Specific Disorders vs. Patient Population

[solumanculver]

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Hey, it kind of seems like some medical specialties focus on a certain set of disorders, like cardiology, while other specialties focus on a certain patient population, like pediatrics. What is psychiatry?

I kind of feel like psychiatry focuses on specific disorders when it should focus on the spectrum of disorders that the mentally ill have... including diabetes and pneumonia and whatever other disorder that schizophrenics are apt to get that would usually be treated by IM. Does this kind of model make any sense? I suppose that it's the purpose of Psych/IM or Psych/FP combined residencies, but shouldn't that be part of an ordinary mainstream psych residency?

 

[whopper]

If I'm interpreting you right I'd agree.

Psychiatrists are physicians, sometimes I think some psychiatrists forget that. I have seen some psychiatrists know very little internal medicine & primary care knowledge.

We of course should be considering factors going on other than the simple medication of a psychiatric illness. E.g. the APA & ADA (American Diabetic Association) have come out with joint guidelines on monitoring patients to prevent metabolic illness, and should a metabolic illness occur, confronting it and coordinating with the appropriate doctor.

Several psychiatric patients have correlated physical problems which (edit: we) should consider.

I hope your post isn't in response to a psychiatrist telling you we don't have a responsibility in these areas.

 

[solumanculver]

If I'm interpreting you right I'd agree..

Hey Whopper. I'd say you were interpreting me right. I didn't mean to be obscure.

I hope your post isn't in response to a psychiatrist telling you we don't have a responsibility in these areas.

No, it's nothing like that. I'm just going to be starting medical school soon, and my interest is psychiatry, but I'm afraid that my vision of psychiatry might not really reflect the reality of psychiatry.

I'm interested in the severely mentally ill. I want to be able to treat schizophrenia itself as well as any kind of metabolic disorders that the patient may have acquired in the course of their treatment. If they've gotten some other medical problem related to their mental illness, like liver damage related to alcoholism, or whatever thing that the homeless mentally ill are liable to acquire, well I want to treat that too.

It just kind of seems like psychiatrists aren't really trained for that sort of thing. Well the residency is four years long, so there must be enough time to get it all in there... It doesn't seem like the mentally ill as a population should be so much more complex than children as a population, and a peds residency is only three years. So psychiatrists have a whole other year but the training still doesn't encompass some of the most common medical problems of the mentally ill.

Well, that's my perception, maybe I'm way off base...

 

[whopper]

As much as I hated USMLE Steps II & III, the one good thing about it is it forces the test taker to know how to care outside of their field of specialty. Every doctor should at least have knowledge of primary care.

We psychiatrists of course shouldn't know GI as well as a gastroenterologist (unless you got the time to study both areas-more power to you), and a good psychaitrist will take into consideration things such as the liver when choosing a med. E.g. they might stay away from depakote in a patient with evidence of strong liver damage.

I hope if you do enter psychiatry, you will keep the same philosophy. Unfortunately I've seen some of the same you're mentioning. Some doctors sometimes act as if something outside their field of specialty is something they don't have to know.

 

[solumanculver]

Hey Whopper, it seems like all that needs to happen is for the requirements of psychiatry residency accredidation to include a bunch more medicine and a bunch more hours per week. Like I sort of mentioned before, if you can do a Med/Peds combined residency in 4 years, it seems like just incorporating a lot more medicine into a psychiatry residency within the 4 years that it already takes should produce psychiatrists that are really really competent at managing the medical needs of their patients.

In fact, looking at the psychiatry residency curriculum at a lot of programs, it kind of seems like the residency could be shortened to three years anyway, which kind of implies that a med/psych residency could probably only take four years. What do you guys do in the fourth year, anyway? Doesn't it routinely get waived at some programs in order to do fellowships?

 

[toby jones]

> it kind of seems like some medical specialties focus on a certain set of disorders, like cardiology, while other specialties focus on a certain patient population, like pediatrics. What is psychiatry?

Interesting question... The Mental (Psychiatric) vs Somatic (e.g., Neurological) distinction is fairly controversial.

> I kind of feel like psychiatry focuses on specific disorders when it should focus on the spectrum of disorders that the mentally ill have...

So the idea is that... The DSM fixes which conditions are psychiatric disorders (whichever conditions are included in the DSM). Then, once we have identified the patients who meet the criteria for having a psychiatric disorder any disorder they have should be treated by psychiatrists?

Oncology could try that... Anybody who has cancer is treated by an oncologist - whether they have a psychiatric disorder or kidney problems or a funny kind of rash...

I guess the concern is that there isn't enough time in the day to study everything and as such, one might be better referring a patient on to another specialist if they have cardiac problems or whatever.

That being said, it would be great if people learned more (generally speaking)...

I guess I'd be worried about what learning more about what is typically regarded as other specialities would be taking away from psychiatry. There are so many things it would be cool to be competent in...

 

[solumanculver]

Hi Toby,
I don't mean to say that psychiatrists have to know everything. Just that they should be able to compentently treat their patients for the kinds of disorders that are really common among the mentally ill... particularly metabolic disorders, but the general run-of-the-mill primary care stuff as well. Of course, specialists would get involved at the appropriate times, just as in any primary care practice. The problem is that the mentally ill probably are lucky to be able to see a psychiatrist, it's probably asking too much for them to see an internist too. Anyway, that internist doesn't want to treat a crazy person... I'm not sure that it's really too much to ask, but then again I'm not even a medical student yet, so maybe someone else can speak to that better than me.

edit: Oh, by the way, I re-read your post and I think I see what you're saying... I definitely don't mean that anyone with a DSM disorder should be treated by a psychiatrist for everything... I'm talking the big disorders, schizophrenia and psychotic disorders, Major Depressive Disorder, Manic Depressive Disorder, Severe OCD... The kinds of disorders whose sufferers often have stereotyped medical problems, like schizophrenia and diabetes from the antipsychotic medication. My major idea is that psychiatrists should also kind of be primary care for the insane... sort of narrowly construed.

 

[billypilgrim37]

My major idea is that psychiatrists should also kind of be primary care for the insane... sort of narrowly construed.

I was of the same opinion, until I actually went through my psych clerkship and realized that psychiatrists have more than enough to deal with focusing as specialists dealing with mental disorders. I agree that in theory the "psychiatrist as PCP for folks with mental illness" would be a nice dream, but there's a handful of reasons why its less than ideal in practice.

Family docs and internists spend three full years learning how to be primary care docs. While once upon a time someone could do just an intern year and be a competent primary care physician, that era ended sometime before I was born. Good primary care is complicated, ever changing, and isn't something you can do well part time. A psychiatrist has the responsibility to recognize risk factors and signs of common medical disorders, to know whether those issues are being adequately addressed by someone who knows what they're doing, and to understand the backwards-forwards relationship of primary care and psychiatric issues. To expect a psychiatrist (or a neurologist, or a neurosurgeon) to give the same level of primary care management as a full-time PCP just isn't consistent with best practices.

If you're not in a top-10 major metropolitan area, there's probably a shortage of psychiatrists (ESPECIALLY in child and gero). In the rural South, you need someone doing 15 med checks so that folks can actually get care. If you expect psychiatrists to manage diabetes, hypertension, and bipolar disorder, you're looking at a 45-60 minute appointment, which means there's somebody else not getting their psychiatric care.

While psychiatrists better be competent at physical exams like any physician, a physical exam is simply not appropriate for many psychiatric patients who already have extensive boundary issues. The person asking extensive questions of a woman about her PTSD symptoms after her rape shouldn't be putting a stethoscope under her shirt, etc. And you can't manage someone's primary care issues if you are not in a position to perform a physical exam at the same capacity as a PCP.

And just to be practical, there's no way for private practice docs to get paid for doing this sort of work. That may seem ridiculous, and it is, but there's no obvious way to think that this could ever be fixed. I never plan to be in private practice, but a substantial portion of the psychiatric work force operates in that context.

I extensively explored the combined psych and primary care, and have two friends pursuing those programs, but they have very specific, non-traditional practice goals. Primary care is a specialty as much as any other, and expecting folks in other specialties to be as competent as primary care specialists in providing primary care just isn't the best patient care we have to offer in most circumstances.

 

[solumanculver]

To expect a psychiatrist (or a neurologist, or a neurosurgeon) to give the same level of primary care management as a full-time PCP just isn't consistent with best practices.

If you expect psychiatrists to manage diabetes, hypertension, and bipolar disorder, you're looking at a 45-60 minute appointment, which means there's somebody else not getting their psychiatric care.

Hey, so do you think the main problem is that psychiatrists can't be good at both mental health and primary care, or that they don't have enough time to do so?

Some people have said that the psychopharmacology stuff isn't that vast a field, so it kind of seems like psychiatrists should be able to master both that and some primary care stuff. Of course, just like pediatricians don't really need to know a lot about, I don't know, Alzheimer's disease or something, psychiatrists wouldn't really need to know the full spectrum of primary care... just the stuff that is common in mentally ill populations.

Well, maybe a psychiatrist should chime in and say whether they have the time to learn that stuff too...

As for the time constraints, that's definitely a problem in practice keeping psychiatrists from doing that kind of stuff, but shouldn't it be trained in residency anyway?

While psychiatrists better be competent at physical exams like any physician, a physical exam is simply not appropriate for many psychiatric patients who already have extensive boundary issues. The person asking extensive questions of a woman about her PTSD symptoms after her rape shouldn't be putting a stethoscope under her shirt, etc. And you can't manage someone's primary care issues if you are not in a position to perform a physical exam at the same capacity as a PCP.

Hey, I've heard this before, but to be honest I don't really understand it. Why can the psychiatrist not do the exam but someone else can? The other guy isn't crossing some boundary too? Is it especially wrong for the psychiatrist to do it because he knows she was raped...

And just to be practical, there's no way for private practice docs to get paid for doing this sort of work. That may seem ridiculous, and it is, but there's no obvious way to think that this could ever be fixed. I never plan to be in private practice, but a substantial portion of the psychiatric work force operates in that context.

Hey, yeah, I've heard about this too. I don't have experience in this. What happens when a patient goes to their PCP with some shingles and a bacterial ear infection? Is that different from a schizophrenic going to a psychiatrist to do a med check and manage his diabetes?

 

[toby jones]

> Some people have said that the psychopharmacology stuff isn't that vast a field, so it kind of seems like psychiatrists should be able to master both that and some primary care stuff.

I would expect that someone could really specialise in psychopharmacology and there would be more than enough to keep them busy for several lifetimes and that would just be in working out what is known at the moment (and never mind future advances). Psychiatry isn't just about psychopharmacology, either. There is the relating to patients aspect (and possibly psychotherapy too).

> Of course, just like pediatricians don't really need to know a lot about, I don't know, Alzheimer's disease or something, psychiatrists wouldn't really need to know the full spectrum of primary care... just the stuff that is common in mentally ill populations.

I think psychiatrists do worry about problems that arise in response to psychopharmacology (movement disorders etc).

> As for the time constraints, that's definitely a problem in practice keeping psychiatrists from doing that kind of stuff, but shouldn't it be trained in residency anyway?

I'm not sure... I thought it was. I thought that people get their general medical training first and then specialise. If you don't do something for a while then I guess you might not be so good with it, however.

> Why can the psychiatrist not do the exam but someone else can?

If you are trying to build good emotional rapport (by being sympathetic etc) so that the person will talk to you about how they are feeling and stuff, then you don't want to be in the position where the person is going to experience you as recapitulating the abuse. If someone else does the physical exam they might well be experienced as recapitulating the abuse - but if the person who does the physical exam isn't involved in their ongoing care it won't matter so much. Also... It could be harder for the person to cope with if they are emotionally vulnerable with a clinician and then physically vulnerable too...

 

[billypilgrim37]

Hey, so do you think the main problem is that psychiatrists can't be good at both mental health and primary care, or that they don't have enough time to do so?

Time restraints are a factor, but my main point is that primary care is a specialty unto itself. It's not like some folks stop training and they're primary care workers, and other folks keep going and they're specialists. Family docs have an eventful 3 year residency after medical school. And primary care docs aren't expected to know a little about everything; they're expected to know A LOT about everything. Not as much as a specialist, of course, but more than enough. There are constantly updated guidelines for managing the bread and butter outpatient issues.

Some people have said that the psychopharmacology stuff isn't that vast a field, so it kind of seems like psychiatrists should be able to master both that and some primary care stuff. Of course, just like pediatricians don't really need to know a lot about, I don't know, Alzheimer's disease or something, psychiatrists wouldn't really need to know the full spectrum of primary care... just the stuff that is common in mentally ill populations.

Like anything, psychopharmacology is as vast as you want it to be. Someone can choose to only superficially understand whatever specialty they enter, and probably survive.

Giving someone a partial version of primary care is simply bad care.

As for the time constraints, that's definitely a problem in practice keeping psychiatrists from doing that kind of stuff, but shouldn't it be trained in residency anyway?

Again, psychiatrists need to understand medical issues, because we are docs managing diseases with medical etiologies. But there's a huge gap between something as simple as knowing to check a TSH on someone on lithium and knowing how to best manage treating hyperthyroidism (which is about as simple and straight forward a medical issue as I could even imagine). Some psychiatrists may be comfortable doing that themselves, but many would rather refer back to the PCP. Not because they don't know how per se, but because a primary care doc or an endocrinologist treats this issue every day, and a psychiatrist simply doesn't.

Why can the psychiatrist not do the exam but someone else can? The other guy isn't crossing some boundary too?

It's not a matter of you crossing their boundary, it's a matter of them not understanding their own boundaries. Personal boundaries are a huge issue for psychiatric patients, especially those with Axis II pathology. This may not make sense until you actually have a psych rotation; it probably didn't for me before then either.

Hey, yeah, I've heard about this too. I don't have experience in this. What happens when a patient goes to their PCP with some shingles and a bacterial ear infection?

Mental health issues are simply more complex than most outpatient medical issues. What does it take for a shingles diagnosis? I walked into my PCP my M1 year, said "hey, I think I've got shingles," raised my shirt up, the dude said, "yep, you've got shingles," and started writing me a prescription for an anti-viral. Diagnosing an ear infection in a kid takes about five minutes. "Oh, they're tugging their ear, let's look..." 30 seconds later "yep, it's red and yucky," then a 5 minute talk about whether to take amoxicillin or not.

In the same period of time a PCP would have diagnosed, wrote scripts, and educated about 2-3 common outpatient medical illnesses, the psychiatrist would still be getting a history of present illness. Not because the psychiatrist is incompetent, but because you really want to know whether the halloween decorations really were telling your patient that their spouse was cheating on them and that their mother hated them (as was the case from my last rotation).

Hey, I remember telling my best friends early in med school, "I'd really love psychiatry, but I don't understand why it's not a sub-specialty of internal medicine," so I absolutely appreciate your thoughts on this process. A much better solution to this problem, however, is for psychiatrists to work much more closely with primary care physicians for comprehensive care for our patients. Our time with our patients to treat them for their psychiatric illnesses is pressed enough, and we best serve our patients by giving them the best available psychiatric and primary care. One provider simply cannot do that, and that is not unique to psychiatrists.

 

[solumanculver]

Hey BillyPilgrim,
Well, I suppose a lot of this will become more clear when I do this psych clerkship. Do you think that those combined IM/Psych residencies will produce physicians that do what I'm talking about, or would billing and time constraints make that unfeasible as well? And if it is still unlikely, then what is the point of those residencies? And lastly, if it is possible to have this kind of career after an IM/Psych residency, why can't psych residencies just be changed to look more like IM/Psych minus a year?

 

[billypilgrim37]

Do you think that those combined IM/Psych residencies will produce physicians that do what I'm talking about, or would billing and time constraints make that unfeasible as well?

The combined programs are, for the most part, too young to really know what those physicians are going to wind up doing, at least in private practice. In academia, there's often ways of doing things a little more creatively. A few (very few--Pitt and Duke come to mind) major academic centers have, for example, med-psych units for patients with psychiatric diagnoses, but need for medical care like anybody else. The combined IM/Psych residencies produce docs that either a) practice in one of these rare niche settings, b) practice as either internists or psychiatrists exclusively, or c) find themselves hyper-qualified for C/L work, but would likely still need to pursue a C/L fellowship. The downside to B) is the referrals where as an internist you would be expected to manage more complicated patients than others, or you would be expected to manage psychiatric patients with complicated medical problems. In private practice, that's essentially non-viable. In academia, things might be much more flexible.

The combined FP/Psych programs, which were most attractive to me, could theoretically offer the one-stop shopping model. But you simply can't bill for a visit as both a psychiatrist and a family doc. And the medical issues of folks with mental illness are going to take much more time to manage than the average patient a family doc would see. While billing would require that the physician see the patient for his medical and psychiatric issues separately, it'd be difficult for a patient to understand why they have to make two visits. It's a cracked out system that makes taking advantaging of a unique training almost impossible.

And if it is still unlikely, then what is the point of those residencies?

Given the few programs that get behind the model, plenty would argue there is little point to these programs unless you have a very specific reason for wanting to pursue them. If you want to be a psychiatrist in northern alaska, it might make a lot of sense to be medicine or family or peds trained as well, since there might not be anybody else around to offer primary care.

And lastly, if it is possible to have this kind of career after an IM/Psych residency, why can't psych residencies just be changed to look more like IM/Psych minus a year?

The APA already projects a shortage of psychiatrists, and there's already a shortage of child psychiatrists in non-urban areas. Part of the problem is that psych training already takes longer than IM, peds, or family training. Child psych training is 5-6 years, and most folks aren't willing to spend that much time making 45K/year when their medical school classmates have been attendings for 2-3 years. So I think IM/Psych minus a year sounds really cool (if practice environment would actually allow it to be viable), as you do, but most folks would not be well-served by that change in training focus.

 

[whopper]

Hey Whopper, it seems like all that needs to happen is for the requirements of psychiatry residency accredidation to include a bunch more medicine and a bunch more hours per week.

I think much of this has already been answered by my colleagues quite well. The only real way to really get some good knowledge in any field is to work in it.

Yes-psychiatry has 4 months of internal medicine, but quality of teaching during those 4 months varies per program. 4 months is also, only 4 months. There are several scenarios where a psyche resident could forget their IM knowledge. I've already seen several attendings get somewhat weak in this area.

I don't think or would expect a psychiatrist to know as much primary care as a PCP, but we have to know it to some degree.

 

[nancysinatra]

I kind of feel like psychiatry focuses on specific disorders when it should focus on the spectrum of disorders that the mentally ill have... including diabetes and pneumonia and whatever other disorder that schizophrenics are apt to get that would usually be treated by IM. Does this kind of model make any sense? I suppose that it's the purpose of Psych/IM or Psych/FP combined residencies, but shouldn't that be part of an ordinary mainstream psych residency?

Hmmm... I'm just wondering how this model would affect the treatment of patients who aren't severely mentally ill, but might be seeing a psychiatrist for milder problems. As an analogy, take pediatrics, which focuses on a specific population. Since I'm an adult, I'd never go to a pediatrician, of course. It's clear to me that pediatricians treat kids, and only kids. Now if psychiatry were defined as a field that "focuses" on a specific group of patients (the mentally ill) rather than a broader field that is accessible when needed by the population in general--then would patients who aren't psychotic, but think they "might" be depressed be all that inclined to go to a psychiatrist? Or would they say to themselves, "psychiatrists treat schizophrenics, not people like me"?

I'm not trying to say that there shouldn't be opportunities for psychiatrists to offer the kind of treatment you're suggesting--but requiring that kind of training might sacrifice one focus for another. What about people who know they want to be full time psychoanalysts (where the patients probably won't be treated with antipsychotics and have the ensuing medical problems)? Of course I think that they too should have the level of internal medical knowledge that's been discussed here, but if the residency specifically shifted its focus more towards internal medicine, something would be lost and some people might feel deprived by that loss. Anyway, that's just my thought on the subject. (Of course I'm not really sure though, not being in residency yet.)

As a side note, what about eating disorders units? They treat the medical problems their patients have, and they even seem uniqually qualified for this. From what I can tell, they might be the only people who have even heard of refeeding syndrome. On my medicine rotation, no one believed me that this syndrome existed...

 

[toby jones]

May I ask what refeeding syndrome is? Is it an imbalence of electrolytes leading to hypoglacemic shock? (excuse my spelling)

 

[manwhoisthursdy]

May I ask what refeeding syndrome is? Is it an imbalence of electrolytes leading to hypoglacemic shock? (excuse my spelling)

It is an electrolyte imbalance, but I don't think hypoglycemia is the main problem. In eating d/o's such as anorexia, the body's metabolism has switched to digesting it's own fat and protein stores. So if you suddenly give a patient carbohydrates, his or her insulin shoots up (of course). This brings glucose into the cells, but along with it brings P, K and Mg. This causes serum hypophos / hypokal / hypomag and the associated problems.

You also get an atrophied gut that isn't used to doing it's job, leading to poor absorption leading to diarrhea and other GI sx.

You can also get respiratory distress (not sure what really causes it, but it's related to the fact that respiratory muscles atrophy just like all other muscles).

 

[solumanculver]

What about people who know they want to be full time psychoanalysts (where the patients probably won't be treated with antipsychotics and have the ensuing medical problems)?

Hey, I hope I don't irritate anyone with this comment, but why bother becoming a psychiatrist if you just want to become a psychoanalyst? Social workers can become psychoanalysts just as easily as psychiatrists, can't they? Well, I kind of think that psychiatry should focus a bit more on neurochemistry than wayward ids... Am I way off base on this?

 

[OldPsychDoc]

Hey, I hope I don't irritate anyone with this comment, but why bother becoming a psychiatrist if you just want to become a psychoanalyst? Social workers can become psychoanalysts just as easily as psychiatrists, can't they? Well, I kind of think that psychiatry should focus a bit more on neurochemistry than wayward ids... Am I way off base on this?

Ah, but if you don't go to medical school, you'll never learn that the wayward ids are just a bunch of evil little neurons hungry for their next dopamine fix!

(BTW--"Wayward Ids" is the best band name suggestion I've seen on this board...you should copyright it now, before someone else does! 😀)

 

[nancysinatra]

Hey, I hope I don't irritate anyone with this comment, but why bother becoming a psychiatrist if you just want to become a psychoanalyst? Social workers can become psychoanalysts just as easily as psychiatrists, can't they? Well, I kind of think that psychiatry should focus a bit more on neurochemistry than wayward ids... Am I way off base on this?

But there definitely are psychiatrists who do psychoanalysis! I'm sure they chose to go to med school rather than social work school for a reason. Since they do exist, I'd assume there are some who make that their main focus. But my point could apply to anyone who hopes to become an expert in any area of psychiatry that isn't focused on the "severely mentally ill." While they still will almost certainly prescribe meds, they wouldn't necessarily be prescribing a lot of the antipsychotics that cause metabolic problems. And their patients might be well enough that they WANT a medicine or primary care doctor to take care of their medical problems. I'm just saying that to change the entire focus of residency it just seems like something else valuable would have to go.

As far as refeeding syndrome, it effects a lot of organs, but yeah, it is mainly characterized by low phosphorous. To avoid it you increase patients' calories slowly. People can die from it. That is why I was surprised that no one knew about it on my medicine rotation, where we do get malnourished patients.

 

[manwhoisthursdy]

Hey, I hope I don't irritate anyone with this comment, but why bother becoming a psychiatrist if you just want to become a psychoanalyst? Social workers can become psychoanalysts just as easily as psychiatrists, can't they? Well, I kind of think that psychiatry should focus a bit more on neurochemistry than wayward ids... Am I way off base on this?

Psychoanalytic institutes certainly accept psychologists as candidates, though I've never known a social worker to become an analyst, but that's just my limited experience.

Anyway, your comment is not irritating, but I think misinformed. A psychiatrist psychoanalyst does not throw everything that is not purely "psychoanalytic" out the window. I am a fourth year med student who is seriously considering becoming an analyst. If I do, I expect to approach my patients psychodynamically, but within the context of a biopsychosocial approach (as all physicians really should). I would prescribe medications as appropriate, but consider social/cultural factors, psychological stressors, coping strategies, object relations, ego defenses, attachment style, etc., as it applied to the patient.

That way, if the patient was a candidate for psychodynamically oriented therapy, I would know what I was doing in offering it. Or I could provide supportive therapy, or CBT, if appropriate.

Also, in the context of medication, I would not simply be confused or frustrated if the patient was noncompliant. I would be in a position to explore the noncompliance (issues of transference and resistance, asking what the medication means to the patient symbolically, does the patient want to be sick, etc).

I have seen repeatedly that non-psychologically-minded but intelligent physicians come to an accurate diagnosis, prescribe the right meds, but then are out of ideas when the patient just doesn't comply. What the hell good did they do the patient?

So basically, to answer your question in another way. A psychiatrist may want to become an analyst so that she is a psychiatrist and also an analyst. If a social worker becomes an analyst ... then she's a social worker and an analyst ... she'll never be a psychiatrist ... unless she goes to med school and then completes a psych residency.

 

[toby jones]

I had a friend who was hospitalized for anorexia earlier this year with a BMI of 11. When he was admitted to the general ward he was seen by a dietician and doctors on the general ward and they figured out a meal plan for him. When he started eating according to the meal plan his electrolytes became unbalanced and he fell into a coma because of hyperglacemic shock (I think because of that but I could be wrong). Seems that the general medical doctor (and the dietician) didn't know that he needed to start eating carefully and slowly... And it almost cost him his life.

When he was in the coma (ICU for a couple of weeks) they started refeeding very slowly indeed. Took a few days before his calorie intake was equal to his energy expenditure.

He is doing fairly well now in an outpatient treatment program 🙂
I am fairly happy with the standard of care and believe that all medical staff involved did the best they could.

You would think, however... That general medical staff (especially dietitions who work with people with eating disorders) would know about this. Or... That they would get a psychiatrist involved right on admission. I don't really understand the break in the loop with that one...

(Interested to hear it is a general issue / problem greater than just one unfortunate incident)

 

[solumanculver]

But my point could apply to anyone who hopes to become an expert in any area of psychiatry that isn't focused on the "severely mentally ill." While they still will almost certainly prescribe meds, they wouldn't necessarily be prescribing a lot of the antipsychotics that cause metabolic problems. And their patients might be well enough that they WANT a medicine or primary care doctor to take care of their medical problems. I'm just saying that to change the entire focus of residency it just seems like something else valuable would have to go.

Hey, I think you're saying that since not all psychiatrists want to work with the severely mentally ill, the focus of a psychiatry residency shouldn't be shifted towards that aim... But isn't that more or less what happens in an internal medicine residency program? You could want to be an outpatient primary care doctor who leaves everything in the hospital to the hospitalists... but during residency you're still taking care of really sick people in a hospital.

It kind of seems like if you want to be a psychiatrist you should be trained to take care of the extremely mentally ill, whatever that entails. If when you get out of residency you want to talk to middle-class housewives about their problems... well, I'm not saying that's wrong, but it's not exactly what psychiatry exists for. I thinks it's probably the same with dermatologists and... mole removal or something. They can do that, but it's probably not their main purpose.

 

[toby jones]

> It kind of seems like if you want to be a psychiatrist you should be trained to take care of the extremely mentally ill, whatever that entails.

I'm not sure what you mean by 'extremely mentally ill'. Psychotherapy has been found to be beneficial to people who are suffering from schizophrenia, bipolar, depression (surely those count as the 'big three') and for eating disorders and the like as well. Aside from that... I thought prescribing Prozac to desperate housewives was within the realm of psychiatry. As was providing psychotherapy. The 'biological revolution' in psychiatry (well, the second one) is actually fairly recent.

> I thinks it's probably the same with dermatologists and... mole removal or something. They can do that, but it's probably not their main purpose.

Hmm... I've heard (somewhat faceciously, perhaps) that detmatologists have three main treatments: Antibiotics, steroids, and chopping things. With respect to 'main purpose' if there is a market then people will be employed in it ;-)

Or consider plastic surgeons. I'm sure some do reconstructions after accidents. There are plenty making their living on purely cosmetic procedures, however...

 

[solumanculver]

I'm not sure what you mean by 'extremely mentally ill'. Psychotherapy has been found to be beneficial to people who are suffering from schizophrenia, bipolar, depression (surely those count as the 'big three') and for eating disorders and the like as well. Aside from that... I thought prescribing Prozac to desperate housewives was within the realm of psychiatry. As was providing psychotherapy.

Hi Toby Jones,
I'm not sure if you're understanding me right. Somebody commented that not all psychiatrists want to work with the "severely mentally ill", so to force them to learn about the iatrogenic metabolic disorders of psychotic patients would be unfair. After all some psychiatrists just want to be psychoanalysts... Well, people have a right to do whatever they want, and psychoanalysis definitely is part of being a psychiatrist... but my feeling is that psychiatry exists for bigger things than that.

I think your "big three" is pretty good, but I'm not convinced that psychoanalysis has ever been shown to help schizophrenics. I think supportive therapy has been shown to help... well what is supportive therapy anyway? It kind of sounds just like what Dr. Phil does... Yeah it's probably helpful for a lot of people.

As for prescribing prozac to depressed housewives, I certainly didn't mean to imply that that was not the sort of thing that psychiatrists should do. I meant psychoanalyzing depressed housewives... Well there's a financial incentive to do it, but it seems kind of silly, and it takes so much time.

Or consider plastic surgeons. I'm sure some do reconstructions after accidents. There are plenty making their living on purely cosmetic procedures, however...

Hey, you're right about plastic surgeons. Well, everybody knows that boob lifts for movie stars is not why we perpetuate this profession of plastic surgery, it's just where most of the money comes from. I'm not saying that these boob jobs shouldn't be done, but it would be silly for plastic surgery fellows to skimp on the more serious (should I say important) parts of the training because... well, they're all going to be doing boobs anyway.

The 'biological revolution' in psychiatry (well, the second one) is actually fairly recent.

Yeah, 'biological revolution' is why I'm interested in psychiatry. If psychiatry was only about psychotherapy I would never want to do it... although now that I think about it, it was my original interest when I was in high school, I read Freud and Jung, pretty fun stuff, though not very scientific.

 

[nancysinatra]

Somebody commented that not all psychiatrists want to work with the "severely mentally ill", so to force them to learn about the iatrogenic metabolic disorders of psychotic patients would be unfair. After all some psychiatrists just want to be psychoanalysts...

That isn't what I said. I said that some people may envision doing more than working with only the severely mentally ill, and that psychiatry is a large field which to its benefit currently trains its students broadly. I believe that all psychiatrists should "learn about the iatrogenic metabolic disorders of psychotic patients." Where did I say that having to learn about such disorders was "unfair"??? What I said was that to CHANGE the nature of residency--so that everyone spends their entire time focusing on one and only one specific subpopulation of patients and their syndromes--might leave out time to learn about other types of patients and make psychiatry narrow. Of course, if you want to lump all those other patients into the catogory of "middle class housewives" who aren't worth "psychoanalyzing," fine. However, to me that attitude seems sadly judgmental.

 

[solumanculver]

That isn't what I said. I said that some people may envision doing more than working with only the severely mentally ill, and that psychiatry is a large field which to its benefit currently trains its students broadly. I believe that all psychiatrists should "learn about the iatrogenic metabolic disorders of psychotic patients." Where did I say that having to learn about such disorders was "unfair"??? What I said was that to CHANGE the nature of residency--so that everyone spends their entire time focusing on one and only one specific subpopulation of patients and their syndromes--might leave out time to learn about other types of patients and make psychiatry narrow. Of course, if you want to lump all those other patients into the catogory of "middle class housewives" who aren't worth "psychoanalyzing," fine. However, to me that attitude seems sadly judgmental.

Hi Nancy Sinatra,
I must have misunderstood you then. I thought you were saying that people who wanted to only do psychoanalysis wouldn't prescribe antipsychotics, so they shouldn't have to focus on that during residency. As for making psychiatry more narrow, actually I think that is what I'm advocating. I think that psychiatry is too broad.

I know a couple who see a psychiatrist for marriage counseling... I don't really think that that's psychiatry, to be honest. Is having a bad marriage a mental disease?

I might be judgmental, by the way, but it has nothing to do with a bias against middle class housewives. I have a problem with how patients with seemingly minor psychiatric pathologies take up a disproportionate amount of time for their endless psychoanalysis, when there are really ill people who need that help more. It seems like... bad social triage. Of course it's a problem with reimbursement more than anything.

 

[toby jones]

> I read Freud and Jung, pretty fun stuff, though not very scientific.

If you read scientists who were writing around the time of Freud and Jung I'm sure you will find that they don't seem very scientific (by today's standards) either!

Try this:

http://books.google.com.au/books?id...chore&sig=yXU03WJlQ4Z1fE5m2akDs9HbECQ#PPP1,M1

You can read some of it online. He maintains that you can test psychoanalytic hypotheses and he looks at neurological findings that support one hypothesis over another hypothesis.

Of course, this is treating psychoanalytic theory as science (there is controversy over whether it is more an art or a science). But you know... There is controversy over whether prescribing psychotropic medications is moe an art or a science, too...

> Is having a bad marriage a mental disease?

Is having hypertension a physical disease? How about obesity? Or is it that... They are conditions that make disease more likely? Isn't that a focus of public health too?

> I have a problem with how patients with seemingly minor psychiatric pathologies take up a disproportionate amount of time for their endless psychoanalysis, when there are really ill people who need that help more.

It is kind of judging 'minor' vs 'really ill' and also judging who needs help more. Sounds like ethical issues to me...