heyjack70

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I was just curious about the typical amount of psychiatric exposure for a family med resident. The local program in our city does not seem to have any psychiatric specific exposure, and this seems like a tragedy given family docs will be managing the majority of mental health patients in the country. I'm sure they get psych patients in their outpatient clinic, but they are then supervised by other family medicine doctors, which just seems lacking. What are you thoughts on this? Is this typical across residencies?

What got me thinking about this was seeing a family med resident on a rotation with a vascular surgeon. Not saying that exposure is unnecessary, but I think having a psych specific continuity clinic, with supervision by a psychiatrist, would be higher yield for future practice.
 

DrMidlife

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Don't judge by counting FM residents on the inpatient psych ward. That's not FM.

Check the residency program website. A lot of FM programs have a faculty member in charge of behavioral health or mental health, such as a PhD or PsyD. Look at the curriculum to see how long and where the psych/behavioral blocks are. Maybe reach out to the BH faculty member to ask questions.

Check the ABFM website. There are behavioral and mental health topics on the FM boards. That's the minimum level of interest in behavioral health in an FM residency.

If psych is interesting to you then look at FM+Psych or FM+BH.

Exposure gets less interesting after 3rd year [edit ->] of med school [/edit], imho, in favor of competence.

Best of luck to you.
 
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VA Hopeful Dr

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I was just curious about the typical amount of psychiatric exposure for a family med resident. The local program in our city does not seem to have any psychiatric specific exposure, and this seems like a tragedy given family docs will be managing the majority of mental health patients in the country. I'm sure they get psych patients in their outpatient clinic, but they are then supervised by other family medicine doctors, which just seems lacking. What are you thoughts on this? Is this typical across residencies?

What got me thinking about this was seeing a family med resident on a rotation with a vascular surgeon. Not saying that exposure is unnecessary, but I think having a psych specific continuity clinic, with supervision by a psychiatrist, would be higher yield for future practice.
You'll get plenty of psych just in your clinic days, don't worry. Plus, that's the type of psych we should be doing - mild/moderate depression, anxiety, stuff like that. Inpatient psych is generally beyond what FPs should be doing anyway. We don't generally have any business managing bipolar or schizophrenia.

As for rotating with vascular - that's pretty useful. After all, managing stable vascular disease is very much within our scope. I also think its handy to know how they do things. If you know the initial tests they do, you can have them done before the referral and save your patient an extra visit with the surgeon. That way, you only refer things that actually need surgery.
 
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DrMidlife

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We don't generally have any business managing bipolar or schizophrenia.
Is it safe to say that in an academic and/or urban setting you don't get near acute crises in mental illness because there are EM docs and psych docs, but in a less-academic less-urban scenario you might manage acute crises in the ED or on the wards?

And chronic management is well within the FM camp, correct?
 

VA Hopeful Dr

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Is it safe to say that in an academic and/or urban setting you don't get near acute crises in mental illness because there are EM docs and psych docs, but in a less-academic less-urban scenario you might manage acute crises in the ED or on the wards?

And chronic management is well within the FM camp, correct?
Well sure, if you're in the ED then this stuff will show up. Its pretty easy there - B52 and consult psych. You'll get that type of thing on your ED rotations. Same scenario on wards, give a nice dose of a neuroleptic and call psych. That's very different than working in the psych hospital trying to stabilize these people for discharge back to society.

I don't like doing chronic management for one simple reason: exacerbations. Mental illness is like anything else, sometimes things go bad. When they do, that's typically outside the realm of FM.
 
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heyjack70

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To be clear, I am a practicing psychiatrist, just inquiring on what seems to be a lack of psych specific training in the local FM residency. I'm not saying FM should be rotating on the inpatient unit because that is not terribly useful (though interestingly the typical med student rotation, which is the only psych specific rotation most doctors will ever get outside of specializing in psychiatry, is on an inpatient unit in 3rd year of med school). I am saying FM would be well served, IMO, with a psych specific clinic where they are exposed to diagnoses beyond mild depression and anxiety. I say this because patients with bipolar and schizophrenia are frequently referred out of the hospital to their family docs, on difficult medication regimens, because there aren't enough psychiatrists. I am clearly biased towards psychiatry being a complicated specialty that FM residents should get more exposure to while in training. I question whether the supervision from a family medicine attending is adequate for evaluation and management of psychiatric conditions in the typical continuity resident clinic. Perhaps in a large city their are adequate referral options for psych management, but in smaller places, not even that small..like <300,000 population, you don't have enough psychiatrists.
 

VA Hopeful Dr

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To be clear, I am a practicing psychiatrist, just inquiring on what seems to be a lack of psych specific training in the local FM residency. I'm not saying FM should be rotating on the inpatient unit because that is not terribly useful (though interestingly the typical med student rotation, which is the only psych specific rotation most doctors will ever get outside of specializing in psychiatry, is on an inpatient unit in 3rd year of med school). I am saying FM would be well served, IMO, with a psych specific clinic where they are exposed to diagnoses beyond mild depression and anxiety. I say this because patients with bipolar and schizophrenia are frequently referred out of the hospital to their family docs, on difficult medication regimens, because there aren't enough psychiatrists. I am clearly biased towards psychiatry being a complicated specialty that FM residents should get more exposure to while in training. I question whether the supervision from a family medicine attending is adequate for evaluation and management of psychiatric conditions in the typical continuity resident clinic. Perhaps in a large city their are adequate referral options for psych management, but in smaller places, not even that small..like <300,000 population, you don't have enough psychiatrists.
Ah, thanks for clarifying.

You have to remember, family medicine has very broad scope. We can't be experts in everything and we can't rotate everywhere. That said, given the high prevalence of mental illness, I think we do get plenty of training in the bread and butter of primary care psychiatry. I think boarded family docs are generally sufficient to supervise this as well.

Outside of that, in my clinic alone in residency besides the large numbers of depressed and anxious patients, I had 2 schizophrenics, 3 bipolars, and a veritable cornucopia of personality disorders. Plus, most if not all programs have someone with additional psych training. My program had an attending double boarded in FM and psych.
 
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heyjack70

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Ah, thanks for clarifying.

You have to remember, family medicine has very broad scope. We can't be experts in everything and we can't rotate everywhere. That said, given the high prevalence of mental illness, I think we do get plenty of training in the bread and butter of primary care psychiatry. I think boarded family docs are generally sufficient to supervise this as well.

Outside of that, in my clinic alone in residency besides the large numbers of depressed and anxious patients, I had 2 schizophrenics, 3 bipolars, and a veritable cornucopia of personality disorders. Plus, most if not all programs have someone with additional psych training. My program had an attending double boarded in FM and psych.
I appreciate the discourse. I think it's fantastic you have an FM/Psych boarded attending. But 2 patients with schizophrenia, 3 with bipolar, this is what I'm talking about as inadequate exposure. I'm not saying there's tons of room for more, it was just in the context of a vascular surgery rotation, how useful is more time assisting on endarterectomies vs adding more psych patients to your panel. My perspective on this really comes from seeing plenty of bad psychiatry from psychiatrists, let alone community FM docs.
 

VA Hopeful Dr

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I appreciate the discourse. I think it's fantastic you have an FM/Psych boarded attending. But 2 patients with schizophrenia, 3 with bipolar, this is what I'm talking about as inadequate exposure. I'm not saying there's tons of room for more, it was just in the context of a vascular surgery rotation, how useful is more time assisting on endarterectomies vs adding more psych patients to your panel. My perspective on this really comes from seeing plenty of bad psychiatry from psychiatrists, let alone community FM docs.
And see that's my exact point. FPs have no business managing bipolar or schizophrenia. You can say what you want about underserved, not enough psychiatrists, or whatever. Managing these things is not something your average FP should be doing. Period.

The experience we do get is sufficient for what is within our usual scope - ED stabilization prior to psych taking over and managing expected side effects of the medications y'all use. Keeping an eye out for metabolic syndrome for neuroleptics, thyroid for lithium, stuff like that. But actually titrating someone's geodon because they're having increased positive symptoms or switching from lithium to depakote? No, that's your job not ours.

As for vascular surgery - in the month I was with them, I spent 2 days in the OR and that was mainly them showing off their endovascular techniques - although even more exposure to different techniques has its value as most of our patients will come back to us with questions about their upcoming surgery. Its nice to know what to tell them. The rest of the time was clinic. As I previously mentioned, this was useful and very much within usual practices for FM.
 
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heyjack70

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And see that's my exact point. FPs have no business managing bipolar or schizophrenia. You can say what you want about underserved, not enough psychiatrists, or whatever. Managing these things is not something your average FP should be doing. Period.

The experience we do get is sufficient for what is within our usual scope - ED stabilization prior to psych taking over and managing expected side effects of the medications y'all use. Keeping an eye out for metabolic syndrome for neuroleptics, thyroid for lithium, stuff like that. But actually titrating someone's geodon because they're having increased positive symptoms or switching from lithium to depakote? No, that's your job not ours.

As for vascular surgery - in the month I was with them, I spent 2 days in the OR and that was mainly them showing off their endovascular techniques - although even more exposure to different techniques has its value as most of our patients will come back to us with questions about their upcoming surgery. Its nice to know what to tell them. The rest of the time was clinic. As I previously mentioned, this was useful and very much within usual practices for FM.
I guess what I'm getting at is you can try to set these boundaries but if you don't have a psychiatrist for referral you are going to be the one managing the medications. I'm not sure if there is a way around that.
 

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I guess what I'm getting at is you can try to set these boundaries but if you don't have a psychiatrist for referral you are going to be the one managing the medications. I'm not sure if there is a way around that.
There very much is. Just because I'm out in the boonies without access to a general surgeon, I don't then need to become proficient at appendectomies. If I can't safely provide a service to a patient, lack of access to someone who can doesn't obligate me to do something I'm not trained or comfortable doing.
 
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heyjack70

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There very much is. Just because I'm out in the boonies without access to a general surgeon, I don't then need to become proficient at appendectomies. If I can't safely provide a service to a patient, lack of access to someone who can doesn't obligate me to do something I'm not trained or comfortable doing.
So what do you do? The surgeon example is a bit off because you would just send them to the ER and they get shipped to a place where the appendix is cut out. But what do you do with serious mental illness that does not warrant inpatient treatment but requires ongoing evaluation and complicated medication management? You can't abandon the patient once they're in your practice.
 

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So what do you do? The surgeon example is a bit off because you would just send them to the ER and they get shipped to a place where the appendix is cut out. But what do you do with serious mental illness that does not warrant inpatient treatment but requires ongoing evaluation and complicated medication management? You can't abandon the patient once they're in your practice.
You don't seem to get it. Its not abandonment if I can't treat what their problem is. If a patient needs a thyroid biopsy, I can't just dump that on the ED as its not an emergency nor can I just do it myself. If the patient has to drive a little ways to get to endocrine, then so be it. Psychiatry is no different.

Local state mental health clinic is my usual go-to. Even poor ole South Carolina offers at least one center within 40ish miles of everyone. That's not ideal, but it'll do.
 

mark v

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I'm an FM doc in a pretty rural town and am fortunate that my residency clinic patients gave me LOTS of opportunity to improve my psych training. Like most programs, we had a PhD over the psych stuff but most of the attendings were pretty good. I stuck around here after residency and at least half my day is psych. The community resources are sub par. Our inpt hospital was closed a few years back. The couple good psychiatrists in town are no longer taking new patients. Whenever a new psychiatrist comes to town, they're so bombarded that they rarely last a couple years until they run for the hills.

I enjoy psych and almost specialized in the field but wanted to do more than just mental health. There's the functional but suffering inside bipolar working mom/dad who wants to feel right to provide for his/her family and then there's the raving schizoaffective who needs Geodon, Depakote, and Seroquel just to function. I can and do plenty of the first variety, not so much on the second. There's LOTS of psych needs in this town and for most of my no money and no insurance patients, it's me or nothing.
 

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Just as some FPs become more proficient in endocrine disorder management or managing high risk OB, I think it is perfectly reasonable for a family doctor to manage psychotic and complex mood disorders. To suggest that FPs have no business managing schizophrenia or bipolar implies great ignorance of the medical practice environments around the US. There is not, nor should there be, a set list of diseases that any one type of provider is limited to address. Your training, comfort level, local practice environment, and (unfortunately sometimes) 3rd party payers decide what is reasonable in your practice.
 

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Just as some FPs become more proficient in endocrine disorder management or managing high risk OB, I think it is perfectly reasonable for a family doctor to manage psychotic and complex mood disorders. To suggest that FPs have no business managing schizophrenia or bipolar implies great ignorance of the medical practice environments around the US. There is not, nor should there be, a set list of diseases that any one type of provider is limited to address. Your training, comfort level, local practice environment, and (unfortunately sometimes) 3rd party payers decide what is reasonable in your practice.
I was speaking in generalizations. If you look hard enough, you can find FPs doing lots of stuff. But, that doesn't mean that most of us should be doing it or that we should all be trained to do it.

Take things like c-sections or colonoscopies. I know family docs doing them, but the vast majority of us shouldn't be doing them and I certainly don't think we should be training all of us to do them.

Same with severe mental illness. If you know you're likely going to be managing those types of patients, do more psych electives in residency. Most of us, however, aren't going to be doing much of that.
 
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This is one area where I think FM as training for primary care far outstrips general IM. It seems like you really have to search out the psych experience in an IM residency whereas it is built into most FM residencies.
 

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We have required psych and VA/behavioral related rotations during PGY-2 or 3 years depending on the schedule and the way one schedules things. Admittedly, given my specialty switch, it has been pushed to PGY-3 (current year).

I'd venture to say that I definitely have lots of experience with depression, anxiety and some bipolar patients. However, when it comes to bipolar and schizophrenia, we should not be actively involved in managing the patient. We should be ensuring compliance and stability, but the psychiatrist should be on board in the outpatient setting. If they aren't, I do whatever I can to ensure the patient is plugged in with a provider and in the interim do what is needed in the form of scripts, labs, social worker involvement, and at least ensuring a psychologist is involved in that person's care. We are not trained in dose titrations of anti-psychotics or mood stabilizers and we should not be doing them just because of lack of access in care. That is in the domain of psychiatry. I do not see neurologists starting and uptitrating on dosages despite being similarly boarded to psychiatrists "ABPN"

It is difficult to be able to manage complicated psych issues in a 15 min visit when you are also managing other medical problems that may also exist. My main issue with these patients is med non-compliance and at that point I really stress the importance of compliance and ensure there are no associated symptoms like sucidality/risk of harm with hallucinations and if so then I BA-52 them and refer to the ED for further eval and inpatient care.

Vascular surgery is key especially for outpatient management. I did a brief wound care rotation not for the inpatient experience but rather for the outpatient experience so I may adopt what I learned from the specialist to my own practice. Opthalmology, ENT, urology, etc. same way. Having had anesthesia experience, I can pretty much answer a lot of my patients' questions about the surgery (and the anesthesia), inform them what to take and not take, do appropriate preop testing as indicated, etc. I also have a general idea of when to refer to gen surg or another surgeon sub-specialist if needed, etc. A lot of times, if the patient wants a surgical opinion, I won't deny them that option. If they are that passionate about it, so be it. I can only counsel them and guide them, but I will not deny them their options. I will however put in that the patient requested a surgical opinion for a certain diagnosis.

I have derm coming up. I plan to set up some cosmetic rotation if possible for a week just to get a feeler for what they do. Also, I am looking forward to my GYN rotation coming up in a few months since I want more experience when it comes to perimenopausal patients and hormones. I often prescribe non-hormonal agents for symptoms and will provide estrogen creams or tablets if lubricants fail. However, I do want more experience from the experts.

Will I ever look to perform a c/s? No. Colonoscopy? No. Appy? No. It's good to have some experience, that's not the point of surgical rotations.
The point of psych rotations is to be able to appropriately manage bread and butter issues, assess for mental disorders, assess for stability of symptoms and recognizing when a patient is not stable, know the side effects of meds and what the various options are. However, it is not for us to start adjusting dosages of psych/mood stabilizing meds with regular reassessment follow-ups. That is on the psychiatrist. Just like operative management is on the surgeons.

At the end of the day, my goal is to be as close to being a "one shop doc" when it comes to medical issues. My goal is DPC. I don't want my patients seeing a specialist for every issue unless they need to.
 
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