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

[NickNaylor]

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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.

I specifically encourage students that I work with to take a stab at interviewing a difficult patient. I usually warn them that an interview might be difficult but encourage them to try nonetheless. Ultimately I’m not sure that the student benefits at all from not seeing these kinds of patients. They’re going to see them at some point no matter what field they do into, why not start getting that exposure now?

 

[Ceke2002]

I specifically encourage students that I work with to take a stab at interviewing a difficult patient. I usually warn them that an interview might be difficult but encourage them to try nonetheless. Ultimately I’m not sure that the student benefits at all from not seeing these kinds of patients. They’re going to see them at some point no matter what field they do into, why not start getting that exposure now?

Thanks for the mid morning chuckle, I just misread that as "I specifically encourage students to not stab difficult patients."

 

[whopper]

Regarding Nasrudin's post about personality disorders....
I agree.

I need to explain this cause this can get a bit complicated.
When you learn about stuff like personality disorders in a psychology course in college it's usually something much more complex. E.g. in an abnormal psychology class they teach you what is normal vs abnormal, not to pathologize abnormal just for being such, and more of the theories of what is personality and how is it measured. You get a test on it and memorize it well cause you want to pass the class.

In residency the lectures are limited to maybe 1 hr on personality disorders, maybe more but usually at most maybe 1 hr per personality disorder. The residents aren't tested, and some are post call and falling asleep in the middle of the lecture. If you were like me you likely didn't pay much attention cause you were still finishing up on your progress notes in the middle of lecture knowing you will not be tested on this at the end of the semester. You also are more likely concerned with USMLE Step III and know this will likely not be on that exam so it becomes low-priority.

This is where residency training in culture causes major differences in usual academic training. A psychologist, for example, will take classes and get extensive tests they must do well on while residents simply have to show up to lecture and only the superficial points are often taught. Instructors are usually attendings who care more about your performance running the inpatient unit than you dozing off in lecture. Residency in effect becomes much more clinical-experience based vs academic based even when the textbook stuff is taught.

It's also hard to emphasize the importance when you're more concerned about patient care (e.g. a suicidal patient) while you're in lecture. I don't see any easy fix to this other than to introduce tests in residency (and most people don't want that), or to have a few months were residents don't do clinical work and just do lectures with exams which will most definitely not happen cause it flies in the face of the entire current structure nor will it be sustainable under the current system because residents doing labor is what pays for residencies.

 

[SmallBird]

Regarding Nasrudin's post about personality disorders....
I agree.

I need to explain this cause this can get a bit complicated.
When you learn about stuff like personality disorders in a psychology course in college it's usually something much more complex. E.g. in an abnormal psychology class they teach you what is normal vs abnormal, not to pathologize abnormal just for being such, and more of the theories of what is personality and how is it measured. You get a test on it and memorize it well cause you want to pass the class.

In residency the lectures are limited to maybe 1 hr on personality disorders, maybe more but usually at most maybe 1 hr per personality disorder. The residents aren't tested, and some are post call and falling asleep in the middle of the lecture. If you were like me you likely didn't pay much attention cause you were still finishing up on your progress notes in the middle of lecture knowing you will not be tested on this at the end of the semester. You also are more likely concerned with USMLE Step III and know this will likely not be on that exam so it becomes low-priority.

This is where residency training in culture causes major differences in usual academic training. A psychologist, for example, will take classes and get extensive tests they must do well on while residents simply have to show up to lecture and only the superficial points are often taught. Instructors are usually attendings who care more about your performance running the inpatient unit than you dozing off in lecture. Residency in effect becomes much more clinical-experience based vs academic based even when the textbook stuff is taught.

It's also hard to emphasize the importance when you're more concerned about patient care (e.g. a suicidal patient) while you're in lecture. I don't see any easy fix to this other than to introduce tests in residency (and most people don't want that), or to have a few months were residents don't do clinical work and just do lectures with exams which will most definitely not happen cause it flies in the face of the entire current structure nor will it be sustainable under the current system because residents doing labor is what pays for residencies.

Hopefully residents will be driven in their learning by the clinical challenges they are encountering. Adult learning theory emphasizes this shift in drives from a focus on proving competency, to seeking content and skills which is responsive to the task at hand. I learned more in residency from lectures which made it clear how the content was responsive to things I was being expected to do at the time. Assessment is a very bad solution to the problems facing graduate medical education.

 

[enoughsaid12]

Regarding Nasrudin's post about personality disorders....
I agree.

I need to explain this cause this can get a bit complicated.
When you learn about stuff like personality disorders in a psychology course in college it's usually something much more complex. E.g. in an abnormal psychology class they teach you what is normal vs abnormal, not to pathologize abnormal just for being such, and more of the theories of what is personality and how is it measured. You get a test on it and memorize it well cause you want to pass the class.

In residency the lectures are limited to maybe 1 hr on personality disorders, maybe more but usually at most maybe 1 hr per personality disorder. The residents aren't tested, and some are post call and falling asleep in the middle of the lecture. If you were like me you likely didn't pay much attention cause you were still finishing up on your progress notes in the middle of lecture knowing you will not be tested on this at the end of the semester. You also are more likely concerned with USMLE Step III and know this will likely not be on that exam so it becomes low-priority.

This is where residency training in culture causes major differences in usual academic training. A psychologist, for example, will take classes and get extensive tests they must do well on while residents simply have to show up to lecture and only the superficial points are often taught. Instructors are usually attendings who care more about your performance running the inpatient unit than you dozing off in lecture. Residency in effect becomes much more clinical-experience based vs academic based even when the textbook stuff is taught.

It's also hard to emphasize the importance when you're more concerned about patient care (e.g. a suicidal patient) while you're in lecture. I don't see any easy fix to this other than to introduce tests in residency (and most people don't want that), or to have a few months were residents don't do clinical work and just do lectures with exams which will most definitely not happen cause it flies in the face of the entire current structure nor will it be sustainable under the current system because residents doing labor is what pays for residencies.

I think a lot of residents will tell you didactics are really overrated. True learning is done by seeing patients. You learn by making mistakes and being in new and uncomfortable situations, not but going through vignettes. Learning in a class room is a relic of the past. Moreover, the “smartest resident” who rocks the PRITE is often the ones that is usually pretty weak clinically.

 

[TexasPhysician]

I think a lot of residents will tell you didactics are really overrated. True learning is done by seeing patients. You learn by making mistakes and being in new and uncomfortable situations, not but going through vignettes. Learning in a class room is a relic of the past. Moreover, the “smartest resident” who rocks the PRITE is often the ones that is usually pretty weak clinically.

While seeing patients is important, I’d prefer residents to also be given time to read up on each diagnosis, medication, and alternative plan recommendations for every patient. In my opinion, (for example) diagnosing schizophrenia 100x is no more educational than 30x. 30x would actually be more educational if the resident used the 70x time to read about medications used, why some are chosen, cost of meds to the system, when to draw labs/how often, how to perform a good AIMS, how to measure improvement, etc.

The problem is that most residents and programs are to blame for not better educating residents. Lectures are infrequent and residents are not wanting to dedicate time to studying after the work hours are done.

The result is giving residents high volume in an attempt to force them to learn by providing enough volume to learn a little from a lot rather than a lot from a little.

 

[Nasrudin]

While seeing patients is important, I’d prefer residents to also be given time to read up on each diagnosis, medication, and alternative plan recommendations for every patient. In my opinion, (for example) diagnosing schizophrenia 100x is no more educational than 30x. 30x would actually be more educational if the resident used the 70x time to read about medications used, why some are chosen, cost of meds to the system, when to draw labs/how often, how to perform a good AIMS, how to measure improvement, etc.

The problem is that most residents and programs are to blame for not better educating residents. Lectures are infrequent and residents are not wanting to dedicate time to studying after the work hours are done.

The result is giving residents high volume in an attempt to force them to learn by providing enough volume to learn a little from a lot rather than a lot from a little.

I agree with this. Except that I'm not sure reading how much I'd need to read about schizophrenia. It's breadth that we are missing. Because of the pedagogy you describe above we are exceedingly vulnerable to a superficial approach to psychiatric care in general. And to being used as prescribing cogs in a machine that functions in the bureaucratic warfare as a perpetual battle over ****ty care vs ****ty reimbursement. We need to know much more about human cybernetic functioning of the person with schizophrenia than the diagnosis itself and what agents to use. That's actually something you can gain from "a little from a lot." In my opinion. So it's not clear to me why you chose that example. The "little from a lot" method is actually perfect for figuring out schizophrenia from other causes of psychosis so as to guide admission decisions and stop polluting the psychiatric databases with diagnoses of primary psychosis when there is no clinical evidence of psychosis outside of drug use that is perhaps superimposed on potential low cognitive functioning at baseline.

But if your point is seeing 30 cases and knowing the history of the diagnosis and treatment approaches and some subtlety of medication choices and how cognitive and occupational rehab is ideal etc. Vs seeing all forms of psychosis and giving haldol dec for all of them, because, who has time to think in this ****hole, just keep moving the meat. Then yes.

 

[whopper]

I think a lot of residents will tell you didactics are really overrated. True learning is done by seeing patients. You learn by making mistakes and being in new and uncomfortable situations, not but going through vignettes. Learning in a class room is a relic of the past. Moreover, the “smartest resident” who rocks the PRITE is often the ones that is usually pretty weak clinically.

It's a balance. Yeah I've seen what you're talking about (the book-smart person who knows nothing of the real world) but I've also seen the type of doctor that doesn't know what they're doing but think they do and because they can leave the unit or group home with nothing that can seriously challenge their viewpoint they think they're okay.

E.g. I see so many doctors simply zonk out patients in nursing homes and groups homes. The nurses don't complain cause many of them want thte patient zonked. The patients don't complain cause they're zonked. But were they able to get in there quickly, "get the job done," and get out? Yes.

Very serious understanding of personality does require some every in-depth study in addition to good clinical skills.

 

[TexasPhysician]

.
But if your point is seeing 30 cases and knowing the history of the diagnosis and treatment approaches and some subtlety of medication choices and how cognitive and occupational rehab is ideal etc. Vs seeing all forms of psychosis and giving haldol dec for all of them, because, who has time to think in this ****hole, just keep moving the meat. Then yes.

This. Developing a differential is an important skill, but diversity is needed rather than volume. Teams should educate and share less common cases.

There is little longitudinal learning. If there was a more unique case on inpatient, no PGY-3’s in outpatient would learn or be informed of the case.

Doubtful this will ever improve as $ is more important than education.

 

[WingedOx]

This. Developing a differential is an important skill, but diversity is needed rather than volume.

Hard to have one without the other, despite what a lot of psych folks claim.

 

[TexasPhysician]

Hard to have one without the other, despite what a lot of psych folks claim.

Disagree. That is what faculty is for. Residents should spend more time with educational cases. I interviewed at places where residents saw volume that would support a salary of $400k+. That is not learning anything but stamina.

I get that what I believe would be best is likely unrealistic.

 

[AD04]

The result is giving residents high volume in an attempt to force them to learn by providing enough volume to learn a little from a lot rather than a lot from a little.

They say it is to promote learning, but the higher volume magically translates to higher revenue to the institutions. When I see my 25th patient for the day and the attending praises me, I know it isn't because I've learning so much (and to be fair, most of my learning takes place when I go home).

Frankly, the people that live and breath psychiatry will succeed no matter where they train. There are always that small group of people (mostly men) who will have no problem working and studying and dedicating 80+ hours a week to what they do. Place them in the worst program with insane hours and absolutely no teaching and they'll still make their way to the top of the field.

I think a lot of residents will tell you didactics are really overrated. True learning is done by seeing patients.

Didactics are overrated. True learning comes from reading SDN though. That's why I'm here =)

 

[TexasPhysician]

Didactics are overrated. True learning comes from reading SDN though. That's why I'm here =)

Lectures in residency suck because faculty are given minimal time to develop quality material or they are lecturing by force. There is no money made by giving better lectures, so institutions don’t provide extra time.

Lectures at conferences can be 100x as good.

 

[enoughsaid12]

While seeing patients is important, I’d prefer residents to also be given time to read up on each diagnosis, medication, and alternative plan recommendations for every patient. In my opinion, (for example) diagnosing schizophrenia 100x is no more educational than 30x. 30x would actually be more educational if the resident used the 70x time to read about medications used, why some are chosen, cost of meds to the system, when to draw labs/how often, how to perform a good AIMS, how to measure improvement, etc.

The problem is that most residents and programs are to blame for not better educating residents. Lectures are infrequent and residents are not wanting to dedicate time to studying after the work hours are done.

The result is giving residents high volume in an attempt to force them to learn by providing enough volume to learn a little from a lot rather than a lot from a little.

Let me rephrase. I don't think seeing patients is purely educational on its own. But I would argue good supervision coupled with seeing patients provides more education than most didactics could provide. All patients have something educational to offer if utilized in an appropriate way. And lets not forget that when your a practicing psychiatrist in the "real world" you will be working within a system. Learning how to navigate this system is educational in its own right and extremely important in Residency.

 

[DD214_DOC]

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

As far as firing patients, the answer is, "Yes and no". Doing so basically requires authoraization from the MTF commander and rarely happens. I managed to do it successfully one time.

The workaround is to keep your boundaries and give gentle suggestions that they should seek care elsewhere.

As far as panel management, this is a general term that only applies to specialists and subspecialists. Balancing the inflow/outflow of patients to keep your overall panel size manageable to preserve access -- and your own sanity. Otherwise, your panel will just balloon to an unreasonable size that destroys access and your time during the duty day.

 

[nancysinatra]

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.

I agree with all this, but when I raised these kinds of questions as a resident, I was threatened with being kicked out of the program. (And yes that's why I was threatened, and yes I was told that was why. I was told to my face and in writing to stop asking so many questions. I have the warning letter to this day and will save it for the rest of my life.) Modern-day psychiatry training has some seriously anti-critical thinking tendencies working against it.

 

[nancysinatra]

One thing they should teach more of is billing and coding.

 

[DD214_DOC]

One thing they should teach more of is billing and coding.

Truth. I found out 3 months into my practice as an attending that I was using the CPT code for prescribing psychologists.

As far as your additional point regarding the DSM, I also agree with that. The DSM is more of a guideline than anything, and really is just a descriptive thing to make communication easier. Unfortunately, patients are under a different impression. I don't get too caught up on labels except for the handful that actually matter due to long-term issues related to prognosis and potential disability.

 

[OldPsychDoc]

Truth. I found out 3 months into my practice as an attending that I was using the CPT code for prescribing psychologists.

As far as your additional point regarding the DSM, I also agree with that. The DSM is more of a guideline than anything, and really is just a descriptive thing to make communication easier. Unfortunately, patients are under a different impression. .

When the media discusses the release of a new edition, as they did with DSM5, as "a new 'Bible' of Psychiatry", how can they not get the wrong impression? Cripes, folks--it's an outline. Nothing more. 🙄

 

[675015]

I agree with all this, but when I raised these kinds of questions as a resident, I was threatened with being kicked out of the program. (And yes that's why I was threatened, and yes I was told that was why. I was told to my face and in writing to stop asking so many questions. I have the warning letter to this day and will save it for the rest of my life.) Modern-day psychiatry training has some seriously anti-critical thinking tendencies working against it.

That sounds awful. My program definitely never tried to fire me for any of these questions but I definitely get lots of blank stares. This has been frustrating, especially as we see a lot of patients from other cultures around the world that don't always line up with the DSM. Some cases DSM just obviously isn't enough but certain attendings have made me feel stupid for trying to bring this up.

 

[WingedOx]

That sounds awful. My program definitely never tried to fire me for any of these questions but I definitely get lots of blank stares. This has been frustrating, especially as we see a lot of patients from other cultures around the world that don't always line up with the DSM. Some cases DSM just obviously isn't enough but certain attendings have made me feel stupid for trying to bring this up.

I kind of wonder where people are practicing /training when I hear stuff like this. I sometimes suspect regional variation to how psychiatry is practiced, but then again a decent number of faculty where I work (we all mostly trained at a different program down the road) have frequently expressed frustration at how dogmatic and rigid some of the residents are about this type of thing and wonder where they're getting it from.

 

[675015]

I kind of wonder where people are practicing /training when I hear stuff like this. I sometimes suspect regional variation to how psychiatry is practiced, but then again a decent number of faculty where I work (we all mostly trained at a different program down the road) have frequently expressed frustration at how dogmatic and rigid some of the residents are about this type of thing and wonder where they're getting it from.

I don't want to over-exaggerate and say that EVERYONE practices this way. We actually have a pretty big global/cultural psychiatry sub-department. There are also many attending in the system who have a "beyond the DSM" (a lecture series we have) approach. However, a lot of the day to day attendings we work with can be concrete about the DSM and so thats just been the bulk of my experience. Maybe its just the culture of our institution which had a lot of people involved in its development?

 

[WisNeuro]

I don't want to over-exaggerate and say that EVERYONE practices this way. We actually have a pretty big global/cultural psychiatry sub-department. There are also many attending in the system who have a "beyond the DSM" (a lecture series we have) approach. However, a lot of the day to day attendings we work with can be concrete about the DSM and so thats just been the bulk of my experience. Maybe its just the culture of our institution which had a lot of people involved in its development?

There's a happy, middle ground area somewhere. I think the sword cuts both ways here. It's bad to be overly rigid and reductionistic. But, I've also seen plenty of the other extreme of someone completely eschewing diagnostic guidelines to essentially shoehorning a patients presentation into a preconceived, wildly inaccurate, or outdated notion of disorders. And, oftentimes when asked about it, they spew some bs about hating the DSM and convention or some such nonsense. In reality, both groups are just ****ty diagnosticians.

 

[WingedOx]

There's a happy, middle ground area somewhere. I think the sword cuts both ways here. It's bad to be overly rigid and reductionistic. But, I've also seen plenty of the other extreme of someone completely eschewing diagnostic guidelines to essentially shoehorning a patients presentation into a preconceived, wildly inaccurate, or outdated notion of disorders. And, oftentimes when asked about it, they spew some bs about hating the DSM and convention or some such nonsense. In reality, both groups are just ****ty diagnosticians.

Oh no doubt, and we certainly don't have a shortage of people who confuse contrarianism for brilliance in these threads either.

Though for better or worse this group is far smaller than the "Poor sleep + racing thoughts = Bipolar -> give seroquel for no good reason" group, so I don't have to deal with them nearly as much.

 

[WisNeuro]

Though for better or worse this group is far smaller than the "Poor sleep + racing thoughts = Bipolar -> give seroquel for no good reason" group, so I don't have to deal with them nearly as much.

Well there's willful ignorance, and then there's just plain ignorance. The latter definitely makes up the lion's share of poor healthcare decisions.

 

[John1513]

How to deal with difficult people who aren’t your medical school/residency peers/academic medicine

——————————

In the “real world,” otherwise known as “adulting,” we physicians will have to inevitably deal with “support staff” who can be incredibly ignorant. They can have the mental processing speed of molasses and argues with you like a 4 year old.

On the long hard road that leads to becoming an attending physician, a doctor can get used to the simple “logic” of our world. Everything has order, function, hierarchy and meaning.

It is not so after residency.

The advice here is:

- don’t lower yourselves to their level. Don’t get sucked into a nonsensical argument of their design
- utilize your “support staff” (clinic manager?) to manage your ‘support staff’
- document each infraction or egregious example of stupidity in the form of a memo or email.
- drop the hammer when it becomes apparent when rehab of character is not possible

 

[Nasrudin]

When the media discusses the release of a new edition, as they did with DSM5, as "a new 'Bible' of Psychiatry", how can they not get the wrong impression? Cripes, folks--it's an outline. Nothing more. 🙄

I hear you boss, but, idk. The whole engine of reimbursement seems to churn on it. And I think "guideline" is underestimating it's effect on how we think, perceive, and act. Our clinical research is misdirected at it's clinical constructs for example.

There's a happy, middle ground area somewhere. I think the sword cuts both ways here. It's bad to be overly rigid and reductionistic. But, I've also seen plenty of the other extreme of someone completely eschewing diagnostic guidelines to essentially shoehorning a patients presentation into a preconceived, wildly inaccurate, or outdated notion of disorders. And, oftentimes when asked about it, they spew some bs about hating the DSM and convention or some such nonsense. In reality, both groups are just ****ty diagnosticians.

I hear you on this. I've been digging into this matter for a project. And I gained an appreciation for what the DSM III was trying to do in terms of increasing reliability. Rather than narrative, idiosyncratic, approaches that made organizing clinical research or even the work flow of health systems difficult and irrational.

But I think there's more validity in other constructs that can account for both what is known and what isn't to direct our efforts more clearly at causation and meaningful intervention. And... also provide for more consistency and reliability.

 

[hamstergang]

I hear you boss, but, idk. The whole engine of reimbursement seems to churn on it.

Don't we all bill through ICD codes, not the DSM?

 

[Nasrudin]

Don't we all bill through ICD codes, not the DSM?

Sure. But as far as I can tell we use the diagnostic criteria sets for the DSM and then just reference the ICD codes for that particular “disorder.”

Is there a conceptual difference?

**Additionally, how sheepish are the liking lurkers to the above post. I can't even distinguish what was meant by it. Let alone like or dislike it. How funny is it. That liking cliques form around some philosophical differences. Come have a talk. Let's figure some things out. I ask sincere questions. Formulated at the edge of my understanding. Help me (and others) learn through the socratic method. Don't be passive-aggressive, mean girls, liking for non-topical reasons.

 

[michaelrack]

Since dsm 5 no longer has schizophrenia subtypes (but icd 10 does and Medicare and insurers don't like unspecified schizophrenia dx), what code are you using

 

[Nasrudin]

Since dsm 5 no longer has schizophrenia subtypes (but icd 10 does and Medicare and insurers don't like unspecified schizophrenia dx), what code are you using

Yeah. I mean, we use the ICD-10 codes in my EMR, but it punches them up accordingly whenever I search for a diagnosis by word search. And for PA's and other things. I've googled the code for the DSM diagnosis, I'm using.

So the question made me wonder if the WHO has a different underlying set of diagnostic premises in how they form the constructs? Because clearly I'm thinking of the diagnostic concepts not the codes. Which to me have been just cross-reference points without further thought.

Am I wrong in thinking that we get trained and taught psychiatric diagnostics by the DSM? The WHO had never much entered my mind as a conceptual framework before, beside understanding that it was an international standardization effort, and the primary billing code reference point.

 

[splik]

The ICD has completely different diagnostic criteria for example schizophrenia only requires one months duration of symptoms in ICD-10 vs DSM-5 and personality disorders are considered axis 1 disorders because they idea is that psychopathology occurs in people with abnormal personalities and that (or temperament) is what is inherited

 

[WingedOx]

...or most importantly, just slap a code on your coding sheet that's close enough to keep the bean counters happy and formulate the case however you want to formulate the case.

 

[Nasrudin]

The ICD has completely different diagnostic criteria for example schizophrenia only requires one months duration of symptoms in ICD-10 vs DSM-5 and personality disorders are considered axis 1 disorders because they idea is that psychopathology occurs in people with abnormal personalities and that (or temperament) is what is inherited

hmmm. I see. Well, the personality structure merging with mood dx in terms of broad category makes sense to me.

How do you see the relationship between mood dx's and extremes of trait loading or personality psychopathology? It seems to me a major problem with DSM (ICD?) diagnostic categories, beyond the fact that categories are unlikely to map onto an external validity of person A has 4 of 9 is doing much better than a person B who has 5 of 9, is that they are not, in fact, discriminately segregating underlying clinical phenomenon that well. Which is why you get patient's that sound like... "34 F with pph of MDD, GAD, PTSD, and cluster B character structure..." and you might be able to make a structured interview case for all of the above.

I don't know what the discriminant value of 1 month is for psychosis. There's so many designer drugs causing psychosis that are so easy to obtain in the US that I can't see that as being helpful. Although I can see thinking of psychosis as organization dysfunction with failure of linear, coherent thought process adaptations to normal goal seeking behaviors required for self-care and protection, without all the flavorful descriptors as being a more clinically elegant idea. You would think, schizophrenia, would be one of the more obvious dx's to make, but the pollution of clinical databases with it and substance-induced psychosis and all manner of you basic "wilding out," is mystifying to me. Do you think that there is something inherent to the establishing of pathological entities for the targeting of intervention to eradication of symptom criteria, as measure by the scales that demonstrate reduction of the same criteria, in creating over diagnosis, particularly since billing seems to work discreetly and correlatively, in this manner?

The above suspicion is one reason I'm looking into models that utilize a spectrum of normal psychic functioning to dysfunction with a way of modeling the details of that dysfunction, as a way to prevent expedient, over diagnosis, and as a way to reinvigorate the choice between talk therapy and medications and perhaps no treatment at all if psychic dysfunction is a matter of external or even intrapsychic obstacles that either can't be mitigated by psychiatry or shouldn't be. Symptoms are not necessarily pathology, in other words, and seeing them as aggregating to underlying causality without actually exploring that with a patient, seems dangerous in the direction of harmful treatment. Symptoms could be a call to change your situation, your adaptive style, or a thousand other things. And this is what bothers me about the DSM. Even it's section III PD group ideas, which at least have a dimensional framework with emphasis on valid functional assessments, seem divorced from positive healthy psychic functioning as a means of adaptation to problems.

 

[Nasrudin]

...or most importantly, just slap a code on your coding sheet that's close enough to keep the bean counters happy and formulate the case however you want to formulate the case.

Yes. I would love to do this. But chart auditing and billing seems to demand a DSM diagnosis with charted sx accordingly with all of these other measures and bureaucratic tools for monitoring progress towards discreet sx reduction goals and Safety. Which, I still can't figure out, how that became a major non-clinical, clinical demand on us.

I realize in PP things are different. But even in PP there seems to be chart audits that would presume the above as standard of care. No?

 

[deleted736562]

While seeing patients is important, I’d prefer residents to also be given time to read up on each diagnosis, medication, and alternative plan recommendations for every patient. In my opinion, (for example) diagnosing schizophrenia 100x is no more educational than 30x. 30x would actually be more educational if the resident used the 70x time to read about medications used, why some are chosen, cost of meds to the system, when to draw labs/how often, how to perform a good AIMS, how to measure improvement, etc.

The problem is that most residents and programs are to blame for not better educating residents. Lectures are infrequent and residents are not wanting to dedicate time to studying after the work hours are done.

The result is giving residents high volume in an attempt to force them to learn by providing enough volume to learn a little from a lot rather than a lot from a little.

Volume is overrated. I feel I learn the most when I spend time with patients to understand what's really going in their mind and to conceptualize why they behave in certain ways. Spending a lot of time with a few patients can help you understand better the 100 patients you're going to see next. The insistence on efficiency and "30 minute interviews" does not promote understanding.

In the same vein, experiencing/learning what goes on in the mind of the depressed/psychotic/anxious/manic patient is far more useful when it comes to interaction with patients and even developing a diagnostic feel rather than memorizing the DSM checklists. Readings in the humanities and exploration of the arts and subjective experience should take precedence.

I also think personality disorders are some of the most useful diagnostic categories we have. They are more conceptual (rather than merely descriptive) than other psych diagnoses and I feel in most cases there's some underlying personality psychopathology which makes patients vulnerable to other psychiatric illnesses.