What Does Mastery in Psychiatry Look Like?

[AD04]

---

Members don't see this ad.

I was browsing YouTube and came across a skillfully done cover of Pink Soldiers:



If you've watched Squid Game, you'll see how he mixed elements of the show with technical musical expertise. To reach this level, he started at 12 years old and had a wide range of musical experiences but focuses on guitar.

Other masters in their respective fiends include:
- Motobu Choki for karate. He learned karate since childhood from various teachers and tested what he learned through actual fights in a red light district. He distilled the techniques to the most effective ones and then trained with them for the rest of his life. He was so good he defeated the most popular karate teacher of his time.

- Pablo Piccaso for art (mainly painting). Child prodigy with early technical mastery. Super prolific and reinvented his art styles several times throughout his life. Achieved fame (and women).

- Bobby Fischer for chess. Started learning at age 6. Obsessed with chess and did a lot of self-studying at first and later got noticed and was trained by mentors. US champion in his teens and world champion as a young adult.

I figured mastery could work in psychiatry as well -- people with exceptional skills in treatment for mental health. Mastery will require (innate?) talent, obsessiveness with the field (which is likely higher in SDN posters than non-SDN posters), and creativity.

How do you engage in deliberate practice in psychiatry?

What does mastery look like in psychiatry?

From those you've observed or worked with, who are the closest to masters in psychiatry? What set their work apart from the average psychiatrist?

For the psychiatrists and non-psychiatrists that treat through therapy, what does mastery look like in therapy?

 

[Ludwig2000]

I’ve actually wondered this too and I’m interested to hear others’ replies.
I think because psychiatry can look like so many different things depending on the different settings, so too can mastery of it.

When I think about it, one guy that comes to mind here is a master of outpatient longitudinal community psychiatry. Thing about him is he makes you feel good any time you talk to him. The warmth and reassurance of a kindly, twinkly eyed grandfather has become one with his Being. The pudding proof is he now sees multiple generations of the same families, and many of the skid row types a lesser me would’ve thought never follow up with a doctor much less a psychiatrist. He probably ends up functionally doing most of their primary care through some means or another.

Another guy I knew in med school, of the academic bent, somehow knew all of the psychiatric literature from historical to cutting edge, and would integrate it seamlessly together into discussions of mechanisms, or whatever other “why” questions I came to him with as a student. I think he just read all the time. But the common element was he’d make you feel good, too.

I guess I gotta work on my twinkly eyes

 

[painballer27]

There is an old user named Phorensic, he deleted a lot of his posts and changed his name to something else now. But I think he is the epitome of mastery and an inspiration to many.

 

[Liquid8]

After I finished my last lot of psychiatry exams, I was speaking to my then inpatient supervisor about future career plans. When I told him I was looking at working in private, he made a comment that made me think – it was along the lines of, “Sometimes I just accept new patient referrals without even looking at them,” and “did I think I was at that level?” To me this implied that one had to have the proficiency to be able to assess and manage anything that walked into the room, despite having access to a referral system that allowed us the opportunity to select for various conditions that we liked or disliked.

While I don’t think it’s a viable way of working to never read referrals, I certainly felt it was something to strive towards at least in terms of having that kind of mindset, especially in terms of the broader concept of “mastery”. When the time came where I was the one receiving and vetting patient referrals, the approach I took was that I needed to be able to have a good idea of what I would do from just reading the referral - often it would be as simple as adjusting a dose or changing a medication.

Still, this didn’t negate the fact that one had to be prepared for anything and have the confidence to deal with any unexpected curve balls within the confinements of a single session. At the start there were things I had to read about in anticipation of new patients – things that weren’t covered in great detail during training like ADHD and autism, older antidepressants or other meds that I’d not had a lot of experience with or unusual physical conditions spring to mind. I haven’t felt the need to do it for a while, aside from the occasional weird condition (eg. pyroluria) or new/unusual procedures (one patient brought up a nerve block procedure for PTSD which I’d never heard of before).

When I think back, our college exams which involved assessing new patients in 50 minutes without any prior knowledge (and all the failed practice exams leading up to this) really gave me the confidence to deal with the majority of presentations. We had to pass this exam twice, whereas the trainees under the previous curriculum only had to pass it once, or could fail it and get through with marks from another assessment. Our college removed that exam shortly after I finished, which fits in with anecdotal evidence that subsequent graduates were less confident in their clinical assessment skills and declining a higher proportion of new referrals.

 

[comp1]

It's a cool philosophical question. However, mastering our work is more like what the Supreme Court said about pornography, I'll more know it when I see it than be able to lay out a set of expectations. It's...different than chess.

 

[deleted1100659]

psychiatry is an art form that requires a delicate balance between appropriate treatment/normalizing normal reactions i.e. not over prescribing. Even the best psychiatrist misses stuff. If a psychiatrist told me they could definitively diagnosis bipolar 2 with 100% accuracy every patient based off an initial visit I would call BS, because the picture isn't always clear. Sometimes people are poor historians as well. Even reading guidelines, they can differ at times and contradict each other. Ive gone through the maudsley multiple times, uptodate, and now working on the new K & S version and all have at least some conflicting viewpoints. Problem becomes it doesnt matter how well something works, patients have to tolerate it well and want to not stop taking it. Often the ones they don't want to stop taking are the ones you want them to stop taking (xanax, adderall, etc). Five differnet "master psychiatrists" are likely to give five different viewpoints when asked about treatment for a particular disorder.

 

[clausewitz2]

A big element of it is this:

Amazon product ASIN 0195389379
Mastery is phronesis to a very great extent. It's not so much about the technical knowledge, though you need that, but about making the right choice for the right reasons. This is not a field where we have really great outcome measures, at least not ones that care what anyone real actually cares about. You do not have an objective standard of performance to measure it against.

 

[erg923]

If you've watched Squid Game, you'll see how he mixed elements of the show with technical musical expertise. To reach this level, he started at 12 years old and had a wide range of musical experiences but focuses on guitar.

Other masters in their respective fiends include:
- Motobu Choki for karate. He learned karate since childhood from various teachers and tested what he learned through actual fights in a red light district. He distilled the techniques to the most effective ones and then trained with them for the rest of his life. He was so good he defeated the most popular karate teacher of his time.

- Pablo Piccaso for art (mainly painting). Child prodigy with early technical mastery. Super prolific and reinvented his art styles several times throughout his life. Achieved fame (and women).

- Bobby Fischer for chess. Started learning at age 6. Obsessed with chess and did a lot of self-studying at first and later got noticed and was trained by mentors. US champion in his teens and world champion as a young adult.

I figured mastery could work in psychiatry as well -- people with exceptional skills in treatment for mental health. Mastery will require (innate?) talent, obsessiveness with the field (which is likely higher in SDN posters than non-SDN posters), and creativity.

How do you engage in deliberate practice in psychiatry?

What does mastery look like in psychiatry?

From those you've observed or worked with, who are the closest to masters in psychiatry? What set their work apart from the average psychiatrist?

For the psychiatrists and non-psychiatrists that treat through therapy, what does mastery look like in therapy?

The notion of this strikes me as somewhat ridiculous. No one knows everything and no one is good (much less "great") at everything. And then there is the... "I can't help you if you don't want to help yourself" issue in this field. Right? If you find the psychiatry/life skills whisper, I'm sure you will let us all know.

The closest I can think of is a couple physician psychiatrists on here who I know who were trained in Europe and then in the US with additional residency or fellowships. And even then, their approach and opinions are sometimes quite controversial. I think there can certainly be master psychopharmacologists, master teachers/instructors, master psychotherapists, masters of the philosophy of science that underlie, etc. But lets be realistic, right? People have lives. Wife. Husband. Children. Friends. Passions. Hobbies. Laziness. All of these are more appealing to most of us than doing more "work." Which is actually called "work"....for a reason.

Also, "House" was a terrible Attending Physician.

 

[FlowRate]

A couple of faculty from my training come to mind.

One faculty person who had extreme knowledge of descriptive psychopathology/history of psychiatry+diagnosis and was our "complex diagnostics clinic" attending. So mastery of a specific body of knowledge.

Another doc who was just extremely good at really getting to the (psychodynamic) heart of a patient visit and had the most inspiring, gentle way with patients. I think a lot of the "masters" in this vein are low-ego, low-anxiety, high-mentalization/metacognition people. The best ones come off as the positive exemplar of "never turn off their psychiatry brain." (vs the negative version where people come off as aloof/weird/disconnected/arrogant/manipulative for the same reason) This would be more of a clinical/interpersonal/empathic/metacognitive mastery.

I've found it challenging to do much deliberate practice as an attending. Therapy supervision gave a particularly good reason to explicitly post-game review right after every therapy patient during training but things are busier and there's less opportunity to review with anyone now.

 

[Stagg737]

What does mastery look like in psychiatry?

Being able to successfully convince any DID patient that they do not have DID, taper them off of their high dose benzo with minimal complaint, and have them complete a DBT program and apply those skills in an insightful way. I can only imagine the Nirvana one would achieve from such a feat.

 

[Candidate2017]

There appears to be a cohort of psychiatrists who manage to blow through 30-40 patients a day for decades without a care, make AT LEAST several times the average psychiatrist income, and never into any legal trouble. Not that I would want to see 30-40 a day. But gosh darn, everything else seems to imply they've mastered the dark arts.

 

[painballer27]

There appears to be a cohort of psychiatrists who manage to blow through 30-40 patients a day for decades without a care, make AT LEAST several times the average psychiatrist income, and never into any legal trouble. Not that I would want to see 30-40 a day. But gosh darn, everything else seems to imply they've mastered the dark arts.

Is this more commonly seen on the inpatient or outpatient side? And why would they get into legal trouble? Are they breaking the law by being efficient?

 

[allantois]

Is this more commonly seen on the inpatient or outpatient side? And why would they get into legal trouble? Are they breaking the law by being efficient?

Def outpatient. Good psychiatry cannot be done in 5 mins. You are going to miss things such as mania, SI, etc.. The patients are definitely not getting good care in those circumstances

 

[Merovinge]

Def outpatient. Good psychiatry cannot be done in 5 mins. You are going to miss things such as mania, SI, etc.. The patients are definitely not getting good care in those circumstances

Particularly because part of the care that comes from seeing a psychiatrist (and let's be frank, any doctor) comes from the doctor-patient relationship. I had outpatients come back making minimal-to-no progress (mostly due to lack of ancillary services in the area) when I was doing OP CAP and they still found a lot of value/meaning from our 30 minutes q2-3 months. Efficacy at E&M and billing cannot replace this work. As it turns out, throwing random medications at learning disorders also does not improve them, although the other provider in town seemed to have made that the standard of practice in the area.

 

[Merovinge]

One faculty person who had extreme knowledge of descriptive psychopathology/history of psychiatry+diagnosis and was our "complex diagnostics clinic" attending. So mastery of a specific body of knowledge.

I trained with a neuropsychiatrist who had such a deep understanding of the brain both neurologically and psychiatrically. He was deeply respected by the neurology and neurosurgery teams that consulted him (for good reason) and it felt like if there was anything complex going in you wanted to just call him right away. I suspect Splik has or had a similar clinical practice. Hard to not be impressed with the mastery even if it's a far cry from my current day to day.

 

[Liquid8]

Being able to successfully convince any DID patient that they do not have DID, taper them off of their high dose benzo with minimal complaint, and have them complete a DBT program and apply those skills in an insightful way. I can only imagine the Nirvana one would achieve from such a feat.

Can remember seeing a new patient who told me she had read a bunch of books, listened to a heap of podcasts and read all the social media groups, and was sure she had all the criteria to diagnose herself with…

Spoiler

BPD. They wanted to do a DBT programme and I was in complete shock.

 

[FlowRate]

Can remember seeing a new patient who told me she had read a bunch of books, listened to a heap of podcasts and read all the social media groups, and was sure she had all the criteria to diagnose herself with…

Spoiler

BPD. They wanted to do a DBT programme and I was in complete shock.

I've had a number of patients like this. People sometimes forget that BPD patients are often particularly good detectors of when they're being BS'd/when things don't feel right. The description of BPD resonates deeply with these patients in a way all of the lazy "bipolar" diagnoses never did.

 

[whopper]

Too hard to say in a simple manner because it's not like there's just one thing. There's plenty of things.

Paradigms for treating inpatient vs outpatient are very different. Medicare vs private insurance vs private pay. Urban vs rural.

While doing forensic inpatient almost every patient had severe psychosis and or Bipolar Disorder. I hardly see that in private practice.

I can mention that there's plenty of idiot things I see bad psychiatrists do so I guess a start could be not make their stupid mistakes. E.g. only prescribe 1 antidepressant, or 1 antipsychotic, and based on the color of the packaging. I'm serious.

Almost all good psychiatrists I've seen read CATIE, STAR*D and STEP-BD.

Also: keep up with journals, latest developments, not diagnose patients with all the same thing, actually get to know their patient instead of a 5 minute visit.

One thing I've seen even good psychiatrists not do is keep a master list of all meds tried and what each med did at specific dosages and durations. I recommend all psychiatrists do this.

 

[mistafab]

One thing I've seen even good psychiatrists not do is keep a master list of all meds tried and what each med did at specific dosages and durations. I recommend all psychiatrists do this.

Care to elaborate?

 

[calvnandhobbs68]

Care to elaborate?

Like keep a running list of all prior med trials in a separate section of the progress note or a separate note for patients. I'm not that great at this myself, I just tend to try to update this in the "prior meds" section of prior psych history I pull forward to every note.

 

[AD04]

Interesting answers. Some were quite outstanding.

I'll give my 2 cents regarding the questions:

How do you engage in deliberate practice in psychiatry?

I like what @Liquid8 said about not screening referrals. This way, you will get the tough cases (severe mental illnesses or severe personality defects). This will strengthen your psychiatric knowledge and social skills (what @Ludwig2000 and @FlowRate said about making people feel good). Another thing to do is to work at various places (even various states) to get a wide exposure to different patients and different settings, which may require different approaches to treatment as @whopper said. And when you get stumped about a case, refer to textbook and articles and experts if available. And if something goes wrong, think about what could have been done to prevent mishaps from happening again. (This also applies to reinforcing boundaries with patients.)

What does mastery look like in psychiatry?

Someone who can attend to any case in any setting. The psychiatrist can get results that are better than average:
- increased productivity (proxy for amount of deliberate practice and obsessiveness to the craft)
- increased show-rate (proxy for skills of establishing therapeutic alliance)
- decreased controlled medication prescriptions (proxy for pharmacology skills)
- decreased re-hospitalization rates < 31 days (proxy for inpatient psychiatric skills)

Sometimes, the outcome will be poor but patient and family understand why the outcome will be poor and accept it without faulting the psychiatrist. The psychiatrist can also give hope in the midst of poor outcomes and let them know of what further steps can be taken to improve the situation. And when patient or family is inappropriate, the psychiatrist can establish boundaries to prevent those behaviors in the future.

From those you've observed or worked with, who are the closest to masters in psychiatry? What set their work apart from the average psychiatrist?

My partner. He's has technical expertise. He is very good at establish rapport with patients and their families. He is has a quick mind and can think of solutions to complex situations. He has excellent documentation to meet standard of care, billing criteria, and defense if reviewed under legal scrutiny. And he is prolific -- even more than me. He meets all of the metrics above.

For the psychiatrists and non-psychiatrists that treat through therapy, what does mastery look like in therapy?

I'm not sure what mastery in therapy look like so I am very curious if anyone else has input about it. I use the extra time mainly to build rapport so they will adhere to the treatment plan, which mainly consists of psychotropics. Providing insight and modifying thoughts and creating new habits are done but are secondary objectives to the therapeutic alliance.

 

[AD04]

One thing I've seen even good psychiatrists not do is keep a master list of all meds tried and what each med did at specific dosages and durations. I recommend all psychiatrists do this.

I highly agree with this. I do this for all my patients.

 

[allantois]

Too hard to say in a simple manner because it's not like there's just one thing. There's plenty of things.

Paradigms for treating inpatient vs outpatient are very different. Medicare vs private insurance vs private pay. Urban vs rural.

While doing forensic inpatient almost every patient had severe psychosis and or Bipolar Disorder. I hardly see that in private practice.

I can mention that there's plenty of idiot things I see bad psychiatrists do so I guess a start could be not make their stupid mistakes. E.g. only prescribe 1 antidepressant, or 1 antipsychotic, and based on the color of the packaging. I'm serious.

Almost all good psychiatrists I've seen read CATIE, STAR*D and STEP-BD.

Also: keep up with journals, latest developments, not diagnose patients with all the same thing, actually get to know their patient instead of a 5 minute visit.

One thing I've seen even good psychiatrists not do is keep a master list of all meds tried and what each med did at specific dosages and durations. I recommend all psychiatrists do this.

Crazy to think that this sounds like bare minimum one should do