What aspect of psychiatry has had the highest skill curve for you as a resident/attending?

[slowthai]

What has been the most difficult thing for you to learn/get comfortable doing?

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[comp1]

Boundary setting and not admitting every chronically suicidal or homicidal patient seems to be the most challenging for a lot of people.

 

[reca]

Incorporating therapy into my appointments. I went to a very biological program and I find myself routinely running out of things to talk about/address 15 minutes into the appointment.

 

[slowthai]

Boundary setting and not admitting every chronically suicidal or homicidal patient seems to be the most challenging for a lot of people.

Can you go into detail about what makes setting boundaries difficult?

 

[comp1]

Imagining the challenges of boundary setting isn't very difficult. You have a patient yelling (often literally) for some sort of controlled substance. You know that explaining why you aren't going to prescribe it, for the 4th time, is going to take another 20 minutes you don't have. Just prescribing it will get the person out of your office immediately. Choose the right...

 

[BiscoDisco]

Incorporating therapy into my appointments. I went to a very biological program and I find myself routinely running out of things to talk about/address 15 minutes into the appointment.

Is this necessarily a bad thing though? For some psychiatrists, their focus and expertise is on biologics. For therapy they refer out to the appropriate source.

 

[Merovinge]

Imagining the challenges of boundary setting isn't very difficult. You have a patient yelling (often literally) for some sort of controlled substance. You know that explaining why you aren't going to prescribe it, for the 4th time, is going to take another 20 minutes you don't have. Just prescribing it will get the person out of your office immediately. Choose the right...

Threatening to report you to the state board, DEA, your hospital board, and spam your business with 1 star reviews will make you really glad to have had good training on handling this in residency...

 

[jbomba]

Threatening to report you to the state board, DEA, your hospital board, and spam your business with 1 star reviews will make you really glad to have had good training on handling this in residency...

In the span of residency I've already been spammed with 1 star review by a patient who was angry I couldn't guarantee admission to a specific hospital from the ER. Another completely psychotic patient complained to the medical board about me for a completely psychotic reason.

Any tips for handling patients (and their demands/threats) these patients when they come into your outpatient practice?

 

[allantois]

In the span of residency I've already been spammed with 1 star review by a patient who was angry I couldn't guarantee admission to a specific hospital from the ER. Another completely psychotic patient complained to the medical board about me for a completely psychotic reason.

Any tips for handling patients (and their demands/threats) these patients when they come into your outpatient practice?

Your best bet is to screen these patients out so they don’t make it through the door

 

[Merovinge]

In the span of residency I've already been spammed with 1 star review by a patient who was angry I couldn't guarantee admission to a specific hospital from the ER. Another completely psychotic patient complained to the medical board about me for a completely psychotic reason.

Any tips for handling patients (and their demands/threats) these patients when they come into your outpatient practice?

Yes.
1) Agree with above, screening is essentially to all the OP cash practice docs I know. You get little control over this with employed jobs.

2) Document in real time (metadata can be a friend even if the concept is terrible) about what occurred, what you discussed, pt's response (quotes are best) and medical decision making as such

3) You are not your google rating, no good psychiatrist will ever have all 5 star reviews. Repeat this mantra to yourself.

4) Try to remember all the patients who do thank you, appreciate you, and most importantly, who's lives you have tangibly improved. Even (or particularly when) the tangibly improved part comes from setting good boundaries and not doing harm. If you see a lot of bad medicine practiced around you it can creep into your psyche. It's up to you to stop that and thankfully we are better trained in psychiatry than any other field to do so. Just because the NP, PCP, or crummy psychiatrist next door doles out Adderall 30 TID like candy does not mean you need to. Don't let arguments like "if I don't do it, someone else will" invade your mind, every crack/heroin dealer on earth says the same thing.

 

[jbomba]

Your best bet is to screen these patients out so they don’t make it through the door

Please forgive my ignorance, still learning the liability side of practice as a pgy4, but, what's the best way to document when I see a patient for an initial evaluation but decide not to take them on as a patient full time? I recogize a doctor patient relationship has been formed, so am I simply required to give them other resources to potential doctors at that point if I don't wish to take them on?

 

[TheRightMedication]

A big part of why I don't set foot in my hospital's ER anymore is it was a source of bad reviews.

Wish I'd learned that one earlier.

 

[allantois]

Please forgive my ignorance, still learning the liability side of practice as a pgy4, but, what's the best way to document when I see a patient for an initial evaluation but decide not to take them on as a patient full time? I recogize a doctor patient relationship has been formed, so am I simply required to give them other resources to potential doctors at that point if I don't wish to take them on?

If they are asking for something inappropriate you document your recommendation. It’s up to them to follow it or seek care elsewhere.

I write in my note literature does not support use of Adderall at doses above blah blah or concomitant benzo and opioid therapy. Offered patient alternative or whatever, patient declined

 

[Stagg737]

During my outpatient year I had a pretty high acuity patient panel and I got a lot of messages about random problems and various "crises". So I had a lot of difficulties not feeling like I was "on duty" when I left the clinic. It was extremely difficult for me to adjust to and I felt on edge a lot during that year. It took a long time to not feel so responsible for my patients since we have so much more control when patients are admitted to inpatient units.

I'm usually very good at compartmentalizing things, but I had a lot of trouble not taking that stress home and "turning it off" when I left the clinic.

 

[jbomba]

If they are asking for something inappropriate you document your recommendation. It’s up to them to follow it or seek care elsewhere.

I write in my note literature does not support use of Adderall at doses above blah blah or concomitant benzo and opioid therapy. Offered patient alternative or whatever, patient declined

Right, but what if you no longer want to see the patient? How do you document and handle this?

 

[ObsequiousAplomb]

Right, but what if you no longer want to see the patient? How do you document and handle this?

That you saw them for a consultation and the two of you mutually agreed to not continue treatment together. Most people won't want to schedule a follow-up once it's clear that you're not budging on an issue like that. They might try to convince you when they think they can succeed in changing your mind. Sometimes it takes being a little extra firm.

 

[jbomba]

That you saw them for a consultation and the two of you mutually agreed to not continue treatment together. Most people won't want to schedule a follow-up once it's clear that you're not budging on an issue like that. They might try to convince you when they think they can succeed in changing your mind. Sometimes it takes being a little extra firm.

Sure, that makes sense. But what if it's not due to the fact the patient wants stimulants. What if it's due to the fact the patient is a borderline train wreck of which you want nothing to do with? How do you handle that with the patient in a way that doesn't send them in to a tizzy?

 

[ObsequiousAplomb]

Sure, that makes sense. But what if it's not due to the fact the patient wants stimulants. What if it's due to the fact the patient is a borderline train wreck of which you want nothing to do with? How do you handle that with the patient in a way that doesn't send them in to a tizzy?

You recommend a comprehensive treatment plan and tell them that your clinic unfortunately is not equipped to provide that. They will want the level of care you recommend and when they hear who might be able to offer it they will seek that clinic out, as long as you're not recommending something they explicitly told you they don't want.

 

[sighchiatry]

What has been the most difficult thing for you to learn/get comfortable doing?

Being ok with not directly intervening / waiting / letting the patient do it or figure it out.

 

[annoyedpsychiatrist]

Acknowledging that when it comes to a treatment plan, sometimes doing the right thing is the least fun thing to do and will at times lead to a patient threatening/complaining about you. PCP dumping chronic benzo use patients on me to taper off and remembering that the patient is often the victim in this scenario because someone who can't read or got their degree from university of phoenix medical school decided xanax high dose TID was 1st line for GAD

 

[whopper]

Boundary setting and not admitting every chronically suicidal or homicidal patient seems to be the most challenging for a lot of people.

Agree. Biggest reason why is cause as healers we should be compassionate and open-minded. These two characteristics are the exact thing that a malingerer is going to try to exploit.

Hard to be compassionate and open-minded while balancing it out with telling people to leave the hospital. It's a very difficult balancing act, not of a few grams on each side of the scale but hundreds of pounds.

Add to this, the academic curriculum really doesn't include this difficult learning curve in any lectures which I think is ridiculous. It's obvious this is an ongoing problem and has been for several decades. Why isn't this issue tackled in research? E.g. percentages of patients malingering who come to the ER with psych complaints. I already know the answer but it's not acceptable. There's no drug money research profits, this type of research is hard to do, and add to this forensic level training on this is not done in general residency.

Which only points to the conclusion that psychiatry academic training wants hospital psychiatrists to do something where they're not trained to do it per the academic curriculum. Yeah with clinical experience you could learn it but it's not part of the structured on-paper curriculum.

It's not just malingerers. It's also cluster B patients who really are suffering but inpatient treatment isn't the answer. Also chronically suicidal patients where they don't commit suicide.

 

[jbomba]

You recommend a comprehensive treatment plan and tell them that your clinic unfortunately is not equipped to provide that. They will want the level of care you recommend and when they hear who might be able to offer it they will seek that clinic out, as long as you're not recommending something they explicitly told you they don't want.

Appreciate the input. Would you avoid starting them on any medications and just make med recs?

 

[ObsequiousAplomb]

Appreciate the input. Would you avoid starting them on any medications and just make med recs?

If they're a borderline trainwreck, then yes, I wouldn't be starting any new medications in general (since they're undoubtedly taking some already). In general I don't recommend starting meds in the outpatient setting that you wouldn't be following. Starting a treatment makes it seem like you're starting a doctor-patient relationship. You can give some psychoeducation and document that you discussed RBA of certain medications, psychotherapies, and levels of care, and that after shared clinical decision-making the plan was for them to seek care elsewhere. Ideally you say the places you recommended or what their plan is to seek out that care. You could, if you want, say more, but I wouldn't say more than that.

I'd bill it as a 90792 and make the note very clear that it was not the start of a treating relationship, that I didn't prescribe any treatment, and there is no plan to follow-up with my office. I wouldn't go for a 99205 or an add-on therapy code. I think that since 90792 is for start of treatment OR consult work it would help to avoid saying it was an initial E&M or part of a psychotherapy plan. That might be overkill though, and I'm probably leaving money on the table.

Where it can get tricky is if they're legitimately out of medications and they came from an inpatient stay to your office with a short supply from the inpatient team. In that case I MIGHT give them a short refill of their regimen while making it clear I don't intend to provide further care and this is only to bridge them to their next provider. This is really me not being as firm as I ought to be on my boundaries, though. It can easily be misconstrued. Ideally they could get in to see their PCP who could give a refill or something. Maybe a crisis center or CSA or CMHC with walk-ins. If they're wealthy enough they can probably convince someone else to see them and write a refill for them in the interim. This is also part of why a great deal of private practice psychiatrists don't see new patients discharged from inpatient care.

 

[ObsequiousAplomb]

Agree. Biggest reason why is cause as healers we should be compassionate and open-minded. These two characteristics are the exact thing that a malingerer is going to try to exploit.

Hard to be compassionate and open-minded while balancing it out with telling people to leave the hospital. It's a very difficult balancing act, not of a few grams on each side of the scale but hundreds of pounds.

Add to this, the academic curriculum really doesn't include this difficult learning curve in any lectures which I think is ridiculous. It's obvious this is an ongoing problem and has been for several decades. Why isn't this issue tackled in research? E.g. percentages of patients malingering who come to the ER with psych complaints. I already know the answer but it's not acceptable. There's no drug money research profits, this type of research is hard to do, and add to this forensic level training on this is not done in general residency.

Which only points to the conclusion that psychiatry academic training wants hospital psychiatrists to do something where they're not trained to do it per the academic curriculum. Yeah with clinical experience you could learn it but it's not part of the structured on-paper curriculum.

It's not just malingerers. It's also cluster B patients who really are suffering but inpatient treatment isn't the answer. Also chronically suicidal patients where they don't commit suicide.

Agreed completely. What's especially frustrating is that the academic curriculum frequently espouses the EXACT opposite view, that everyone with any risk factors NEEDS an admission if they come into an ER. Residents who try to learn the subtlety are frequently accused of letting their countertransference guide them to harming a patient or committing flagrant malpractice or being incompetent.

 

[calvnandhobbs68]

It's not just malingerers. It's also cluster B patients who really are suffering but inpatient treatment isn't the answer. Also chronically suicidal patients where they don't commit suicide.

Right I think this is something I've gotten more comfortable doing the last year with my handful of borderline teenagers that are suicidal every single time in my office and have been inpatient multiple times.

It's very reasonable to state that repeated inpatient hospital admissions have not shown consistent benefit for this patient, may actually have a negative effect by reinforcing maladaptive coping, evidence for reducing risk from chronic suicidality, especially in the context of a suspected personality disorder, is longitudinal outpatient treatment, here are the programs I've recommended for them, the family has/has not followed up with this, and it is not clear that SI for this particular patient today conveys any greater immediate risk of suicide than at prior visits. Which is why I'm not sending them to the hospital.

 

[clausewitz2]

PCP dumping chronic benzo use patients on me to taper off and remembering that the patient is often the victim in this scenario because someone who can't read or got their degree from university of phoenix medical school decided xanax high dose TID was 1st line for GAD

Now, now, no need to malign the good name of Hollywood Upstairs Medical College.

 

[clausewitz2]

Agreed completely. What's especially frustrating is that the academic curriculum frequently espouses the EXACT opposite view, that everyone with any risk factors NEEDS an admission if they come into an ER. Residents who try to learn the subtlety are frequently accused of letting their countertransference guide them to harming a patient or committing flagrant malpractice or being incompetent.

I can recommend Joel Paris' Half in Love With Death. Very succinct and clinically relevant guide for how to deal with chronically suicidal patients of all stripes.

 

[mistafab]

Agree. Biggest reason why is cause as healers we should be compassionate and open-minded. These two characteristics are the exact thing that a malingerer is going to try to exploit.

Hard to be compassionate and open-minded while balancing it out with telling people to leave the hospital. It's a very difficult balancing act, not of a few grams on each side of the scale but hundreds of pounds.

Add to this, the academic curriculum really doesn't include this difficult learning curve in any lectures which I think is ridiculous. It's obvious this is an ongoing problem and has been for several decades. Why isn't this issue tackled in research? E.g. percentages of patients malingering who come to the ER with psych complaints. I already know the answer but it's not acceptable. There's no drug money research profits, this type of research is hard to do, and add to this forensic level training on this is not done in general residency.

Which only points to the conclusion that psychiatry academic training wants hospital psychiatrists to do something where they're not trained to do it per the academic curriculum. Yeah with clinical experience you could learn it but it's not part of the structured on-paper curriculum.

It's not just malingerers. It's also cluster B patients who really are suffering but inpatient treatment isn't the answer. Also chronically suicidal patients where they don't commit suicide.

Agreed completely. What's especially frustrating is that the academic curriculum frequently espouses the EXACT opposite view, that everyone with any risk factors NEEDS an admission if they come into an ER. Residents who try to learn the subtlety are frequently accused of letting their countertransference guide them to harming a patient or committing flagrant malpractice or being incompetent.

I was actually surprised by this. Our program does a lot of teaching around this topic. There’s also a bunch of excellent clinical papers published in this area. I think one was called “the therapeutic discharge” or something like that, particularly aimed at training residents to discharge well. I had thought most academic programs would not be discharge-averse.

My biggest learning curve is definitely outpatient. It seems that the skill ceiling is much higher.

 

[Mad Jack]

Agreed completely. What's especially frustrating is that the academic curriculum frequently espouses the EXACT opposite view, that everyone with any risk factors NEEDS an admission if they come into an ER. Residents who try to learn the subtlety are frequently accused of letting their countertransference guide them to harming a patient or committing flagrant malpractice or being incompetent.

My academic curriculum certainly didn't, we were trained in careful assessment for appropriate admission or referral since the vast majority of people presenting with SI will have risk factors but we simply don't have even a fraction of the beds needed to treat them all as inpatients and the majority of them can be managed using outpatient and community resources

 

[smalltownpsych]

Is this necessarily a bad thing though? For some psychiatrists, their focus and expertise is on biologics. For therapy they refer out to the appropriate source.

Agreed about the emphasis part, but if you do not develop solid psychotherapy skills you might find that some of the other problems that the psychiatrists are talking about in this thread will be much more difficult to deal with. It can literally be the difference between making lots of money and enjoying your job or being punched in the face and threatened with lawsuits. I would bet there are quite a few psychiatrists that would say that the biological part is the easier part of the job.

 

[splik]

Is this necessarily a bad thing though? For some psychiatrists, their focus and expertise is on biologics. For therapy they refer out to the appropriate source.

Yes it absolutely is a bad thing to be a mindless psychiatrist. And often those psychiatrist who claim to be more biological have a shockingly bad understanding of neuroscience as well. When all you have is a hammer everything looks like a nail. Most psychiatrists these days are not doing psychotherapy proper, but to be practicing at your very best ("top of your license") you have to be able to formulate patients from different perspectives, recognize the role of psychosocial factors in the presentation, identify transference, countertransference, resistance, and and utilize common factors (e.g. therapeutic alliance, empathy, positive regard, genuineness, and expectancy) to create a healing environment. The data is quite clear from clinical trials and prospective community studies that patients do better with more empathic physicians who create a better therapeutic environment. Put another way, the meds "work better" when you have a strong therapeutic relationship with your doctor. The converse is also true, if you are not empathic and not effective at creating therapeutic alliances your patients may do worse than no treatment at all.

It is also much more rewarding and enriches the work. I see a lot of people with clearly identifiable neurological diseases driving their symptoms (in some cases can even pinpoint the lesion) and even in those patients it's never just about the brain. As Hippocrates supposedly said, it is more important to know what kind of person has the disease than what disease the person has.

 

[G Sheb]

It's definitely the skills you need to create a therapeutic environment as mentioned above, from the frame, to boundaries, to listening, to empathy. These are skills learned by experience from a century of practice. It takes a lifetime to hone them, and essentially the therapeutic relationship is for me what makes the field engaging.
Empathy utilized in the correct setting is by far the most important tool in the toolbox.
80% of the work is about the relationship and keeping patients engaged in their care. I think anyone can probably read the APA guide and prescribe meds.
I would also add to that the observational and phenomenological aspects of psychiatry. Being able to create distance to observe and interpret behavior.
I found that my therapy training in interpersonal psychoanalysis was far more beneficial than anything I've learned in residency.

 

[TheRightMedication]

Couldn't agree with splik and smalltown more. In particular, I agree that someone who only uses a biological approach has no idea what they're doing for the following reasons -

1. Anyone with an adequate grasp of the relevant physiology knows that an even deeper knowledge of the physiology is for research purposes only.

Show me a body of evidence that demonstrates that a sophisticated matching of patient physiological characteristics to the mechanism of action of drugs yields any benefit at all and I will gladly put my foot in my mouth.

2. Anyone with an adequate grasp of the feild of psychiatry knows that everything in Splik's post above is true. Therefore, to offer patients only meds and Somatic treatments is inadequate.

3. To advertise yourself as a specialist in an inadequate approach is foolish, and to make a fool of your patients by persuading them to work with you on the basis of said expertise is cruel.

 

[annoyedpsychiatrist]

I agree that the ideal treatment encompasses therapeutic and lifestyle approach but it is not an easy thing to encompass in a 20, or even 30 minute f/u. And doing it on a sustained basis such as weekly or biweekly is not common/sustainable with most outpatient jobs. I even explain that to the patient "zoloft is not a fix for your stressors, it is a small part of the equation" and focus on brief bits of therapy each visit, depending on the patient. To summarize, in outpatient psychiatry were often limited by time constraints.

 

[Candidate2017]

What has been the most difficult thing for you to learn/get comfortable doing?

I think most of answers in this thread boils down to: Learning to be comfortable in the eye of the storm.

Imagining the challenges of boundary setting isn't very difficult. You have a patient yelling (often literally) for some sort of controlled substance. You know that explaining why you aren't going to prescribe it, for the 4th time, is going to take another 20 minutes you don't have. Just prescribing it will get the person out of your office immediately. Choose the right...

I feel almost all patients challenge boundaries more insidiously than the easily identifiable substance seekers. For example, almost all patients seek a magic pill, and it's easy to hand out a med and move on to the next patient instead of telling them the truth: It ain't gonna work that well if they keep doing what they're doing.

I can't sleep [but I won't stop smoking weed]
Dr: sleep med

My kid acts up [but I'm a terrible parent]
Dr: Abilify, Risperdal, and Clonidine. BTW have they tried Daytrana?

 

[Candidate2017]

Is this necessarily a bad thing though? For some psychiatrists, their focus and expertise is on biologics. For therapy they refer out to the appropriate source.

At baseline, every psychiatrist should be an expert in managing and prescribing most psychotropics. Unless you are Stahl, an academic researcher or the like, any resident or clinical psychiatrist who says they went to a "biological program" is really saying they went to a program that did not provide them with therapy training.

On a side note, prescribing is actually the easiest part because prescribing medications is evidence based, thus very algorithmic, like any medical specialty. The hardest part of any medical specialty is diagnosing.

It's ok to decline to do therapy. But the purpose of having adequate therapy training is to understand the patient, understand yourself, and understand how to modulate the interaction between you and the patient.

 

[erg923]

Is this necessarily a bad thing though? For some psychiatrists, their focus and expertise is on biologics. For therapy they refer out to the appropriate source.

Have to agree that this makes little sense, and that I don't really understand what this means?

"Focus on biologics" is for bench scientists....or at least someone who is NOT practicing healthcare services on humans in front of them.

I mean, that's not really 'clinical psychiatry" at all. Is it? That would be a "psychopharmacologist"..... which is fine for a research setting/study, or some limited medication consultations if one has that level of demonstrated expertise. But for general psychiatry practice (inpatient or outpatient) I don't think that's what we want/aspire to?

 

[calvnandhobbs68]

My kid acts up [but I'm a terrible parent]
Dr: Abilify, Risperdal, and Clonidine. BTW have they tried Daytrana?

i've got at least one of these a day

Also yes the "psychopharmacologist" thing is hilarious. Bro there's like 10 actual truly different med classes in psychiatry, I would expect everybody who graduates from a psychiatry residency to be an "expert" in the medications you need to use for your field.

It's like going to a pulmonologist who says they're an "expert in respiratory pharmacology"

 

[rjs2131]

I agree that the ideal treatment encompasses therapeutic and lifestyle approach but it is not an easy thing to encompass in a 20, or even 30 minute f/u. And doing it on a sustained basis such as weekly or biweekly is not common/sustainable with most outpatient jobs. I even explain that to the patient "zoloft is not a fix for your stressors, it is a small part of the equation" and focus on brief bits of therapy each visit, depending on the patient. To summarize, in outpatient psychiatry were often limited by time constraints.

I like how you described this, and that first portion is exactly why I feel 90833 add-ons are justified for 30 min visits. Those of us who spend that time (or more on occasion) are much more likely to have a better therapeutic relationship with our patients and consequently, better outcomes.

 

[clausewitz2]

Have to agree that this makes little sense, and that I don't really understand what this means?

"Focus on biologics" is for bench scientists....or at least someone who is NOT practicing healthcare services on humans in front of them.

I mean, that's not really 'clinical psychiatry" at all. Is it? That would be a "psychopharmacologist"..... which is fine for a research setting/study, or some limited medication consultations if one has that level of demonstrated expertise. But for general psychiatry practice (inpatient or outpatient) I don't think that's what we want/aspire to?

Wait, are you saying it's not standard of care to regularly have patients on antidepressants do forced swim tests as an outcome measure? S**t.

BRB, draining the pool

 

[Merovinge]

i've got at least one of these a day

Also yes the "psychopharmacologist" thing is hilarious. Bro there's like 10 actual truly different med classes in psychiatry, I would expect everybody who graduates from a psychiatry residency to be an "expert" in the medications you need to use for your field.

It's like going to a pulmonologist who says they're an "expert in respiratory pharmacology"

I wish that were the case and yet somehow I consistently see this not being so. I'd say roughly 50%-75% (depending on the setting) of patients I see managed by other board certified psychiatrists have done a good job with medications (which of course leaves 25-50% who have not). Particularly when you get out into the 2nd/3rd line treatments where things are still quite well known but would require someone to at least pretend to keep up to date on the latest literature. I recently saw a patient that had 6 trials of medication and thought wow, that's basically exactly what I would have done, and that happens quite rarely (this patient did come from an academic psychiatric clinic).

Everyone keeps talking like doing a good job with medication is trivial, and maybe it is for the types of doctors who spend their free time between patients on SDN (points at self), but that does not mean every patient seeing a psychiatrist is done justice by their pharmacologic treatment. There is this consistent drum beat in this thread about psychiatrists only showing their differential value based on their therapy acumen or diagnostic skills, but I will push back and say I consistently find value-add spots for myself as someone takes pride in psychopharmacology.

"Little" things like knowing how to treat side effects (atropine drops, Viagra, beta blockers etc.), when to use lithium/clozapine and how to walk someone through this, appropriate Remeron or TCA usage, getting light box therapy setup, catching hyponatremia from Trileptal/carbamazepine, and many more can all make a huge difference in any one patient's life. I bang the drum as hard as anyone from evidenced based psychotherapy and see it change lives all the time, but that does not mean psychiatric medication management is doable at full value by an FMNP or someone who focused entirely on psychoanalytics and has never read a RCT in their career.

 

[whopper]

Mistafab:I was actually surprised by this. Our program does a lot of teaching around this topic. There’s also a bunch of excellent clinical papers published in this area. I think one was called “the therapeutic discharge” or something like that, particularly aimed at training residents to discharge well. I had thought most academic programs would not be discharge-averse.

If this is the case you have at least 1 astute psychiatrist, likely a few, who were able to go above and beyond and modify the teaching curriculum to compensate for the lack of education in the national curriculum.

While I was at U of Cincinnati we similarly did the same. Our ER psych unit knew how to deal with such patients, and this was taught very well. I later went to an institution where it was not, and there were no consistent psychiatrists working ER because they had problems just holding onto doctors. Their priority was simply having a warm body with a degree instead of maintaining consistent and good treatment guidelines. Similarly where I did my residency training (and this was years ago so maybe it's not true now) in NJ they had a psych ER and the two psychiatrists who worked there the most had pretty much no training on malingering and cluster B. They didn't have good skills on a therapeutic discharge.

 

[psychmd03]

Gotta say I am surprised at the lack of people saying that knowing and understanding the business side of medicine was not a larger learning curve. For me that curve hit third year in residency when I started moonlighting and I realized the "teching" of billing and coding we received was not really gonna do anything in the real world. I find it to be a fundamental part to understand and it is rarely taught at a level that actually does any good. And a lack of understanding will leave you missing out on a lot of money you likely earned but will never collect or you have it taken back.

A learning curve becoming an inpatient attending that was large was two fold. Being able to give my treatment an idea of dc planning dates and predicting ideas of dc so they can do their job was tough but you can get pretty good at this by recognizing the patterns of patients that are coming in. Someone "suicidal with voices" but truly actually just using heroin that isnt motivated for treatment 4-6 days likely 5 will be fine for them. The second learning curve was how to barter with patients to get them to take meds and or dealing with the fact that I will rarely be able to get my patient onto "optimal" by the book treamtent.

 

[smalltownpsych]

I wish that were the case and yet somehow I consistently see this not being so. I'd say roughly 50%-75% (depending on the setting) of patients I see managed by other board certified psychiatrists have done a good job with medications (which of course leaves 25-50% who have not). Particularly when you get out into the 2nd/3rd line treatments where things are still quite well known but would require someone to at least pretend to keep up to date on the latest literature. I recently saw a patient that had 6 trials of medication and thought wow, that's basically exactly what I would have done, and that happens quite rarely (this patient did come from an academic psychiatric clinic).

Everyone keeps talking like doing a good job with medication is trivial, and maybe it is for the types of doctors who spend their free time between patients on SDN (points at self), but that does not mean every patient seeing a psychiatrist is done justice by their pharmacologic treatment. There is this consistent drum beat in this thread about psychiatrists only showing their differential value based on their therapy acumen or diagnostic skills, but I will push back and say I consistently find value-add spots for myself as someone takes pride in psychopharmacology.

"Little" things like knowing how to treat side effects (atropine drops, Viagra, beta blockers etc.), when to use lithium/clozapine and how to walk someone through this, appropriate Remeron or TCA usage, getting light box therapy setup, catching hyponatremia from Trileptal/carbamazepine, and many more can all make a huge difference in any one patient's life. I bang the drum as hard as anyone from evidenced based psychotherapy and see it change lives all the time, but that does not mean psychiatric medication management is doable at full value by an FMNP or someone who focused entirely on psychoanalytics and has never read a RCT in their career.

I guess when I’m thinking the knowledge of psychotherapy skills would be an important differentiator, I was assuming solid medical and pharmacological knowledge for psychiatrists as a baseline. Kind of like the mistake of thinking that psychologists would have a solid base research that would steer them toward evidence based therapy only to find out that some of my colleagues wouldn’t know an exposure protocol from a DBT worksheet and think EMDR is the answer.

 

[calvnandhobbs68]

I wish that were the case and yet somehow I consistently see this not being so. I'd say roughly 50%-75% (depending on the setting) of patients I see managed by other board certified psychiatrists have done a good job with medications (which of course leaves 25-50% who have not). Particularly when you get out into the 2nd/3rd line treatments where things are still quite well known but would require someone to at least pretend to keep up to date on the latest literature. I recently saw a patient that had 6 trials of medication and thought wow, that's basically exactly what I would have done, and that happens quite rarely (this patient did come from an academic psychiatric clinic).

Everyone keeps talking like doing a good job with medication is trivial, and maybe it is for the types of doctors who spend their free time between patients on SDN (points at self), but that does not mean every patient seeing a psychiatrist is done justice by their pharmacologic treatment. There is this consistent drum beat in this thread about psychiatrists only showing their differential value based on their therapy acumen or diagnostic skills, but I will push back and say I consistently find value-add spots for myself as someone takes pride in psychopharmacology.

"Little" things like knowing how to treat side effects (atropine drops, Viagra, beta blockers etc.), when to use lithium/clozapine and how to walk someone through this, appropriate Remeron or TCA usage, getting light box therapy setup, catching hyponatremia from Trileptal/carbamazepine, and many more can all make a huge difference in any one patient's life. I bang the drum as hard as anyone from evidenced based psychotherapy and see it change lives all the time, but that does not mean psychiatric medication management is doable at full value by an FMNP or someone who focused entirely on psychoanalytics and has never read a RCT in their career.

I mean I guess it’s true, it might be too much to expect people to know basic management or how to look up uptodate guidelines without being an “expert psychopharmacologist”.

Kind of like the teenager I got from an inpatient unit recently who was taken off the SSRI he was on for a couple weeks and put on Buspar for no apparent reason. Surprise surprise his GAD is still out of control and only thing the homeopathic dose of Buspar did was make him dizzy.

 

[G Sheb]

"Little" things like knowing how to treat side effects (atropine drops, Viagra, beta blockers etc.), when to use lithium/clozapine and how to walk someone through this, appropriate Remeron or TCA usage, getting light box therapy setup, catching hyponatremia from Trileptal/carbamazepine, and many more can all make a huge difference in any one patient's life. I bang the drum as hard as anyone from evidenced based psychotherapy and see it change lives all the time, but that does not mean psychiatric medication management is doable at full value by an FMNP or someone who focused entirely on psychoanalytics and has never read a RCT in their career.

I get what you're saying, but that's a low bar honestly, though there are definitely too many in our field who do worse.
But I do think one should and can give deeper thought into pharmacology, as in, think a bit more about side effect profile, drug/drug interactions, patient-specific circumstances and stay up to date on the latest evidence. Also worth keeping in mind as someone mentioned that some tend to go overboard with this, and make all sort of claims and clinical decisions based on unsupported hypotheticals around neuroscience and physiology, sort of in the "Stahl" mode.

Still, the 'soft' skill sets around communication are much more challenging and more high yield imo, and also set apart the better psychiatrists from the rest. I'm hesitant to call them "therapy skills" because they can be equally powerful in a "medication management" appointment or even an ER evaluation. (though therapy training can do wonders to improve them).

 

[Merovinge]

I get what you're saying, but that's a low bar honestly, though there are definitely too many in our field who do worse.
But I do think one should and can give deeper thought into pharmacology, as in, think a bit more about side effect profile, drug/drug interactions, patient-specific circumstances and stay up to date on the latest evidence. Also worth keeping in mind as someone mentioned that some tend to go overboard with this, and make all sort of claims and clinical decisions based on unsupported hypotheticals around neuroscience and physiology, sort of in the "Stahl" mode.

Still, the 'soft' skill sets around communication are much more challenging and more high yield imo, and also set apart the better psychiatrists from the rest. I'm hesitant to call them "therapy skills" because they can be equally powerful in a "medication management" appointment or even an ER evaluation. (though therapy training can do wonders to improve them).

It's a low bar for us talking here on SDN maybe. I went to an above average university training program and even in my class I would say about 75% did a good job with this "low bar". Don't get me started on some of the other folks I've interacted with who clearly went into psychiatry because it was all they could get into decades ago and their knowledge of psychopharmacology. This is not even withstanding the amount of psychiatric medication managed by PCPs and NPs.

Soft skills are essential in all of patient facing medicine, and psychiatry more than any other field (except maybe palliative medicine). That does not mean that knowing all the side effects, management of those side effects, all drug-drug interactions, how to understand pharmacogenetics and the BS they put out into the world, thoughtful and evidenced based approaches to treatment resistant conditions etc etc is trivial. People are making the thousands of hours to see thousands of patients needing thoughtful services in this regard as something that anyone could do. Being the best you can be at pharmacology is real skill, it makes a real difference in people's lives. It's okay to acknowledge that and hope that we still work on psychotherapy training and soft skills.

 

[comp1]

I'm sure the business side of it would be a huge learning curve. I knew I had no knowledge of that stuff and stayed well away from any job where I was even allowed to negotiate things like RVUs or salaries, much less trying to run a private practice.

 

[BACyeahyouknowme]

I wish that were the case and yet somehow I consistently see this not being so. I'd say roughly 50%-75% (depending on the setting) of patients I see managed by other board certified psychiatrists have done a good job with medications (which of course leaves 25-50% who have not). Particularly when you get out into the 2nd/3rd line treatments where things are still quite well known but would require someone to at least pretend to keep up to date on the latest literature. I recently saw a patient that had 6 trials of medication and thought wow, that's basically exactly what I would have done, and that happens quite rarely (this patient did come from an academic psychiatric clinic).

Everyone keeps talking like doing a good job with medication is trivial, and maybe it is for the types of doctors who spend their free time between patients on SDN (points at self), but that does not mean every patient seeing a psychiatrist is done justice by their pharmacologic treatment. There is this consistent drum beat in this thread about psychiatrists only showing their differential value based on their therapy acumen or diagnostic skills, but I will push back and say I consistently find value-add spots for myself as someone takes pride in psychopharmacology.

"Little" things like knowing how to treat side effects (atropine drops, Viagra, beta blockers etc.), when to use lithium/clozapine and how to walk someone through this, appropriate Remeron or TCA usage, getting light box therapy setup, catching hyponatremia from Trileptal/carbamazepine, and many more can all make a huge difference in any one patient's life. I bang the drum as hard as anyone from evidenced based psychotherapy and see it change lives all the time, but that does not mean psychiatric medication management is doable at full value by an FMNP or someone who focused entirely on psychoanalytics and has never read a RCT in their career.

You know, I had heard this idea that the pharmacology is banal and simple from a few of my program’s attendings. The ones who made these remarks were obviously trained well before me. I never thought the pharmacology was simple, and I thought mastering it involved progressive improvements in knowledge and skill, like anything else.

So I have this theory that the dismissive “pharmacology is easy” comments are coming from people who trained in an era that really valued the dynamic/analytic side of our profession, and patients getting better with “just pills” threatens the primacy of that worldview, and thus they mount these defensive responses.

Just my armchair analysis anyway.

 

[calvnandhobbs68]

You know, I had heard this idea that the pharmacology is banal and simple from a few of my program’s attendings. The ones who made these remarks were obviously trained well before me. I never thought the pharmacology was simple, and I thought mastering it involved progressive improvements in knowledge and skill, like anything else.

So I have this theory that the dismissive “pharmacology is easy” comments are coming from people who trained in an era that really valued the dynamic/analytic side of our profession, and patients getting better with “just pills” threatens the primacy of that worldview, and thus they mount these defensive responses.

Just my armchair analysis anyway.

Very interesting analysis there. Unfortunately for you I finished fellowship in the last couple years 😆

Doing a good job with medication isn't trivial but I'm also of the mindset that anyone who graduates a residency should have at least a decent knowledge of what to do or not with medications. On top of this, most of the people calling themselves "expert psychopharmacologists" aren't exactly the people on ACT teams prescribing clozapine and lithium on a daily basis...