pyschiatrists as primary care docs?

[Macumazahn]

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Here is something that I have been thinking about, and thought it would be good to hear from other psych residents on the subject.

I'm a psych intern and love psychiatry. However, I love alot of other things in medicine too. And I hate to think that I'm going to give up all the rest of my medicine skills just because I chose to do psychiatry.

Basically, I would like to be able to treat my psych patients for other basic medical illness, such as UTIs, minor URIs, uncomplicated HTN, and/or maintain controlled diabetes. I think these are such common conditions, many of my psych patients have these comorbid conditions. And many of the meds they are on may work with or against the psych meds I am prescribing.

I kinda get mixed feelings from the attendings I ask on the subject. Some only treat psych issues, and would get a medicine consult for even the most basic non-psych issue. These folks cite litigation and competency for their main reasons. Of course you shouldn't treat someone if you do not feel that you are competent, but unfortunately, not treating because you don't want to get sued is also a valid argument in today's world. Other psychiatrists, mostly those in an inpatient psych ward, will treat the minor stuff I listed below.

I feel that everyone is getting so specialized nowadays that a lot of docs cannot see the big picture anymore and don't keep up with basic medical treatment. I think this exacerbates the current problem of not having enough primary care docs.

Just wondering what fellow psychiatrists-in-training think on the matter.

 

[Doctor Bagel]

Well, I'm still a med student, but I think all physicians should have basic competency in treating the things you mentioned above, and it seems reasonable to me that a psychiatrist should take care of this stuff for psychiatric inpatients. The litigation thing seems like a cop-out, too, because you're not really placing yourself at great risk by a uti or controllable HTN. That's a whole other discussion, though.

However, if you want to do somewhat complicated primary care type of stuff or have that be a big part of your job, maybe you'd be happier in a med/psych or fm/psych program. The people I know at my school's fm/psych program told me things similar to what you're saying when telling me why they opted for fm/psych.

 

[OldPsychDoc]

I feel that I'm competent to read a chart, check labs, etc on uncomplicated HTN, DM, etc, and so I will renew stable meds, start a little first-line treatment, etc., in the absence of a primary care doc. OTOH, I do NOT do physical exams on my outpts (save the occasional neuro check), so if I think the plan of care requires a PE for treatment--off they go.

 

[Doctor Bagel]

I feel that I'm competent to read a chart, check labs, etc on uncomplicated HTN, DM, etc, and so I will renew stable meds, start a little first-line treatment, etc., in the absence of a primary care doc. OTOH, I do NOT do physical exams on my outpts (save the occasional neuro check), so if I think the plan of care requires a PE for treatment--off they go.

Do you not do the physical exam because of boundary issues or time/interest issues?

 

[billypilgrim37]

Inpatient, it makes sense to do as much medicine as you are personally comfortable with. Your attendings aren't silly, though. When a mistake is made at a hospital, a whole hospital is liable. That's deep pockets.

Outpatient, a psychiatrist trying to manage the primary care issues of their patience is ill-conceived. You get x number of minutes with each patient. You are a specialist in psychiatry. Each of those x number of minutes you are devoting to something other than the thing in which you are a specialist is robbing the patient and the community of a psychiatrist. While there is certainly a primary care shortage, there is a greater shortage of psychiatrists in the world.

Of course, there are exceptions. If the pt refused to go to a PCP despite your encouragement despite obvious need, and any other number of possible stopgaps that might need to be in place. But routinely taking time away from the precious few minutes you can see a patient to deal with something that someone else could do more efficiently and more skillfully? That sounds like a net loss for your community of patients.

Those that are double- or triple-boarded, the argument is of course entirely different (a) they're properly trained and skillful in these issues, b) they can see their patients for separate medicine and psych appointments and bill accordingly if they know how to set proper boundaries, c) many theoretically wish to serve communities where availability of each service is genuinely poor, which is less true in areas within 20 miles of a residency program, etc.

 

[masterofmonkeys]

I guarantee I can handle routine HTN, diabetes, and MSK complaints better than a typical primary care doc can handle psych. *shrug*

In the hospital setting, I believe we should do what we're comfortable with. I set my standard roughly by what surgeons are willing to do medically. Basically, if the medical issue is not severe enough for them to be admitted for it, I'll take a stab at it.

 

[OldPsychDoc]

Do you not do the physical exam because of boundary issues or time/interest issues?

Yes. 😉

The former with outpatients, but also because our clinic offices are set up without actual exam rooms.

On inpatient, because it is a better use of time/interest to have our residents and PAs do these, and consult where needed.

 

[whopper]

There is debate about psychiatrists doing physical exams. In Kaplan & Sadock there is mention that "psychiatrists do not do routine physical exams." There is also mention in various texts that for psychiatrists to do such exams, it could create boundary, and liability issues.

Where I did residency, we were supposed to do physical exams. As a result, several who were supposed to do them before the person hit psychiatry such as the ER doctors simply checked off everything was normal without even doing an examination. For that reason, it became imperative for a psychiatrist to do one because we had to make certain the patient was truly medically cleared, and not just another dump job that was to the degree where it could have easily been caught by an ER doctor actually doing their job right. (I very much understand there are grey area cases, but about once a week we'd get at least one dump that was far beyond excusable). Likewise I'd see some psychiatry attendings and residents not do a physical exam and mark off everything as normal or do a perfunctory job on the exam.

In common practice, it is beneficial to at least check up on the person's appearance. E.g. scars on forearms, hygiene (bad breath, dirty clothes, greasy hair), etc.

If you want to do primary care practice, I'd follow the above advice. You will have to deal with the following issues.

1) several insurance companies will not want to provide coverage, or may dramatically increase your premiums because you are doing primary care.
2) if you work as a psychiatrist in several venues such as outpatient, or in an inpatient facility where psychiatrists are not doing the physical medical care of the patients, you will become rusty on physical medical care. E.g. I've worked in a facility last year where I was not supposed to do physical exams. Do you think I had time to practice physical exams on my own? Of course IMHO my own skills in that area were dulled. Despite that, at times I would do an examination because some of the IM attendings IMHO were doing perfunctory jobs, and I had to catch the physical medical problem myself. However I've seen several psychiatrists at the same place be over 10 years outside of physical medical practice. I thought to myself -darned, I'm better not become that psychiatrist that doesn't know anything about medicine. Working in forensic fellowship, those talents are being even more dulled since I'm evaluating people on a basis even more removed from the physical medical model.
3) Your patients will ask you "what kind of doctor are you?" and if you tell them you are a psychiatrist by training, that's not exactly going to inspire confidence in them if you are treating their various medical problems such as CHF, or inflammatory bowel syndrome.
4) should you be sued for malpractice, your training will certainly not help you in court unless you did a combined residency.

I currently have psychiatric malpractice insurance, and my insurance company specifically stated that I am not covered to treat nonpsychiatric medical problems.

 

[kugel]

I kinda get mixed feelings from the attendings I ask on the subject. Some only treat psych issues, and would get a medicine consult for even the most basic non-psych issue. These folks cite litigation and competency for their main reasons.

As you point out, litigation is an issue. Even if you feel competent, there is the issue of protecting your group/hospital/residency. This is basically a Risk Management question.
Let's see, to whom should I direct a Risk Management question if I want the best informed answer?
THE RISK MANAGEMENT ATTORNEY associated with your program/hospital/insurance!
Most residents/attendings do not have much training on these questions and the vast majority of their answers will come from myth and rumor - not facts. Books contain general concepts and cannot answer for your situation, hospital, state.

A Risk Mgt attorney once told me that she'd have a lot fewer cases end up in court if physicians just stopped using the word "liability," because they are usually giving out wrong information when they say it. She said she'd agree to stop telling her colleagues what medicines to take if the physicians would stop telling their colleagues what their liability is.

If you want good info about psychiatric diagnosis, start by asking a psychiatrist - not an attorney who's had some cases involving psychiatry. If you want good info about medical risk management, ask a medical risk management attorney - not a physician.

 

[michaelrack]

from a practical standpoint, you can do this on an inpatient basis. Ie, if you admit a schizophrenic with stable DM, you can treat both problems and can always get a consult if the DM gets out of control.

You really can't do this on an outpatient basis. What are you going to do if someone you have been treating for schizophrenia and "stable" DM calls you and tells you their blood sugar is 600? Are you going to tell them that they are now "unstable" and they have to find someone else to serve as their primary care doc??

There are a lot of other practical difficulties in combining psychiatry and primary care in an outpatient basis, even for those of us who are trained in both and know what we are doing (or in my case, once knew what I was doing- I don't do much general IM anymore and my knowledge is withering)

I would advise the OP not to try to do outpt primary care with just psychiatry residency training.

 

[whopper]

IMHO, any inpatient psychiatrist worth their salt is going to keep decent knowledge of managing HTN, diabetes, metabolic disorders (both in too much and too little food) and reading EKGs.

Any psychiatrist should also be able to read labs.

All those situations happen in an order where an inpatient psychiatrist is very likely to encounter these problems and situations where they will not fall out of practice. On a daily basis I'd have multiple patients with HTN and diabetes.

However I do recall several situations in residency where the person had a BP of 129/85 (or some other ridiculous amount such as 140/90-just once, not 3 times) and a medical consult was ordered for hypertension, then a fuming IM doctor would come in and start reelling his anger at me, even though I was against the consult to begin with and recommended to the attending not to order it (or not come in as a form of protest).

 

[Doctor Bagel]

However I do recall several situations in residency where the person had a BP of 129/85 (or some other ridiculous amount such as 140/90-just once, not 3 times) and a medical consult was ordered for hypertension, then a fuming IM doctor would come in and start reelling his anger at me, even though I was against the consult to begin with and recommended to the attending not to order it (or not come in as a form of protest).

Yeah, no one wants to be the person (or shouldn't want to be anyway) who calls pointless consults. Consulting IM for stuff like this is similar to IM people consulting C/L teams for a patient with adjustment disorder (seen it!). IMO, there are just basic levels of competency that all physicians should have. It urologists can deal with this stuff, why can't psychiatrists?

But, hmm, the outpatient stuff is interesting. I'm still curious about the practice model for people who do outpatient im/psych or fm/psych. Do they divide their practice, or do mainly primary care while having extra skills for psych patients?

 

[whopper]

I'm still curious about the practice model for people who do outpatient im/psych or fm/psych. Do they divide their practice, or do mainly primary care while having extra skills for psych patients?

Don't know the answer to that, though I suspect the PDs of those combined programs would have the best knowledge of that.

In primary care, psychiatry is very important. PCPs usually are the first line of treaters for mental illness, not psychologists or psychiatrists. This was verified in studies. I've seen several family practices hire a psychologist for psychiatrist as a consultant to advise them how to handle these things.

I figure that's where these people probably end up working, but as the consultant in addition to doing the actual family practice or IM work. That's just my speculation.

 

[michaelrack]

But, hmm, the outpatient stuff is interesting. I'm still curious about the practice model for people who do outpatient im/psych or fm/psych. Do they divide their practice, or do mainly primary care while having extra skills for psych patients?

Outside of academia, most dual-certified docs do one or the other- its hard to do both psychiatry and IM at the same time. Most end up doing psychiatry. For those few who end up in primary care, they do a little more psychiatry than the average pcp; like other pcp's they usually bill as a pcp.