public perception and psychiatrists- how do we change this....

[vistaril]

I know you like to be all negative and stuff, but talking to some of the old guards of psychiatry, the field's respectability has improved SIGNIFICANTLY since the 60s. One of the preeminent psychiatrist/administrators came by and talked to us once and said, back in the days if you went into psychiatry your parents went into mourning. The rise of psychopharmacology and biological psychiatry, as much as many people hate it, has basically put a huge stamp of credibility in the field, in that psychiatry, as opposed to psychology, is a MEDICAL specialty. Ever since then the field has been moving in that direction.

The idea of "more therapy" clearly doesn't work because before meds all we had was therapy, and that's all we did and we were very protective of it. And no, psychiatry was definitely NOT more respectable then.

Basically if you want to improve respectability, you need (1) more pay (2) lots of arcana/evidence/specialized knowledge/cool gizmos (3) exclusivity. The best way to do these things is probably splitting psychiatry into subspecialties and research. i.e. internal medicine/primary care has little respect, but cardiology has oodles. This is really already true--I think subspecialists in psychiatry command a much higher respectability than general psychiatrists even in the public's mind's eye.

don't agree with much of this post....for one psychiatry at one time *did* have more prestige in it's history....in the decade and a half after ww2, a much higher % of american med students entered psychiatry and it was seen differently. The 60s/70s did bring about a different viewpoint....I would certainly argue that 12-15 or so years ago psychiatry was seen in a better light because there was more optimism surrounding psychopharm.....

the rise of psychopharm and biological psychiatry had the potential a while back to transform psych, but that never happened because it turns out the new drugs aren't all that much better(or arent better at all maybe) than the old drugs. ooops.......unless new drugs come out(and there are none in the pipeline), the perception against these drugs that have been out now for 10-15 years is only going to become more negative.

Im not sure what subspecialties in psychiatry you are talking about. There is child(which is debatable whether that is more respected), but the other fellowships(which nobody really does) certainly arent more respected.....there is a reason geri fellowships don't fill. Addiction is something internal medicine, family medicine also does...and is not prestigous in the least. Forensics people associate with prisons. Psychosomatic medicine isn't a real fellowship...that is general adult psychiatry.

Also not sure what 'gizmos' you are talking about. If it's tms....lol.

You're just more optimistic than me.

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[splik]

Psychiatry has only existed less than, what, 100 years? Internal medicine predates the Greeks. (And a lot of people have respect for primary care and general IM. Depends where you go.) I imagine that our "respectability" is similar now to what it was when Freud started the field, which is, not that great but better than nothing.

Freud did not start the field of psychiatry, psychiatry was a product of the enlightenment and the term psychiatry was coined in 1808 by Johann Christian Reil. Freud was not a psychiatrist and did not treat psychiatric patients (i.e. patient with dementia praecox, melancholia, mania etc) he treated patients with hysteria and other nervous disorders that back then would be treated by neurologists. Outside the US, Freud and psychoanalysis never had a discernible impact on psychiatry. There are many important alienists who predate Freud or were contemporary e.g. Pinel, Falret, Morel, Ballaiger, Kraepelin, Maudsley etc.

As for psychiatry being a fellowship of neurology. This is ridiculous largely because there are many many more psychiatrists than their are neurologists, we just don't need that many neurology residents or residencies. Plus most neurology residencies are based in large academic centers because neurology is an academic specialty, whilst psychiatry is far more community based with most programs being affiliated with some medical school but being community based. I like neurology, but my neurology rotation was by far the worst experience of intern year, this might be because the neurology residency is so-called 'malignant' but I would never do psychiatry if I had to waste my time doing a neurology residency first. If people want to do more neurology, you can spend your elective time doing it. Granted, I think they could teach more functional neuroanatomy and cognitive neuroscience in residency, and neurology clinic is a useful experience, but inpatient neurology is largely a waste of time for psychiatrists. There's a reason neurology and psychiatry are no longer one specialty, why we now have our own journals, and combined residency programs died a good death - it just isn't possible to have a sufficiently strong knowledge base for both or keep up to date with both. medicine continues to move towards increasing subspecialization this is a trend that is only going to get worse in the future.

 

[vistaril]

I hear that a lot about neurologists, that they can't stand anything psych related. Do you think the same is true of, say, internists? Or is it just that we work more with neuro so we are more critical of them?

If it was all one residency, and there were some fellowships geared toward psych, then instead of being a PD, you'd be a fellowship director, and presumably those who apply would be very interested in working with the mentally ill. Likely they would be a bit burned out though from having had to learn epilepsy and strokes, etc.

But under your scenario *everyone* would pretty much end up having to do 6 years(rather than 4) to end up doing what they want. I think we both graduate in a few months right? I'm going off and doing something I feel *more than competent* to do....I have no absolutely no interest in diagnosing and treating acute strokes or multiple sclerosis or doing EMGs. I would be extremely unhappy if I was looking at another 2 years to do what I want to do(treat SMI patients and do suboxone) because I had to spend gobs of time learning how to work up stroke, when to give TPA, epilepsy, etc.....

There are a lot of people who already complain that the medical training model is too ineffecient....4 years of med school + internship(for most things) + residency + fellowship(for many fields, not so much psych).........by extending this even more by combining general neuro and general psych training, that just adds even more to an inefficient model. And Im pretty sure in a 1+3 'clinical neuroscience' residency a fellowship would most certainly be required to gain any real degree of expertise in an area you really wanted to work in.

 

[FLpk1girl86]

A federal prosecutor who graduated from Duke law school asked me at a bar tonight to explain to him the difference between a psychiatrist and a psychologist. Lots of people have no clue.

As long as there are scientologist sympathizers and people who think that "personal responsibility" means that everyone else has to do what they personally think is right regardless of their own behavior, I don't think psychiatrists are going to be popular.

The only people who respect psychiatrists are people with mental illness or with family members with mental illness who have been helped by a psychiatrist. Otherwise, we're just part of the communist conspiracy putting fluoride in the water or something like that, driving around our porsche's and flying to the caribbean on pfizer's private jet every weekend.

At my mother's elementary school, they pretty much think a child psychiatrist is the cat's pajamas. When I told my family I was going to be a psychiatrist, they were disgusted. When I told them I was going to be a child psychiatrist, I suddenly became the best thing that ever happened. Another teacher's son is an anesthesiologist, and another is a orthopedic surgeon. It's pretty clear they're just as impressed by me as they are the others. Heck, they have a harder time understanding that the anesthesiologist is a doctor than the child psychiatrist. Don't underestimate the cluelessness of even educated people.

You can put the world "child" in front of anything and it immediately becomes more important. People care about children, even when they don't care about adults.

This is true, it's difficult to understand illness of the mind, unless you see it first hand.


I honestly don't care much about "public perception"... yes it's annoying that people make ignorant statements when I say I'm considering psychiatry, but it would be equally annoying if I went into a field with good PR (Omg you're a Anesthesiologist, i heard they make soo much money).... i've learned it's fruitless to worry about what people think you.


The more important issue, over perception, is medical law and insurance coverage. Those should be governed by laws of science and not "how people feel about the realness of mental health" i.e. Insurances, governments, schools, should respect and recognize mental illness and treat it just as well as body illness. That would make a more meaningful advancement to the field.


My 2 cents.

 

[dl2dp2]

Well sure if you can get the same respect for psych that derm has, that would be great, but the thing is, dermatologists do cosmetic stuff for celebrities, whereas we work with homeless people. And I'm all for new technology but I just don't see it. What inventions have we had in psych, ever, aside from the typicals, atypicals, and antidepressants? Ok there's ECT, TMS, etc but ECT has been around forever and hasn't garnered us a ton of prestige.

Right. Here's an idea: split psychiatry into two fields. People who want to work with homeless people can go into one field, and people who don't can do some kind of uber competitive fellowship.

OH WAIT. That already exists...that's called psychoanalytic training at a top program.

And yeah, I think the second point you make is also legit. There's no intervention really on the horizon right now. I think the kind of respectability visteril is looking for is going to take 50-100 years to achieve (at the LEAST), primarily through research.

I'm not really sure how to think of the possible respectability in the 40s...first of all, I've never heard of it. It's not talked about by the senior faculty. It might be a golden era for American psychoanalysis, but I think most psychiatrists back then run big asylums, and the image of psychiatry in the 40s or prior depicted in literature is rarely positive. Also, the fact that psychoanalytic dominance back then might have contributed to respectability is not surprising to me and conforms to my hypothesis, because (1) psychoanalysis was closed to anybody but an MD (2) it's esoteric and full of jargons, even though we now know much of the jargon is not particularly useful or scientific (3) exclusivity and apprenticeship in training.

One reason for the loss of respectability that just popped up in my mind, now that I'm thinking about this carefully, has to do with the pharma's campaign of simplifying everything to a "chemical imbalance". Everybody GETS it. Everybody GETS how you can fix it with a med. Everybody KNOWS it can't POSSIBLY be true. The APA should do a campaign emphasizing the complex "neural circuitry" and multiple "neurotransmitter systems", spill some genetics and acronyms, show some images of the brain and various parts. Make sure psychiatrists SOUND smart. The billions spent on research should yield SOMETHING, right?? Just because writing the prescription is easy doesn't mean that the public out there should KNOW that. It's called spin, getting people to believe what you want them to believe, if that's your thing.

To me, respectability is so much about what you say you do and how you do it than what you actually do.

Meanwhile, if you really cared enough about what psychiatrists actually did, you'd find that the complexity involved in prescribing an antidepressant has more to do with certain non-medical aspects, and occasionally medical aspects, and I don't think if you are good it's particularly easy in reality, but communicating this wouldn't make you sound more prestigious. It would more likely make you sound like a really good social worker, even though I genuinely don't think as yet most of the other professionals are trained to do this kind of information integration.

And just to follow-up my soap box a bit more, American psychiatry has really already split into smaller chunks. Realizing that it's a huge specialty (2-3x size of neurology?), the way things are practiced in one region vs. another is very very different, and different psychiatrists have radically different priorities. In certain markets, most of the public know the difference between an MD and a psychologist, being a psychiatrist of a certain pedigree is quite prestigious and is essentially equivalent to being a dermatologist in both the kind of demographics, reimbursement, style of practice, etc...

It's not really possible to enhance the overall respectability of psychiatry, IMHO because it's like saying let's enhance the overall respectability of primary care physicians. This task is too large, complex and heterogeneous to be accomplished through anything but tediously slow progress of research.

 

[dl2dp2]

f

Im not sure what subspecialties in psychiatry you are talking about. There is child(which is debatable whether that is more respected), but the other fellowships(which nobody really does) certainly arent more respected.....there is a reason geri fellowships don't fill. Addiction is something internal medicine, family medicine also does...and is not prestigous in the least. Forensics people associate with prisons. Psychosomatic medicine isn't a real fellowship...that is general adult psychiatry.

No I agree with what you are saying. There's no hope right now to enhance the respectability factor except through through some kind of marketing. The only real hope is long term investment into research--and maybe splitting the field--and for SURE not combining neurology and psychiatry. Neurology itself has a respectability issue and wants to be more like cardiology--really isn't something we should aspire to be.

I also disagrees with the more therapy idea. Given how poorly respected therapists are these days, I doubt that trying to be more like a therapist would make you more respectable. Just look at your list. If you want more respect, you want to be more like an engineer and a doctor, i.e. jargons, technical language, exclusivity with a hint of fiduciary duty...and while nurses are highly respected, it's not particularly prestigious...I doubt anyone who wants to be a psychiatrist even entertained the idea of being a nurse. Cutting the pharma ties would help, except then there'll be literally no money left for research.

 

[vistaril]

And just to follow-up my soap box a bit more, American psychiatry has really already split into smaller chunks. Realizing that it's a huge specialty (2-3x size of neurology?), the way things are practiced in one region vs. another is very very different, and different psychiatrists have radically different priorities. In certain markets, most of the public know the difference between an MD and a psychologist, being a psychiatrist of a certain pedigree is quite prestigious and is essentially equivalent to being a dermatologist in both the kind of demographics, reimbursement, style of practice, etc...
.

there is NO region of the country where cash pay analysis(which I assume is the market you are talking about) is very common relative to psychiatrists who take insurance. Try searching the following areas(all which rank VERY HIGH, top 20 actually, in wealthiest zip codes in the country: Potomac, Md; Northbrook, Il; ny zip code area 10023; sugarland, Tx. One NE market, one north atlantic coast market, one south market, one affluent midwest market. All have bunches of psychiatrists who take insurance(a few even medicare!) vs very few(at least with an online web presence) who do cash pay only.

Furthermore, some of the cash pay psychiatrists across the country have rates that are not sky-high. I've seen this number of $300-$350/hr thrown out a lot in this forum. Of the 25000 or so psychiatrists who are practicing in the US right now, I bet there aren't even 1500 who are consistently filling their weekly schedules with $350/hr self pay patients......there certainly aren't any in this forum.

 

[vistaril]

f

No I agree with what you are saying. There's no hope right now to enhance the respectability factor except through through some kind of marketing. The only real hope is long term investment into research--and maybe splitting the field--and for SURE not combining neurology and psychiatry. Neurology itself has a respectability issue and wants to be more like cardiology--really isn't something we should aspire to be.

I also disagrees with the more therapy idea. Given how poorly respected therapists are these days, I doubt that trying to be more like a therapist would make you more respectable. Just look at your list. If you want more respect, you want to be more like an engineer and a doctor, i.e. jargons, technical language, exclusivity with a hint of fiduciary duty...and while nurses are highly respected, it's not particularly prestigious...I doubt anyone who wants to be a psychiatrist even entertained the idea of being a nurse. Cutting the pharma ties would help, except then there'll be literally no money left for research.

splitting the field into what exactly?

and your ideas about jargons and technical language are problematic because people are becoming more and more aware that the DRUGS ARENT VERY GOOD. Advertising as an expert pharmacologist who is a wizardry at sophisticated treatment algorithms and could lecture Stephen Stahl himself on pharm is only going to go as far as the public's perception(especially the professional class) of how good the drugs can be, and again that trend is increasingly tilting against us.

 

[dl2dp2]

Furthermore, some of the cash pay psychiatrists across the country have rates that are not sky-high. I've seen this number of $300-$350/hr thrown out a lot in this forum. Of the 25000 or so psychiatrists who are practicing in the US right now, I bet there aren't even 1500 who are consistently filling their weekly schedules with $350/hr self pay patients......there certainly aren't any in this forum.

lol. this is the difference between you and me. i'm at a program where almost NONE of the faculty takes insurance (excepting the fact that some of them take SMI patients through a clinic/hospital). maybe that's why we have such different perspectives. i'm not disagreeing with you at all, it's just that everyone i know is in that 1500.

also i like how you shoot down all my ideas without proposing any idea of your own. given that i know a few power players in the field maybe i can relay your opinion to them at some point.

 

[michaelrack]

lol. this is the difference between you and me. i'm at a program where almost NONE of the faculty takes insurance (excepting the fact that some of them take SMI patients through a clinic/hospital). maybe that's why we have such different perspectives. i'm not disagreeing with you at all, it's just that everyone i know is in that 1500.

also i like how you shoot down all my ideas without proposing any idea of your own. given that i know a few power players in the field maybe i can relay your opinion to them at some point.

I agree with vistaril on this one. Are your faculty seeing patients 40 hrs a week at $350 per hour????

On the other hand, it wouldn't be too hard to have a side practice (for a doc who also has an inpt or comm mental health center or other type of practice) of several half day clinics a week where you see cash pts for $150 for a 25 minute appt.

 

[dl2dp2]

On the other hand, it wouldn't be too hard to have a side practice (for a doc who also has an inpt or comm mental health center or other type of practice) of several half day clinics a week where you see cash pts for $150 for a 25 minute appt.

OH of course this is the norm. But this ramps up and down. Who wants to see 40 hours of cash anyway? All I'm saying is that he portrays psychiatry as this 90805 grindhouse with very little respect, and I think for a decent proportion of psychiatrists and for a decent proportion of their work, it's not particularly fair to compare their practice to internal medicine, and much fairer to compare their practice to something like derm, or even some kind of nice internal medicine subspeciailty, like rheum or endocrine. And I think that's the image we want to portray, and it's the dominant theme that APA is pushing for ("mental illness IS a physical illness, blah blah").

Also, FYI, yes for those faculty, mostly voluntary, who have a full time practice, they fill their 40 hours with $350 cash. And live VERY VERY well. lol

 

[michaelrack]

Also, FYI, yes for those faculty, mostly voluntary, who have a full time practice, they fill their 40 hours with $350 cash. And live VERY VERY well. lol

I stand corrected. In my part of the country, I don't know any psychiatrists who are able to do this- but I practice medicine in the deep south (MS), one of the poorer areas of the country.

 

[vistaril]

lol. this is the difference between you and me. i'm at a program where almost NONE of the faculty takes insurance (excepting the fact that some of them take SMI patients through a clinic/hospital). maybe that's why we have such different perspectives. i'm not disagreeing with you at all, it's just that everyone i know is in that 1500.

also i like how you shoot down all my ideas without proposing any idea of your own. given that i know a few power players in the field maybe i can relay your opinion to them at some point.

ha power players in the field wouldn't care what I have to think.

And I threw the 1500 as a ridiculously high number....I don't think the real number(who actually FILL practices with $350hr+ patients) is anywhere near that high.

And how many private patients do your full time faculty see? I imagine most probably see a very limited number of patients....thats much different than having a full practice built that way. After all, they are presumably working full time in academia.

Im sure there are a few psychologists out there charging hat much cash pay as well....but like in psychiatry it's just a miniscule fraction, and usually not representative of filling a schedule with that many. Hell there are some 'life coaches' out there who are not psychologists or psychiatrists who charge as much.....

 

[nancysinatra]

Freud did not start the field of psychiatry, psychiatry was a product of the enlightenment and the term psychiatry was coined in 1808 by Johann Christian Reil. Freud was not a psychiatrist and did not treat psychiatric patients (i.e. patient with dementia praecox, melancholia, mania etc) he treated patients with hysteria and other nervous disorders that back then would be treated by neurologists. Outside the US, Freud and psychoanalysis never had a discernible impact on psychiatry. There are many important alienists who predate Freud or were contemporary e.g. Pinel, Falret, Morel, Ballaiger, Kraepelin, Maudsley etc.

True enough, thanks for pointing that out.

As for psychiatry being a fellowship of neurology. This is ridiculous largely because there are many many more psychiatrists than their are neurologists, we just don't need that many neurology residents or residencies. Plus most neurology residencies are based in large academic centers because neurology is an academic specialty, whilst psychiatry is far more community based with most programs being affiliated with some medical school but being community based. I like neurology, but my neurology rotation was by far the worst experience of intern year, this might be because the neurology residency is so-called 'malignant' but I would never do psychiatry if I had to waste my time doing a neurology residency first. If people want to do more neurology, you can spend your elective time doing it. Granted, I think they could teach more functional neuroanatomy and cognitive neuroscience in residency, and neurology clinic is a useful experience, but inpatient neurology is largely a waste of time for psychiatrists. There's a reason neurology and psychiatry are no longer one specialty, why we now have our own journals, and combined residency programs died a good death - it just isn't possible to have a sufficiently strong knowledge base for both or keep up to date with both. medicine continues to move towards increasing subspecialization this is a trend that is only going to get worse in the future.

Ok but for all the huge numbers of psychiatrists that are out there, if we're so ubiquitous, why do people dislike us so much and why are we still in a shortage? The public doesn't hate primary care.

No doubt there are people on this board who wouldn't become psychiatrists if the residency included neuro. But there are other people, not on this board, who would have been more likely to go into psych if the residency was combined. That includes a lot of behavioral neurologists, and just generally anyone who considered psych but didn't want to lose their general medical knowledge.

We have this huge DMS and the vast majority of the conditions never walk in the door. (When's the last time you saw a case of pure and simple kleptomania?) It seems hard to justify a whole specialty where all you really need to know is psychosis, mood, substance and the tiny number of other things that turn up occasionally, but never so rarely as to be zebras. And don't tell me we treat dementia and delirium because we don't. We treat their "behavioral aspects."

And psychiatry seems like the least requiring of medical knowledge. I don't feel like I need an MD degree to do my job on a daily basis. It helps at times, but it isn't essential. Some days I feel like a social work background might have been just as good.

Look, I'm just saying these things--other people say them too. I don't have all the answers but my rationale for combining with neuro would be to redefine our own field a bit. You can look at it two ways--we can continue to be overtrained MDs doing only psychiatry, or we could psychiatrically undertrained neurologists doing some psychiatry. The advantage of the 2nd option is that more people would be drawn into the field. Would it solve the shortage, no, but it might help with public perception and diversify our field.

 

[vistaril]

OH of course this is the norm. But this ramps up and down. Who wants to see 40 hours of cash anyway? All I'm saying is that he portrays psychiatry as this 90805 grindhouse with very little respect, and I think for a decent proportion of psychiatrists and for a decent proportion of their work, it's not particularly fair to compare their practice to internal medicine, and much fairer to compare their practice to something like derm, or even some kind of nice internal medicine subspeciailty, like rheum or endocrine. And I think that's the image we want to portray, and it's the dominant theme that APA is pushing for ("mental illness IS a physical illness, blah blah").

Also, FYI, yes for those faculty, mostly voluntary, who have a full time practice, they fill their 40 hours with $350 cash. And live VERY VERY well. lol

well at 350/hr with little overhead I would love to see 40-50 cash pay patients to consume my whole week......

and 90805 codes are not the 'grindhouse' code....90805(or at least under the old system) is actually a code where you can see 2 follow ups an hour. Those aren't bad jobs to get on salary if you can.

But like I said, I looked fairly extensively online in four HIGH INCOME(some of the highest actually) zip codes across the country, and I saw a ton of psychiatrists who all take insurance.

If you're planning on filling your practice with hour long sessions at $350/hr cash(which would allow to have very very little overhead), I think that's great and quite an accomplishment if you do it. The problem is that if you only do that 1 or 1 and a half days a week your overhead advantages of running that way aren't as great.

One possible avenue is to build a partial boutique practice where you work a salaried position in addition. The downside of this is you're going to be renting office space that you aren't putting to use a lot. Either that or using someone elses space for that day or day and a half a week, which is going to cut into your hourly rate. Another downside to leasing out someones elses space for your limited boutique practice is that pts who are forking out 350 dollars aren't going to be super impressed with someone who doesn't even have their own nice building/suite.

Im looking to do suboxone on the side for just 1 day a week and some of the same problems are coming up.

 

[vistaril]

No doubt there are people on this board who wouldn't become psychiatrists if the residency included neuro. But there are other people, not on this board, who would have been more likely to go into psych if the residency was combined.

but you also have to consider all the neurologists who may not have chosen neuropsych if it involved a ton of mood d/os, anxiety d/os, psychotic disorders, therapy, etc.....

do agree that the vast vast vast majority of what we see comprises about 5-10% total of the DSM.

 

[vistaril]

OH of course this is the norm. But this ramps up and down. Who wants to see 40 hours of cash anyway? All I'm saying is that he portrays psychiatry as this 90805 grindhouse with very little respect, and I think for a decent proportion of psychiatrists and for a decent proportion of their work, it's not particularly fair to compare their practice to internal medicine, and much fairer to compare their practice to something like derm,

another difference between derm and psychs who cater to exclusive cash pay clientele is that derms running the same kind of offices get MUCH MORE than 350/hr gross for their services.

 

[dl2dp2]

another difference between derm and psychs who cater to exclusive cash pay clientele is that derms running the same kind of offices get MUCH MORE than 350/hr gross for their services.

No you are right. Even the pure cash psychs make less than pure cosmetic derms, but I think given the logarithmic utility curve, the level of reimbursement is fairly similar.

Also, your little search is not going to be informative because yes there are lots of insurance taking psychiatrists, but people with means don't really use them. There's a "hidden" referral network for cash psychiatrists. Secondly, "cash" is not cash. There's something called balance billing out of network coverage, though that gravy train might be leaving the station fairly soon. Nevertheless, given that even medicare pays what? $100 for a 45 min session? A lot of people are willing to do quality combined treatment for $600 a month out of pocket.

If you are really interested in how to build such a practice, I can point you to people who might be able to mentor you. This is provided though that you have the right credentials.

In conclusion, yes, psych is not quite derm. But for not an unsubstantial number of psychiatrists, it's like 30% derm. And all I'm saying is that if you want "respect" then you need to increase that 30% model to 100%. I.e. create a separate residency program, name it something else, generate a completely new professional identity, where only a few selected elite are allowed to practice like that...etc. etc.

Or, alternatively, maybe you could just go into your own therapy to make peace with the fact that you picked a job that currently doesn't have a lot "respect" however you want to define it.

 

[dl2dp2]

Look, I'm just saying these things--other people say them too. I don't have all the answers but my rationale for combining with neuro would be to redefine our own field a bit. You can look at it two ways--we can continue to be overtrained MDs doing only psychiatry, or we could psychiatrically undertrained neurologists doing some psychiatry. The advantage of the 2nd option is that more people would be drawn into the field. Would it solve the shortage, no, but it might help with public perception and diversify our field.

There is something to this, which is maybe we should just change the name of the field, which by the way is something many departments are already doing. i.e. Johns Hopkins Department Psychiatry and Behavioral Science. How about just Department of Behavioral Medicine. And just change the name of the specialty to Behavioral Medicine. We are behavioral medicine physicians.......and we can have a subspecialty called cosmetic behavioral medicine

 

[dl2dp2]

I stand corrected. In my part of the country, I don't know any psychiatrists who are able to do this- but I practice medicine in the deep south (MS), one of the poorer areas of the country.

You and I are both right. What I'm saying is that the practice of psychiatry between the deep south and where I am is SO different that it might as well be two different medical specialties altogether. Also, while you don't necessarily make a ton of money, you also don't need to make a ton of money living where you are, which is also nice. I think this specialty is one of the weird specialties in medicine where the ceiling is much higher in large cities, even if the averages are higher in rural/underserved areas.

 

[Jorje286]

I agree with you nancysinatra, but I just want to say that trying to restructure the training solely based on perception is not a good idea. The fact is that psychiatry has been in perpetual identity crisis since its inception and it is still trying to find its foothold- and that's just a consequence of our (lack) of understanding of the mind. Nothing bad with that. Regardless of how people perceive psychiatry, society will always need it because of how prevalent mood/psychotic disorders are and the real potential to influence the lives of any person - not just the mentally ill. The rapprochement between neuro and psych WILL happen sooner or later - imo that is just inevitable. Maybe not a complete merge, but you cannot pretend to move the discipline into the domain of brain science while ignoring the rest of the "organic" pathology of the CNS. I think it's uber pathetic that the system is still built on the nonsensical dualistic model. You will not be a good psychiatrist if you don't understand the physiology and the anatomy of the brain - and you will not be a good neurologist if you ignore behavior.

 

[nancysinatra]

but you also have to consider all the neurologists who may not have chosen neuropsych if it involved a ton of mood d/os, anxiety d/os, psychotic disorders, therapy, etc.....

True enough. This is just my one little idea--not saying it would solve all the problems. I guess the way I would see it is that psych would be sub-specialty of neuro, and so would some of the neuro stuff that seems bread and butter to them now, although what, I couldn't tell you.

Interventional cardiology is a subspecialty of cardiology, and I'm sure there are cardiologists who have no interest in that (few, but some).

do agree that the vast vast vast majority of what we see comprises about 5-10% total of the DSM.[/QUOTE]

Mainly I don't get why we are required to spend 4 years learning about approximately 3 diagnoses, in a field that requires no command of imaging, labs, anatomy, physical exam, and demands no technical skill. The things that are hard about psychiatry take forever to learn, and the things that are easy can be learned in 6 months. I'm not saying I couldn't stand to do better in nearly every aspect of my job, just that I doubt that's the reason why residency lasts four years. I truly think we're here to keep hospital costs down. I'd much rather be a neuro/IM intern than a serf.

 

[nancysinatra]

another difference between derm and psychs who cater to exclusive cash pay clientele is that derms running the same kind of offices get MUCH MORE than 350/hr gross for their services.

And yet another difference is that they deal with rashes and skin diseases and we, presumably, deal with mental health issues. Ideally people should choose their field based on what interests them.

Botox training is available to all MDs, isn't it? Why not just call yourself a GP and set up a botox shop? You could underprice derm and still make more than you would in psych, and thereby soak up some of the market that can't afford derm. Of course, your patients might not look so great in the end...

 

[michaelrack]

We are behavioral medicine physicians......:

Patients will think that the the title means that we control behavior with medicine.

 

[michaelrack]

Also, while you don't necessarily make a ton of money, you also don't need to make a ton of money living where you are.

The only psychiatry I do is occasional weekend locum work to keep up my skills. As a sleep specialist, I make more $ than the typical psychiatrist.

Although I practice in northern MS, I live in Memphis TN. Private schools in Memphis are expensive. Approx 20 months ago I moved from Jackson MS to Memphis TN- my income increased with the move, but I still have the expense of my house in Jackson- I hope to be able to unload that soon.

 

[vistaril]

You and I are both right. What I'm saying is that the practice of psychiatry between the deep south and where I am is SO different that it might as well be two different medical specialties altogether. Also, while you don't necessarily make a ton of money, you also don't need to make a ton of money living where you are, which is also nice. I think this specialty is one of the weird specialties in medicine where the ceiling is much higher in large cities, even if the averages are higher in rural/underserved areas.

As someone who has lived in the midwest, northeast, and deep south for at least two years each since high school....this is ridiculous. I've also interviewed for positions next year(some phone interviews granted) and the responsibilities at each job were pretty similar. granted I've never lived on the west coast before. You're a psychiatrist wherever you go....if it helps you sleep better at night to tell yourself you are 'like a dermatologist' because of what zip code you practice in, that's fine....but I don't think that is common. You mention some of your senior faculty do this on the side.....senior faculty at large academic centers(regardless of region) do not represent most psychiatrists. Some of the senior faculty I know have 7 figure grants....that doesn't mean that this somewhow defines what psychiatry is like here because they do this.

I don't doubt that there are some psychiatrists out there who cater to exclusively upscale out of pocket patients at $350/hr.....just like there are some psychologists(I know of a couple) who do the same thing. If you can bring in patients(either by skill, word of mouth/reputation, or some other reason) who are willing to pay that....hats off to you. But just look on this board for starters....who here is *filling* their clinic, in any region, with $350+ therapy patients?

 

[vistaril]

In conclusion, yes, psych is not quite derm. But for not an unsubstantial number of psychiatrists, it's like 30% derm. And all I'm saying is that if you want "respect" then you need to increase that 30% model to 100%. I.e. create a separate residency program, name it something else, generate a completely new professional identity, where only a few selected elite are allowed to practice like that...etc. etc.

but what would this residency program even be called? And what would the 'new professional identity' be significant for, except that it only sees cash patients?

Im also confused because on the one hand you are talking about cash pay sessions(presumably with an analytic bent in NYC, LA, SF, etc) and on the other hand you are talking about 'technical jargon', increasing the complexity of psychopharm, etc.....those two things don't seem to go hand in hand. Patients who are paying $350 for an hour session don't want stephen stahl to be their psychiatrist....they want Dr Melfi. And I can guarantee you Dr Melfi doesn't give a flip about the Stephen Stahls of the world for the most part.

the bottom line is that there is a finite number of people in this country willing to pay $350+ to see a psychiatrist regularly......and that number is pretty small. I could get extra training at an analytical institute sure, but I just don't think I would be good enough(as a therapist or a self promoter) to fill up my clinic with such cash pay patients.....I'd imagine I could get some, which is what I see some people doing now.

 

[DJspreadsheet]

but what would this residency program even be called? And what would the 'new professional identity' be significant for, except that it only sees cash patients?

Im also confused because on the one hand you are talking about cash pay sessions(presumably with an analytic bent in NYC, LA, SF, etc) and on the other hand you are talking about 'technical jargon', increasing the complexity of psychopharm, etc.....those two things don't seem to go hand in hand. Patients who are paying $350 for an hour session don't want stephen stahl to be their psychiatrist....they want Dr Melfi. And I can guarantee you Dr Melfi doesn't give a flip about the Stephen Stahls of the world for the most part.

the bottom line is that there is a finite number of people in this country willing to pay $350+ to see a psychiatrist regularly......and that number is pretty small. I could get extra training at an analytical institute sure, but I just don't think I would be good enough(as a therapist or a self promoter) to fill up my clinic with such cash pay patients.....I'd imagine I could get some, which is what I see some people doing now.

Why not just take decent insurance while making efforts to get some cash pay converts or newbs. Even if you don't fill, which you probably won't, at least you've set the stage for a transition - and any business is good business. Worst case, you get zero cash pay and fill your rolls with non-medicaid patients and make 250k/annum.

Whatever happens, happens.

 

[vistaril]

And yet another difference is that they deal with rashes and skin diseases and we, presumably, deal with mental health issues. Ideally people should choose their field based on what interests them.

Botox training is available to all MDs, isn't it? Why not just call yourself a GP and set up a botox shop? You could underprice derm and still make more than you would in psych, and thereby soak up some of the market that can't afford derm. Of course, your patients might not look so great in the end...

you could if you filled your clinic with botox patients, but this isn't realistic. Heck even highly thought of cosmetic derms can't fill their whole clinic with self pay botox patients alone(they have to do a lot of other more time consuming self pay cosmetric procedures)....

and there is already a group of physicians who aren't derms underpricing derms on botox. They are called family medicine physicians(many of whom do weekend courses on procedural cosmetics)....so we would have to be undercutting the people who undercut derms/plastics.

A psychiatrist who advertises as a GP(since I've been alive I have never seen a 'GP' btw....I think they went the way of the dodo about 35 years ago) doing botox and other cosmetic procedures would be a psychiatrist who doesn't see any patients I think. If someone is shopping around and looking for a bargain on botox or other cosmetic stuff, the natural place they would likely end up is at an primary care physicians office who has some experience in procedures.

 

[vistaril]

Why not just take decent insurance while making efforts to get some cash pay converts or newbs. Even if you don't fill, which you probably won't, at least you've set the stage for a transition - and any business is good business. Worst case, you get zero cash pay and fill your rolls with non-medicaid patients and make 250k/annum.
.

it's just not that easy.....making 250k/year seeing insured patients in the outpt world(assuming you work no weekends, no locum inpt coverage, etc) just isn't as easy as some of you guys make it out to be. Look up the numbers for what the old 90805 pays in your area...now multiply by 16. Now subtract the occasional no show, the frequent denied or reduced claim, your med mal(you've got to pay for this since you arent in academia or working a salaried job that covers it), the cost of licensure/certificates per year, disability insurance for yourself(sometimes paid for you in salaried positions), the reduction you get(about 6% on average) everytime someone swipes a credit card to paytheir copay(which many will).....and all of this is *before* general overhead expenses(office and billing staff, rent, electricity, etc)......

 

[DJspreadsheet]

it's just not that easy.....making 250k/year seeing insured patients in the outpt world(assuming you work no weekends, no locum inpt coverage, etc) just isn't as easy as some of you guys make it out to be. Look up the numbers for what the old 90805 pays in your area...now multiply by 16. Now subtract the occasional no show, the frequent denied or reduced claim, your med mal(you've got to pay for this since you arent in academia or working a salaried job that covers it), the cost of licensure/certificates per year, disability insurance for yourself(sometimes paid for you in salaried positions), the reduction you get(about 6% on average) everytime someone swipes a credit card to paytheir copay(which many will).....and all of this is *before* general overhead expenses(office and billing staff, rent, electricity, etc)......

Fine. I defer that you know better than I. But from a business perspective, you have a guaranteed pool of customers. Your only challenge is to harness even a modicum of business sense and set yourself apart, in some way, from the other guy down the street. Given that a lot of psychiatrists are, shall we say, less than ideal - this should be even easier.

Psych is almost like a glitch in the matrix. It's filled with opportunity - you just have to know how to capitalize on it.

Question: how hard is it to employ a pre-charge when booking an appt? Say, when you schedule the appt, the office bills $50 on your credit card - to be refunded upon arrival at the appt. Otherwise you forfeit it.

 

[vistaril]

Fine. I defer that you know better than I. But from a business perspective, you have a guaranteed pool of customers. Your only challenge is to harness even a modicum of business sense and set yourself apart, in some way, from the other guy down the street. Given that a lot of psychiatrists are, shall we say, less than ideal - this should be even easier.
.

Just because people going into psychiatry aren't very competitive(relative to competitive specialties) doesn't mean you are competing against hopelessly clueless people with no business sense.

And in terms of the guaranteed pool of customers....sure, most psychiatrists once they establish themselves can fill their books. But this doesn't guarantee that you are going to make a lot of money. The biggest thing going against us are the insurance companies, who will only continue to slash rates.

 

[notdeadyet]

you could if you filled your clinic with botox patients, but this isn't realistic.

Once again, probably depends on your geographic area. I know an FP doc who became a local botox specialist and did exactly that.

 

[DJspreadsheet]

Just because people going into psychiatry aren't very competitive(relative to competitive specialties) doesn't mean you are competing against hopelessly clueless people with no business sense.

And in terms of the guaranteed pool of customers....sure, most psychiatrists once they establish themselves can fill their books. But this doesn't guarantee that you are going to make a lot of money. The biggest thing going against us are the insurance companies, who will only continue to slash rates.

You skipped my very important question.

And I've seen some genuine goobers in PP having no problem generating income. I'm not fearful.

 

[kumar28]

ah..there goes vistaril again..with his negative spin on everything. I tell you the guy is a crafty troll who knows how to play on the edge so as not to get caught. Every topic that the guy brings up he always (in his crafty vistaril way) knows how to spin it negatively to make it appear that he genuinely cares about the field however is the first to pounce on every and any postive response to the field that anyone brings up. Been on these forums for 10 years.. I used to like reading these forums before this guy got on here..now he just floods it with nonsense and negativity (although I know its got some validity but if you really follow this guy he's full of it)

 

[vistaril]

Once again, probably depends on your geographic area. I know an FP doc who became a local botox specialist and did exactly that.

yes...I do too...they were *family practice* docs....not psychiatrists.

A family practice doc is obviously be in a better position to market themselves doing simple cosmetic procedures than a psychiatrist. In fact it's not uncommon for many fm physicians to do a decent portion of such work on the side. Acting as if family medicine docs and psychiatrists have a level playing field to enter such a market is ridiculous though.....many completely reasonable people may try to save a few bucks on what derm or plastics charges and find a fam medicine physician who makes botox a part of his practice. Those same patients aren't going to say "hmmmm....maybe I should look to a psychiatrist as well".....

 

[notdeadyet]

yes...I do too...they were *family practice* docs....not psychiatrists.

No. This guy markets himself as Dr. Nick, botox specialist. He does not draw any attention to the fact that he is a family practitioner, this is obvious from his website and print marketing. In fact, he likely goes at length to not mentioning it, as patients otherwise
see "Dr. Nick, botox specialist" and assume he's a dermatologist.

A family practice doc is obviously be in a better position to market themselves doing simple cosmetic procedures than a psychiatrist. In fact it's not uncommon for many fm physicians to do a decent portion of such work on the side.

You must have misread my post. He doesn't do this on the side. This is all he does. And marketing himself as a family practice doc is the last thing he would want to do.

Acting as if family medicine docs and psychiatrists have a level playing field to enter such a market is ridiculous though.....many completely reasonable people may try to save a few bucks on what derm or plastics charges and find a fam medicine physician who makes botox a part of his practice.

Things like this said with confidence betrays that you don't really have a great grip on business. Or business is just done very different down your way.

Most folks out my way that look for botox, literally look up "botox doctor." They look at rates and quality of marketing materials. They look at convenience. They go heavily by word of mouth. They do not dig up info for looking at the primary board certification of their botox doc. Those patients that do end up going to dermatologists. For the rest of the pool, they're more inclined to care about parking and wait times than board certification.

Those same patients aren't going to say "hmmmm....maybe I should look to a psychiatrist as well".....

Exactly. They aren't looking at the type of primary board cert of their doctor at all.

It's about the market. If it's flooded with botox folks, family practitioners will only be able to line up side gigs, like they seem to be doing out your way. In less flooded markets, like the semi-rural one outside of a secondary size city that this dude was operating in, it was an open market that could have supported several folks doing the same.

We'll agree to disagree. I acknowledge that your experience might be valid out your way, but to pretend it's universal is foolish.

 

[notdeadyet]

And for the record, it would be a cold day in hell before I'd be out there doing botox injections, for a whole slew of reasons. Just pointing out that when discussing business, pretending how it's done in your one area is universal is bad business sense.

 

[dl2dp2]

Although I practice in northern MS, I live in Memphis TN. Private schools in Memphis are expensive. Approx 20 months ago I moved from Jackson MS to Memphis TN- my income increased with the move, but I still have the expense of my house in Jackson- I hope to be able to unload that soon.

That is a good point. There are expensive ways to live no matter where you live. I don't have a really good answer for you, but I'm assuming you are doing well as a psychiatry trained sleep specialist. So this is one way for vistaril to achieve his particular brand of respectability -> shed the professional identity completely and be a sleep doctor by doing a fellowship in that.

I don't doubt that there are some psychiatrists out there who cater to exclusively upscale out of pocket patients at $350/hr.....

You are not understand what I'm saying. The point of "respectability" as you defined it, i.e. more $$, more prestige, more exclusivity both in lay public and medical fields requires (1) exclusivity in training. (2) exclusivity in skills. (3) exclusivity in pay source. Both high profile psychanalytic treatment/combined therapy and complex psychopharm PERHAPS meet some of these criteria for your definition of "respectability", which means that it's often common in private practice for both of these types of work to command a high salary, and high respect from at least the limited number of patients from a particular demographic of patients. However, you insist that no, even these subspecialists don't garner any respectability, because they don't meet the full criteria. Furthermore, you refuse to either get the mentorship or obtain the credentials to gain additional respectability within the field.

But the specialty isn't founded on this basis, and therefore can't ever achieve the kind of wholesale respectability that you demand. At its core psychiatry is a really complicated, heterogenous specialty, with a lot of it dealing with non-cosmetic, non-medical business that's pretty dirty and disorganized on the one hand, humanizing and rewarding on the other. The selection process for "respect" happens AFTER residency if you want to capture that. This is why I suggested that if you really want the dermatology kind of "respectability", we'd have to split the field into small fields, with well off patients specifically shuttled to one subspecialty, etc., or invent a ton of studies/procedures to read or do and bill for. Clearly you are not interested in doing the research to make the latter happen, or the advocacy to make the former happen.

Unless, as another poster said, the point of this thread then is just you trying to bemoan again how psychiatry has no respectability per se... lol in which case I'm not sure what to say except to say, maybe it's time to get therapy yourself.

 

[Ibid]

But what about all the highly publicized school shootings where invariably there's outcry in the media that the perpetrator wasn't "diagnosed" in time and kept away from society?

That is a local problem to the US which is about the availability of guns. There are places where their is no anti-psychiatry movement. The reason for that is that psychiatry is done differently in those places. To be honest I would be looking at that....

The "survivors" of involuntary commitment might not believe it's a good thing, and their views may be as valid as anyone else's and worth hearing in a lot of cases, but the public won't necessarily agree, because society actually fears the mentally ill.

Exactly...society fears the "mentally ill". They don't fear people who are scared, anxious, fearful, confused or variously unhappy to some degree or other. So tyrannically insisting that mental distress is a brain disease (forget the nuance, we are talking about the public here) is to insist on a conceptualization of distress that the public increasingly doesn't buy into and at the same time fans the flames of stigma and discrimination.

It is articulated in a variety of ways but imo what the public increasingly does buy into is the idea that capitalism creates structures that exacerbate human distress and pharm and mental health services collude to make cash out of that distress. Anyone reading some of the posts on this thread would be hard pressed not to come to the conclusion that that analysis had some merit.

It's not usually laid out that starkly or even articulated exactly like that but essentially that is how biological psychiatry has managed to maneuver itself onto the wrong side of the publics affection. imo

 

[vistaril]

That is a good point. There are expensive ways to live no matter where you live. I don't have a really good answer for you, but I'm assuming you are doing well as a psychiatry trained sleep specialist. So this is one way for vistaril to achieve his particular brand of respectability -> shed the professional identity completely and be a sleep doctor by doing a fellowship in that.



You are not understand what I'm saying. The point of "respectability" as you defined it, i.e. more $$, more prestige, more exclusivity both in lay public and medical fields requires (1) exclusivity in training. (2) exclusivity in skills. (3) exclusivity in pay source. Both high profile psychanalytic treatment/combined therapy and complex psychopharm PERHAPS meet some of these criteria for your definition of "respectability", which means that it's often common in private practice for both of these types of work to command a high salary, and high respect from at least the limited number of patients from a particular demographic of patients. However, you insist that no, even these subspecialists don't garner any respectability, because they don't meet the full criteria. Furthermore, you refuse to either get the mentorship or obtain the credentials to gain additional respectability within the field.

But the specialty isn't founded on this basis, and therefore can't ever achieve the kind of wholesale respectability that you demand. At its core psychiatry is a really complicated, heterogenous specialty, with a lot of it dealing with non-cosmetic, non-medical business that's pretty dirty and disorganized on the one hand, humanizing and rewarding on the other. The selection process for "respect" happens AFTER residency if you want to capture that. This is why I suggested that if you really want the dermatology kind of "respectability", we'd have to split the field into small fields, with well off patients specifically shuttled to one subspecialty, etc., or invent a ton of studies/procedures to read or do and bill for. Clearly you are not interested in doing the research to make the latter happen, or the advocacy to make the former happen.

Unless, as another poster said, the point of this thread then is just you trying to bemoan again how psychiatry has no respectability per se... lol in which case I'm not sure what to say except to say, maybe it's time to get therapy yourself.

well for starters I believe Michael is board certified in internal medicine. So that puts him in a little different category. Most sleep people are neurology or IM trained. I realize that there are probably a few that are trained in psych only, but these are rare.

Second, I understand you just fine. I just think your argument is partly wrong and partly wishful thinking. And I disagree that exclusivity of pay source goes towards respectability. Neurosurgeons(who do mostly intracranial stuff) and interventional cardiologists would not rate high by this metric, but they have a ton of respect/prestige.

I agree that high profile psychoanalytic training goes towards some of what you talk about....I disagree that 'complex psychopharm' does. Just how hard do you think 'complex psychopharm' is for mood and anxiety d/os? It's not brain surgery.

The idea of splitting psychiatry off into different fields isn't practical(like is done with neurology) because as another poster said there just isn't that much there. Neurology can have movement d/o specialists, stroke specialists, neurointerventionalists, etc....what are we going to have? Mood disorder specialists? OCD specialists? People do advertise as being experts in those things of course....but that's not a subspecialty of general psychiatry...that's just someone who is a psychiatrist who has a particular interest and skill for that particular pathology.

As to the point of this thread.....well I came across that survery from gallop, and the point was to mainly post it for others to see. I admit that I don't have any answers. I think one thing that would help would be if we had better candidates going into psychiatry, but I don't know how to make that happen.

 

[nancysinatra]

Unless, as another poster said, the point of this thread then is just you trying to bemoan again how psychiatry has no respectability per se... lol in which case I'm not sure what to say except to say, maybe it's time to get therapy yourself.

Ok I have a question. Everyone gets on Vistaril's case for being such a Debbie Downer about psychiatry. You're even telling him to go to therapy for crying out loud. But come on. Have you read the pathology forum lately? Or the surgery forum? They're all Debbie Downers. Since when was it a requirement that to be on SDN you had to be all sunshine and rainbows and unicorns and lollypops?

Now I for one think that people should think about the kind of respect and prestige it is they want in life before choosing a specialty. It's ridiculous to do a psych residency and whine that we aren't as respected (or paid) as much as derms. But it's not ridiculous to be complaining that we aren't admired by the general public, or within medicine generally, because that's just humiliating and discouraging.

I don't think the general public cares much about dermatologists. They do distrust psychiatrists. If we opened up botox practices (which, do you even need to be an MD to do that? aren't there spas that do it too?) -- that's not going to make us look any better. The public thinks we're sell outs already.

I think we would need to invent some new treatments and develop better predictors for violence and suicide if we want more respect. And not continually recruit bottom feeders which lets be honest, at times is a problem in our field.

If we just want to be more enviable in the eyes of other doctors then opening up botox practices and making more $$$ might help. Now never say never. Maybe some psychs could pull it off. HOWEVER, I doubt there are many who could get very far with a botox practice. You have to do a good job after all. Those are going to be picky patients even if they don't look up your credentials. You mess up their face even in the slightest and word will get around, and it won't be the HIPAA friendly word with no names or pictures attached--people will take pictures of your bad work and they will go viral and you will be that doctor on the 6pm news. Or an angry patient will slash your tires.

Seriously how much of the facial musculature can you guys cough up at this point?

But that aside--the vast majority of outpatient dermatology seems like something you could read in a book, right, and start practicing? So why don't psychiatrists just convert to derm practices? And advertise themselves as GPs with a derm focus or whatever? So what if the term is outmoded, it's legal, right?

(I'm not saying derm doesn't require a residency, obviously it does, but you could probably get away with doing a crappy job for awhile, at least until you miss a melanoma.)

 

[vistaril]

But that aside--the vast majority of outpatient dermatology seems like something you could read in a book, right, and start practicing? So why don't psychiatrists just convert to derm practices? And advertise themselves as GPs with a derm focus or whatever? So what if the term is outmoded, it's legal, right?

(I'm not saying derm doesn't require a residency, obviously it does, but you could probably get away with doing a crappy job for awhile, at least until you miss a melanoma.)

well I think the obviously problem with this is that most derm is still 'medical derm', and to be reimbursed through insurance for most medical derm you're going to have to get on their insurance panels for those visits and procedures.....you aren't going to do be able to do that being be/bc'd in only psychiatry.

I also think derm can be pretty darn complicated and intellectual. If it were so easy then family medicine and general internists wouldn't be referring so many patients to derm....they would just handle it themselves.

 

[DOC PENGUIN]

well I think the obviously problem with this is that most derm is still 'medical derm', and to be reimbursed through insurance for most medical derm you're going to have to get on their insurance panels for those visits and procedures.....you aren't going to do be able to do that being be/bc'd in only psychiatry.

I also think derm can be pretty darn complicated and intellectual. If it were so easy then family medicine and general internists wouldn't be referring so many patients to derm....they would just handle it themselves.

Vistiral, You obviously think psychiatry is a lower caliber specialty of medicine. You're blaming people as if someone ELSE started this thread. Why don't you DO something about it and CHANGE it. Your actions speak louder than words.

 

[Doctor Bagel]

I think we would need to invent some new treatments and develop better predictors for violence and suicide if we want more respect. And not continually recruit bottom feeders which lets be honest, at times is a problem in our field.

Overall, I agree with these -- maybe we're not respected because we don't have great treatments or diagnostic tools for our sickest patients. Our drugs aren't that great, and our diagnostic categories are kind of made up. I just spent part of my day yesterday working in an emergency psychiatry walk-in setting and realizing how little I could do to help the patients who came in and not because I'm not good at what I do (not saying I am, but "the greatest psychiatrist in the whole world" or whatever couldn't do much in this setting for these patients).

 

[nancysinatra]

Vistiral, You obviously think psychiatry is a lower caliber specialty of medicine. You're blaming people as if someone ELSE started this thread. Why don't you DO something about it and CHANGE it. Your actions speak louder than words.

But Vistaril didn't say that psychiatry is a lower caliber of medicine. He was responding to my suggestion we convert ourselves into dermatologists without doing derm residencies, so as to live the easy life of derm. Are you saying that that derm is NOT complicated?

If it's not, that would be great, because then we can all do just like I suggested. As far as getting on insurance panels, what we'd need to do is make derm practice the standard of care for psychiatrists nationwide. The APA could issue a guideline stating that "a quick skin check" is now recommended for all outpatient psychiatry visits. After all many skin conditions can have an emotional effect. Once that gets integrated into practice, insurance will have to pay for it. Then we can expand. The APA can recommend more derm each year as part of our psychiatric assessments, until finally, we are doing mostly derm.

 

[DOC PENGUIN]

But Vistaril didn't say that psychiatry is a lower caliber of medicine. He was responding to my suggestion we convert ourselves into dermatologists without doing derm residencies, so as to live the easy life of derm. Are you saying that that derm is NOT complicated?

If it's not, that would be great, because then we can all do just like I suggested. As far as getting on insurance panels, what we'd need to do is make derm practice the standard of care for psychiatrists nationwide. The APA could issue a guideline stating that "a quick skin check" is now recommended for all outpatient psychiatry visits. After all many skin conditions can have an emotional effect. Once that gets integrated into practice, insurance will have to pay for it. Then we can expand. The APA can recommend more derm each year as part of our psychiatric assessments, until finally, we are doing mostly derm.

I don;t think doing dermatology would be effective. i thought it was satire. Never mind my blunt misunderstanding. My point is that Vistiral should change a department and Change his field for the better.

 

[Armadillos]

This thread is a train wreck for all involved. First off whose idea was it that derm is some highly respected field psych should aspire to? Derm is only prestigious WITHIN MEDICINE due compensation and how competitive it is. If you ask a bunch of the general population, they would say either "Pimple Popper" or "Only spent 3 minutes with me and started cutting stuff off me without answering any of my questions"


Also all the discussion of how to best charge X hundred dollars an hour cash probably isn't going to help the reputation of the field either.

Honestly I think the one of the most realistic ways psychiatrists could up their prestige in the eyes of the general public is if outpatient psychiatry had a bit of a "holistic" approach towards the health of the "whole" patient (holistic with a lower case h, not the hocus pocus mushrooms salesmen). Make the interplay of mental health and physical health a greater focus of each visit. Make things like diet (like actual diet advising, not just "eat better"), exercise, sleep hygiene, stress management, smoking cessation, etc. integral parts of the outpatient practice of psychiatry instead of "check boxes" that get sped through.

The combination of training in psychotherapy and motivational interviewing along with the knowledge of physiology/pathophysiology gained during medschool might put psychiatrists in a unique position to offer effective patient education and possibly modify behavior. The general public loves the idea of having the ability to sit down and talk to a physician for 30 minutes, and realistically psych is one of the only fields where that length of interaction is anywhere close to the norm.

Obviously family medicine is where this is supposed to happen, but we all know thats getting less and less true over time, so maybe this could be an area of medicine psych could expand into a little bit. I know its probably a half-baked idea, but probably more productive than trying to become botox mills.

 

[Salpingo]

Honestly I think the one of the most realistic ways psychiatrists could up their prestige in the eyes of the general public is if outpatient psychiatry had a bit of a "holistic" approach towards the health of the "whole" patient (holistic with a lower case h, not the hocus pocus mushrooms salesmen). Make the interplay of mental health and physical health a greater focus of each visit. Make things like diet (like actual diet advising, not just "eat better"), exercise, sleep hygiene, stress management, smoking cessation, etc. integral parts of the
outpatient practice of psychiatry instead of "check boxes" that get sped through.

In a similar vein, I think the best way to be thought of as medical doctors would be to act like medical doctors. Let psychiatrists bill for physical and neurological exams. Sure, this might negatively effect healthcare costs initially (probably a huge upswing in unnecessary echoes for benign murmurs, or MRIs for questionable focal neuro signs), but that would improve as these skills become incorporated into training. But this would only work if there was a financial incentive to do so.

 

[dl2dp2]

Obviously family medicine is where this is supposed to happen, but we all know thats getting less and less true over time, so maybe this could be an area of medicine psych could expand into a little bit. I know its probably a half-baked idea, but probably more productive than trying to become botox mills.

Except, family medicine wouldn't really fit the bill for Vistaril in term of "respectability" either. Let's face the facts here, if there's any specialty even less desirable than psych it'd be FM. So far we have: let's turn psych into neurology. let's turn psych into derm. let's turn psych into FM. Clearly none of these ideas will work It's really kind of hilarious how this thread ended up.

Psych is psych. Psych is 30% psychopharm, 30% derm (i.e. psychoanalysis), 30% FM, 10% SW, with differing proportions at various times.

I think we would need to invent some new treatments and develop better predictors for violence and suicide if we want more respect. And not continually recruit bottom feeders which lets be honest, at times is a problem in our field.

I completely agree with you. First of all I'm personally involved in research in developing quantitative, precise predictions for exactly the kind of substantial outcomes you are talking about--but it's SLOW. I understand your frustration, but given how big and and complex this field is, you need to be more patient. Or, perhaps you'd like to get personally involved in research yourself? Second of all, when this work is done we'll basically have what I was talking about initially: a technical field with acronyms flying around, blah blah score for risk stratification, blah blah trial shows this combo is better than that combo for this risk score of this syndrome X Y Z. checking various tables, maybe a blood test or two here and there, standardized instruments everywhere, an imaging marker or two, a genetic marker or two, etc. maybe one infusions here and there, a rare procedure here and there, complicated algorithms for treatment, etc. i.e. rheumatology. This might happen in the next 20-50 years.

This is my modest, but likely the most realistic answer: turn psych into rheum. Watch me, it's gonna happen: ketamine infusion is already here... it's only a matter of time... And, this is basically the standard answer NIMH/NIDA/APA/AACAP etc. has for y'all. DSM is gonna become RDoC. Unless you think they are all stupid...

Also, recommending him for therapy isn't at all pejorative. Perhaps this reflects the institutional culture here, but everyone is in therapy here. It just seems that it's possible that he may have some deeper issues to resolve and perhaps he could benefit from some exploratory therapy. JUST a suggestion. And I understand your frustration too, but if you gotta sympathize with the fact that research is hard to do and progress is slow and there's just no other way about it. At the same time, there is a lot of HOPE and inspiration and genuinely good things in the field. There's NOTHING like getting a psychotic patient on cloazpine and seeing him literally wake up. There's NOTHING like getting your badly depressed lonely middle aged outpatient back on the job market and dating and feeling hopeful about life again, with my admittedly limited arsenal of poor meds. At the end of the day I think with all the problems we have this field is still the most engaging field in medicine. A lot of your patients, no matter how much money they have, are really desperate and it's up to YOU to inspire some hope and make their lives genuinely better, and you CAN! If the uncertainty of daily practice really bothers you so much, and you get frustrated a lot at work, I think therapy for you might not be such a bad idea either.