Psychiatric Ethics Stumper

[nancysinatra]

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So recently I happened to be perusing the Code of Conduct, or Ethical Guidelines or whatever it is called that is put out by the APA. One of the rules is that it is unethical to practice outside your area of competence. I take "area of competence" to mean "psychiatry."

But anyone who has finished intern year can get a state medical license and be a GP. Will they be a good one? Who knows. Still isn't the "area of competence" for all MDs who have done an intern year "everything?"

How do GPs get malpractice insurance by the way?

 

[st2205]

So recently I happened to be perusing the Code of Conduct, or Ethical Guidelines or whatever it is called that is put out by the APA. One of the rules is that it is unethical to practice outside your area of competence. I take "area of competence" to mean "psychiatry."

But anyone who has finished intern year can get a state medical license and be a GP. Will they be a good one? Who knows. Still isn't the "area of competence" for all MDs who have done an intern year "everything?"

How do GPs get malpractice insurance by the way?

I don't know. There are numerous things I don't understand, like why it's appropriate for mid-levels to practice child psychiatry but inappropriate for general psychiatrists to do so.

With regard to GPs, I've only really seen them in limited settings (CHCs and such). Not sure how the malpractice works.

 

[vistaril]

So recently I happened to be perusing the Code of Conduct, or Ethical Guidelines or whatever it is called that is put out by the APA. One of the rules is that it is unethical to practice outside your area of competence. I take "area of competence" to mean "psychiatry."

But anyone who has finished intern year can get a state medical license and be a GP. Will they be a good one? Who knows. Still isn't the "area of competence" for all MDs who have done an intern year "everything?"

How do GPs get malpractice insurance by the way?

In america 'GPs' haven't practiced(except in very isolated and unusual circumstances) in the capacity you describe in 30+ years. So to answer your question about malpractice, they don't get it.

And no, not everyone who did an intern year can 'be a GP'. If I just quit residency and opened up my own family medicine clinic in town and called myself a 'GP', I wouldn't be able to get on insurance panels. I wouldn't be able to get malpractice. And I may even have some issues with my state licensing board....all the time they have hearings on people who are practicing/doing things without reasonable qualifications. A family medicine doc about an hour away(who was board certified in fam med) opened up an office and started doing minor outpt surgical procedures in his offices, and was investigated and closed down.

 

[PikminOC]

In america 'GPs' haven't practiced(except in very isolated and unusual circumstances) in the capacity you describe in 30+ years. So to answer your question about malpractice, they don't get it.

And no, not everyone who did an intern year can 'be a GP'. If I just quit residency and opened up my own family medicine clinic in town and called myself a 'GP', I wouldn't be able to get on insurance panels. I wouldn't be able to get malpractice. And I may even have some issues with my state licensing board....all the time they have hearings on people who are practicing/doing things without reasonable qualifications. A family medicine doc about an hour away(who was board certified in fam med) opened up an office and started doing minor outpt surgical procedures in his offices, and was investigated and closed down.

You could, as a GP, charge cash and not deal with insurance..

 

[vistaril]

You could, as a GP, charge cash and not deal with insurance..

well yeah, but why exactly would patients see that person?

choice A: see a family medicine physician or internist who has completed a three year residency in their field, is board certified, has priviledges, malpratice insurance and takes their insurance(so they pay less). Or alternatively if they are not insured they can pay cash.

choice B: see someone who completed just a year of residency, is not board eligible or board certified in anything, has 1/3 the training, cannot get on insurance panels so your insurance is useless, does not likely have malpractice insurance,. etc.....


it would make absolutely no sense for a patient to pick choice B in that scenario. That is why there is no such thing as a 'GP' anymore, and in fact when most people use this term they are referring to a board eligible family medicine physician in most cases.

 

[michaelrack]

well yeah, but why exactly would patients see that person?

choice A: see a family medicine physician or internist who has completed a three year residency in their field, is board certified, has priviledges, malpratice insurance and takes their insurance(so they pay less). Or alternatively if they are not insured they can pay cash.

choice B: see someone who completed just a year of residency, is not board eligible or board certified in anything, has 1/3 the training, cannot get on insurance panels so your insurance is useless, does not likely have malpractice insurance,. etc.....


it would make absolutely no sense for a patient to pick choice B in that scenario. That is why there is no such thing as a 'GP' anymore, and in fact when most people use this term they are referring to a board eligible family medicine physician in most cases.

http://forums.studentdoctor.net/showthread.php?t=978242 There are some docs who are able to work as a physician without finishing residency.

In some areas, there isn't much of choice A, but there is a choice C: see a NP who takes insurance. Many patient would take C over B, but if the doc who didn't complete residency took medicare (which doesn't require residency completion) he would get some patients. It would be hard, however, for the doc to run a profitable clinic.

 

[PikminOC]

Youd be surprised...

 

[vistaril]

Youd be surprised...

I work in a *very large* area(population wise) and I don't know of a single person running a real clinic in a 'GP' sense who has only completed 1 year of residency.

There are a few people who dropped out of residency after a year or so who do use their medical license in some capacity, but this is a capacity that would not be referred to as working as a gp(which is a term that is antiquated). For example, some of the 'medical marijuana' clinics in california are run this way. There are a few people out there doing things like contracted employment physicals who fall in this category as well, but they arent running their own clinic and wouldnt be called 'gps'

But if someone can show me the website of a primary care/family medicine clinic that is being run by someone who only completed 1 year of residency, I'm all eyes....

 

[PikminOC]

I work in a *very large* area(population wise) and I don't know of a single person running a real clinic in a 'GP' sense who has only completed 1 year of residency.

There are a few people who dropped out of residency after a year or so who do use their medical license in some capacity, but this is a capacity that would not be referred to as working as a gp(which is a term that is antiquated). For example, some of the 'medical marijuana' clinics in california are run this way. There are a few people out there doing things like contracted employment physicals who fall in this category as well, but they arent running their own clinic and wouldnt be called 'gps'

But if someone can show me the website of a primary care/family medicine clinic that is being run by someone who only completed 1 year of residency, I'm all eyes....

im not in a large area..im in a very underserved area...
in the bigger practices, patients do see nurses..
so honestly...a gp is totally a major step up..
DOCU on SDN is a gp..

 

[michaelrack]

DOCU on SDN is a gp..

DOCU currently (with the situations she gets into, I wouldn't be surprised if she lost it in a few years) does have a medical license, but is not practicing (to my knowledge) as a GP, as defined by Vistaril in his 1:14 pm post. I do admit she is practicing some type of medicine

 

[notdeadyet]

in the bigger practices, patients do see nurses..
so honestly...a gp is totally a major step up..

Given the choice between seeing a PA or NP vs. seeing a modern-day GP (meaning someone who likely washed out of residency after completing only intern year), I'd take the PA or NP five days to Sunday.

This is not a slight against folks from the oldie days when standard was intern-only. I'm talking about modern days when someone unable or unwilling to finish residency fires off all sorts of red flags.

 

[PikminOC]

But they at least completed medical school..and all three steps...thats major knowledge..

 

[notdeadyet]

A research oriented ED doc I worked with plotted Step 1, 2, and 3 scores of residents for many years and compared it against the different instruments they used to measure effectiveness as a physician and he found absolutely no correlation. Standardized tests tell you how good you are at standardized tests. The information in the Step exams (and the exams throughout medical school) are essentially the memorization of factoids. And all those factoids get lost once you get any kind of distance from them, unless they are reinforced with training.

I'll take a doc over a comparably talented PA any day. But I would take a great or even good PA over a bottom 1% physician any day of the week. For every Greek tragedy among folks who have tried several times to get through residency, there are dozens of cautionary tales of drugs, theft, lying, and incompetency.

But to each their own....

 

[PikminOC]

A research oriented ED doc I worked with plotted Step 1, 2, and 3 scores of residents for many years and compared it against the different instruments they used to measure effectiveness as a physician and he found absolutely no correlation. Standardized tests tell you how good you are at standardized tests. The information in the Step exams (and the exams throughout medical school) are essentially the memorization of factoids. And all those factoids get lost once you get any kind of distance from them, unless they are reinforced with training.

I'll take a doc over a comparably talented PA any day. But I would take a great or even good PA over a bottom 1% physician any day of the week. For every Greek tragedy among folks who have tried several times to get through residency, there are dozens of cautionary tales of drugs, theft, lying, and incompetency.

But to each their own....

And that's when the noctors come in...

 

[vistaril]

im not in a large area..im in a very underserved area...
in the bigger practices, patients do see nurses..
so honestly...a gp is totally a major step up..
DOCU on SDN is a gp..

not as a gp she isn't.

Heck, a lot of residents currently 'practice' medicine in some form during their residency. They aren't board eligible yet either. But there is something different about that(being in good standing as a resident, and these people usually have completed more than 12 months) vs not having completed residency and not being in good standing at a current program. Furthermore, current residents would not get approval from their training program director to work as a free standing family medicine clinic physician(a gp) in all likelihood. That is a significant distinction.


I also disagree vehemently that seeing someone who did 1 year of internship(and likely flunked out, was kicked out for ethical reasons or misconduct,etc) is 'major step up' from seeing a primary care NP. In that situation, you're talking about someone who is in the BOTTOM 1% of all medical school graduates. There is no way the average NP in primary care isn't better than the BOTTOM 1% of all medical school graduates, especially when you consider the NP likely has a lot more experience as well.

 

[PikminOC]

not as a gp she isn't.

Heck, a lot of residents currently 'practice' medicine in some form during their residency. They aren't board eligible yet either. But there is something different about that(being in good standing as a resident, and these people usually have completed more than 12 months) vs not having completed residency and not being in good standing at a current program. Furthermore, current residents would not get approval from their training program director to work as a free standing family medicine clinic physician(a gp) in all likelihood. That is a significant distinction.


I also disagree vehemently that seeing someone who did 1 year of internship(and likely flunked out, was kicked out for ethical reasons or misconduct,etc) is 'major step up' from seeing a primary care NP. In that situation, you're talking about someone who is in the BOTTOM 1% of all medical school graduates. There is no way the average NP in primary care isn't better than the BOTTOM 1% of all medical school graduates, especially when you consider the NP likely has a lot more experience as well.

So how many years until a PC NP is equal to or better than a physician?
Are you saying an NP who has practiced X years is smarter than or equal to an IM or FP who just completed 3 years of residency?
How many hours does a physician train and how complex is the training compared to an NP?
in ALL CASES, you dont know what you dont know...

 

[Psychiatrized]

So recently I happened to be perusing the Code of Conduct, or Ethical Guidelines or whatever it is called that is put out by the APA. One of the rules is that it is unethical to practice outside your area of competence. I take "area of competence" to mean "psychiatry."

But anyone who has finished intern year can get a state medical license and be a GP. Will they be a good one? Who knows. Still isn't the "area of competence" for all MDs who have done an intern year "everything?"

How do GPs get malpractice insurance by the way?

I find it hard to believe that a psych intern year could be consided a good general overview to practice as a GP as they are usually quite psych heavy. Maybe 4-6 months medicine, 2 months neuro and the rest various psych rotations. I would not feel competent to practice as a GP with a psych internship under my belt.

Since the psych internship is linked to the rest of the program, would it qualify for an intern year that would meet the requirements for a state medical license? I would hazard a guess that it might depend on the state.

 

[st2205]

I don't quite understand how readily we proclaim those who don't finish residency as the "bottom 1%" and view it as a one-size-fits-all problem with generalizations about how they couldn't hack it. Our very own masterofmonkeys didn't finish residency, yet I don't think many here would be itching to label him as such. The four years of medical school (and completed internship in the context of this discussion) weeds out a lot of people. Obviously there are still incompetent people who get booted out after that point or who even finish training, but I'd be willing to guess that an amalgam of the scenarios approaches that of our MasterofMonkeys to a degree more than it resembles our quick and dirty generalizations we're casting on "those" who don't finish.

 

[michaelrack]

Since the psych internship is linked to the rest of the program, would it qualify for an intern year that would meet the requirements for a state medical license? I would hazard a guess that it might depend on the state.

In most caes, it qualifies

 

[vistaril]

So how many years until a PC NP is equal to or better than a physician?
Are you saying an NP who has practiced X years is smarter than or equal to an IM or FP who just completed 3 years of residency?
How many hours does a physician train and how complex is the training compared to an NP?
in ALL CASES, you dont know what you dont know...

there is a HUGE difference between an IM/FP graduate who has completed their training program vs one who has completed one year.

So no...an NP/PA who has a decade of experience or more wouldn't on average be 'better' than a new FM/IM grad just out of school. Of course there are exceptional np's/pa's who may be, but on the whole I would think a new IM/FP grad is a better practitioner than the average PA/NP with a lot of experience.

But again, we are talking about someone who only completed 1 year of residency(and likely wasnt even very good in that year).....I wouldn't want that person coming near me in an unsupervised setting.

 

[vistaril]

I don't quite understand how readily we proclaim those who don't finish residency as the "bottom 1%" and view it as a one-size-fits-all problem with generalizations about how they couldn't hack it. QUOTE]

You are right in that failure to finish isn't due to one thing exclusively. It is due to several possible things. These could include laziness, ethical issues, substance abuse issues, cognitive issues, etc.....

Finishing residency(meaning eventually finishing, even with some setbacks, obstacles, and/or remediation) is the norm. Programs work *very* hard to allow/help struggling residents finish. A resident who starts a residency and doesn't eventually finish *some* residency in *some* field is very rare. My guess is that only about 1-2% of residents fall in that category(2% is probably high), and thus bottom 1% is probably appropriate.

 

[st2205]

I don't quite understand how readily we proclaim those who don't finish residency as the "bottom 1%" and view it as a one-size-fits-all problem with generalizations about how they couldn't hack it. QUOTE]

You are right in that failure to finish isn't due to one thing exclusively. It is due to several possible things. These could include laziness, ethical issues, substance abuse issues, cognitive issues, etc.....

Finishing residency(meaning eventually finishing, even with some setbacks, obstacles, and/or remediation) is the norm. Programs work *very* hard to allow/help struggling residents finish. A resident who starts a residency and doesn't eventually finish *some* residency in *some* field is very rare. My guess is that only about 1-2% of residents fall in that category(2% is probably high), and thus bottom 1% is probably appropriate.

If we're equating bottom 1% to be synonymous and correlate with the "1%" (probably more like 5-8%) that didn't finish then sure. But my argument is that using "didn't finish" as a test for identifying the first percentile is neither sensitive nor specific to any appreciable degree.

 

[st2205]

.

 

[vistaril]

If we're equating bottom 1% to be synonymous and correlate with the "1%" (probably more like 5-8%) that didn't finish then sure. But my argument is that using "didn't finish" as a test for identifying the first percentile is neither sensitive nor specific to any appreciable degree.

there is no way 5-8% of people don't finish. Maybe this many(or more) don't finish their original residency program on time, or even there original program at all(at estimate this is in that range)....but the majority of people who dont finish their original residency program do finish a residency somewhere....often in another field.

And it's not 100% specific...but it's pretty close. I mean people just don't go around 'not finishing'(a huge deal which is catrastrophic) for trivial reasons. The reasons that happens to their careers are usually very relevant and related to their ability to practice medicine reasonably and safety. Again, that may be secondary to ethical issues, cognitive, or substance abuse.