Scope of psychiatry

[citizenbang]

What is the scope of psychiatry? Will an insurance company reimburse psychiatrists who venture into neurological diseases, such as treating headaches, fibromyalgia, or seizures? I ask because I enjoy learning about the brain and incorporating diversity into my life.

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[Bartelby]

You may want to do a dual residency. I don't know if you can get paid for treating headaches or seizure disorders but both are clearly neuro's turf. Fibromyalgia psych can probably bill for in one way or another. You should probably have training in neurology if you are going to practice it regularly regardless of what the rules say.

Something like teaching relaxation techniques etc as behavioral adjuncts to treatment for neurological disorders or managing behavioral disorders stemming from neurological disorders should be fair game.

 

[Manicsleep]

Insurance companies may or may not. It depends on the context.
Opening a headache clinic or an epilepsy clinic is usually not even done by regular neurologists and is left to specialists these days.

Then again, you are a physician and if you have the training you can do it, especially if that training is in neuropsychiatry. There are a few neuro heavy programs. If not, stay away. Also, it depends on malpractice coverage.

I see a lot of things in sleep, including seizures, conduction abnormalities etc that I sometimes 'treat' but will eventually refer to someone else.

 

[whopper]

Hard to say. E.g. Cogentin, propranolol, Ativan, etc are all given to treat side effects caused by psychotropic meds, and it's the standard.

But how about giving a BP med to treat stimulant-induced HTN? Or how about a psychiatrist to gives a bunch of psychotropics (e.g. Lamictal, Cymbalta, amitriptyline) to treat chronic pain without a mood disorder? Pain disorder is a psychiatric disorder in the DSM. Just when does that pain cross outside of the psychiatric given that pain is highly subjective?

Or how about a psychiatric disorder caused by a general medical condition? These are DSM psychiatric disorders. What if I treated the psychiatric disorder by treating the medical condition?

Psychiatry is a branch of medicine where there's a grey zone between what is psychiatric and what is not. Some of those grey areas are accepted to be within the realm of psychiatry. Others aren't, but haven't been marked off as definitely not psychiatric. Just that no one's given an answer on it, and perhaps there isn't one.

 

[Sneezing]

Pain as long as you aren't tossing out opiods is just fine. There are some pain fellowships that take psychiatry grads.

Headache fellowships also take psychiatry grads.

I wouldn't touch treating epilepsy unless you knew how read an EEG really well. Neuro programs don't necessarily give mastery teaching but basics. If there is that much gray area in neurology EEG reading I would expect a psychiatrist to have spent sizeable time and electives learning the skills to come across as an epileptologist.

 

[st2205]

I think these raise interesting questions about the more broad scope of psychiatry. I find it somewhat interesting that psychiatry as a field keeps fighting off the notion that they're 'not real doctors' but then will continue to assert the bounds of psychiatry and certainly not dabble in any other medical realms because, hey, 'we're not real doctors'. I'm talking about things like running a TSH/FT4 and starting something like a levothyroxine. Apparently something like this is frowned upon and needs to be referred to a 'real doctor' or a mid-level who will have 'more expertise'. I understand some of this gets shaped by malpractice insurance and reimbursement, but it seems funny to me that a group of society that is openly considered underserved is having very basic medical needs be funneled out to anywhere but the treating physician (psychiatrist).

I've been somewhat curious about the primary care psychiatry program that UTSW is doing http://www.utsouthwestern.edu/utsw/cda/dept28657/files/98630.html

The UT Southwestern Psychiatry program was fortunate to be selected to be one of the few pilot sites for special training for psychiatrists to function in a primary care role for many of their patients.

There has been debate in recent years about whether psychiatrists should be considered primary care physicians. For many of our patients we are the only physician they see, and, when we do refer them, they often don't follow through, get inferior care, and unfortunately many of our colleagues in other specialties are uncomfortable with them and just as happy not to spend time with them. What has evolved is the concept of Primary Care Psychiatry. Psychiatrists provide the principal care that many if not most psychiatric patients receive.

In considering preparing future psychiatrists for this role, some programs have developed combination med/psych or family practice/psych programs. We gave careful consideration to this possibility but concluded that it is not realistic to expect someone to become a fully competent psychiatrist and a fully competent internist or family practitioner and to maintain this throughout a career. Follow-up data on combination programs tends to confirm this position. Recently, however, funding became available to train Primary Care Psychiatrists. We jumped at the chance and received special funding for this model program.

Those who opt for the additional training (towards the end of the PGY 2) will begin seeing patients in a specially designated ½ day clinic in the PGY-3. They will be supervised on every patient by both an internist and a psychiatrist. In addition, they participate in a special monthly case conference that focuses on the comprehensive care of patients from this clinic. In the PGY 4, residents who have selected this track undertake a special focus. Residents have undertaken research projects on the recognition and treatment offered psychiatric patients with Hepatitis B, or ambulatory C/L experiences in HIV, Sleep Medicine, Gastroenterology or other medical subspecialties.

We are very excited about this program, which graduated its first group of residents in June, 2002. We are currently conducting research to determine how effectively this pilot project is working. To us, this is the best answer to the dilemma that all psychiatrists have struggled with in recent years, and which we hear so much about from our applicants.

I think there are a lot of things medically that likely effect people long term relating to psychiatry, in addition to posing risk of increased mortality. Theoretically, is it really that bad for a psychiatrist to manage some common medical issues? I'm not talking about trying to manage AFib, or MS, or a triple A. I mean things like DM, lipids, HTN, etc. that may not get managed elsewhere, depending on patient population. Maybe some do this -- I have no idea since I haven't really seen the entire spectrum of psychiatry. But this seems not to be the case from my understanding.

If someone codes on the psych floor, do the psychiatrists twiddle their thumbs while they page for a FNP to come run the code? I don't mean this as an insult to anyone here as it seems most everyone here is pretty passionate about what they do and up on their medical knowledge, but it seems like the general direction the field is in is to shift anything that seems like it may have a definable underlying pathophysiology to some other field, forgetting that at one point in time they actually completed medical school.

I think the bottom line is that a FNP will treat nearly anything without anyone raising an eyebrow, but psychiatry seem to walk on eggshells with "Oh we can't do that..." or "We shouldn't be treating that..." or "We're not qualified to interpret..." I should probably qualify that, within the context of this thread, I'm not necessarily advocating delving into the nitty-gritty of neuro or any other specialty, but at least being able to manage some of the more well understood conditions that any physician should be able to manage, especially those that pertain to psych.

Jumbled rant, getting late.

 

[digitlnoize]

I think there are a lot of things medically that likely effect people long term relating to psychiatry, in addition to posing risk of increased mortality. Theoretically, is it really that bad for a psychiatrist to manage some common medical issues? I'm not talking about trying to manage AFib, or MS, or a triple A. I mean things like DM, lipids, HTN, etc. that may not get managed elsewhere, depending on patient population. Maybe some do this -- I have no idea since I haven't really seen the entire spectrum of psychiatry. But this seems not to be the case from my understanding.

I think many of these diseases fall within psychiatry's spectrum of care, simply because they are, largely, BEHAVIORAL diseases. The obesity epidemic that's causing the explosion of DM, lipids, HTN is a behavioral issue (although a case could be made for addiction too, I think) and could, I think, be very well managed my psychiatrists. If there were enough of us to go around, I would say that seeing a psychiatrist (or at least a mental health professional) should be part of the standard of care for all of these issues, given their large behavioral component.

 

[notdeadyet]

You could send a patient to a psychiatrist for behavioral issues like overeating (though you could probably get as much effect for a lot cheaper sending the person to a psychologist or therapist).

But it would be a cold day in Hades before as a PCP I'd refer a patient to a psychiatrist to manage hi hypertension.

 

[Manicsleep]

When I ran an inpatient unit, I was the primary care physician. I was responsible for everything including managing HTN, cholesterol, headaches, pain and whatever else came my way. I had to be comfortable with ECGs and to a lesser but some degree, radiologic studies.

But if the patient had severe HTN, an infection or an acute abdomen etc I called medicine, surgery or whoever very quickly.

So your scope is that you are a full fledged doctor but you have to know your limits. Learning everything about medicine is important because it teaches you those limits and allows you to practice medicine safely and properly.

 

[michaelrack]

Will an insurance company reimburse psychiatrists who venture into neurological diseases.

depends on the state and insurance company. Reimbursement would be less likely if mental health benefits were carved out from general medical benefits.

 

[michaelrack]

I've been somewhat curious about the primary care psychiatry program that UTSW is doing http://www.utsouthwestern.edu/utsw/cda/dept28657/files/98630.html


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sounds like a bad idea to me. It's hard enough for a med/psych grad to practice "primary care psychiatry", let alone someone with the limited primary care training such a program would provide.

 

[Manicsleep]

I've been somewhat curious about the primary care psychiatry program that UTSW is doing http://www.utsouthwestern.edu/utsw/c...les/98630.html

sounds like a bad idea to me. It's hard enough for a med/psych grad to practice "primary care psychiatry", let alone someone with the limited primary care training such a program would provide.

I understand why some you think this is a bad idea but I have an alternate view on it. These physicians wouldn't serve the same role as a fully functional PCP with a panel of 2-3000 patients or more. But this would make these physicians much better trained for working where they are the only person seeing the patient. Often it allows them to fit into a group system better. I would love to see more of such physicians. Currently we have outpatient consult hours with our PCPs and I think someone like this would naturally fit into that role. The only other option is a dually trained physician who also is not perfect because they have been partially trained in both and are masters of none (I don't believe that, just that there is always something to criticize).

By the same nature, I have heard some, including physicians, say family medicine doctors shouldn't be seeing kids or delivering babies or doing minor surgical procedures...and I always respond that because they 'waste' so much time learning that, they shouldn't see adults either.

In an age where we are seeing NPs/PAs/psychologists and other mid levels gain access to the practice of medicine, we should encourage this type of training. It fulfills a need and allows for gaps to be filled although it is not ideal. In an ideal world, every one would see a specialist in the concierge model but that is a very expensive proposition.

 

[ghost dog]

sounds like a bad idea to me. It's hard enough for a med/psych grad to practice "primary care psychiatry", let alone someone with the limited primary care training such a program would provide.

Not sure what you mean; family MDs do the above already, without any additional training / fancy pants fellowships.

In fact, the majority of psych management is performed by primary care. You guys handle the severe cases.

 

[michaelrack]

Not sure what you mean; family MDs do the above already, without any additional training / fancy pants fellowships.

In fact, the majority of psych management is performed by primary care. You guys handle the severe cases.

I have no problem with primary care docs doing basic psychiatry. I personally don't think it's a good idea for psychiatrists to try and practice limited primary care, but recognize that there are differing view points