Things Not Taught in Residency that Should've Been....

[whopper]

1) Dealing with patients with Borderline Personality:
Where I did residency they didn't teach much about this other than just they needed DBT then taught pretty much close to nothing about DBT nor was anyone in the department skilled in utilizing DBT as a treatment.
Add to the problem that a significant portion of patients coming into the ER had a cluster B personality and the staff members including the psychiatrist didn't know how to deal with them either and usually admitted them despite that the hospitalization wouldn't help the patient's real issue.

2) Dealing with malingerers:
Same thing. Some doctors where I did residency let malingerers stay in the hospital as long as they wanted. They never had a methodology on treating them other than to give-in.

3) Turning down bogus med consults.
About 2/3 of the med consults I got were bogus. They didn't meet a criteria where the consult should've been ordered in the first place. E.g. a patient refuses a procedure but it turned out the doctor never explained why the patient needed it or the risks and benefits of it. The pt often times told us they refused because "the guy was going to stick something inside of me and just told me I needed it but I didn't know what was going on."

The department had no guidelines given forth to the other physicians on what to do before ordering a consult nor did they seem interested in making any. Politically speaking, what was really going on was the attendings didn't want to rise to the occasion and communicate to improve the system and just dumped all their woes on to the residents. The residents took the $hit sandwich and ate it cause that's what residents do.

4) Describing good guidelines on what makes a patient "medically cleared."

5) Psychometric testing:
The bottom line is the statistical knowledge needed for many psychological tests are beyond the scope of what is taught is psych residency or medical school such as graduate level knowledge of statistics. The emphasis on a proper interface with psychiatrists and psychologists in utilizing this testing was never done in a satisfactory method.

I do see some residencies rising to the situation and providing good education on all of the above but I see the majority of problems do not. While I was at U of Cincinnati I did feel these were all adequately covered but bear in mind that this program was an exception. E.g. one of the top forensic psychiatrists was teaching faculty there and was very open to working with residents and students so the malingering thing was covered. The Borderline PD was well covered there too.

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[WisNeuro]

To add something that should be part of any doctoral level residency training

6) How to properly do a medical decision making capacity evaluation.

 

[wolfvgang22]

I was taught all these things in residency, and even had an outpatient rotation that was focused on DBT. Of course, it takes ongoing professional development to become competent in these areas. I'm sad to hear a lot of programs may not cover these areas.

 

[whopper]

Wolfgang, please add where you did your training so applicants can be aware.

I did my general residency training and UMDNJ in Camden NJ. It's possible they might've upped their game cause it's been years since I've been there. The borderline and malingering problem was to the degree where staff members would get into arguments and there was a lot of avoidable trash talking about various people for admitting or throwing out patients who should've had the opposite happen.

Instead of the logical, "let's learn about DBT or malingering" approach, they instead just let the problem fester.

 

[wolfvgang22]

Wolfgang, please add where you did your training so applicants can be aware.

I did my general residency training and UMDNJ in Camden NJ. It's possible they might've upped their game cause it's been years since I've been there. The borderline and malingering problem was to the degree where staff members would get into arguments and there was a lot of avoidable trash talking about various people for admitting or throwing out patients who should've had the opposite happen.

Instead of the logical, "let's learn about DBT or malingering" approach, they instead just let the problem fester.

I'm not going to post here where I did training to avoid losing relative anonymity to random google users. However, any medical student, resident, or physician may PM me anytime if sufficiently interested.

 

[NickNaylor]

#3 is a particular point of irritation for me because, at least at our institutions, the psychiatric consult service is treated MUCH differently than other services. It is the only service where “the patient wants to talk with psychiatry” - this is not the listed reason for the consult, mind you, but is often the primary motivation behind the consult - is acceptable. If I did that with cardiology or endocrinology or any other medical service, they would laugh.

I think the majority of psychiatric consults are inappropriate - e.g., “recommendations for starting an SSRI,” nonsense as above, etc. - but sadly the attendings perceive institutional pressure to see all-comers, regardless of the ridiculousness of the request.

 

[PikminOC]

Gotta keep everyones rvus up..

 

[DD214_DOC]

I'll add a couple

1) How to say, "No", to a patient or parent. You're the expert, not them. Don't give in to a demand simply because you're afraid they'll get mad. So what if they do?

2) Meds are indicated far less often than you were probably taught or believe.

3) Re-evaluating the need to continue meds should be part of the treatment plan

4) Panel management. This probably should be number one and I bet isn't taught in most residency programs. Learn how to properly manage your panel as far as tracking your patients and getting rid of them. It's very easy to get overwhelmed and in a bad place if you're not actively monitoring and regulating the flow of patients in and out of your panel.

5) Expectation management. Unrealistic expectations for therapeutic benefit is probably the number one reason treatment, "doesn't work". Also ties in to #2. Don't get sucked onto the, "merry go round", with patients -- that obnoxious ride that keeps going but never gets anywhere. Patients who constantly return and complain that nothing works, which results in almost constant changes to meds in an attempt to achieve an outcome that will never actually happen. Refuse to ride and manage expectations instead. Better yet, don't prescribe something when nothing is indicated.

6) Give the boot to people who don't engage or comply. Don't waste your time continuing to see someone who doesn't engage in the process and/or isn't compliant with treatment reccs. Spend some time trying to figure out why and what could possibly be done to change this, but don't drag it out forever. If, despite adequate effort, you can't get anywhere with the patient, cut them loose with the option to try again when they're ready and instead put that time and effort towards a patient who would actually benefit from it.

7) Boundaries and limits with patients. Learn this from the beginning and get comfortable with angry reactions. Giving in to entitled and demanding patients will only result in your burn out. Your health and well-being are equally important and only you will actually care about it.

 

[ziggyhope]

Wow, after reading some of the points in this thread, I am very thankful for the training I am getting! There are certainly things that can be improved, but out of the points everyone listed, I think the only ones pertinent at my institution are:
1. We are taught fairly well on how to "deal" with patients with Borderline Personality, but we do not have enough exposure to DBT (and DBT providers are really hard to find).
2. We do need better knowledge of psychometric testing.

Regarding CL service, I'll just leave these articles below, helped me a lot in thinking about bad consult questions and how to be effective as a CL resident. Also, I absolutely refuse to do capacity evals, but happy and willing to teach any provider how to do one themselves. Feel free to PM if anyone cares enough to know where I train.

 

[clausewitz2]

Wow, after reading some of the points in this thread, I am very thankful for the training I am getting! There are certainly things that can be improved, but out of the points everyone listed, I think the only ones pertinent at my institution are:
1. We are taught fairly well on how to "deal" with patients with Borderline Personality, but we do not have enough exposure to DBT (and DBT providers are really hard to find).
2. We do need better knowledge of psychometric testing.

Regarding CL service, I'll just leave these articles below, helped me a lot in thinking about bad consult questions and how to be effective as a CL resident. Also, I absolutely refuse to do capacity evals, but happy and willing to teach any provider how to do one themselves. Feel free to PM if anyone cares enough to know where I train.

Very few C&L services can afford to turn down many consults given reimbursement. The successful ones barely pay for themselves.

 

[randomdoc1]

I'll add a couple

1) How to say, "No", to a patient or parent. You're the expert, not them. Don't give in to a demand simply because you're afraid they'll get mad. So what if they do?

2) Meds are indicated far less often than you were probably taught or believe.

3) Re-evaluating the need to continue meds should be part of the treatment plan

4) Panel management. This probably should be number one and I bet isn't taught in most residency programs. Learn how to properly manage your panel as far as tracking your patients and getting rid of them. It's very easy to get overwhelmed and in a bad place if you're not actively monitoring and regulating the flow of patients in and out of your panel.

5) Expectation management. Unrealistic expectations for therapeutic benefit is probably the number one reason treatment, "doesn't work". Also ties in to #2. Don't get sucked onto the, "merry go round", with patients -- that obnoxious ride that keeps going but never gets anywhere. Patients who constantly return and complain that nothing works, which results in almost constant changes to meds in an attempt to achieve an outcome that will never actually happen. Refuse to ride and manage expectations instead. Better yet, don't prescribe something when nothing is indicated.

6) Give the boot to people who don't engage or comply. Don't waste your time continuing to see someone who doesn't engage in the process and/or isn't compliant with treatment reccs. Spend some time trying to figure out why and what could possibly be done to change this, but don't drag it out forever. If, despite adequate effort, you can't get anywhere with the patient, cut them loose with the option to try again when they're ready and instead put that time and effort towards a patient who would actually benefit from it.

7) Boundaries and limits with patients. Learn this from the beginning and get comfortable with angry reactions. Giving in to entitled and demanding patients will only result in your burn out. Your health and well-being are equally important and only you will actually care about it.

This!! Also, non medication means of intervention! My program was also very good with a strong emphasis on training us in therapy. That is one of the most powerful tools I have. Build a good rapport, gain pt trust. Address sleep hygiene, motivational interviewing, exercise, increase structure in your day, stay away from toxic settings, lose weight, get a therapist that’s actually good, etc.

I wish there was more emphasis on private practice. Knowing limit setting and cutting loose patients who waste our time is also important to minimize burnout but harder to do in a big system. PP is actually very feasible and we should refuse to be cogs in big systems with a consumer based mentality!

Adult ADHD...seriously. What is a proper eval and treatment guidelines. I see so many on stims based on one cc of “can’t concentrate.” My understanding is ADHD is a disorder of inhibition and executive function versus predominantly attention. Encountered a lot of records with even neuropsych reports and even the neuropsychologist seemed pretty shotty at working up adult inattention symptoms.

 

[WisNeuro]

Adult ADHD...seriously. What is a proper eval and treatment guidelines. I see so many on stims based on one cc of “can’t concentrate.” My understanding is ADHD is a disorder of inhibition and executive function versus predominantly attention. Encountered a lot of records with even neuropsych reports and even the neuropsychologist seemed pretty shotty at working up adult inattention symptoms.

Most of us don't do these. Majority of insurance will not pay for neuropsych codes to evaluate ADHD. So, it's either private pay, or not a real neuropsychologist, probably a diploma mill psychologist who does testing and has dreams of being one. Only place tese are routinely done by neuropsychs is probably the VA, because billing is not an issue. But anyway, it's all clinical history. Ideally it's made at a younger age so we can get objective school reports and the like. But, the majority of people coming in 40+ do not have those records, and no one is going through the trouble of trying to track down 20+ year-old school records. So, I'm guessing most people are getting a diagnosis from a short interview and a questionnaire. Anything more is a waste of time and probably not very reimbursable.

 

[ziggyhope]

Very few C&L services can afford to turn down many consults given reimbursement. The successful ones barely pay for themselves.

Yea I understand in the real world money plays a huge part in how to run C&L services, and I have no expertise regarding that at all. It is my personal opinion that if a hospital chooses to have a C&L service, it should be run in a way to provide effective care for patients, which means the primary team should have a very specific question for us to answer. As far as capacity, not only do I think it is not helpful, it may even be harmful to the patient and primary team for me to comment on it in my note.

 

[WisNeuro]

Yea I understand in the real world money plays a huge part in how to run C&L services, and I have no expertise regarding that at all. It is my personal opinion that if a hospital chooses to have a C&L service, it should be run in a way to provide effective care for patients, which means the primary team should have a very specific question for us to answer. As far as capacity, not only do I think it is not helpful, it may even be harmful to the patient and primary team for me to comment on it in my note.

What aspect of capacity is not helpful? Do you mean not commenting on it in every note, or that you don't think the capacity eval in general is not helpful? These evals are hugely helpful, if done at the right moments and the right way.

 

[ziggyhope]

What aspect of capacity is not helpful? Do you mean not commenting on it in every note, or that you don't think the capacity eval in general is not helpful? These evals are hugely helpful, if done at the right moments and the right way.

I am speaking from the perspective of a psychiatric consultant in the general hospital setting. I do not mean that in general capacity evals are not useful, and the key words are "the right moment and the right way", which is usually not how/why we are consulted in the first place.

 

[WisNeuro]

I am speaking from the perspective of a psychiatric consultant in the general hospital setting. I do not mean that in general capacity evals are not useful, and the key words are "the right moment and the right way", which is usually not how/why we are consulted in the first place.

I agree, some of the time, providers want me to do a blanket "capacity" eval, when there is no question at the moment, just that they want that information should they "need" it. In those cases, provider education is the most helpful. 80% ish of the time, the patient is just disagreeing with the provider for some reason, usually because no one actually took the time to explain what was going on, the different alternatives, and the risks and benefits of each. I'd say I get about 1-2 out of 10 patients who actually do not have the medical decision making capacity.

Additionally, I have overruled capacity determinations that were done incorrectly. Mostly, it's a provider who made a capacity determination without actually doing the eval or without actually telling the patient that they were evaluating capacity. It's amazing how much a difficult (competent) patient straightens up and becomes less combative when you tell them they need to listen and do their best because someone wants to initiate guardianship proceedings otherwise.

 

[Salpingo]

I agree, some of the time, providers want me to do a blanket "capacity" eval, when there is no question at the moment, just that they want that information should they "need" it. In those cases, provider education is the most helpful. 80% ish of the time, the patient is just disagreeing with the provider for some reason, usually because no one actually took the time to explain what was going on, the different alternatives, and the risks and benefits of each. I'd say I get about 1-2 out of 10 patients who actually do not have the medical decision making capacity.

Additionally, I have overruled capacity determinations that were done incorrectly. Mostly, it's a provider who made a capacity determination without actually doing the eval or without actually telling the patient that they were evaluating capacity. It's amazing how much a difficult (competent) patient straightens up and becomes less combative when you tell them they need to listen and do their best because someone wants to initiate guardianship proceedings otherwise.

In addition to this "provide me with the pseudo-legal license to do whatever I want without having to talk any more to this ridiculous person" there are a couple of other problems with the capacity consult.

1. The patient obviously lacks capacity around the medical intervention. The consulting team believes they need psych to sanctify their decision, for legal reasons. When you ask over the phone what law are they worried about, they say, well, this is what we had to do last time a patient lacked capacity. When you mention last time it was also unnecessary, and just because you've done something before doesn't justify it, to which there is a long pause, and the whooshing sound of them uploading vacation pics to Instagram. They ask if you need the room number, and you say sure, let me get a pen.
2. The patient is actually toeing the line of demonstrating capacity, and if you pull together the basic threads resembling ideas, you can kind of see how you justify their choice, in the same way you can see a picture when you stand far away from an Impressionist painting (really far away). We're actually really bad at assessing these ambiguous cases. Like, you're only slightly better off flipping a coin, bad.
3. The patient obviously has capacity, but has a psychiatric history, and the team is just kinda put off about doing a procedure (or are worried they'll be sued).

I don't find that we add any value with the capacity assessment itself but figuring out ways to restore capacity, or help repair ruptures in the treatment relationship.

 

[FlowRate]

I agree, some of the time, providers want me to do a blanket "capacity" eval, when there is no question at the moment, just that they want that information should they "need" it. In those cases, provider education is the most helpful. 80% ish of the time, the patient is just disagreeing with the provider for some reason, usually because no one actually took the time to explain what was going on, the different alternatives, and the risks and benefits of each. I'd say I get about 1-2 out of 10 patients who actually do not have the medical decision making capacity.

Additionally, I have overruled capacity determinations that were done incorrectly. Mostly, it's a provider who made a capacity determination without actually doing the eval or without actually telling the patient that they were evaluating capacity. It's amazing how much a difficult (competent) patient straightens up and becomes less combative when you tell them they need to listen and do their best because someone wants to initiate guardianship proceedings otherwise.

My issue is usually with capacity evals where the team tells me "well, the patient keeps changing their mind, has trouble remembering the information, and seems confused about what's going on." Do you really need me to see the patient to figure out that they don't have capacity to make that decision?

 

[WisNeuro]

@Salpingo I agree, in your second point, there are definitely the grey area cases, and I don't mind being called in for those. I'm curious about some of the reasons for disagreements in that study, I can't get the whole thing at the moment, so I don't know if they hit on it.

I think the main thing where I've practiced is that most of the providers on the inpatient units really have never been taught how to do a capacity eval, or what constitutes medical decision making capacity in an individual. We're planning a grand rounds talk on this very thing, but I'm skeptical it will make a huge dent in these referrals.

@FlowRate In these cases, I wonder if they really just want someone else to do the write up and take that portion of the perceived liability.

 

[ziggyhope]

Such great points in this discussion, this is why I love it here. I recognize I have the luxury of being a resident and not worrying about billing. I wonder if I will change my mind when "real world" pressures are on when I finish training.

@WisNeuro I am thinking about creating a similar lecture for medical interns, I don't know if it will change much, but we have to start somewhere.

 

[John1513]

I'll add a couple

1) How to say, "No", to a patient or parent. You're the expert, not them. Don't give in to a demand simply because you're afraid they'll get mad. So what if they do?

2) Meds are indicated far less often than you were probably taught or believe.

3) Re-evaluating the need to continue meds should be part of the treatment plan

4) Panel management. This probably should be number one and I bet isn't taught in most residency programs. Learn how to properly manage your panel as far as tracking your patients and getting rid of them. It's very easy to get overwhelmed and in a bad place if you're not actively monitoring and regulating the flow of patients in and out of your panel.

5) Expectation management. Unrealistic expectations for therapeutic benefit is probably the number one reason treatment, "doesn't work". Also ties in to #2. Don't get sucked onto the, "merry go round", with patients -- that obnoxious ride that keeps going but never gets anywhere. Patients who constantly return and complain that nothing works, which results in almost constant changes to meds in an attempt to achieve an outcome that will never actually happen. Refuse to ride and manage expectations instead. Better yet, don't prescribe something when nothing is indicated.

6) Give the boot to people who don't engage or comply. Don't waste your time continuing to see someone who doesn't engage in the process and/or isn't compliant with treatment reccs. Spend some time trying to figure out why and what could possibly be done to change this, but don't drag it out forever. If, despite adequate effort, you can't get anywhere with the patient, cut them loose with the option to try again when they're ready and instead put that time and effort towards a patient who would actually benefit from it.

7) Boundaries and limits with patients. Learn this from the beginning and get comfortable with angry reactions. Giving in to entitled and demanding patients will only result in your burn out. Your health and well-being are equally important and only you will actually care about it.

Can we fire patients in Milmed? Also, how do we manage our panel?

 

[Nasrudin]

I'll add one:

#DSM Uselessness
#DSM as rigid archaicism
#DSM as infectious superficial anti-clinical structures that open our clinical processes to false endeavors and focuses like "safety," which is quickly becoming a pseudo-clinical entity in our language and clinical processes.

I have the growing sense that the personality theory researchers are screaming off in a direction that is much more clinically useful and much more correlated to neurobiological and evolutionary sciences. Their clinical interpretation structures are actually useful and meaningful to patients, which act as clinical hypothesis generators that provocate a collaborative co-formulation with patients to map the meaning of their symptoms. Rather than treat them as some frozen, abstract, rationalist reality unto themselves.

I think there is a dangerous level of emergent public common sense that perceives showing up see a psychiatrist for 10-15 minutes, telling them that you're anxious a lot, and receiving a dx of Anxious Alot Disorder (GAD), and then being given a medication to obliterate an unpleasant feel, is .... f'n absurd. The rationalist, inferiority-complexed, of the medical tribe among us, respond to this cognitive dissonance of clinical uselessness by doubling down on making word categories a rationalist religion. As if... it we can just get the word boxes right we can segregate Bipolar Disorder in 6 discreet categories. And in the process, we leave the public behind. The meaning of their sx lost in our dictums to make them organize into our archaic structures.

We are losing public trust. And the muggles of medicine remain temperamentally aversive of our sphere of activity anyway. Our word categories making them even more inept and useless at dealing with human consciousness issues than if they never heard of our Statistical Manual of Diagnostics.

With our DSM in hand. We unironically give diagnostic equivalents of "the patient has evil aires." And we justify this with statistics that people with miasmatic problems generally complain of this, and this, and this... at some marginal differential rate. Such that these are things that explain "Bad Aires Disease."

The patient comes in with complaints, we impose our word categories to clarify their complaints. And then give them a medication for it. Because in an environment of expediency who has time for anything else.

Furthermore, as this process creeps into our perceptual notions, it becomes how we think of people and their problems. And I propose that when this happens. When we are already preloaded to think superficial algorithms of clinical pathology. And we are already compromised by expedient interests fitting expedient times in expedient encounters. Then we have no resistance to notions of algorithmic safety screens as being asinine. Because it's no more ridiculous and expedient and useless than anything else we do. So we learn to think and act and perceive patient encounters in terms of compressing their risk to themselves in algorithmic risk stratifying word screens. And we become the ideological tools of far left advocacy groups. Who see the world as full of helpless babies to exercise our motherly superiority over. Becoming worse than just useless. But harmful. Corrosive of patient agency for their own health.

We need to teach the rebels and creatives and subversives among us. That the time for their coming into fully independent and courageous being is NOW. There has never been a time in psychiatry that is more ripe for creative rebellion.

I've left the reservation. And there are treasures of clinically useful techniques just laying on the ground everywhere outside its impoverished boundaries. I'm thrilled and amazed as I go forward. But... am also alarmed. Disturbed. And disheartened that my field is doubling down on archacism. And not even having the insight to be boldly archaic enough. So that they could help formulate the modern human's isolation from our mythological roots. Just ignorantly arahciac and isolated to a few decades in the 20th century. Stuck there. Losing the public trust and all sense of meaning of what they're doing.

It bothers me that most residents will be stuck on the reservation. And that patients are stuck there with them, if they're just helpless enough and not their own agent enough, to consume it unthinkingly.

I'm having a hard time understanding how other people are not seeing cause for alarm. Or as cause for desperate, heroic acts of creative rebellion.

 

[watto]

Have you tried Miltown? It's delicious!

Just kidding. I have many of the same feelings as Nasrudin (who IMO should inherit the vacated throne of The Last Psychiatrist) - getting off the reservation is one way of reducing cognitive dissonance but I wonder if there needs to be a more formal organization of this perspective. Give the movement a name and a set of guiding principles and you have psychiatry's Dogme 95.

 

[Salpingo]

@Salpingo I agree, in your second point, there are definitely the grey area cases, and I don't mind being called in for those. I'm curious about some of the reasons for disagreements in that study, I can't get the whole thing at the moment, so I don't know if they hit on it.

I think the main thing where I've practiced is that most of the providers on the inpatient units really have never been taught how to do a capacity eval, or what constitutes medical decision making capacity in an individual. We're planning a grand rounds talk on this very thing, but I'm skeptical it will make a huge dent in these referrals.

@FlowRate In these cases, I wonder if they really just want someone else to do the write up and take that portion of the perceived liability.

I’m fine getting involved in these consults, and find them interesting. I just don’t think declaring someone to have capacity (or not) itself is that clinically relevant, as much as the etiology for the loss of capacity and how/to what extent it can be restored (a philosophy not always taught in residency).

It’s great that you’re giving grand rounds on the topic, if only to get medical residents to be more aware of their patients and their patients understanding of what’s being done to them. I’d argue that it shouldn’t reduce consults, but increase them - when residents determine a patient lacks capacity, who do you think they’re going to call?

 

[FlowRate]

I have the growing sense that the personality theory researchers are screaming off in a direction that is much more clinically useful and much more correlated to neurobiological and evolutionary sciences.

I often wonder why I haven't heard much more than the DSM-type personality disorders in our didactic sessions. We did have a good course on historical descriptive psychopathology / psychpathology beyond the DSM, but it was focused more on the major mood/thought disorders. Haven't heard much about Million or five factor or whatever. Then again, there are two more years of didactics to go.

So we learn to think and act and perceive patient encounters in terms of compressing their risk to themselves in algorithmic risk stratifying word screens.

IF someone says the word suicide, THEN they go inpatient, right? (/sarcasm)

 

[Salpingo]

I'll add one:

#DSM Uselessness
#DSM as rigid archaicism
#DSM as infectious superficial anti-clinical structures that open our clinical processes to false endeavors and focuses like "safety," which is quickly becoming a pseudo-clinical entity in our language and clinical processes.

I have the growing sense that the personality theory researchers are screaming off in a direction that is much more clinically useful and much more correlated to neurobiological and evolutionary sciences. Their clinical interpretation structures are actually useful and meaningful to patients, which act as clinical hypothesis generators that provocate a collaborative co-formulation with patients to map the meaning of their symptoms. Rather than treat them as some frozen, abstract, rationalist reality unto themselves.

I think there is a dangerous level of emergent public common sense that perceives showing up see a psychiatrist for 10-15 minutes, telling them that you're anxious a lot, and receiving a dx of Anxious Alot Disorder (GAD), and then being given a medication to obliterate an unpleasant feel, is .... f'n absurd. The rationalist, inferiority-complexed, of the medical tribe among us, respond to this cognitive dissonance of clinical uselessness by doubling down on making word categories a rationalist religion. As if... it we can just get the word boxes right we can segregate Bipolar Disorder in 6 discreet categories. And in the process, we leave the public behind. The meaning of their sx lost in our dictums to make them organize into our archaic structures.

We are losing public trust. And the muggles of medicine remain temperamentally aversive of our sphere of activity anyway. Our word categories making them even more inept and useless at dealing with human consciousness issues than if they never heard of our Statistical Manual of Diagnostics.

With our DSM in hand. We unironically give diagnostic equivalents of "the patient has evil aires." And we justify this with statistics that people with miasmatic problems generally complain of this, and this, and this... at some marginal differential rate. Such that these are things that explain "Bad Aires Disease."

The patient comes in with complaints, we impose our word categories to clarify their complaints. And then give them a medication for it. Because in an environment of expediency who has time for anything else.

Furthermore, as this process creeps into our perceptual notions, it becomes how we think of people and their problems. And I propose that when this happens. When we are already preloaded to think superficial algorithms of clinical pathology. And we are already compromised by expedient interests fitting expedient times in expedient encounters. Then we have no resistance to notions of algorithmic safety screens as being asinine. Because it's no more ridiculous and expedient and useless than anything else we do. So we learn to think and act and perceive patient encounters in terms of compressing their risk to themselves in algorithmic risk stratifying word screens. And we become the ideological tools of far left advocacy groups. Who see the world as full of helpless babies to exercise our motherly superiority over. Becoming worse than just useless. But harmful. Corrosive of patient agency for their own health.

We need to teach the rebels and creatives and subversives among us. That the time for their coming into fully independent and courageous being is NOW. There has never been a time in psychiatry that is more ripe for creative rebellion.

I've left the reservation. And there are treasures of clinically useful techniques just laying on the ground everywhere outside its impoverished boundaries. I'm thrilled and amazed as I go forward. But... am also alarmed. Disturbed. And disheartened that my field is doubling down on archacism. And not even having the insight to be boldly archaic enough. So that they could help formulate the modern human's isolation from our mythological roots. Just ignorantly arahciac and isolated to a few decades in the 20th century. Stuck there. Losing the public trust and all sense of meaning of what they're doing.

It bothers me that most residents will be stuck on the reservation. And that patients are stuck there with them, if they're just helpless enough and not their own agent enough, to consume it unthinkingly.

I'm having a hard time understanding how other people are not seeing cause for alarm. Or as cause for desperate, heroic acts of creative rebellion.

It’s hard to engage in creative destruction when you don’t know what you’re rebelling against. I’m okay with residencies teaching “by the book” in the first 2.5 years, as long as they present some of the history and alternative phenomenological systems.

 

[Shikima]

This!! Also, non medication means of intervention! My program was also very good with a strong emphasis on training us in therapy. That is one of the most powerful tools I have. Build a good rapport, gain pt trust. Address sleep hygiene, motivational interviewing, exercise, increase structure in your day, stay away from toxic settings, lose weight, get a therapist that’s actually good, etc.

I wish there was more emphasis on private practice. Knowing limit setting and cutting loose patients who waste our time is also important to minimize burnout but harder to do in a big system. PP is actually very feasible and we should refuse to be cogs in big systems with a consumer based mentality!

Adult ADHD...seriously. What is a proper eval and treatment guidelines. I see so many on stims based on one cc of “can’t concentrate.” My understanding is ADHD is a disorder of inhibition and executive function versus predominantly attention. Encountered a lot of records with even neuropsych reports and even the neuropsychologist seemed pretty shotty at working up adult inattention symptoms.

One step further in this thinking, how to develop an appropriate differential diagnosis based on the complaint "can't concentrate."

 

[WisNeuro]

It’s great that you’re giving grand rounds on the topic, if only to get medical residents to be more aware of their patients and their patients understanding of what’s being done to them. I’d argue that it shouldn’t reduce consults, but increase them - when residents determine a patient lacks capacity, who do you think they’re going to call?

They can call all they want. My time is 80% outpatient. So, if my time is full up, they are on their own. When my hours are up for the day, I go home.

 

[clausewitz2]

I often wonder why I haven't heard much more than the DSM-type personality disorders in our didactic sessions. We did have a good course on historical descriptive psychopathology / psychpathology beyond the DSM, but it was focused more on the major mood/thought disorders. Haven't heard much about Million or five factor or whatever. Then again, there are two more years of didactics to go.

IF someone says the word suicide, THEN they go inpatient, right? (/sarcasm)

My program is equally useless when it comes to didactics regarding personality disorders, but at this point I have given up on the notion that I am going to get very much that is useful out of most didactics and just make sure to do my own reading. I suspect I have learned more from reading books and papers suggested by various people on this forum and sources that branched out from that than in almost all of our formal didactics to date.

The didactics I have had that have been even vaguely useful fell into one of two categories:

1) Talks by researchers with extensive clinical careers about their particular area of expertise, e.g., a major figure in OCD research who also runs our OCD specialty clinics and is certified in E/RP talking about OCD

2) Therapy didactics with extensive discussion of actual material and that function as group supervision.

I am always sonewhat amazed by some requests for didactics sessions from others for formal lectures on things like "DBT skills". Like, there are excellent manuals for that kind of thing and they are really not hard to understand (use effectively, sure, but not comprehend), it would never occur to me to not just read up on them myself if I thought it would be useful or interesting to me. I am sort of terrified by the idea of practicing psychiatrists who have only ever learned formally from didactics sessions and CMEs.

 

[WingedOx]

1) Dealing with patients with Borderline Personality:
Where I did residency they didn't teach much about this other than just they needed DBT then taught pretty much close to nothing about DBT nor was anyone in the department skilled in utilizing DBT as a treatment.
Add to the problem that a significant portion of patients coming into the ER had a cluster B personality and the staff members including the psychiatrist didn't know how to deal with them either and usually admitted them despite that the hospitalization wouldn't help the patient's real issue.

2) Dealing with malingerers:
Same thing. Some doctors where I did residency let malingerers stay in the hospital as long as they wanted. They never had a methodology on treating them other than to give-in.

3) Turning down bogus med consults.
About 2/3 of the med consults I got were bogus. They didn't meet a criteria where the consult should've been ordered in the first place. E.g. a patient refuses a procedure but it turned out the doctor never explained why the patient needed it or the risks and benefits of it. The pt often times told us they refused because "the guy was going to stick something inside of me and just told me I needed it but I didn't know what was going on."

The department had no guidelines given forth to the other physicians on what to do before ordering a consult nor did they seem interested in making any. Politically speaking, what was really going on was the attendings didn't want to rise to the occasion and communicate to improve the system and just dumped all their woes on to the residents. The residents took the $hit sandwich and ate it cause that's what residents do.

4) Describing good guidelines on what makes a patient "medically cleared."

5) Psychometric testing:
The bottom line is the statistical knowledge needed for many psychological tests are beyond the scope of what is taught is psych residency or medical school such as graduate level knowledge of statistics. The emphasis on a proper interface with psychiatrists and psychologists in utilizing this testing was never done in a satisfactory method.

I do see some residencies rising to the situation and providing good education on all of the above but I see the majority of problems do not. While I was at U of Cincinnati I did feel these were all adequately covered but bear in mind that this program was an exception. E.g. one of the top forensic psychiatrists was teaching faculty there and was very open to working with residents and students so the malingering thing was covered. The Borderline PD was well covered there too.

Gonna be honest, I thought my program was pretty solid on all 5 of these.

 

[WingedOx]

It’s hard to engage in creative destruction when you don’t know what you’re rebelling against. I’m okay with residencies teaching “by the book” in the first 2.5 years, as long as they present some of the history and alternative phenomenological systems.

I sometimes wonder how much of this can actually be taught. I'm increasingly of the opinion that clinical rigidity is due to the clinician, not the tools he uses.

 

[WingedOx]

One step further in this thinking, how to develop an appropriate differential diagnosis based on the complaint "can't concentrate."

I've probably been spending 25% of my clinical time on a single patient with "can't concentrate" as a CC. 28 year old in finance who came to our clinic abusing methylphenidate, also taking clonazepam, sometimes xanax. He's burned thru 4 different psychiatrists by this point. I'm not sure what concentration even means to him, seeing as though before he came here he was constantly using his stims to pull 16 hour workdays and he still can't keep regular sleep schedules. He's been calling the triage line/showing up in the ED/calling patient advocate/trying to schedule early appointments so damn often due to his complaints of not being able to adequately study for his CFA exam that I basically had to write a page-long note justifying why I'm not going to waste my time responding to him anymore.

 

[Nasrudin]

In regards to by the book. Or having a basis from which to counter-formulate the DSM:

It’s incumbent upon the psych resident to undergo a self-study of the great clinicians and the philosophical roots of the major developments in psychology. That is the book. If the DSM is the book then, you’re essentially a slave to one, absurd approach.

We have tremendous strengths of many clinical encounters in the widest possible set of venues. It makes our clinical common sense powerful. When armed with better ideas. For instance, many super bright psychologists I’ve worked with had no idea what kind of nonsense pollutes the clinical encounter. I just read a neuropsych eval that dutifully charted a series of delusions in a Parkison’s patient on dopamine agonists and it was reported as reality. This type of thing.

On the other hand, we could become as dumb as ortho PA’s if we approach our work with the same set of clunky ideas every time.

Which brings up the clinical rigidity question. That is actually part of my point. Everything good that a good clinician does in an encounter is outside of the reference points of the DSM. So it is clinician dependent.

Why then do we employ a useless set of ideas to communicate our work to patients and other clinicians?

2-3 years of self-study and I’m on my own feeling confident. While being considered some sort of rebellious weirdo. I’m able to stand against a wall of institutional conformity with passionate, individual confidence. Knowing that the frontier of my own knowledge gathering is the only thing I trust.

I’m not some intellectual tour de force. I’m just an industrious, passionate, heretic. Who after a lifetime of practice and necessary adaptation. Knows when the “adults” in the room don’t know what the F their talking about. That their evidence is shotty. That adherence to dogma is frighteningly inept.

In regards to a counter-movement.

Sign me up.

Right now I’m the village weirdo. On my own.

 

[John1513]

I'll add one:

#DSM Uselessness
#DSM as rigid archaicism
#DSM as infectious superficial anti-clinical structures that open our clinical processes to false endeavors and focuses like "safety," which is quickly becoming a pseudo-clinical entity in our language and clinical processes.

I have the growing sense that the personality theory researchers are screaming off in a direction that is much more clinically useful and much more correlated to neurobiological and evolutionary sciences. Their clinical interpretation structures are actually useful and meaningful to patients, which act as clinical hypothesis generators that provocate a collaborative co-formulation with patients to map the meaning of their symptoms. Rather than treat them as some frozen, abstract, rationalist reality unto themselves.

I think there is a dangerous level of emergent public common sense that perceives showing up see a psychiatrist for 10-15 minutes, telling them that you're anxious a lot, and receiving a dx of Anxious Alot Disorder (GAD), and then being given a medication to obliterate an unpleasant feel, is .... f'n absurd. The rationalist, inferiority-complexed, of the medical tribe among us, respond to this cognitive dissonance of clinical uselessness by doubling down on making word categories a rationalist religion. As if... it we can just get the word boxes right we can segregate Bipolar Disorder in 6 discreet categories. And in the process, we leave the public behind. The meaning of their sx lost in our dictums to make them organize into our archaic structures.

We are losing public trust. And the muggles of medicine remain temperamentally aversive of our sphere of activity anyway. Our word categories making them even more inept and useless at dealing with human consciousness issues than if they never heard of our Statistical Manual of Diagnostics.

With our DSM in hand. We unironically give diagnostic equivalents of "the patient has evil aires." And we justify this with statistics that people with miasmatic problems generally complain of this, and this, and this... at some marginal differential rate. Such that these are things that explain "Bad Aires Disease."

The patient comes in with complaints, we impose our word categories to clarify their complaints. And then give them a medication for it. Because in an environment of expediency who has time for anything else.

Furthermore, as this process creeps into our perceptual notions, it becomes how we think of people and their problems. And I propose that when this happens. When we are already preloaded to think superficial algorithms of clinical pathology. And we are already compromised by expedient interests fitting expedient times in expedient encounters. Then we have no resistance to notions of algorithmic safety screens as being asinine. Because it's no more ridiculous and expedient and useless than anything else we do. So we learn to think and act and perceive patient encounters in terms of compressing their risk to themselves in algorithmic risk stratifying word screens. And we become the ideological tools of far left advocacy groups. Who see the world as full of helpless babies to exercise our motherly superiority over. Becoming worse than just useless. But harmful. Corrosive of patient agency for their own health.

We need to teach the rebels and creatives and subversives among us. That the time for their coming into fully independent and courageous being is NOW. There has never been a time in psychiatry that is more ripe for creative rebellion.

I've left the reservation. And there are treasures of clinically useful techniques just laying on the ground everywhere outside its impoverished boundaries. I'm thrilled and amazed as I go forward. But... am also alarmed. Disturbed. And disheartened that my field is doubling down on archacism. And not even having the insight to be boldly archaic enough. So that they could help formulate the modern human's isolation from our mythological roots. Just ignorantly arahciac and isolated to a few decades in the 20th century. Stuck there. Losing the public trust and all sense of meaning of what they're doing.

It bothers me that most residents will be stuck on the reservation. And that patients are stuck there with them, if they're just helpless enough and not their own agent enough, to consume it unthinkingly.

I'm having a hard time understanding how other people are not seeing cause for alarm. Or as cause for desperate, heroic acts of creative rebellion.

—-

Agree. It is troubling to see how many teens now are on meds and are seeing psychiatry. Isn’t teenage angst a part of growing up? Getting in college is stressful, teenage dating can be painful. Troubling. Emo music is now replaced with Prozac and Buspar for our current teens.

 

[Madden007]

I feel inadequate too. Any one interested in sharing some more articles or links that they have found to be helpful in treating the malignerer and bpd pts?

 

[Onions]

I have the growing sense that the personality theory researchers are screaming off in a direction that is much more clinically useful and much more correlated to neurobiological and evolutionary sciences.

The humorists were right, all along.

Anxious Alot Disorder (GAD)

Look, all the DSM really does is [attempt to] provide a Gaussian surface that definitely must somehow somewhere contain within it a thing that is (whew, hey!) just the same like all the other comforting mother's teats that we can answer multiple choice questions about in our First Aid review books. The Gaussian surface is supposed to shrink and shrink until one day, eureka! Science discovers the PATHOPHYSIOLOGY of Being Anxious Alot and we've nailed the res ipsa. But the assumption is that the Gaussian surface does contain only one Thing. Or that it contains anyThing at all. Which is why Foucault's Discipline and Punish needs to be required reading in medical school: because any physician should recognize the breadth of possibility that lies beyond what feels like a truly primal urge to assume power over nature by the processes of categorization and compartmentalization. Yeah, I don't think psychiatrists are uniquely cursed with the obligation to cut loose from these fetters. The DSM represents one iteration of a paradigm, like any other, and as you say, it's a pretty old one (about 300 years old, to be more precise).

And given that, I wonder how it is possible to become a thoughtful psychiatrist--or physician, period--without, as you suggest, heavy exposure to the spectrum of human consideration of phenomenology, dialectics, history, linguistics, and psychoanalysis. I mean, obviously it is possible because people do it. But I often feel like a gerbil, nibbling with all my gerbil friends, all content in a little cage of our own construction. What if medical education and training asked us to dismantle the cage? Who among us would actually skitter away into the tall grass?

 

[Nasrudin]

The humorists were right, all along.


Look, all the DSM really does is [attempt to] provide a Gaussian surface that definitely must somehow somewhere contain within it a thing that is (whew, hey!) just the same like all the other comforting mother's teats that we can answer multiple choice questions about in our First Aid review books. The Gaussian surface is supposed to shrink and shrink until one day, eureka! Science discovers the PATHOPHYSIOLOGY of Being Anxious Alot and we've nailed the res ipsa. But the assumption is that the Gaussian surface does contain only one Thing. Or that it contains anyThing at all. Which is why Foucault's Discipline and Punish needs to be required reading in medical school: because any physician should recognize the breadth of possibility that lies beyond what feels like a truly primal urge to assume power over nature by the processes of categorization and compartmentalization. Yeah, I don't think psychiatrists are uniquely cursed with the obligation to cut loose from these fetters. The DSM represents one iteration of a paradigm, like any other, and as you say, it's a pretty old one (about 300 years old, to be more precise).

And given that, I wonder how it is possible to become a thoughtful psychiatrist--or physician, period--without, as you suggest, heavy exposure to the spectrum of human consideration of phenomenology, dialectics, history, linguistics, and psychoanalysis. I mean, obviously it is possible because people do it. But I often feel like a gerbil, nibbling with all my gerbil friends, all content in a little cage of our own construction. What if medical education and training asked us to dismantle the cage? Who among us would actually skitter away into the tall grass?

I love these ideas. You given me a better understanding of the why the gerbil needs the cage. I hadn't thought about the thinking behind the DSM in the context of phylogeny or mastering through categorizing etc. That's a brilliant way of thinking about it. It maps an earlier stage of natural sciences that began in observation and information gathering.

The difference is that the DSM is not without premise. It has become a book of maladies. For which treatments find a target. And we talk about the efficacy of those treatment in terms of reduction of maladies. And then lo and behold... our success rates remains marginal, at best. And the "evidence-based" among us. Favor things like the Beck Inventory. So we can chart out the fluctuating negative feels with precision. Because...we can say... we're evidence based gerbils.

I love your notion of fully complexifying our understanding of human predicaments. But I guess. I don't understand why the other gerbils aren't busy skittering into the unknown. In awe of the world outside of the wheel. And the maze.

I really think that there are constructs that map onto the neuroscience and the meaning of what happens to gerbils. How gerbils be. That can help them understand the casual links of their own gerbil feels. That have the humility to represent what we know and don't know about gerbil science accurately. Such that intervention strategies can point in better directions that the obliteration of gerbil feels.

If you hadn't noticed. I couldn't be more excited about the gerbil metaphor.

 

[SmallBird]

I'll add one:

#DSM Uselessness
#DSM as rigid archaicism
#DSM as infectious superficial anti-clinical structures that open our clinical processes to false endeavors and focuses like "safety," which is quickly becoming a pseudo-clinical entity in our language and clinical processes.

I have the growing sense that the personality theory researchers are screaming off in a direction that is much more clinically useful and much more correlated to neurobiological and evolutionary sciences. Their clinical interpretation structures are actually useful and meaningful to patients, which act as clinical hypothesis generators that provocate a collaborative co-formulation with patients to map the meaning of their symptoms. Rather than treat them as some frozen, abstract, rationalist reality unto themselves.

I think there is a dangerous level of emergent public common sense that perceives showing up see a psychiatrist for 10-15 minutes, telling them that you're anxious a lot, and receiving a dx of Anxious Alot Disorder (GAD), and then being given a medication to obliterate an unpleasant feel, is .... f'n absurd. The rationalist, inferiority-complexed, of the medical tribe among us, respond to this cognitive dissonance of clinical uselessness by doubling down on making word categories a rationalist religion. As if... it we can just get the word boxes right we can segregate Bipolar Disorder in 6 discreet categories. And in the process, we leave the public behind. The meaning of their sx lost in our dictums to make them organize into our archaic structures.

We are losing public trust. And the muggles of medicine remain temperamentally aversive of our sphere of activity anyway. Our word categories making them even more inept and useless at dealing with human consciousness issues than if they never heard of our Statistical Manual of Diagnostics.

With our DSM in hand. We unironically give diagnostic equivalents of "the patient has evil aires." And we justify this with statistics that people with miasmatic problems generally complain of this, and this, and this... at some marginal differential rate. Such that these are things that explain "Bad Aires Disease."

The patient comes in with complaints, we impose our word categories to clarify their complaints. And then give them a medication for it. Because in an environment of expediency who has time for anything else.

Furthermore, as this process creeps into our perceptual notions, it becomes how we think of people and their problems. And I propose that when this happens. When we are already preloaded to think superficial algorithms of clinical pathology. And we are already compromised by expedient interests fitting expedient times in expedient encounters. Then we have no resistance to notions of algorithmic safety screens as being asinine. Because it's no more ridiculous and expedient and useless than anything else we do. So we learn to think and act and perceive patient encounters in terms of compressing their risk to themselves in algorithmic risk stratifying word screens. And we become the ideological tools of far left advocacy groups. Who see the world as full of helpless babies to exercise our motherly superiority over. Becoming worse than just useless. But harmful. Corrosive of patient agency for their own health.

We need to teach the rebels and creatives and subversives among us. That the time for their coming into fully independent and courageous being is NOW. There has never been a time in psychiatry that is more ripe for creative rebellion.

I've left the reservation. And there are treasures of clinically useful techniques just laying on the ground everywhere outside its impoverished boundaries. I'm thrilled and amazed as I go forward. But... am also alarmed. Disturbed. And disheartened that my field is doubling down on archacism. And not even having the insight to be boldly archaic enough. So that they could help formulate the modern human's isolation from our mythological roots. Just ignorantly arahciac and isolated to a few decades in the 20th century. Stuck there. Losing the public trust and all sense of meaning of what they're doing.

It bothers me that most residents will be stuck on the reservation. And that patients are stuck there with them, if they're just helpless enough and not their own agent enough, to consume it unthinkingly.

I'm having a hard time understanding how other people are not seeing cause for alarm. Or as cause for desperate, heroic acts of creative rebellion.

The DSM is helpful for applying clinical trial data. A rich formulation of a patient with depression should get at whether their thoughts and feelings are a normal response to a aversive environment or whether there is some differences in how their brain is processing their experiences. But the 40% of people who responded to SSRIs in trials were simply people who had 5/9 criteria, without such considerations. This is part of why I find clinical trials that assess neater constructs (such as the 9 large RCTs of antipsychotics for ‘aggression’) to be of greater value. I have heard of psychiatrists who take a clinical approach of withholding a medication if they think there is a big ‘personality’ or ‘environment’ component and while this is superficially logical for the most part it’s not empirically supported.

 

[Nasrudin]

The DSM is helpful for applying clinical trial data. A rich formulation of a patient with depression should get at whether their thoughts and feelings are a normal response to a aversive environment or whether there is some differences in how their brain is processing their experiences. But the 40% of people who responded to SSRIs in trials were simply people who had 5/9 criteria, without such considerations. This is part of why I find clinical trials that assess neater constructs (such as the 9 large RCTs of antipsychotics for ‘aggression’) to be of greater value. I have heard of psychiatrists who take a clinical approach of withholding a medication if they think there is a big ‘personality’ or ‘environment’ component and while this is superficially logical for the most part it’s not empirically supported.

The DSM is not just helpful in applying pharmaceutical interventions. They help reduce human consciousness into "evidence" for using them as opposed to other things, including doing nothing at all. Your vague notions of "thoughtful formulation" take only the smallest of steps in a better direction. And your notion of alternate formulation "not being empirically supported" is circular logic, as far as I can tell.

Please explain what you mean in further detail. Are you saying that the DSM helps characterize symptoms such that inventory tools used in research can measure something?

Please elaborate on your idea of "neater construct."

I appreciate your response. I welcome it, because I want to learn how to counter-formulate in ways that recognize the best aspects of the opposing argument.

For example I have been deploying Cybernetic Big 5 theory in which you can easily incorporate traumatic relational mapping, more elaborate goal theory, attachment theory, object relational theory, psychodynamic ideas and of course feed in basic relational, social, physiological, circumstantial and historical fields of information. This, as far as I can tell, is far superior in clarifying the patient's causes of distress. (Which, please, tell me why that should not be the goal, rather than clarifying the particulars of state pathos?)

Then the discussion of medications can be had critically. As part of a larger understanding. Where the diagnosis does not become incorporated into the identity as a frozen pathological construct. But is more layered hypotheses for further exploration, discovery, and for experiementing with novel adaptations for resolving intrapsychic, interrelational, goal orientation problems.

Many people are walking out of my office with no medications. They're thinking about what we discovered about them. What questions that we had in session. What hypothesis we created. With penultimate regards for meaning. Not the stenography of state changes.

What we come up with in these sessions fits the categories of the DSM only very occasionally.

Please attack my argument. My goal is to be effective. And useful.

 

[Onions]

Many people are walking out of my office with no medications.

Well, is this a reflection of your practice, or your patient population? Why should people walk away with no medications? You are a careful, thoughtful, thinking person who seeks discovery, not just findings. Awesome. Guess what. So is my mother. You are in the unique position to be the Psych-Iatrist. The mindhealer. My best friend from middle school can talk to me about my problems, but he can't lead me on an expedition into the moonscape of my mental life, purposing and repurposing travel gear and materials from the environment to ensure our mutual survival and arrival in one piece, perhaps each stronger and wiser for it, at the end of the journey. That we are biological beings is, as you've said in other threads, basically a trivial fact.

tl;dr: e.g., Lithium is the first line treatment for acute mania. It's also great for this broader (neater?) construct of "impulsivity." Science says so. So maybe you could thole out some cold night in the foothills of some moon mountain range without a warm fire, but damn, if you've got sticks, and you've got a flint and steel, why the hell would you?

 

[Nasrudin]

Well, is this a reflection of your practice, or your patient population? Why should people walk away with no medications? You are a careful, thoughtful, thinking person who seeks discovery, not just findings. Awesome. Guess what. So is my mother. You are in the unique position to be the Psych-Iatrist. The mindhealer. My best friend from middle school can talk to me about my problems, but he can't lead me on an expedition into the moonscape of my mental life, purposing and repurposing travel gear and materials from the environment to ensure our mutual survival and arrival in one piece, perhaps each stronger and wiser for it, at the end of the journey. That we are biological beings is, as you've said in other threads, basically a trivial fact.

tl;dr: e.g., Lithium is the first line treatment for acute mania. It's also great for this broader (neater?) construct of "impulsivity." Science says so. So maybe you could thole out some cold night in the foothills of some moon mountain range without a warm fire, but damn, if you've got sticks, and you've got a flint and steel, why the hell would you?

haha. interesting. I'm not opposed to medication. They should just be used thoughtfully. I'm not aversive of receptor-based psychopharm either. I think psychopharm is best thought of cybernetically. Where alterations in neurotransmission can be thought of in terms of healthier more active and meaningful goal seeking. What I don't do is act out of compulsion from the need to "fix" something. And it's only one piece of gear for the journey. As you say.

If you are thinking in terms of moon journies. Then you're already off the DSM map.

Also, that we are biological beings is perhaps one of the main mysterious facts of all...? I'm not sure if that was a grammatical error or if you've misinterpreted me.

I see talk therapy modalities as more stable long-term biological interventions. And medications as necessary in some cases.

Why shouldn't they leave my office with questions they didn't know they had and no facile and fatuous answer in a pill? Given the mysterious predicament of being a human.

 

[Onions]

But I guess. I don't understand why the other gerbils aren't busy skittering into the unknown. In awe of the world outside of the wheel. And the maze.

Well, this was really precisely my thought. The Medical Degree is a Doctoral Degree. More Capital Letters Makes You Smarter. Or so I thought before I came to medical school. But my MS1 roommate, who accomplished far better exam scores than I ever did, who ended up cakewalking his way through a competitive residency match, seemed to be concerned chiefly with 3 things within the scope of his own existence: 1) First Aid review books, 2) ultimate frisbee, 3) televised football. With consumption of the former two reserved strictly for well proscribed playtime. Attempts to engage him on the subject of literally any other entity in the universe were met with condescending smiles and a whiff of "that's cute but the grownups are talking, sweetie. Now back to my First Aid review book." I realized that my roommate was not the exception but the rule. Medical school is vocational school.

How this is a problem is elucidated by a comment made by a professor of mine, a pathologist, who once mentioned that, when interviewing medical student candidates, he looks for evidence of intellectual curiosity. Well that's just great. You have to be Leonardo Da Vinci to get in, but then God help you if you dare become anything more than Bartleby the Scrivener. Wouldn't it be cool if medical education and training actually supported the project of erudition and reflection, rather than teach us to decline the same with a resounding, collective "I would prefer not to" ?

I think psychopharm is best thought of cybernetically. Where alterations in neurotransmission can be thought of in terms of healthier more active and meaningful goal seeking.

I see talk therapy modalities as more stable long-term biological interventions. And medications as necessary in some cases.

Yes! The steersman IS the boat. We all know medications have stagnated. Vybrid? Brintellix? What is this bull****. Take me back to the glory days of Largactil. You can only reach so far when you jam your thumb up the butthole of the brain. At a certain point you've got to just come in from above with your other hand and see if you can tickle your own fingers.

 

[Nasrudin]

Well, this was really precisely my thought. The Medical Degree is a Doctoral Degree. More Capital Letters Makes You Smarter. Or so I thought before I came to medical school. But my MS1 roommate, who accomplished far better exam scores than I ever did, who ended up cakewalking his way through a competitive residency match, seemed to be concerned chiefly with 3 things within the scope of his own existence: 1) First Aid review books, 2) ultimate frisbee, 3) televised football. With consumption of the former two reserved strictly for well proscribed playtime. Attempts to engage him on the subject of literally any other entity in the universe were met with condescending smiles and a whiff of "that's cute but the grownups are talking, sweetie. Now back to my First Aid review book." I realized that my roommate was not the exception but the rule. Medical school is vocational school.

How this is a problem is elucidated by a comment made by a professor of mine, a pathologist, who once mentioned that, when interviewing medical student candidates, he looks for evidence of intellectual curiosity. Well that's just great. You have to be Leonardo Da Vinci to get in, but then God help you if you dare become anything more than Bartleby the Scrivener. Wouldn't it be cool if medical education and training actually supported the project of erudition and reflection, rather than teach us to decline the same with a resounding, collective "I would prefer not to" ?



Yes! The steersman IS the boat. We all know medications have stagnated. Vybrid? Brintellix? What is this bull****. Take me back to the glory days of Largactil. You can only reach so far when you jam your thumb up the butthole of the brain. At a certain point you've got to just come in from above with your other hand and see if you can tickle your own fingers.

"Jamming your thumb up the butthole of the brain." Love it.

Yes that would be cool.

I guess it is cool now. In the sense that I think anyone who is good at this, develops these capacities an interests on their own merits. I just want us to able to express this within our clinical constructs. Or within clinical constructs that allow for the flexibility to express these dimensions of human experience.

 

[Attending1985]

I'll add a couple

1) How to say, "No", to a patient or parent. You're the expert, not them. Don't give in to a demand simply because you're afraid they'll get mad. So what if they do?

2) Meds are indicated far less often than you were probably taught or believe.

3) Re-evaluating the need to continue meds should be part of the treatment plan

4) Panel management. This probably should be number one and I bet isn't taught in most residency programs. Learn how to properly manage your panel as far as tracking your patients and getting rid of them. It's very easy to get overwhelmed and in a bad place if you're not actively monitoring and regulating the flow of patients in and out of your panel.

5) Expectation management. Unrealistic expectations for therapeutic benefit is probably the number one reason treatment, "doesn't work". Also ties in to #2. Don't get sucked onto the, "merry go round", with patients -- that obnoxious ride that keeps going but never gets anywhere. Patients who constantly return and complain that nothing works, which results in almost constant changes to meds in an attempt to achieve an outcome that will never actually happen. Refuse to ride and manage expectations instead. Better yet, don't prescribe something when nothing is indicated.

6) Give the boot to people who don't engage or comply. Don't waste your time continuing to see someone who doesn't engage in the process and/or isn't compliant with treatment reccs. Spend some time trying to figure out why and what could possibly be done to change this, but don't drag it out forever. If, despite adequate effort, you can't get anywhere with the patient, cut them loose with the option to try again when they're ready and instead put that time and effort towards a patient who would actually benefit from it.

7) Boundaries and limits with patients. Learn this from the beginning and get comfortable with angry reactions. Giving in to entitled and demanding patients will only result in your burn out. Your health and well-being are equally important and only you will actually care about it.

I am getting better and better at this but you’re right absolutely not taught to me. Actually I was taught the opposite. Thank you for sharing this.

 

[WingedOx]

1) How to say, "No", to a patient or parent. You're the expert, not them. Don't give in to a demand simply because you're afraid they'll get mad. So what if they do?

FWIW, I think this needs to be a focus at the M3-4 level, or even as a basic SP encounter in M2. The inability to do this is so widespread across disciplines.

I've toyed with the idea of a SP encounter scenario for students where the SP berates the sh-t out of the student when the student has to tell the patient no to an inappropriate medication request. I'd rather have them working on something like this than whatever useless "interdisciplinary collaboration exercises" schools are having M1-2s do nowadays.

 

[clausewitz2]

FWIW, I think this needs to be a focus at the M3-4 level, or even as a basic SP encounter in M2. The inability to do this is so widespread across disciplines.

I've toyed with the idea of a SP encounter scenario for students where the SP berates the sh-t out of the student when the student has to tell the patient no to an inappropriate medication request. I'd rather have them working on something like this than whatever useless "interdisciplinary collaboration exercises" schools are having M1-2s do nowadays.

I was frankly shocked during SP training in medical school where the closest we came to having to deal with human emotions was delivering relatively mild bad news. We were never taught how to deal with angry patients. I am a little surprised that there are psychiatrists who did not receive training in this given how much inpatient work we do, but then I have heard that in some states inpatient units do not have involuntary patients, so one must not get the experience of someone screaming about how they will murder you because you are a filthy Zionist who is trying to give them AIDS. Or just threatening to put you through a window if you admit them involuntarily.

Medical students would benefit hugely from dealing with that kind of negative affect directed at them. Unfortunately I don't think you're allowed to say anything vaguely mean to medical students these days, even in the service of training.

 

[OldPsychDoc]

I've toyed with the idea of a SP encounter scenario for students where the SP berates the sh-t out of the student when the student has to tell the patient no to an inappropriate medication request. I'd rather have them working on something like this than whatever useless "interdisciplinary collaboration exercises" schools are having M1-2s do nowadays.

We've been doing this in our simulation center, but not until internship.

 

[WingedOx]

We've been doing this in our simulation center, but not until internship.

Interesting. I don't think I ever did any sim center stuff during residency except for a basic certification thing during orientation so that I could do a lumbar puncture/central line on a dummy. It seems like one of those universal skills that needs to be taught, but hard to determine when. You want students/trainees to learn to handle this stuff early enough but also they need to have enough background knowledge to be able to do the clinical counseling aspect of dealing with said patients to effectively explain why why you're saying no.

 

[Celexa]

I was frankly shocked during SP training in medical school where the closest we came to having to deal with human emotions was delivering relatively mild bad news. We were never taught how to deal with angry patients. I am a little surprised that there are psychiatrists who did not receive training in this given how much inpatient work we do, but then I have heard that in some states inpatient units do not have involuntary patients, so one must not get the experience of someone screaming about how they will murder you because you are a filthy Zionist who is trying to give them AIDS. Or just threatening to put you through a window if you admit them involuntarily.

Medical students would benefit hugely from dealing with that kind of negative affect directed at them. Unfortunately I don't think you're allowed to say anything vaguely mean to medical students these days, even in the service of training.

Even on the floors, we were usually steered away from 'difficult' patient situations. I understand keeping students away if the presence of a student will make the situation actively worse, but I was surprised by how much we were coddled on the interpersonal interactions level in terms of what patients we were assigned. We did have an SP situation where we had to tell the SP their relative was dead. I would have welcomed more difficult SP interactions.

 

[Amygdarya]

Medical students would benefit hugely from dealing with that kind of negative affect directed at them. Unfortunately I don't think you're allowed to say anything vaguely mean to medical students these days, even in the service of training.

This is so true. The most difficult interaction I’ve ever had with an SP was an actor giving me a hard time about getting his sexual history. Though we’re having an internship bootcamp right now and we have delivering bad news and talking to patients about medical mistakes sims on the schedule.

Even on the floors, we were usually steered away from 'difficult' patient situations. I understand keeping students away if the presence of a student will make the situation actively worse, but I was surprised by how much we were coddled on the interpersonal interactions level in terms of what patients we were assigned.

I agree with you, too. Students are generally shielded from the more difficult patients largely for students’ protection.
Though I was lucky in that my very first rotation was inpatient geri medicine where most of the folks were either delirious as a result of a medical issue or having medical issues as a result of their moderate to severe dementia, so I got yelled at by patients in different states of consciousness pretty much daily. One of my patients with moderate dementia threatened to report me to my superiors (after I did something she didn’t like but that had been discussed with the whole team and had been approved by the attending, and was ultimately good for the patient). But I was fine with all that. And that’s how I knew I could do psychiatry
On later rotations I would be more proactive about picking up “difficult” patients or patients with “difficult” families and, frankly, after giving me some nominal resistance residents were only happy to have someone else (mostly) deal with these patients. Ultimately almost all of my patients on medicine sub-I had some frank psychiatric disorders and/or personality or behavioral issues. So this can happen if you’re proactive about it, but the vast majority of students aren’t - in fact, most are only too happy not to have to deal with emotional/personality/behavioral issues.