Psychiatry should have a prelim year

[Ludwig2000]

I’m a psych intern and while the instant gratification part of me is happy that I don’t have to slog through medicine for a year, I am really feeling like it was a mistake for psych residency to have stopped requiring a full prelim year. I don’t think I’m the only one who feels this way, although it may be a rarer sentiment amongst people my age than the old guard. But I feel like a lot of the anxieties some have around psychiatry- “putting down the stethoscope,” mid-level encroachment to name a couple, would be well allayed by a prelim year. Psychiatry should be a medical specialty. That’s where we fit into the mental health field. If we don’t get full-on intern training, I feel some of even that niche is lost to us. We’ve already given away psychoanalysis, and we are currently giving away our prescription rights. But I think there would be major systemic benefits to our being more medically confident going into psych residency. Again, it should be a specialty. We can say Oh but the psych floors still wouldn’t have staff that would do blood draws, we’d still have to consult medicine for DM/HTN, blah blah blah, but I think if SOME “medicalization” of psychiatry were occurrring just at the level of residents, maybe some of the rest of the cultural and systemic changes would follow. Am I right? Am I wrong?

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[liquidshadow22]

Until our understanding of Psychiatric illness and treatments advance, you will not see this shift in training. Right now, the necessity for further medicine training is not there. Normal prelim year would do nothing to protect against mid-level encroachment. Same thing is happening in IM and FM.

If our treatments become more medicalized, (higher risk of side effects and more biological based monitoring), then I could see this shift.
For example if we identify more autoimmune causes of depression that require more medicalized treatments, then you might see a more systematic push for this. There is a reason why there are only a handful med/psych units in the country, the need just is not there.

 

[Mad Jack]

I’m a psych intern and while the instant gratification part of me is happy that I don’t have to slog through medicine for a year, I am really feeling like it was a mistake for psych residency to have stopped requiring a full prelim year. I don’t think I’m the only one who feels this way, although it may be a rarer sentiment amongst people my age than the old guard. But I feel like a lot of the anxieties some have around psychiatry- “putting down the stethoscope,” mid-level encroachment to name a couple, would be well allayed by a prelim year. Psychiatry should be a medical specialty. That’s where we fit into the mental health field. If we don’t get full-on intern training, I feel some of even that niche is lost to us. We’ve already given away psychoanalysis, and we are currently giving away our prescription rights. But I think there would be major systemic benefits to our being more medically confident going into psych residency. Again, it should be a specialty. We can say Oh but the psych floors still wouldn’t have staff that would do blood draws, we’d still have to consult medicine for DM/HTN, blah blah blah, but I think if SOME “medicalization” of psychiatry were occurrring just at the level of residents, maybe some of the rest of the cultural and systemic changes would follow. Am I right? Am I wrong?

Most psychiatry programs have their residents medically manage all but the most complex patients on the psych floor. This keeps your feet wet enough to handle most of what you will see in psychiatry. We have a couple of residents in my program that did prelims after not matching, and they have basically forgotten most of the day-to-day management by the end lf second year. Gaining a few extra months of medical experience at the cost of a few months of psychiatry may improve your medical skills, but it would likely reduce your psych skills as a fresh attending.

 

[Taddy Mason]

... We’ve already given away psychoanalysis...

Psychoanalysis was never “ours” to begin with.

 

[Ludwig2000]

Until our understanding of Psychiatric illness and treatments advance, you will not see this shift in training. Right now, the necessity for further medicine training is not there. Normal prelim year would do nothing to protect against mid-level encroachment. Same thing is happening in IM and FM.

If our treatments become more medicalized, (higher risk of side effects and more biological based monitoring), then I could see this shift.
For example if we identify more autoimmune causes of depression that require more medicalized treatments, then you might see a more systematic push for this. There is a reason why there are only a handful med/psych units in the country, the need just is not there.

I like the argument, but my feeling is that the current cultural gestalt is such that if we do identify an autoimmune cause of a subtype of depression- whatever that disease gets named will no longer become a psych-managed disease. Similar to anti-NMDA encephalitis. I want to preempt the medicalization of psychiatry so we don’t keep giving our field away

 

[Ludwig2000]

Psychoanalysis was never “ours” to begin with.

There was a time when only doctors could practice it

 

[romanticscience]

Couldn't you just craft your own "prelim" year with extra medicine electives (eg, toxicology, neurology, palliative care, oncology)? Albeit, you would have to defer them to PGY-3/4. Also, I'm sure no one would mind if you drew blood or performed minor procedures on your psych patients.

One thing to consider is the scope of practice as defined by your malpractice insurer. Yea, you can legally do anything as a licensed MD. But, are you insured to do it? If I told my medmal company that I was drawing blood, giving TB tests, and suturing up my cutters, my rates would probably increase to that of an internist.

I went to a residency notorious for demanding medical competence among its trainees (eg, we have call shifts where we are the only in-house medical coverage for the whole 300-bed psych hospital which includes a geri/med-psych unit). They said it somehow increased our respect in the hospital at-large and among other trainees. Who knows? I wouldn't do any more medicine just to feel equal to my pain med-school classmates.

You may want to look into residencies where the demand to learn medicine was like mine (eg, hopkins and MGH). I think they have you do like cardiac ICU lol. As much as I liked the Perspectives of Hopkins, it kept me from applying.

 

[calvinhobbes]

Most programs already make you do at least 6 months of medicine (or peds, or mix of both if you want and the program offers it) in the first year. So a prelim is not really needed.

 

[erg923]

There was a time when only doctors could practice it

Because why?

 

[Stagg737]

I like the argument, but my feeling is that the current cultural gestalt is such that if we do identify an autoimmune cause of a subtype of depression- whatever that disease gets named will no longer become a psych-managed disease. Similar to anti-NMDA encephalitis. I want to preempt the medicalization of psychiatry so we don’t keep giving our field away

If a patient on the med floor gets identified as having an autoimmune cause of a subtype of X condition, the IM/FM docs are also very unlikely to be the ones managing the disease, as it'll get automatically referred to a specialist. I don't really think knowing which specialist to consult is really a valid reason for a full intern year.

I can appreciate your sentiment with the thread, but if one is really concerned about getting an adequate gen med education with their psych residency there are other ways to do this. Look for programs with a high med-psych presence, ask current residents what they're expected to medically manage vs. punting to others, find out when other didactics are and attend them when able (something that can be reasonable for psych that isn't for most other fields).

 

[Monocles]

Absolutely not. If psychiatry trainees love medicine then they should feel free to ask for additional "medicine" rotations on a voluntary basis or pick more psychosomatic electives as a pgy-4. No need to impose it on the rest of your cohort.

(Disclaimer: I am biased though. Haven't seen my stethoscope since intern year and my white coat since MS3...)

 

[adaptation1]

An extra 6 months of medicine during training is not going to make Psychiatry more medicalized. I'm not sure Derm is more medicalized because of a prelim year - it's the fact that they are working with something visible. The reason psychiatry is less medicalized has to do the nature of the pathology. Until the day arrives that we can diagnose Schizophrenia or Depression with a scan or blood test....

 

[ERK123]

When was the last time psych had a full intern year, the 1970s? This seems like a horrible idea. None of your justifications make much sense to me. What exactly is the benefit of us doing several months of MICU and CCU?

 

[Sushirolls]

To answer OP question, wrong.

 

[adiradirim]

Normally I would agree with this, but there is so much of IM/FM/EM/Peds that is so out of the scope of the normal day to day practice of psychiatry, that it would be a giant waste of time to spend months doing it. I could see some acute visits being helpful with URIs, UTIs, rashes, skin infections etc., but how many pap smears, rectal exams, OCPs, or screening colonoscopies do I have to do to become a psychiatrist?

You're better off doing psych-adjacent rotations like neurology, movement disorders, neurodevelopmental, neuro-radiology, sleep, headache, pain, eating disorders, or gender clinics to get the medical aspect of it. If it was available, you could make a pretty robust intern year and I think some of these rotations will make you a better psychiatrist depending on your future plans.

 

[Celexa]

Hard no from me on a prelim year. However I would be in favor of more standardization and rigor in the medical experience accross medical schools and residencies. Low rigor in medical school rotations + no required M4 non-psych subi + low expectations/low responsibility/low volume off service rotations for psych interns can def lead to problematic medical knowledge deficits. but that's a function of quality, not quantity.

 

[dl2dp2]

The field IS getting more medicalized, but in a completely different way that's outside of the routine practice of internal medicine. Routine internal medicine is a poor entree into newer somatic treatments as delivered. I actually see it as more of an integrated IR track--possibly more procedurally oriented "fellowships" done during 4th year.

 

[michaelrack]

Because why?

Only MD's could do psychoanalysis initially because Freud was physician... and the psychoanalytic institutes required an MD (or the European equivalent).

 

[michaelrack]

Personally, I feel that Neurology and Psychiatry should have the same requirements for an intern year

 

[erg923]

Only MD's could do psychoanalysis initially because Freud was physician... and the psychoanalytic institutes required an MD (or the European equivalent).

I am aware. I was asking really/actually, why?

As in....more than an "appeal to authority" argument. Perhaps there is not one? Maybe there is backstory? More to it?

Maybe there is reason some practitioners hang on to a relatively ridiculous and overly-complex and non-parsimonious explanation of human behavior, whilst the rest of the behavioral sciences moves on? Just wondering...

 

[NontradCA]

I am aware. I was asking really/actually, why?

As in....more than an "appeal to authority" argument. Perhaps there is not one?

Probably because Psychiatry was more paternalistic and elitist than it is now? I can’t be sure, but every time I read about the history of psychiatry that’s what I find.

 

[ERK123]

I am aware. I was asking really/actually..... why....as in more than an appeal to authority argument?

Freud is irrelevant to this question, especially after he expired (1938?)

I think the only reason is that physicians wanted a monopoly on psychoanalysis for financial reasons and prestige. I don’t think it had anything to do with Freud. This is one reason why psychology is so CBT oriented due to the long held discrimination against them becoming psychoanalysts. This has been quite consequential as so much of the therapy based research is performed by PhDs who are much more well versed in CBT than psychoanalytic principles.

 

[Sushirolls]

Personally, I feel that Neurology and Psychiatry should have the same requirements for an intern year

Would it really change the quality or practice style of post residency physicians? I.e. would Neurology be more adept at handling their psychosomatic patients? Would Psychiatrists be more adept at spotting neurological conditions?

I doubt it. And personally even if I were more Neuro inclined, I wouldn't want to do the next step in work up of imaging, EMG, LPs, etc because all of those now take more insurance prior authorization or office infrastructure. No thanks.

 

[erg923]

This is one reason why psychology is so CBT oriented due to the long held discrimination against them becoming psychoanalysts.

The objective results of the 30 years prior were fantastic? Don't think so. Lets not simply it too much...k?

 

[ERK123]

The objective results of the 30 years prior were fantastic? Don't think so. Lets not simply it too much...k?

I don’t understand your comment

 

[Armadillos]

Don’t see much utility in more general medical training intern year, it’s so unrelated to general practice of psych that even if you finished intern year at same level of medicine resident by time you get to be an attending you’ve completely forgotten it. Would be better use of training to get more practicing managing TCA and MAOIs than most of us do instead of extra gen med

 

[Bartelby]

A psychiatrist (by intern year) has two years of studying basic medical science, two years of medical school clinical rotations, and six months of medicine + neurology. The large majority of that time is spent on topics other than psychiatry. If we added six more months of medicine in intern year, psychiatrists might feel somewhat more comfortable managing typical IM issues, though we typically don't really need to manage those and the patient would be better served by an internist who will remain up to date on the incredible breadth of issues they handle. Meanwhile in order to gain those six months of medicine you have to give up six months of something within psychiatry; psychotherapy time, elective rotations in subspecialty clinics, etc. That trade-off does not seem worth it to me.

 

[whopper]

Just my opinion.

The non-psych training in residency should be done first. I've noticed that psych residents that start out later aren't up to speed with their IM colleagues on the IM stuff and the breaking-in period of the first 3 months those residents already had done, but psych residents aren't broken-in in that same manner. So say psych resident is in their 6th month and starts IM, he/she's treated as the village idiot and not expected to do anything serious such as see patients in the ICU, handle IVs, even the minor procedures, etc.

Also abnormal psychology, psychometric testing, and post-introductory statistics should be taught as if credit courses, not a lecture where you just show up and if you're post-call you can sleep through it. I still see several psychiatrists who don't understand abnormal psychology on a basic level and start misdiagnosing based on any complaint. "My husband was looking at another woman he must have OCD!"

Those courses should be taught 3rd year, the year where in many residencies things get much easier due to the reduced call schedule. The problem being that the residents will actually have to take a real statistics course and medical schools don't have a math professor on board for this.

 

[Mass Effect]

You're better off doing psych-adjacent rotations like neurology, movement disorders, neurodevelopmental, neuro-radiology, sleep, headache, pain, eating disorders, or gender clinics to get the medical aspect of it. If it was available, you could make a pretty robust intern year and I think some of these rotations will make you a better psychiatrist depending on your future plans.

Agree with the above. The lack of the above in psychiatry residency is a shame as there is quite a bit of overlap. I have a lot of patients on my panel with ASD, sleep disorders, movements disorders, and chronic pain. I also went through all of residency and treated a grand total of 2 eating disordered patients.

 

[Mass Effect]

Also abnormal psychology, psychometric testing, and post-introductory statistics should be taught as if credit courses, not a lecture where you just show up and if you're post-call you can sleep through it. I still see several psychiatrists who don't understand abnormal psychology on a basic level and start misdiagnosing based on any complaint. "My husband was looking at another woman he must have OCD!"

This. Psych residency should not assume that everyone was a psychology major in college. Much of this stuff is not taught at any decent level in residency. You may have one lecture on biostats or psychometric testing and if you're post call or on vacay, you miss it. So much basic psychology/abnormal psychology knowledge (read: not necessarily therapy) missing from training.

 

[comp1]

Extraordinarily hard no from me. I work on a psych unit where we have to manage minor medical illnesses, but it's also the only one like that for about 75 miles around. Everywhere else has an internist who does that. Concur with the above insurance argument and we do NOT need internist level malpractice costs. They certainly don't get paid more for it. Just because you learn something in residency does not mean you're going to retain it, particularly if the system isn't set up for you to use it. Also, I'll admit that I chose psychiatry because I really didn't like what the rest of medicine had to offer. I'm not into the whole hazing culture that goes on in medicine and surgery.

 

[Merovinge]

This. Psych residency should not assume that everyone was a psychology major in college. Much of this stuff is not taught at any decent level in residency. You may have one lecture on biostats or psychometric testing and if you're post call or on vacay, you miss it. So much basic psychology/abnormal psychology knowledge (read: not necessarily therapy) missing from training.

Statistics at least has been much more heavily emphasized in both med school and on the STEP exams (which is great IMO). I'd be more than a bit concerned about leaving this type of training to 3rd year in residency, however actual (mandated) journal clubs are a great chance to apply the statistics to real research. My adult and child training both had one of the very top academicians from the respective program lead journal club and it was easily one of the best learning experiences.

 

[FlowRate]

Personally, I feel that Neurology and Psychiatry should have the same requirements for an intern year

Why? Neuro actually does medicine stuff throughout their residency.

 

[Old&InTheWay]

A prelim year would be terrible. You would end up doing a full year of hospital medicine including multiple months of ICU. I really feel like we should be exposed more to outpatient medicine, as the issues dealt with in the clinic are those we are most likely to encounter in psychiatry. There are combined IM/Psych and FM/psych residencies for people who want to do medicine in addition to psych.

 

[Mass Effect]

Statistics at least has been much more heavily emphasized in both med school and on the STEP exams (which is great IMO). I'd be more than a bit concerned about leaving this type of training to 3rd year in residency, however actual (mandated) journal clubs are a great chance to apply the statistics to real research. My adult and child training both had one of the very top academicians from the respective program lead journal club and it was easily one of the best learning experiences.

I don't think you should leave it solely to PGY 3 year. But the biostats I learned in med school was very basic. I think residency should expand on it and delve deeper into what the numbers really mean particularly in context of journal articles as you said.

 

[clausewitz2]

I don't think you should leave it solely to PGY 3 year. But the biostats I learned in med school was very basic. I think residency should expand on it and delve deeper into what the numbers really mean particularly in context of journal articles as you said.

Don't forget basic philosophy of science/ philosophy of medicine stuff like 'why RCTs don't license the inferences you think they do and aren't always strictu sensu the best form of evidence,' 'why your confidence intervals do not mean what you think they mean' and 'basic conceptual analysis and the dog's breakfast you have to choose diagnosis codes from.'

Epistemic humility in general would be a tremendous blessing for many colleagues I have worked with, even if they don't realize it.

 

[whopper]

This. Psych residency should not assume that everyone was a psychology major in college.

I majored in psychology in college and noticed in residency I was strongly differing in opinions with several attendings. Of course I kept my mouth shut or was diplomatic. I even speculated maybe I was being a bit narcissistic and that they must know more than I did. No. I mentioned this on the forum but the head of my department asked me to work for the department my 4th year and told me I was better than more than half the attendings in the department and my episodes of self-doubt were not warranted.

I remember at times I'd ask for a psychology consult to the attending (and we had a psychologist in the hospital) and the attending was like "why?" And instead of opening his mind and looking into it was dismissive. E.g. we had a patient with head trauma I told him that we ought to do some testing on his cognition. It turned out the guy had the mentality of simply medicating patients then discharging them instead of trying to figure out what was going on for real.

Add to this in fellowship I worked with a top forensic psychologist ( this guy that worked with Paul Applebaum for years), and he filled in the psychology training I (and pretty much every resident) should've had in residency. I'd sometimes ask him to do a consult in the hospital floor (we all worked in the same university) for really really tough cases. E.g. a guy in the unit that you just know will commit suicide not now, but maybe months from now and you can't hold him against his will cause it's not an immediate desire. I also had a very weird case of first-break psychosis in a 60's year old where all the the usual labs were normal (TSH, UDS, BMP, LFT, UA, CBC w/ diff) and the guy did major testing on that patient showing he likely wasn't faking it, that his cognition was intact, but his paranoia was off the scale. Turned out he had antiphospholipid antibody disorder that was likely causing the psychosis. The psychology testing significantly helped me lock-on this was psychosis, and not something else.

 

[Mad Jack]

Personally, I feel that Neurology and Psychiatry should have the same requirements for an intern year

Neuro has 6 months of medicine, 2 months of other specialties. Psych is 4 months of medicine, 2 months of neuro. We could increase psych to 6 months of medicine and 2 months of neuro, but I really doubt those two months are going to be life changing

 

[Liquid8]

Having trained in a system where after graduation every doctor does a general internship year (mandatory rotations in general medicine, surgery, ED plus optional terms in general practice, nights, psych etc) before being able to apply for further specialisation, I can’t say that I’d be a worse doctor for having done it and there are things that I still use now. However, the longer one goes from their basic medical training it’s more likely that a more conservative approach will be adopted we won’t be actively keeping up with that area of medicine - knowing what you don’t know and what is outside your area of expertise is also important.

OTOH, if I hadn’t gone through a general internship, I may have well picked up some of that knowledge through other means. Without having gone through a US style programme where early specialisation is the norm, it is hard to specify, because a lot of those things flow automatically and I’m not consciously thinking if I learnt something from internship or during my psychiatry training. For us, one of the criteria for applicants to psychiatry training looks at their competence in general medicine, as mandatory training rotations in CL and Aged are going to have you dealing with patients with multiple medical comorbidities.

Here doctors considering applying for psychiatry are often encouraged to work a second general year to broaden their experiences prior to going down the specialisation route. I think breadth of experience is probably more important than overall time outside of psychiatry, afterall there are overlaps in almost every other area.

 

[MrFlyGuy]

Psychiatry should be a three year residency. Fourth year for people not going into CAP is completely unnecessary. This is especially true in the age of Noctor. It blows my mind that the NP student at my program asked me to look over her progress note because no one has ever reviewed hers before and she is going to be independently practicing in 3 months while I'm going to be a mid year intern.

 

[samac]

As someone who just did their first day back on psychiatry after a series of off service months:

 

[Sushirolls]

Psychiatry should be a three year residency. Fourth year for people not going into CAP is completely unnecessary. This is especially true in the age of Noctor. It blows my mind that the NP student at my program asked me to look over her progress note because no one has ever reviewed hers before and she is going to be independently practicing in 3 months while I'm going to be a mid year intern.

There are "specialist" NDs in Psychiatry, too.