like, you can always set up your own practice providing outpatient, partial hospital, inpatient, consult, forensic etc services

How close is the field to being able to implement some of the genetic and imaging advancements for patient care as opposed to just research (for example, I've read a bit about some work looking at getting large amounts of genetic data for schizophrenic patients in the hopes of better targeting therapies)?
I use imaging all the time, and sometimes refer to neurogenetics for genetic testing. When I was a junior resident, I would order genetics myself, but now I'm of the opinion it's inappropriate for a psychiatrist to do so (unless they are an expert in medical genetics). Better to leave it to the experts who will select the appropriate genetic testing, provide counseling to the patient and family, and take the appropriate history and exam. We use imaging in the diagnoses of dementias, viral and limbic encephalitis, and to identify neurological diseases manifesting with psychiatric symptoms etc. We use genetic testing in Alzheimer's disease, frontotemporal dementia, huntington's disease, wilson's disease, mitochondrial disease, and autism (karyotyping and chromosomal microarray) already.

Mental disorders such as "schizophrenia" are artificial constructs that we invented and don't map onto real processes so most of the research that has previously done on genetics and imaging etc has been a complete waste of time. I don't see genetics making major developments to the treatment of mental illness. Look at it like this, the huntingtin gene on chromosome 4 was identified in 1983. We still have no treatments for huntington's. the genes we have found with the largest effects in "schizophrenia" (and autism etc) are rare chromsomal microdeletions etc, and only contribute a small fraction of cases (5% or so). Many cases have little to do with genetics. Psychiatric syndromes are complex genetic disorders involving often multiple genes of small effect with environmental and stochastical factors. Even if we did have the capacity to "personalize" treatments based on genetics, it is not cost-effective. Who is going to pay for the homeless psychotic guy to get some hypothetical personalized multimillion dollar treatment?

The real exciting developments we're seeing are that some of what gets labeled as "psychiatric" is actually due to brain diseases (for example autoimmune diseases causing psychosis, or the C9orf72 hexanucleotide repeat expansion and mania etc), some of which are treatable or even curable. Psychiatric disorders are syndromes. Much of what we call "schizophrenia" has more to do with the social environment, and other environmental exposures (e.g. drugs, infections) than to genetics.

Are there roles in administration, or in industry, for psychiatrists? Being frank, I guess I'm curious about your opinion about whether psychiatrists are at a disadvantage compared to higher-reimbursed specialties (i.e. Surgical subspecialists) or broader specialties (i.e. Internal medicine) when they try to jump to hospital leadership or other admin/non-clinical work later on in a career?
Psychiatrists are over represented in administrative positions. The skills you develop as a psychiatrist in managing systems issues, and working with personality disorders will come in handy in administrative positions. For example Thomas Detre, a psychiatrist, transformed UPMC into the mega monstrosity health system it is today. Many medical school deans have been psychiatrists. Herb Pardes, a psychiatrist, was the President and CEO of New York Presbytarian Hospital for many years earning over a million a year. Kenneth Davies, current CEO of Mt Sinai is also a psychiatrist, earning over 4million a year. We also have our own freestanding psychiatric hospitals that need physician leaders and pay substantially. For example steven sharfstein earned over a million a year as CEO of Sheppard Pratt for many years. Psychiatrists are in a highly advantageous position compared to other physicians to assume administrative positions. Of course there are psychiatrists in other lower level administrative positions too, including leadership of their own department. A chair of psychiatry at a top academic medical center can potentially be earning 500-800k+ a year (need to have a strong research track record and be able to bring in grants from NIH and private funding). other administrative positions include heading the american board of psychiatry and neurology (for 900k a year) or CEO of the american psychiatric association for 650k a year. obviously few become c-level executives in any field, these are just examples.

In this day and age, it is probably a good idea to do an MBA (preferably somewhere like Harvard or Stanford though not a dealbreaker by any means) if you want break into healthcare administration etc.

As for industry, quite a few psychiatrists have gone into tech trying to develop tech solutions in psychiatry; psychiatrists have always done well in pharma; a few psychiatrists have gone into management consulting or spent some time doing so. Going to a top medical school is the more important determinant especially for the latter.

What are some of the stronger neuro/biological-based residencies for psychiatry?
being more biologically based means there are deficiencies in training, but traditionally the "biological" programs are WashU, Iowa, and, UPitt, Hopkins. Of these, I think hopkins does a particularly good job of training psychiatrists though the relative lack of training in psychodynamic psychotherapy is a weakness. In this day and age there should be no "biological" psychiatrists - clinical neuroscience is an important foundation for the field though less relevant than say neuropsychiatry, but you can't be a great psychiatrist unless you also consider the psychological, social, cultural, spiritual, ethical, and medicolegal aspects of care. If you are not interested in psychological aspects of medicine, I don't see how you can be a good psychiatrist. Programs to focus on one element are necessarily producing psychiatrists whose training is not well balanced. Somehow other programs (for example columbia, mgh/mclean, and ucla manage to provide a strong training that covers the breadth of psychiatry and allows for some level of specialization according to other interests).

Any programs you see residents come from that you feel on the whole seem particularly well prepared, or, more to the point, any psych residencies you think do a really great job of training future psychiatrists?
Good psychiatrists exist in spite of their training, not because of it.

Do you guys think the gravy train is going to end in psychiatry soon? Like some guy (or committee) who decides how much physicians get paid for each service says " Why are we paying psychiatry so much, does the stuff they do even work?"
There is no "gravy train". Psychiatrists can be paid well or poorly paid (seen as low as $75/hr), but not as well as most other fields. There is a natural ebb and flow in physician compensation. Psychiatrists did very well in the 60s and 70s, and then the insurance companies decided they'd had enough of paying for endless psychotherapy, and year long+ hospitalizations, but the field adapted and survived. In the 1990s, psychiatrists' income was affected by managed care even more so, and you saw the rise of the 15 minute visit. The pendulum has swung the other way in recent years, and it's becoming more commonplace for 60 mins+ new visits and 30 minute follow ups to be standard. Of course, quite rightly, people will always be looking at whether there'sfat to cut, and whether we are providing value. You will continue to have a job and do well as long as you ask these questions for yourself. Psychiatrists aren't currently in danger of outpricing themselves, but if we do then psychologists and NPs will just take our place. If our stuff doesn't even work, then quite rightly we shouldn't be paid for it. As long as you adapt to the evolving world, and offer skills that others do not, you will continue to earn a decent living and be in demand. since most psychiatrists can't (or dont want to) do what I do, let alone an NP, I don't think I have anything to worry about.

Second, on average how many hours a week do you guys really work? I see most psychiatrist work less, like 36-40hrs a week.
I know people who work 5hrs a week to 80+hrs a week. I work 55hrs on average. biggest variables for me are how much forensic work i'm doing, and any other stuff I have to do (i.e. writing and reviewing papers, editorial stuff etc.)
 
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However if you like building meaningful relationships with people, want to have more time with each patient, enjoy listening to the stories of your patients, like neuroscience and psychopharmacology,are interested in psychosocial and cultural aspects of health, are committed to social justice and humanitarianism, enjoy working with and advocating for some of the most marginalized and disadvantaged groups, are interested in what makes people the way they are and why people do the things they do, then psychiatry might be a good fit for you.
Check, check, check, check lol


Thanks for taking time to do this AMA, doc! Aside from attending a conference or two, joining my psych interest group, doing extra psych rotations and getting some decent academic LORs, what else should an interested student do to make himself stand out as wanting to be a psychiatrist?

Shadow? Volunteer in mental health?

_________________________________

It's a ways out for me as an M2, but do you have any tips on learning about different residency programs? As you mentioned earlier, some provide a better balance of training than others -- how do you make that judgement?

Thanks!
 
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Are there any papers or book chapters you can recommend on performing and documenting a psychiatric exam (judging affect, mood, thought process, etc.)?
The best introduction to descriptive psychopathology is as mentioned above Fish's Clinical Psychopathology. I much prefer the 2nd edition (by Max Hamilton) than the newer edition but I suppose it would suffice. If you would like to read a longer text, then Symptoms in the Mind by Andrew Sims (any edition will do though the older editions are a bit homophobic by today's standards). For the neurobehavioral MSE, The Mental Status Examination Neurology is highly recommended (any edition), as is Cognitive Assessment for Clinicians (by john hodges).

This paper provides some definitions with decent reliability for terms used to describe disorders of thought and gives examples.

I think med students and residents should do a thorough MSE, but in the real world no one bothers anymore, except in forensic reports.

Thanks for taking time to do this AMA, doc! Aside from attending a conference or two, joining my psych interest group, doing extra psych rotations and getting some decent academic LORs, what else should an interested student do to make himself stand out as wanting to be a psychiatrist? Shadow? Volunteer in mental health?
As mentioned elsewhere please don't attend conferences to "show interest" (and dont put it on your CV unless you actually presented or chaired a session).

Do whatever most interests you. you don't have to do research. I want to see that you have some sort of aptitude and motivation for something - this could be research, teaching, advocacy, policy, administration, innovation, journalism/writing etc. If you like teaching you could do near-peer teaching to junior medical students on psychiatry topics. You could develop a psych related taught elective course for med students or undergrads If you like public education you could do talks to particular communities or in schools on mental health topics. If you are tech savvy you could develop a mental health related app. If you like writing, you could write an article or op-ed for a local (or national) paper on a mental health related topic. If you fancy advocacy you could get involved with NAMI or other such groups (possibly on the board of directors of the local chapter) or write letters to the editor whenever you see articles with inaccurate or stigmatizing presentations of persons with mental illness. If you aren't interested in research but somewhat academically inclined, you could write up a case report, a review article, even something for the American Journal of Psychiatry Resident's Journal. If you are interested in leadership, you could join your county's mental health board, or become president or PsychSIGN. If you fancy doing some mental health related volunteering and think it will give you some skillz or experience you wouldn't otherwise have, go for it. If you are particularly creative you might create a short movie that is mental health related etc etc.

You are only limited by imagination. I don't want to see cynical attempts to "show interest" for the sake of it, rather some actual evidence. The more original or creative, the better.

Also bear in mind if you get good board scores, you won't have to make as much of case you're interested in psych - its the one who did poorly everyone is more suspicious of (perhaps unfairly).

It's a ways out for me as an M2, but do you have any tips on learning about different residency programs? As you mentioned earlier, some provide a better balance of training than others -- how do you make that judgement?
The APA and IPS meetings typically have a residency fair organized by psychSIGN. Only a selection of programs are represented but you'd get some flavor from attending. In addition you can look at the websites of programs and read the interview review threads on the psych forum here. In general, the further away from the coast the program is, the less psychotherapy training (and thus less balance) the program has. there are exceptions of course. and then of course you interview at places and get your own feel.
 
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The best introduction to descriptive psychopathology is as mentioned above Fish's Clinical Psychopathology. I much prefer the 2nd edition (by Max Hamilton) than the newer edition but I suppose it would suffice. If you would like to read a longer text, then Symptoms in the Mind by Andrew Sims (any edition will do though the older editions are a bit homophobic by today's standards). For the neurobehavioral MSE, The Mental Status Examination Neurology is highly recommended (any edition), as is Cognitive Assessment for Clinicians (by john hodges).

This paper provides some definitions with decent reliability for terms used to describe disorders of thought and gives examples.

I think med students and residents should do a thorough MSE, but in the real world no one bothers anymore, except in forensic reports.



As mentioned elsewhere please don't attend conferences to "show interest" (and dont put it on your CV unless you actually presented or chaired a session).

Do whatever most interests you. you don't have to do research. I want to see that you have some sort of aptitude and motivation for something - this could be research, teaching, advocacy, policy, administration, innovation, journalism/writing etc. If you like teaching you could do near-peer teaching to junior medical students on psychiatry topics. You could develop a psych related taught elective course for med students or undergrads If you like public education you could do talks to particular communities or in schools on mental health topics. If you are tech savvy you could develop a mental health related app. If you like writing, you could write an article or op-ed for a local (or national) paper on a mental health related topic. If you fancy advocacy you could get involved with NAMI or other such groups (possibly on the board of directors of the local chapter) or write letters to the editor whenever you see articles with inaccurate or stigmatizing presentations of persons with mental illness. If you aren't interested in research but somewhat academically inclined, you could write up a case report, a review article, even something for the American Journal of Psychiatry Resident's Journal. If you are interested in leadership, you could join your county's mental health board, or become president or PsychSIGN. If you fancy doing some mental health related volunteering and think it will give you some skillz or experience you wouldn't otherwise have, go for it. If you are particularly creative you might create a short movie that is mental health related etc etc.

You are only limited by imagination. I don't want to see cynical attempts to "show interest" for the sake of it, rather some actual evidence. The more original or creative, the better.

Also bear in mind if you get good board scores, you won't have to make as much of case you're interested in psych - its the one who did poorly everyone is more suspicious of (perhaps unfairly).


The APA and IPS meetings typically have a residency fair organized by psychSIGN. Only a selection of programs are represented but you'd get some flavor from attending. In addition you can look at the websites of programs and read the interview review threads on the psych forum here. In general, the further away from the coast the program is, the less psychotherapy training (and thus less balance) the program has. there are exceptions of course. and then of course you interview at places and get your own feel.
Thank you! I appreciate your honesty and it's good to see that psych programs are as holistic as I'd suspect they are at evaluating candidates' apptitude and interest.
 
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neriticzone

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Basic question from an MS1 here interested in the field. When psychiatrists meet new patients, do you perform a physical exam/order labs before prescribing and starting therapy? Are vitals/weight taken at each follow up? Or is this generally gathered from the PCP?
 
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Basic question from an MS1 here interested in the field. When psychiatrists meet new patients, do you perform a physical exam/order labs before prescribing and starting therapy? Are vitals/weight taken at each follow up? Or is this generally gathered from the PCP?
In most settings, psychiatrists don't perform physical examination (e..g. listening to heart and lungs, palpating abdomens etc). In some inpatient or emergency room settings (for example academic medical centers), psychiatrists do perform admission physical examinations. However in most inpatient settings, the medical issues are usually delegated to an internist or NP. This is not because psychiatrists can't do this, but because if we spent our time dealing with the many medical comorbidities we'd never be able to adequately deal with the psychiatric issues. In outpatient settings, it is usually inappropriate or not possible to do a full physical examination on patients. In the psychotherapy setting (particularly more psychoanalytically informed treated), there is the issue of boundaries, and it is not appropriate to be touching your undressed patients. During residency training, psych residents on inpatient services usually do spend a great deal of time dealing with medical issues, especially when on call.

In terms of taking vitals/weights at each visit - well this depends on the setting. If you are seeing patients for weekly therapy (or even twice or three times a week!) they will get very annoyed and having their vitals/weights taken. Usually we only do this when necessary (we need to monitor weight, BP etc annually and at the first visit) or when we work in medical settings (for example an outpatient HIV clinic) the medical assistants will usually take the vitals etc each visit as they would for the ID docs.

Each specialty has its specialized examination. Just like an ophthalmologist will focus on eyes or an orthopedic surgeon will focus on the musculoskeletal system, the psychiatrist focuses his or her exam on the higher mental functions (arousal, attention and concentration, memory, language, executive function, visuospatial/motor, behavior, speech [rate, rhythm, volume, cadence, prosody, syntax, grammatism] mood and affect, personality, thought form and content, perception, insight and judgement). There is a specific exam for catatonia, and the assessment of neuroleptic malignant syndrome, serotonin syndrome, and for abnormal involuntary movements (basically a focused neurological exam using something called the AIMS).

In terms of labs, most psychiatrists do order or request someone else order labs on their patients. This is because 1) often medical problems can present psychiatrically and 2) therapeutic drug monitoring is necessary when prescribing medications. For example before starting an antipsychotic medication we will check lipids and A1c as metabolic syndrome is a common complication of antipsychotics. Before starting lithium we will check BUN, Cr, CBC, TSH, Ca+ because lithium can affect renal function, thyroid, and parathyroid function. Clozapine requires monitoring of absolute neutrophil count because it causes agranulocytosis, as troponin as it can cause myocarditis. In asian patients, we will usually do genotyping for HLA-B*1502 before prescribing carbamazepine, because of the risk of Stevens-Johnson syndrome. Valproic acid can cause hepatic failure so we check LFTs. carbamazepine can cause agranulocytosis and pancreatitis etc. Several drugs we may monitor serum levels of (e.g. amitriptyline, imipramine, clozapine, lithium, valproic acid to avoid toxicity etc.)

Psychiatrists frequently request EKGs as many of our drugs (particularly antipsychotics) can affect the QT interval, leading to potentially fatal torsades de pointes.

I specialize in dementias and so will often order and look at imaging (e.g. MRI scans, FDG-PEG, DaT imaging etc), sometimes order EEGs, and if not already done will order routine labs we do in patients presenting in dementia (TSH, B12, folate, Vit D, Vit E). In patients who've had bariatric surgery we order a whole panel of vitamins and minerals that may be deficient and cause neuropsychiatric symptoms. In more unusual or atypical presentations I will order serum and CSF studies for various vasculitis, infectious, autoimmune, paraneoplastic, and toxic etiologies).

But this all depends on the subspecialty, patient population, and practice setting.
 

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Can you compare psychiatry practice between the US and other developed countries, like say, Britain. What do you think are the pros and cons of mental health practice in the US? What can be improved?
 

'froDiva

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You make neuropsyche sound so interesting. Thanks for this AMA
 
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Can you compare psychiatry practice between the US and other developed countries, like say, Britain. What do you think are the pros and cons of mental health practice in the US? What can be improved?
There are more differences within the US in mental health care than between developed countries, though there are differences. One of the biggest differences between US and UK mental health services, is the latter is community oriented. Community psychiatry does not really exist in any meaningful form in the US, it is largely very barebones. 50% of counties in the US do not have a single mental health provider. the figure is worse for psychiatrists (185 of 254 Texas counties do not have a single psychiatrist). the problem is not one of shortage, but distribution. Psychiatrists, more than other specialists, concentrate in major metropolitan areas. In the US there is also a skew, in that 1 in 3 people receiving some kind of mental health care does not have a mental disorder. And most people (particularly in the elderly) receiving treatment for depression do not even meet criteria for major depressive disorder. In the UK services are provided in the community, psychiatrists are more likely to visit patients in distress in their homes, and the services are mainly frontlined by nurses (as opposed to social workers or untrained case managers etc in the US). There is a big emphasis in the UK on keeping patients out of hospital so their are home treatment teams that will come and bring patients medication in their home, will come and watch patients throughout the day so they don't hurt themselves. There are crisis resolution teams who will come and meet patients. Their are assertive outreach teams who will go out into the community to find patients (particularly the more seriously ill and homeless ones). In the US care is fragmented and community services few and far between. Even though things like assertive community treatment (ACT) were developed in the US, they are actually more well developed in other countries that have invested in these services.

Another difference is that US mental health services are heavily medicalized. Even psychologists have signed up for the medical model and make diagnoses and some even push for privileges to prescribe drugs themselves! In the UK this is mostly unthinkable. Psychologists don't believe in diagnoses and biomedical approaches to psychological distress and even resist against medicalizing more serious mental illness like psychoses and provision of psychological treatments for these patients. There is also better integration/communication with primary care services in the UK, so patients can access psychotherapetic treatments (CBT) from therapists of various training through IAPT (increasing access to psychological therapies). It is not perfect, but it has provided a lifeline and effective treatment to people who would not otherwise have been able to receive psychotherapy.

Psychiatry has a hard time with recruitment in other countries, much more so than here. Some years ago over 80% of UK psychiatric trainees were IMGs from europe, india and so on; I don't know what the % is today. In the US, 30-40% of psychiatric trainees are IMGs.

Psychiatrists here are much less well versed in the social basis of psychiatry. In fact American Psychiatry has been very resistant to the idea that mental illness, including the most serious mental illness, are caused by and exacerbated by significant social factors. Some have argued this was the result of the backlash from when psychiatrists would blame parents for their children's mental illness, but since this was the case in the UK too, it does not explain it. Plus social factors go beyond the family to neighborhood effects (for example where you are born impacts your chances of developing schizophrenia), discrimination, alienation, social disadvantage, race/ethnicity, sexual orientation, trauma, migration and so on. these factors are almost completely ignored in american psychiatry.

in the UK psychotherapy is its own medical specialty in psychiatry. So medical psychotherapists do not usually prescribe medications, and other psychiatrists do not usually provide psychotherapy. There are exceptions to this, but things are more divided than they are in the US.

There is of course very wide variation of treatment in the US, some of it is truly excellent. Much of it is less so. There is no system. Care is fragmented. People without significant problems utilize a large proportion of services. Consumption of psychiatric drugs is popular and common amongst those without major mental disorders. Psychiatrists have largely abandoned rural areas, as well as abandoning the mentally ill. Increasingly psychiatrists go into private practice and do not accept insurance. Psychiatrists are the least likely of medical specialists to accept insurance with less than 50% in office-based private practice accepting insurance.

There are more complex reasons why American Psychiatry is quite different from psychiatry practiced elsewhere which I won't go into but are tied to late capitalism, and the role of psychiatry as a tool to oppress the masses, to obfuscate endemic causes of misery, and manage subjectivity. Conversely in some other countries (for example, France or Argentina, the purpose of psychiatry and psychoanalysis in particular, was to liberate).
 
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neriticzone

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I appreciate your thorough responses, splik.

Two more questions from me:
1) Did you learn about psychoanalysis/dynamics/CBT all in residency? How did it feel learning psychotherapy and then being expected to treat patients at the same time? Seems like it would be a challenge to me.
2) Is it appropriate to ask a psychiatrist to shadow a psychotherapy appt?

I guess I asked three questions
 
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1) Did you learn about psychoanalysis/dynamics/CBT all in residency? How did it feel learning psychotherapy and then being expected to treat patients at the same time? Seems like it would be a challenge to me.
I am not sure what your question is exactly. I learned quite a bit about psychoanalytic therapy and CBT etc before residency and also trained in hypnosis. During residency I received training in psychodynamic/analytic psychotherapy, CBT, supportive therapy, DBT, group therapy, motivational interviewing, and some specific approaches to treatment based on the principles of other therapy (cognitive processing therapy, affective cognitive therapy, dynamic interpersonal therapy etc). Part of how you learn psychotherapy is by treating patients under close supervision of an experienced therapist. So, as with many things in medicine, you are learning by doing. Where I trained, we videoed all our sessions and thus could watch them or parts of them in session with supervisors. We were also expected to have our own personal psychotherapy as part of our training, and attend a weekly process group. There were also various group supervision formats where we discussed challenging cases and our countertransference towards these patients, receiving feedback from the group. Sure, you read as well, attend trainings on technique (in the case of CBT), and seminars on psychodynamic theory etc but that is a much smaller part of the training, most of the learning occurs in supervision (individual or group) and in working with patients. It is challenging, but probably no more so than any other procedure. That said, one challenge is that medical training is possibly the worst preparation for the practice of psychotherapy, so one has to "unlearn" all the horrible things they did to you in medical school so you can again be empathic and connect with patients. Physicians often have a hard time not trying to "fix" things or think in a technical way about things due to training, but that kind of approach goes against the basic principles of psychotherapy.

It is of course a steep learning curve when treating your first cases. It's also hard to get good cases as a resident since the kinds of patients who come to resident clinics are by definition difficult or unusual (who the hell is going to want to see a resident?!) and not necessarily a good case. I really hated doing therapy at first because I had such terrible patients and felt so inadequate because they just got worse and worse. Also when you start out you are supposed to be working within a particular therapeutic modality, whereas in the real world, we tend to be a bit more flexible and it's less artificial. It was only later on when I got some great patients to work with that I again loved psychotherapy and got to see its transformative power.

Psychoanalysis is a more intensive form of psychotherapy that was of course informed by the writings of Freud (though contemporary analysis has evolved a lot and the caricature of a silent analyst sitting behind an analysand reclining on a couch is not reflective of current practice, and probably was never accurate). Psychiatrists learn psychoanalytic psychotherapy (to varying extent depending where you train - some programs do not provide this at all, whereas other expect residents to see patients for this type of therapy twice a week). In contrast psychoanalysis is typically 4+ times a week (though sometimes defined as 3 times a week nowadays) and training involves personal training analysis, treating cases under supervision of an analyst, and attending seminars and case conferences over at least 4 years. This is above and beyond psychiatry residency, though you can start this training during your residency if your program allows you the time off to attend seminars etc.

Also because psychoanalytic therapy features much less in all training programs than it did a generation ago, analytic institutes often offer a 2-yr certificate or 1-yr fellowship program that residents can undertake during or after training to get more exposure to psychoanalytic readings and approaches. Depending on the institute, this may or may not involve having personal analytic therapy and treating patients under supervision twice weekly etc.


2) Is appropriate to ask a psychiatrist to shadow a psychotherapy appt?
Yes, you won't be able to shadow a psychiatrist for individual psychotherapy because you would then be part of the therapy! However I usually try to show students some psychotherapeutic techniques during a regular psychiatric interview and then discuss and formulate the case, I will let students sit in on sessions involving hypnosis (the patient's eyes are closed and they;re not usually bothered then), or participate in groups. Austen Riggs has an elective for medical students in psychoanalytic psychotherapy, and the motivated student at some medical schools can treat their own patient under supervision using psychotherapy. Some places utilize one way mirrors for training (particularly for family therapy but sometimes individual too) and that instance it may be possible for students to observe. Some places have psychotherapy case conferences where you will be able to hear discussions of cases and the thoughts of other therapists. Your local analytic institute may also have a program for the public on psychoanalytic topics related either to clinical work or psychoanalysis in culture and the arts etc.
 
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neriticzone

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Thanks for your response. My first question was not formulated very well, in part because the lack of knowledge I have of psychotherapy itself. Your answer was very informative and what I was looking for! All of the psychiatrists I have shadowed so far didn't seem to practice much psychotherapy, so it is nice to have a general idea about how the training/practice of psychotherapy looks.
 

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Giving a shot at reviving this thread, which is excellent (thank you).

My questions are regarding the connection between culture and mental health. I understand if cultural psychiatry isn't your main line of work--but I figured you have probably come across patients from different backgrounds in your long years of training.

I find the topic fascinating--I think if culture affects how we see and think about most of the world around us, it probably affects our experience of mental health as well. It's interesting to think that people from different cultural backgrounds may report mental health symptoms in certain ways (e.g. Asian/Asian Americans reporting more somatic symptoms than mood-based symptoms). I also think people of color have historically been shafted or neglected by psychiatry (as by the rest of the health system).

Those thoughts lead to my two questions:

1. Are findings that certain minority groups may experience mental health in certain ways helpful--or do they run the risk of drawing blanket conclusions and doing more harm than good?

2. Where are we now in terms of the field acknowledging and addressing racial disparities in how patients are diagnosed and treated for mental health illnesses? Or even what disparities there are in entire systems of how mental health services are delivered?
 
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Excellent questions. I am glad you have brought up the issue of cultural aspects of mental health. I don't see how one can be a psychiatrist and not think of culture. It is one of the dimensions of care we should always been thinking about to help us formulate patients and our approach to management. It is an area I do have some level of expertise in. I used to teach cultural formulation to the residents and oversee the social and cultural psychiatry course. I am often asked to speak about issues of intersectionality related to LGBTQ people of color and mental health. At my institution, and many others, "contributions to diversity" which include teaching, training, mentoring, clinical care and research around minority populations and supporting students and trainees from minority backgrounds is part of criteria for promotion/academic advancement and we even have a vice chair for diversity. In my clinical work doing consultation-liaison psychiatry and neuropsychiatry, cultural aspects are vary relevant to informing the presentation. Even in my forensic work, I was recently retained to assess whether cultural factors were relevant to the defendant's criminal conduct.

1. Are findings that certain minority groups may experience mental health in certain ways helpful--or do they run the risk of drawing blanket conclusions and doing more harm than good?
It is important to remember that there are more differences within cultures, than between cultures. One only has to look at the United States to see people have a wide different range of beliefs, experiences, manifestations of distress, pathways to health care, help-seeking behaviors, and expectations. However it is very helpful to have some understanding of the historical, political, and social and cultural context of a particular patient. For example understanding the history of the Khmer Rouge may be particularly helpful in understanding Cambodians, or understanding the context of the Vietnam war may be helpful in understanding some Vietnamese individuals. Having an understanding of different religious beliefs can also be helpful in understanding coping, support, beliefs about mental illness, and where treatment fits in or needs to be tailored. We can alo know that some things in general are truisms. For example chinese psychiatrists for many years never diagnosed depression, because it has no cultural salience. Instead these patients we would call MDD, are diagnosed with neurasthenia (shenjing shuairuo) the most prominent symptom of which is fatigue. Incidentally, neurasthenia is a 19th century American diagnosis that typically made in wealthy white women, and yet almost no one uses this diagnosis in America today (I still diagnose it on occassion). Or in Japan, patients with schizophrenia as a rule are treated with multiple antipsychotics (like 3 + various other sedatives) because of how unacceptable it is for people to be causing a scene. Patients from many non-western cultures have a more somatic idiom of distress. The DSM represents a template for experiencing distress that is not universal and yet is often treated as if it is when diagnoses like PTSD are a product of western culture and do not have the same cultural salience in many other cultures. We also know that the kinds of delusions and hallucinations people experience in psychosis varies from place to place.

That said, we should never make assumptions about a patient. In fact many times there is a failure or breakdown because racist assumptions are made. What we do is elicit what this particular patient's beliefs are, what they think are causing their symptoms, what support they rely on, how other people in their family respond to their symptoms, their beliefs about what will work, their value systems etc. The most useful bit of the DSM is probably the cultural formulation interview, which provides a nice semi-structured interview for eliciting this information and again we are focusing on individual belief systems.

2. Where are we now in terms of the field acknowledging and addressing racial disparities in how patients are diagnosed and treated for mental health illnesses? Or even what disparities there are in entire systems of how mental health services are delivered?
Taking the cultural approach above, I would say "the field" does not exist with any uniformity and you will see wide differences from place to place, institution to institution, and individual practitioners. Some places are much more interested in exploring issues related to minority status including issues of race, sexual orientation, gender and so on. Whereas others are less so. Remember that psychiatry just like any other institution is racist. That is a fact. Psychiatry may have had more of a problem with this than some other medical specialties, but let's face it racism is endemic in medicine even at elite so-called "liberal" institutions. There has been more interest in looking and things like race and inequality in recent years. The minority stress theory for example provides one way of understanding how minority individuals may experience more health problems, and the concepts of microaggressions and microtraumas have also been helpful at looking at the everyday insults and attacks on identity and integrity minority individuals experience. The fact that mental health systems may re-enact the traumas and marginalization that individuals from minority backgrounds experience in their every day life is another aspect that more attention has been paid to.

There are huge differences in how mental health services are delivered. African Americans are less likely to seek help, more likely to receive treatment in jails and prisons, more likely to come to the mental health services via the police and criminal justice systems, more likely to be involuntarily treatment, more likely to receive older drugs, and more likely to receive outpatient commitment ("assisted outpatient treatment").

Patients from many other minority cultures may also be reluctant to seek psychiatric help and having serious mental illnesses can be a significant source of shame and worry of "what will people think". At the same time, some cultures provide a greater level of support. for example psychosis appears to be less common in Latinos in America and the prognosis more favorable, which is believed to be due to good social and community support.

Unfortunately, the US is very much behind Europe in exploring how factors related to race, marginalization, migration, and social exclusion affect the most serious mental illness, which is deliberate. We do not seem to want to know the answer and instead try to pretend that biology alone drives "schizophrenia" when there is considerable evidence that much of this is driven by social forces.

Medical students from minority backgrounds have been less likely to choose psychiatry than other medical specialties, and in fact one of the reasons for the decreaing popularity of psychiatry amongst medical students in the past had been the growing number of minority medical students. We very much want our workforce to reflect the populations treated, and if we are to take these issues more seriously then we do need to cultivate a more diverse workforce. American Indians and male african american medical students are particularly conspicious by their absence. The American Psychiatric Association offers travel awards for minority medical students to attend the IPS meeting (which is next week so too late now but an excellent meeting with more focus on these cultural issues), the APA meeting, and to do electives in HIV psychiatry and Addictions psychiatry. Not many people apply so we would love to have more applicants and you have a decent shot of getting it if you apply (Medical Student Travel Awards and Opportunities). Also some institutions offer scholarships for medical students to do away rotations there, such as the University of Washington.

BTW there is no such as think as a "mental health illness" it's just a mental illness, or if you don't like the term illness "mental health problem". Language is important.
 

Coupd'Cat

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Excellent questions. I am glad you have brought up the issue of cultural aspects of mental health. I don't see how one can be a psychiatrist and not think of culture. It is one of the dimensions of care we should always been thinking about to help us formulate patients and our approach to management. It is an area I do have some level of expertise in. I used to teach cultural formulation to the residents and oversee the social and cultural psychiatry course. I am often asked to speak about issues of intersectionality related to LGBTQ people of color and mental health. At my institution, and many others, "contributions to diversity" which include teaching, training, mentoring, clinical care and research around minority populations and supporting students and trainees from minority backgrounds is part of criteria for promotion/academic advancement and we even have a vice chair for diversity. In my clinical work doing consultation-liaison psychiatry and neuropsychiatry, cultural aspects are vary relevant to informing the presentation. Even in my forensic work, I was recently retained to assess whether cultural factors were relevant to the defendant's criminal conduct.

It is important to remember that there are more differences within cultures, than between cultures. One only has to look at the United States to see people have a wide different range of beliefs, experiences, manifestations of distress, pathways to health care, help-seeking behaviors, and expectations. However it is very helpful to have some understanding of the historical, political, and social and cultural context of a particular patient. For example understanding the history of the Khmer Rouge may be particularly helpful in understanding Cambodians, or understanding the context of the Vietnam war may be helpful in understanding some Vietnamese individuals. Having an understanding of different religious beliefs can also be helpful in understanding coping, support, beliefs about mental illness, and where treatment fits in or needs to be tailored. We can alo know that some things in general are truisms. For example chinese psychiatrists for many years never diagnosed depression, because it has no cultural salience. Instead these patients we would call MDD, are diagnosed with neurasthenia (shenjing shuairuo) the most prominent symptom of which is fatigue. Incidentally, neurasthenia is a 19th century American diagnosis that typically made in wealthy white women, and yet almost no one uses this diagnosis in America today (I still diagnose it on occassion). Or in Japan, patients with schizophrenia as a rule are treated with multiple antipsychotics (like 3 + various other sedatives) because of how unacceptable it is for people to be causing a scene. Patients from many non-western cultures have a more somatic idiom of distress. The DSM represents a template for experiencing distress that is not universal and yet is often treated as if it is when diagnoses like PTSD are a product of western culture and do not have the same cultural salience in many other cultures. We also know that the kinds of delusions and hallucinations people experience in psychosis varies from place to place.

That said, we should never make assumptions about a patient. In fact many times there is a failure or breakdown because racist assumptions are made. What we do is elicit what this particular patient's beliefs are, what they think are causing their symptoms, what support they rely on, how other people in their family respond to their symptoms, their beliefs about what will work, their value systems etc. The most useful bit of the DSM is probably the cultural formulation interview, which provides a nice semi-structured interview for eliciting this information and again we are focusing on individual belief systems.

Taking the cultural approach above, I would say "the field" does not exist with any uniformity and you will see wide differences from place to place, institution to institution, and individual practitioners. Some places are much more interested in exploring issues related to minority status including issues of race, sexual orientation, gender and so on. Whereas others are less so. Remember that psychiatry just like any other institution is racist. That is a fact. Psychiatry may have had more of a problem with this than some other medical specialties, but let's face it racism is endemic in medicine even at elite so-called "liberal" institutions. There has been more interest in looking and things like race and inequality in recent years. The minority stress theory for example provides one way of understanding how minority individuals may experience more health problems, and the concepts of microaggressions and microtraumas have also been helpful at looking at the everyday insults and attacks on identity and integrity minority individuals experience. The fact that mental health systems may re-enact the traumas and marginalization that individuals from minority backgrounds experience in their every day life is another aspect that more attention has been paid to.

There are huge differences in how mental health services are delivered. African Americans are less likely to seek help, more likely to receive treatment in jails and prisons, more likely to come to the mental health services via the police and criminal justice systems, more likely to be involuntarily treatment, more likely to receive older drugs, and more likely to receive outpatient commitment ("assisted outpatient treatment").

Patients from many other minority cultures may also be reluctant to seek psychiatric help and having serious mental illnesses can be a significant source of shame and worry of "what will people think". At the same time, some cultures provide a greater level of support. for example psychosis appears to be less common in Latinos in America and the prognosis more favorable, which is believed to be due to good social and community support.

Unfortunately, the US is very much behind Europe in exploring how factors related to race, marginalization, migration, and social exclusion affect the most serious mental illness, which is deliberate. We do not seem to want to know the answer and instead try to pretend that biology alone drives "schizophrenia" when there is considerable evidence that much of this is driven by social forces.

Medical students from minority backgrounds have been less likely to choose psychiatry than other medical specialties, and in fact one of the reasons for the decreaing popularity of psychiatry amongst medical students in the past had been the growing number of minority medical students. We very much want our workforce to reflect the populations treated, and if we are to take these issues more seriously then we do need to cultivate a more diverse workforce. American Indians and male african american medical students are particularly conspicious by their absence. The American Psychiatric Association offers travel awards for minority medical students to attend the IPS meeting (which is next week so too late now but an excellent meeting with more focus on these cultural issues), the APA meeting, and to do electives in HIV psychiatry and Addictions psychiatry. Not many people apply so we would love to have more applicants and you have a decent shot of getting it if you apply (Medical Student Travel Awards and Opportunities). Also some institutions offer scholarships for medical students to do away rotations there, such as the University of Washington.

BTW there is no such as think as a "mental health illness" it's just a mental illness, or if you don't like the term illness "mental health problem". Language is important.
@splik, thank you for the thoughtful and informative reply. It sounds like you've spent much time considering the way that your patients' individual beliefs affect their mental health as well as imparting what you've learned to trainees. I admire that and appreciate the food for thought.

Per your note that medical students from minority backgrounds have been less likely to choose psychiatry--I agree. That's one reason why I'm particularly encouraged by the group of students in my graduating year who are pursuing psychiatry. Around half of us come from minority backgrounds. Wanting to change things for our communities has been extra motivation for us, and I'm excited to see what we do. I'll also pass along your information about travel awards.

Thanks as well for the correction of "mental health illness." I'm not sure where that came from! Although, I do still get tripped up over terms like disease/disorder/problem/illness and mulling over which ones are less or more stigmatizing...or if avoiding the use of one or the other just adds to stigma. In any case, what I wrote here isn't even a phrase. I'll be more careful in the future.
 
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