Psychiatry: Removed from traditional "medicine"?

[DD214_DOC]

I am very interested in pursuing psychiatry over surgery or EM. However, it seems to me that psychiatry is distanced from "traditional" medicine: trad. med being wearing scrubs, white coat, doing rounds, interacting with other staff, cutting people open, etc. I think you guys understand what I mean.

For those who in residency or attending psychiatry, could you please share your thoughts? I don't intend to let something minor such as this interfere with my career decision, but I'm curious.

---

Members don't see this ad.

 

[Big Lebowski]

Well, it's tough to say....because I'm not quite sure what you're asking.

From what I've read in your post, if you concern is wearing scrubs, white coats, cutting someone open, doing rounds, interacting with other staff...it depends. You can wear scrubs on call....I guess you could wear a white coat whenever you want (unless told not to)...no, you won't cut anyone open, but you might get the chance to suture...yes, you will most likely do rounds on an inpatient service...yes, you will probably interact with other staff especially on consult/liason, med/psych services.

As for keeping in touch with traditional medicince...I think the degree of this varies program to program. Of course, anywhere the consult/liason service is going to have close ties to other services. The same goes for hospitals with a med/psych unit. And geriatrics will probably incorporate a good amount of general medcine. As we understand mental illness better and the biological treatment become more sophisticated, a good working knowledge of medicine and neurology is of importance. Of course you can choose to lose touch with basic medicine, but your skills as a good psychiatrist will suffer.

Hope this helps...

 

[PublicHealth]

Great topic. You may be interested in psychosomatic medicine, a new subspecialty branch of psychiatry that focuses on treating patients with comorbid medical and psychiatric problems. It's becoming a popular field among early-career psychiatrists. The fellowship is one-year long, and psychosomatic (or consultation-liaison) psychiatrists are in seemingly high demand. Not surprisingly, many D.O.'s are attracted to this field.

Here are some links for more info:

http://www.psychosomatic.org/

http://www.apm.org/

http://www.hawaiiresidency.org/icpm2003/

Here's a recent article on psychosomatic medicine from Psychiatric Times:

Optimistic Outlook for ECPs Who Choose Psychosomatic Medicine

Tomer Levin, M.D.

Early career psychiatrists should pay close attention to the recent acceptance of psychosomatic medicine, also known as consultation-liaison (C-L) psychiatry, as a full-fledged subspecialty.

The field of psychosomatic medicine deals with psychiatric problems in people with other types of medical illnesses. It represents the interface between psychiatry and the rest of medicine.

(Other psychiatric subspecialties recognized by the American Board of Medical Specialties are geriatric psychiatry, child and adolescent psychiatry, forensic psychiatry, and addiction psychiatry.)

The process of approving psychosomatic medicine as a subspecialty was a long-fought battle. It involved attaining approval by APA, American Board of Psychiatry and Neurology (ABPN), and, in March, the American Board of Medical Specialties. The newly won ability to gain a certificate of added qualifications in this field will result in increased recognition and status for C-L psychiatrists, some 30 years after one of its forefathers, George Engels, M.D., first published his famous biopsychosocial model. The first ABPN certification examinations for added qualifications in psychosomatic medicine will be held in late 2004 or early 2005.

Subspecialty status will likely result in an increase in the number of C-L fellowship programs and positions open to formally trained C-L psychiatrists, according to Stephen Saravay, M.D., chief of C-L psychiatry at Long Island Jewish Medical Center.

Saravay believes that all psychiatric programs will need to expand to address the clearly defined educational requirements for residency and fellowship training in this area. Psychiatric centers without C-L programs will need to establish them to remain competitive, he said. "This is an exciting time for early career psychiatrists contemplating a future in psychosomatic medicine," he said.

Adam Chester, D.O., an early career psychiatrist who has chosen psychosomatic medicine as his subspecialty, graduated from the Long Island Jewish Medical Center C-L fellowship in 1998. He was soon recruited by Flushing Hospital, a busy suburban hospital with an ambitious agenda for expanding psychiatric services.

Chester was appointed as chief of C-L psychiatry at Flushing Hospital and deputy head of residency training for Flushing Hospital and its larger sister hospital, Jamaica Hospital. He pointed out that his C-L training gave him a head start in developing his career. "The field is wide open, and a trained C-L psychiatrist can make a considerable impact on clinical care and teaching," explained Chester.

Long Island Jewish Medical Center runs one of the largest fellowship training programs in C-L psychiatry in the country. It accepts five fellows annually and offers training in a variety of clinical areas?inpatient, primary care, cognitive therapy in the medically ill, program development, psycho-oncology, and neuropsychiatry.

"Subspecialty status for C-L psychiatry will lead to an expanded job market and new career opportunities for psychiatrists trained in C-L," according to Maurice Steinberg, M.D., director of the C-L fellowship program at the hospital. He expects a significant increase in interest in C-L fellowships as graduates realize that in light of the availability of certification in this area, such training will now be a necessity for a career in C-L psychiatry. "We have already begun to see an increase in applications in recent months," he said.

The field of psychosomatic medicine already offers numerous peer-reviewed journals such as Psychosomatics, Psychosomatic Medicine, General Hospital Psychiatry, International Journal of Psychiatry in Medicine, Journal of Psychosomatic Research, and Psycho-oncology.

There are also several comprehensive and well-established textbooks. The national organization representing practitioners in this field, the Academy of Psychosomatic Medicine (APM), and a variety of offshoots, such as the American Psycho-oncology Society, represent C-L psychiatrists and facilitate research.

C-L fellowship programs are listed on the APM?s Web site at www.apm.org. Accredited fellowship programs meet the standards of the APM, and the Web site is a good place for those interested in a career in C-L psychiatry to start their search. Job opportunities for C-L psychiatrists are also listed on this site.

Footnotes

Dr. Levin is an early career consultation-liaison psychiatrist who heads the psycho-oncology program at Long Island Jewish Medical Center in New York.

 

[MacGyver]

Psychiatry is the most diverse multifaceted aspect of medicine.

By comparison, all other doctors are simple pill-pushers and knife-wielders.

Psychiatry is the ONLY branch of medicine that does not rely exclusively on a disease-biology model.

Psychiatry has 4 major perspectives, with disease/biology being only one of them.

Psychiatry will be the biggest medical field of the future. We know pretty much how the heart and kidneys work. By comparison, we know almost NOTHING about how the brain and behavior work.

The brain-mind discontinuity problem is the biggest medical mystery that has yet to be solved.

Psychiatry has the most potential to advance of any field in medicine. In many other medical fields, the broad strokes have already been written and just minor footnotes are being appended.

With psychiatry, its totally different. There are huge, major discoveries at a level thats far more fundamental to human medicine than anything the other specialty fields have to offer.

 

[DD214_DOC]

This is good news indeed. It sounds like a very promising field. Could you clarify exactly what C-L psych. is, though? I skimmed through your post and surmised that C-L psych is the treatment of mental conditions as a result of being diagnosed with or having an illness?

Thanks for the heads up. As a future DO and possibly psychiatrist, I will definitely keep my eye on this one. I remember talking to a PA at my doctor's office one day while being examined. I told him I was interested in psychiatry, and he told me how, "this area needs them badly -- you could become a very, very wealthy man doing that here." While I'm not highlighting the money facet, is there really a shortage of psychiatrists?

 

[Sanman]

I believe it stands for consultation-liason psychiatry. As for a definition, someone lese is gonna have to help me out.

 

[Big Lebowski]

C-L is consult/liason. It is basically just like any other consult service. For example, a patient gets admitted to a medicine service for some reason or another but has compounding psychiatric issues. A medicine may ask a psychiatrist to consult on their patient while in the hospital.

 

[PublicHealth]

Originally posted by JKDMed
This is good news indeed. It sounds like a very promising field. Could you clarify exactly what C-L psych. is, though? I skimmed through your post and surmised that C-L psych is the treatment of mental conditions as a result of being diagnosed with or having an illness?

Thanks for the heads up. As a future DO and possibly psychiatrist, I will definitely keep my eye on this one. I remember talking to a PA at my doctor's office one day while being examined. I told him I was interested in psychiatry, and he told me how, "this area needs them badly -- you could become a very, very wealthy man doing that here." While I'm not highlighting the money facet, is there really a shortage of psychiatrists?

Wow, this is the most action this forum has seen in weeks!

Although I cannot cite official sources (partly because I just woke up), I have heard from various sources that psychiatrists are in high demand. Reasons cited include: increase in psychiatric morbidities (think anxiety disorders in the wake of 9/11, depression, autism, ADHD, etc.), lack of interest in psychiatry among medical students, insurance issues pertaining to psychiatric services, and "emotional stress" of dealing with the mentally ill. There are others, but these are the most salient.

If you get a chance, shadow some psychiatrists in inpatient and outpatient services to get a sense of what they do on a daily basis. Many have balanced active research programs into their schedule, which allows them to help advance the field while treating patients.

At this point in my career (applying to med school), I can think of no other field that would provide as much day-to-day fulfillment and opportunities as psychiatry. I'm glad to hear that others feel similarly.

Cheers,

PH

 

[psyuk]

Psychiatry will be the biggest medical field of the future. We know pretty much how the heart and kidneys work. By comparison, we know almost NOTHING about how the brain and behavior work.

The brain-mind discontinuity problem is the biggest medical mystery that has yet to be solved.

Psychiatry has the most potential to advance of any field in medicine. In many other medical fields, the broad strokes have already been written and just minor footnotes are being appended.

With psychiatry, its totally different. There are huge, major discoveries at a level thats far more fundamental to human medicine than anything the other specialty fields have to offer.

macguyver, you are my hero!!!!

 

[DD214_DOC]

I've pretty much ruled out any medical field. I agree with what has been said regarding psychiatry, and it is currently in battle with surgical fields (I like to use my hands). I'll try to shadow some psychiatrists sometime soon.

Thanks for the great info guys.

 

[Thewonderer]

For me, I do believe that there is a shortage of psychiatrists. However, that being said, I don't see it being a ludicrative field for any time soon.

Traditionally, psych illness has stigma and moral values associated with it. Whether you like it or not, many people continue to treat psych illnesses not as diseases but rather "moral failings." These are not going to change. Plus, it is easy for government to cut fundings. They cannot justify budget cuts to police force nor education but cutting psychiatric services available in the county mental health center and state psychiatric hospital is easy. Cut into this area in general does not generate a lot of political opposition.

I think this is a turbulent time for psychiatry. Many hospitals have cut their psych units from 5 down to 1. Isn't Brigham and Women totally done away with its inpatient psych? Hospitals are getting rid of inpt psych in favor of the more ludicrous outpt psych services. But even that, because psych is not procedure-based (other than electroconvulsive therapy), psych is not a money-making machinery despite the perceived shortage of psychiatrists.

The reasons for going into psych should be based on enthuasiasm regarding the specialty and on the rare opportunities to work with pts who are otherwise shunted by the society. however, money definitely should not be in the equation because I can only see it getting worse with state budget cuts and HMO penetration (they already mess up the psych services in California).

 

[ckent]

Originally posted by MacGyver
Psychiatry is the most diverse multifaceted aspect of medicine.

By comparison, all other doctors are simple pill-pushers and knife-wielders.

Psychiatry is the ONLY branch of medicine that does not rely exclusively on a disease-biology model.

Psychiatry has 4 major perspectives, with disease/biology being only one of them.

You clearly lack any experience of actually being on the other side of the table as a health care provider. Just to give you one statistic, ~40% of patients GI docs are consulted are eventually diagnosed with Irritable bowel syndrome, a syndrome that many, if not most, GI docs believe a patient's own psycho-pathology plays an almost predominant role in. Doctors may not tell patients that they "it's all in your head", but they are thinking it and seeing it very often in just about all specialties. Even when there is real "biological" pathology involved, psycho-somatic responses frequently contribute significantly to a patient's complaints (eg asthma, I even have a patient with Cystic fibrosis that is a real, debilitating, fatal disease, but even my pulmonology attending was saying yesterday 'her life revolves around her disease' after listening to many of her complaints). There isn't a disease out there that isn't influenced by a patient's psycho-social condition, and you'd be hard pressed to find a physician who won't acknowledge it. Granted, many don't do anything to treat it like a psychiatrist would, but that's why they are psychiatrist. And all other doctors besides psychiatrists are "Simple pill pushers and knife wielders"? The only other thing that psychiatrists will sometimes, and I emphasize sometimes, do besides "push pills" is therapy. And at then end of the day, therapy is basically just talking to the patient and trying to make the patient feel better or see things differently, something again, that just about all physicians do.

 

[DD214_DOC]

Therapy is more than talk my friend, though it may appear otherwise from the other perspective, just as surgery may appear to be nothing more than legalized assault.

 

[MacGyver]

Originally posted by ckent
You clearly lack any experience of actually being on the other side of the table as a health care provider.

I'll put my clinical experience up against yours any day of the week pal

Just to give you one statistic, ~40% of patients GI docs are consulted are eventually diagnosed with Irritable bowel syndrome, a syndrome that many, if not most, GI docs believe a patient's own psycho-pathology plays an almost predominant role in.

So? GI docs largely ignore anything that doesnt fit into a disease/biology model.

Doctors may not tell patients that they "it's all in your head", but they are thinking it and seeing it very often in just about all specialties.

If thats how YOU really view the human condition, then you are destined to be a poor doctor.

these people are suffering from real conditions. Anybody that goes by the "its just in your head" nonsense is an absolute fool.

Even when there is real "biological" pathology involved, psycho-somatic responses frequently contribute significantly to a patient's complaints (eg asthma, I even have a patient with Cystic fibrosis that is a real, debilitating, fatal disease, but even my pulmonology attending was saying yesterday 'her life revolves around her disease' after listening to many of her complaints).

So what? That doesnt lessen what psychiatrists do.

There isn't a disease out there that isn't influenced by a patient's psycho-social condition, and you'd be hard pressed to find a physician who won't acknowledge it.

You totally misread my comments. I NEVER said that only psych diseases are affected by psychosocial circumstances.

I said that psychiatrists are the ONLY people who do a real analysis of psycho-somatics. All other docs, by and large, just blow it off and dont even address it at all.

Granted, many don't do anything to treat it like a psychiatrist would, but that's why they are psychiatrist.

Fine, then submit to my point that psychiatrists are the only docs who do a thorough analysis of a patients condition based on factors OTHER than disease/biology.

And all other doctors besides psychiatrists are "Simple pill pushers and knife wielders"?

Yeah thats right. Its incredibly complicated to cure someone of depression. For high blood pressure, the treatment is much more direct, repeatable across multiple patients, and "cookie-cutter" molded.

The only other thing that psychiatrists will sometimes, and I emphasize sometimes, do besides "push pills" is therapy. And at then end of the day, therapy is basically just talking to the patient and trying to make the patient feel better or see things differently, something again, that just about all physicians do. [/B]

You obviously know nothing about psychiatry. Next time you want to cast doubt on someone's clinical experience, you might want to check your own first.

 

[ckent]

Originally posted by MacGyver
I said that psychiatrists are the ONLY people who do a real analysis of psycho-somatics. All other docs, by and large, just blow it off and dont even address it at all.

Fine, then submit to my point that psychiatrists are the only docs who do a thorough analysis of a patients condition based on factors OTHER than disease/biology.

Yeah thats right. Its incredibly complicated to cure someone of depression. For high blood pressure, the treatment is much more direct, repeatable across multiple patients, and "cookie-cutter" molded.

You obviously know nothing about psychiatry. Next time you want to cast doubt on someone's clinical experience, you might want to check your own first.

Ok, I won't argue with most of your points because again, a lot of them make no sense to me as a fourth year medical student. Suffice it to say, I have treated patients with major depression and hypertension before, and I guarentee you that treating major depression with psychosis and suicidal ideation is a *lot* easier then treating someone with hypertension and end-stage renal disease as far as today's medications go. As far as psychoanalysis in concerned, only the old psychiatrist still do it as most studies have proven that it is worthless. The standard psychiatry history and physical sheet might be slightly more "comprehensive" then other specialties when you are talking about a person's psych history, but every good physician takes a social history, and even on my pulmonary consult forms, there is a section asking what the patient has in the way of support systems. As far as "psycho-somatics" go, the vast majority of them are actually not treated by psychiatrists as they routinely refuse to go see one or they get upset when it's even brought up, and thus they are treated by whatever specialty happens to cover their "disease". I do agree that psychiatrists are the best trained to treat psycho-somatics though, but they generally don't get the opportunity until very late in the "disease" or until the patient finally gains some insight. And finally, many psychiatrist would argue with you regarding how they view things in a way other then "disease/biology", as that is the direction that a lot of psychiatrist would like to see their field head and that is where most of their diseases, if not all of their diseases, presently lie. Nobody asks a schizophrenic what it was like for him growing up anymore to try and "psychoanalyze" him and figure out why he's acting so crazy. It's what you call "biology". Cheers.

 

[Sonya]

I believe there is a high demand for psychiatrists, but not PAID ones. What i am trying to say is there is a great need for psychiatrists, but with changes like HMOs, insurance policies, etc (thewonderer said it well), there is not money to pay for them. so, often they also end up practicing as GPs.

 

[MacGyver]

Originally posted by Sonya
I believe there is a high demand for psychiatrists, but not PAID ones. What i am trying to say is there is a great need for psychiatrists, but with changes like HMOs, insurance policies, etc (thewonderer said it well), there is not money to pay for them. so, often they also end up practicing as GPs.

I've never heard of a single psychiatrist who was unable to find a job and make at least 130k per year.

Many GPs make under 100k

 

[Thewonderer]

Originally posted by ckent
And at then end of the day, therapy is basically just talking to the patient and trying to make the patient feel better or see things differently, something again, that just about all physicians do.

Most doctors in medicine or sugery don't even bother talking to patients to make them feel better or see things differently. As a med student, yes, since you have time to talk to pts while you rotate through medicine or surgery. But no, your residents do not because they need sleep. And no, your attendings do not because they don't get paid for talking to their patients (but they do get paid for 5 minute post-op check in their clinic to make sure the wound is not infected).

Psychoanalysis is not "useless." It is useful for psychiatrists to understand their patients and useful for certain psychiatric illnesses such as those involving characterology or basically personality disorder problems. Remember, the pts need to have the capability to gain insight and must be at least average in intelligence in order to use it. Therefore, that rules out all pts with mental ******ation, those with schizophrenia, etc. Also, remember, Freud was never stupid enough to use psychoanalysis on schizophrenic pts; in fact he avoided them. And there is a reason. Psychoanalysis got a bad name because, think about it: other than psychoanalysis, what weapons did psychiatrists have to treat people with mental illness before the advent of SSRI's, etc.? Nothing other than psychoanalysis. For them, they had to use analysis on every patient back then! Therefore, of course, it does not work on many of these patients because schizophrenia is not going to respond no matter how many days and nights you spend with the patients. But now that we have some psychotropic meds, hopefully psychoanalysis will regain and readjust to its rightful place, namely used ONLY to treat pts who will benefit from it, mostly personality disorders.

another danger of psychoanalysis is when people use it on analyzing "normal" people who do not suffer from psych pathology. That is a wrong way of using it and that makes it acquiring more bad names and making into a pseudoreligion.

 

[ckent]

I think that you are using the term "psychoanalysis" too broadly. The psychoanalysis that I was refering to is what Freud did, the traditional lay in a chair and analyze how your unconscious effects your conscious, and how it all relates back to your parents and id complexes etc. That method of psychology has proven to ineffective in studies for virtually every psychiatric disorder, including depression. The only one that I think that it remotely helps is one of the personality disorders, I can't remember one. The vast majority of psychiatrists and psychologists accept this, and therefore you'd be hard pressed to find someone doing psychoanalysis who isn't a "crack-pot" or really old. Almost all psychologists and psychiatrists who do therapy do some form of "talk" therapy. They actually did a study and even those psychologists who consider themselves "strict cognitive behavioralists" ended up not doing cognitive behavioral therapy the majority of the time with their patients, and instead did the more general "talk" therapy. There's one other big form of therapy that I"m blanking on right now, I think that it's desensitization, not sure, but even desensitization is only used for phobias. So the only therapy that has proven effective for depression is really CBT, which is essentially talk therapy. Talk therapy is essentially one person listening to someone and trying to give them insight, and being supportive. I'm no psychiatric expert, but this is my understanding of it. As far as in-patient psychiatry is concerned, there is virtually no psychotherapy going on with the psychiatrists. They do have group therapy and life-training, but with insurance companies these days, it's just a progress note and discharge usually before the medications have even had a chance to start working. And just because you don't see your attendings talking to patients, it doesn't mean that they don't. Especially in private practice, I've noticed that patients usually get to know their physicians fairly well, even the surgeons. Even after the surgery and post-op period, the patients usually follow up for several months to years depending on their disease. I think most residents, like med students, know to try to say a few kind words or be supportive if they notice that their patient is really upset about something, they aren't robots. The only exception I guess would be the interventional radiologists, I've never seen them really talking to patients. I am actually a big believer in therapy, as I've been in it myself and it's really useful when things are overwhelming to have someone to talk with who won't turn it against you one day.

 

[watto]

Word. Psychoanalysis cannot be discounted for things like personality disorders - I know for borderlines it is one of the best ways to go, possibly after an early round of interpersonal group psychotherapy.

And it's not as though there's only one form of psychoanalytic practice--though Freud's explanations may be lacking, his discussion of transference and countertransference has been updated by others so that it can be used in different models.

It's not easy to do psychoanalysis. Ordinary conversation with a psychiatric patient can be a minefield. Saying the incorrect thing can be negatively therapeutic. Many physicians, including inadequately trained psychiatrists, are guilty of this.

I guess what I'm trying to say is that psychotherapy isn't as easy as it sounds. Or, if it is, you're doing it wrong.

 

[watto]

Oh sorry, one more thought. One thing I read that made a lot of sense re: this subject was from a psychiatrist who commented that meds grease the wheels for psychotherapy and psychotherapy made it easier for the meds to work. Symbiosis.