Psychotherapy vs. Biological training

[PsychDOMBA]

How do you know if you want more of a psychotherapy based training or a biological training? I understand all programs have to do both, but there are definite residency programs that offer more of one vs. the other.

Thanks!

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[Manicsleep]

Are you interested in either one more than the other?
Are you interested in certain fields or subspecialties within psychiatry?
Do you actually want to subspecialize?
Are you particularly weak certain areas?
Do you know what you want to do when you grow up in terms of private practice, HMO, academics, government etc?
How much is location a factor for both practice and residency?
If yes, what location?

What do you consider biological and what do you consider psychotherapy?

Some questions to think about and clarify in your head. It would also allow people to give you better answers but I think it will allow you to answer the question yourselves. How does that make you feel?

 

[whopper]

This is a tough subject to answer because any program will likely be able to offer more than the overwhelming majority of new residents will know in the beginning no matter how good or bad that program is in either area.

IMHO psychiatry programs at the very least should teach the following (and most do not).
Dialectical Behavioral Therapy: how to do it for real, not just know that DBT is the treatment for borderline PD as the answer to the board exam.

In addition to the above, CBT (and all of it's variations such as exposure therapy), psychodynamic based therapy, object relations, and family therapy.

Most programs I know of only give training in brief supportive therapy, and when I say training, I mean they stick you with a patient and expect you to learn it on your own. Unfortunately, most programs teach residents the above things but not so much in practice. They'll just give reading material stating that treatment X is appropriate for condition Y but not actually show treatment X in practice.

 

[billypilgrim37]

Come on whopper, every program teaches you how to use Depakote, Buspar, and Thorazine to help borderlines regulate their labile affects.

 

[zenman]

How does that make you feel?

What do you think about this question?

 

[Doc Samson]

How do you know if you want more of a psychotherapy based training or a biological training? I understand all programs have to do both, but there are definite residency programs that offer more of one vs. the other.

Thanks!

All programs are supposed to do both, but many pay only lip service to psychotherapy. My recommendation has always been to get good all around training and then you can choose after residency how you want to practice/specialize. Why would you close the door to an entire field of treatment before having tried it? Realistically, this translates to finding a residency with a strong psychotherapy program since all of them will teach you how to manage medication and almost all of them will give you some exposure to ECT. I guess the only outliers in terms of the "biological" approach would be programs that could offer you exposure to psychosurgery or DBS as a resident (a very small group).

 

[st2205]

I guess the only outliers in terms of the "biological" approach would be programs that could offer you exposure to psychosurgery or DBS as a resident (a very small group).

Do elaborate. I always give my obligatory response of psychosurgery any time someone questions the relevance of surgical training for someone intending to go into psychiatry, but would be welcome to knowing more about places that give exposure to this. Would exposure really add anything to training other than experience, I mean it's not as if they'll be able to do anything extra. I'm quite pooped so I hope this made sense.

 

[Doc Samson]

Do elaborate. I always give my obligatory response of psychosurgery any time someone questions the relevance of surgical training for someone intending to go into psychiatry, but would be welcome to knowing more about places that give exposure to this. Would exposure really add anything to training other than experience, I mean it's not as if they'll be able to do anything extra. I'm quite pooped so I hope this made sense.

I doubt there's anywhere that offers psychosurgery rotations as a routine part of their four year curriculum, but I imagine that most of the places that have psychosurgery programs would be open to having elective time or perhaps a fourth-year longitudinal experience with them. In my experience, MGH has a robust psychosurgery program, and I believe that Toronto also has one. DBS is a little more broadly available:

http://www.medtronic.com/your-health/obsessive-compulsive-disorder-ocd/WCM_PROD024701

 

[strangeglove]

Do elaborate. I always give my obligatory response of psychosurgery any time someone questions the relevance of surgical training for someone intending to go into psychiatry, but would be welcome to knowing more about places that give exposure to this. Would exposure really add anything to training other than experience, I mean it's not as if they'll be able to do anything extra. I'm quite pooped so I hope this made sense.

I'm doubtful that in such a situation the surgical team would let a psychiatrist touch the patient with a 10-foot pole. Therefore, I don't think surgical training is of much more relevance here than it is for, say, a C-L psychiatrist.

 

[st2205]

I'm doubtful that in such a situation the surgical team would let a psychiatrist touch the patient with a 10-foot pole. Therefore, I don't think surgical training is of much more relevance here than it is for, say, a C-L psychiatrist.

Sorry I need to reclarify the points I was asking about as I was only half-coherent when they were written. With the subject being about programs being slanted more toward psychotherapy or biology DS responded about psychosurgery. I was curious more about if there was much benefit in really being able to gain exposure to psychosurgery, enough so to say that it would add, in any appreciable amount, a more well-trained psychiatrist in the biological side, so to speak. Thus my question was more along the lines of what kind of benefit would this theoretically have (i.e. would this be a rotational experience that's somewhat novelty in nature [show up, observe, leave] or could it possibly be more focused in being able to get a pretty good appreciation for pre- and post-op care of psychosurgery patients as well getting better training in end-of-the-line refractory mental illness and the type of workups that could/would be done to rule in or rule out candidacy for psychosurgery).

 

[st2205]

Just wanted to give a quick update with some further reading from MGH's site

Although the number of psychosurgical procedures performed in the world today is unknown, it is estimated that fewer than 25 patients are operated upon annually in the United States and Great Britain, while only 1-2/year undergo psychiatric neurosurgery in Australia.

http://neurosurgery.mgh.harvard.edu/functional/Psychosurgery2001.htm

Also, according to the American Society for Stereotactic and Functional Neurosurgery there are 15 Functional Neurosurgery fellowships in the US and 3 in Canada. These programs all focus on movement disorders and seizures, with virtually nothing said for psychosurgery. The only exception was, as mentioned, MGH with quite a bit of detail about psychosurgery.

 

[dl2dp2]

The answer to your question is no. Psychiatry as it is and I think within our lifetime, will remain a non-procedurally oriented specialty. While nobody has a crystal ball, I predict the likely future "procedure" that can be billed for more involves things like medication assisted psychotherapy, ketamine infusion (and other drugs) protocol in acute suicidality, etc. as opposed to transitioning psychiatry into surgery. And even if things like say endovascular intervention for depression emerge, specialties like IR/neuroIR will get the first dip of the pie (as they should...what do we know about blood vessels and catheters???). I do see, though, if DBS becomes more prevalent in refractory suicide/OCD, psychiatrist would learn how to adjust the modulator, like neurologists for Parkinsons and essential tremor. But this is very different from actually performing the surgery itself.

But the idea that the future of psychotherapy, especially intensive, "brain based", pharmacologically assisted, imaging guided, "virtual reality" enhanced, etc. psychotherapy would be a "procedure" that would require a medical license is not that far fetched in my opinion (i.e. maybe within my lifetime). Nor is very specific imaging procedures, say reading SPECT for designing depression medication regimen with computer algorithmic assistance. I think if they can demonstrate real cost effectiveness, Medicare would be willing to allow for charging new procedure RVUs for these. But as it is, these are essentially research programs, not clinical practices. So, to answer your question, if you are interested in DBS, you should look for a program that has a strong DBS research group (i.e. Mount Sinai), as opposed to a big neurosurgery service.

Meanwhile, you can always carve out a niche doing only ECT. I've seen a few attendings doing this. Although if money is your thing ECT doesn't reimburse as well as you think it does.

Sorry I need to reclarify the points I was asking about as I was only half-coherent when they were written. With the subject being about programs being slanted more toward psychotherapy or biology DS responded about psychosurgery. I was curious more about if there was much benefit in really being able to gain exposure to psychosurgery, enough so to say that it would add, in any appreciable amount, a more well-trained psychiatrist in the biological side, so to speak. Thus my question was more along the lines of what kind of benefit would this theoretically have (i.e. would this be a rotational experience that's somewhat novelty in nature [show up, observe, leave] or could it possibly be more focused in being able to get a pretty good appreciation for pre- and post-op care of psychosurgery patients as well getting better training in end-of-the-line refractory mental illness and the type of workups that could/would be done to rule in or rule out candidacy for psychosurgery).

 

[st2205]

The answer to your question is no. Psychiatry as it is and I think within our lifetime, will remain a non-procedurally oriented specialty. While nobody has a crystal ball, I predict the likely future "procedure" that can be billed for more involves things like medication assisted psychotherapy, ketamine infusion (and other drugs) protocol in acute suicidality, etc. as opposed to transitioning psychiatry into surgery. And even if things like say endovascular intervention for depression emerge, specialties like IR/neuroIR will get the first dip of the pie (as they should...what do we know about blood vessels and catheters???). I do see, though, if DBS becomes more prevalent in refractory suicide/OCD, psychiatrist would learn how to adjust the modulator, like neurologists for Parkinsons and essential tremor. But this is very different from actually performing the surgery itself.

But the idea that the future of psychotherapy, especially intensive, "brain based", pharmacologically assisted, imaging guided, "virtual reality" enhanced, etc. psychotherapy would be a "procedure" that would require a medical license is not that far fetched in my opinion (i.e. maybe within my lifetime). Nor is very specific imaging procedures, say reading SPECT for designing depression medication regimen with computer algorithmic assistance. I think if they can demonstrate real cost effectiveness, Medicare would be willing to allow for charging new procedure RVUs for these. But as it is, these are essentially research programs, not clinical practices. So, to answer your question, if you are interested in DBS, you should look for a program that has a strong DBS research group (i.e. Mount Sinai), as opposed to a big neurosurgery service.

Meanwhile, you can always carve out a niche doing only ECT. I've seen a few attendings doing this. Although if money is your thing ECT doesn't reimburse as well as you think it does.

Again, I'd like to reiterate that my statements and questions did not imply surgery having a big part in psychiatric practice or that psychiatrists would ever train to do psychosurgery. The question I asked was if it could be beneficial being exposed to a different population of mentally ill patients, much in the same way that residency is designed to show all ends of the spectrum (i.e. psych in FP, outpatient psych, inpatient psych, involuntary inpatient, ECT, etc.) and not so that psychiatrists would pick up the knife. This is much in the same way that neurology residents aren't rotating through nephrology and psychiatry to be able to run a dialysis clinic or do long-term psychotherapy, but because those are prevelant issues that need to be considered in their practice (I'm not implying psychosurgery ever will or should be prevelant).

In any case, I think some of the confusion may have stemmed from me stating that psychosurgery (i.e. frontal lobotomy) is a response I give to those who question, and therefore subtly disparrage, the necessity of medical (in this case surgical) training to end up practicing psychiatry. I had thought it was understood that this comment is made tongue-in-cheek.