Psychiatry and Palliative Medicine

[rpkall]

I was wondering if any of you all had any information on Psych as a gateway to a palliative med fellowship. I've always been extremely interested in hospice-type care, but I'm really not sure I want to do a FM/IM residency just so I can specialize in it later on. I heard over on the Palliative Med boards that psych is a potential path towards fellowship, but I'm not sure whether this scheme will churn out psychiatrists who are less than comfortable making medical decisions in a hospice setting because the 1-2 years of fellowship isn't enough. Obviously, you have intern year of psych residency to fall back on, as far as clinical medicine skills--but honestly, by the time you're done with all 4 years of psych, you're pretty far away from knowing all the details...

I can see some obvious plusses of having a psych background in a hospice setting--so it may be that the clinical medicine can be learned at the bedside of the course of a career, but that the psych training makes for better preparedness when it comes to the family psychodynamics in the context of death and dying.

Any of you know any psychiatrists who did this? Are they happy with the extent of their training in the 2 year palliative fellowship?

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[Anasazi23]

I don't know anyone that used psychiatry as a path to palliative care. However, I don't think that you should be overly concerned that your psychiatry training + fellowship training would have you ill-prepared for such a career.

To be quite honest, the degree of medical complication in hospice is relatively light. From my experiences with it (we have famous hospice in our hospital which I covered both as a psychiatry resident and medical intern), the important topics include management of pain, management of end of life agitation and delirium, some light ID, and the like.

 

[cleareyedguy]

If you want to work within palliation and/or a hospice as a psychiatrist, you should consider not doing a palliative medicine fellowship and instead consider doing a c-l fellowship at a place that sees a lot of cancer patients (like Memorial Sloan Kettering or MD Anderson). You could also try a place with an in-house hospice, though it's probably best to get the best general training as possible before taking on palliative medicine.

 

[rpkall]

Thanks, both of you, for the replies--your input is much appreciated.

Sazi, from what you've observed--are people with the medicine mindset/background equivalently "equipped" (compared with a psychiatrist, for example) when it comes to family issues and psychiatric care in the end stages of life? I just don't want to have to call a psychiatrist to sit and "be" with one of my patients or one of their family members to help them cope in that final hour when it may count the most. Conversely, I don't just want to be a consulting psychiatrist with no prior relationship with the patient/family, trying to start one at an awkward time in that family's coping process...

Cleareyedguy, are you more of the opinion that general medical training would be more applicable, or rather general psychiatry training with a strong psychopharm background, etc, etc...?

Thanks again, folks.

 

[Anasazi23]

I just don't want to have to call a psychiatrist to sit and "be" with one of my patients or one of their family members to help them cope in that final hour when it may count the most.

I don't think you would ever have to do this as the attending unit chief (unless you wanted to). Not to sound flippant, but that's what social workers, psychologists, clergy, nurses, and volunteer staff do quite well.

My role there as a psychiatrist was primarily as a C/L consultant. No one would have stopped me from conducting supportive psychotherapy on an ongoing case, but I really didn't get involved too much in that. Other residents more interested in that aspect pursued it more.

 

[Anasazi23]

I should mention also...my experience with hospice is somewhat limited, but I'm not sure if physicians as unit chiefs are sitting around the nurse's station, waiting for something to go wrong. They're basically doing other things, or working in another section of the hospital or location, and come to conduct patient care when they're called. If the hospice is in a residency program, of course they do even less than that - little more than morning rounds and out.

 

[cleareyedguy]

If you want to learn how to interview and understand psychological issues, you should do a psych residency. Psychiatrists who work with the the terminally ill and don't ever do therapy (supportive or whatever) are--I think--doing their patients and themselves a disservice. It isn't easy to learn these techniques, and you not only won't learn these techniques during a medicine residency, but you will be relentlessly discouraged from seeing a patient from a psychological point of view so that you can focus on their medical problems.

If you maintain this interest during a psychiatry residency, there will be plenty of opportuity to work within palliative medicine later on.

If your primary interest is in the medical aspects of terminal illness, or if you want to be grow up to be a hospice administrator, then it's fine to skip the psych training.

 

[cleareyedguy]

1 more thing:

There is much more to psychotherapy than sitting around, and it's not something that can be done by every random nurse, social worker, and volunteer, as someone implied above. There are multiple issues of alliance, of family dynamic, etc. within a hospital visit, and these are the stuff that seprates psychiatry from all other fields.

 

[Anasazi23]

You are not expected to, nor in many cases should you, engage in a therapeutic relationship with a family member. Of course, many if not most of the presentations of end stage disease do not allow the patient to be coherent and 'up and ready' for therapy. Many are near comatose, obtunded, or disoriented.

Don't discount the value of things like familial and clergy support in the setting of hospice. They could likely do a better job than most of us.

 

[rpkall]

Thanks again for your points of view on this. It always helps to speak to people who are further along in their training. Much appreciated!

 

[Sleepygator]

My primary residency is in psychiatry and for a while, I was interested in HPM. I did an extended rotation as a resident, which was invaluable.

Even though I did a straight medicine internship, I did not feel as comfortable with the medical aspect of HPM as my medicine colleagues.

I was more comfortable with depression, delirium, and dementia. But I was pretty rusty with all the other symptoms - pain, nausea, etc

In my opinion, it would be difficult to become an HPM physician without the HPM fellowship if your primary residency is straight psychiatry. Obviously, med-psych is better prepared. Doing multiple rotations in HPM and maybe even in the ICU (yes, the ICU!) might help those psychiatry residents who are interested in HPM.

Many jobs for full-time HPM want IM/FP with or without HPM training. I do not recall any jobs looking for an HPM physician who is a psychiatrist. Again, this does not mean it can not be done.

 

[Chimed]

My primary residency is in psychiatry and for a while, I was interested in HPM. I did an extended rotation as a resident, which was invaluable.

Even though I did a straight medicine internship, I did not feel as comfortable with the medical aspect of HPM as my medicine colleagues.

I was more comfortable with depression, delirium, and dementia. But I was pretty rusty with all the other symptoms - pain, nausea, etc

In my opinion, it would be difficult to become an HPM physician without the HPM fellowship if your primary residency is straight psychiatry. Obviously, med-psych is better prepared. Doing multiple rotations in HPM and maybe even in the ICU (yes, the ICU!) might help those psychiatry residents who are interested in HPM.

Many jobs for full-time HPM want IM/FP with or without HPM training. I do not recall any jobs looking for an HPM physician who is a psychiatrist. Again, this does not mean it can not be done.

My understanding (which is admittedly limited) is that psychiatrist who work in palliative care are typically members of a large multi-disciplinary team. They typically work in larger academic centers and function mainly with the psychiatric and/or pain issues that come up rather then being the primary Doc for the patient. They would also do well working in a research center looking at the co-morbid psychiatric conditions with these patients.

 

[dianamd]

I was wondering if any of you all had any information on Psych as a gateway to a palliative med fellowship. I've always been extremely interested in hospice-type care, but I'm really not sure I want to do a FM/IM residency just so I can specialize in it later on. I heard over on the Palliative Med boards that psych is a potential path towards fellowship, but I'm not sure whether this scheme will churn out psychiatrists who are less than comfortable making medical decisions in a hospice setting because the 1-2 years of fellowship isn't enough. Obviously, you have intern year of psych residency to fall back on, as far as clinical medicine skills--but honestly, by the time you're done with all 4 years of psych, you're pretty far away from knowing all the details...

I can see some obvious plusses of having a psych background in a hospice setting--so it may be that the clinical medicine can be learned at the bedside of the course of a career, but that the psych training makes for better preparedness when it comes to the family psychodynamics in the context of death and dying.

Any of you know any psychiatrists who did this? Are they happy with the extent of their training in the 2 year palliative fellowship?

Do the Triple Board program if you want to do pediatric palliative care and psych. Someone from Mt. Sinai did that a few years ago and got a big time job at Sloan-Kettering -- the first such trained person at that glorious hospital.

Triple Board is at Brown, Hawaii, Pitt, Tufts, Mt. Sinai, and a few others. The advantage for palliative care is that you are trained in the medicine side of things (not just psychiatry) and therefore are able to do real palliative care type work. I considered it but decided against, since I don't want to do C-L or palliative care or any other medical type specialty.

 

[hippiedoc13]

The institution where I am doing my residency is affiliated with a large regional hospice. Residents from our institution, from both the psychiatry side and the medicine/peds/family med side, have the opportunity to do rotations there. And I know several of our psychiatry grads now work as attendings over there a few days a week. From speaking with them my understanding is that they are indeed part of a large multi-specialty, multi-disciplinary team and they mostly manage issues that fall well within the purview of their psychiatric training, as someone said above.

 

[Doc Samson]

Do the Triple Board program if you want to do pediatric palliative care and psych. Someone from Mt. Sinai did that a few years ago and got a big time job at Sloan-Kettering -- the first such trained person at that glorious hospital.

Triple Board is at Brown, Hawaii, Pitt, Tufts, Mt. Sinai, and a few others. The advantage for palliative care is that you are trained in the medicine side of things (not just psychiatry) and therefore are able to do real palliative care type work. I considered it but decided against, since I don't want to do C-L or palliative care or any other medical type specialty.

In my experience, triple board = peds, psych, child psych. What program are you referring to?

 

[dianamd]

In my experience, triple board = peds, psych, child psych. What program are you referring to?

exactly.

That would be for peds palliative care. For an adult palliative care training, possibly med/psych followed by palliative care. I thought about psych with a geri psych fellowship, but then you don't have training in the medicine that is essential to palliative care.