Psychiatry (much more straightforward than internal medicine)- It's a lot easier to be a mediocre psychiatrist than a mediocre internist
I am not entirely sure this is true. Even if it is, I’m not sure why your benchmark for this question would be how difficult it is to practice a given specialty poorly. That probably has far more to do with other factors than the inherent difficulty.
It’s also a lot easier to practice crappy psychiatry and get away with it, just because the evidence base is much more open to interpretation in a lot of areas, around both diagnosis and treatment.
It is indeed very possible to be a terrible psychiatrist, but I don’t think this is the reason. It probably has more to do with the fact that the severely mentally ill are highly vulnerable. These patients often have functional, cognitive or financial limitations that make it difficult to consult with an attorney and bring a substantive malpractice suit.
Agree. Psych and Neurology were big offenders where I did my residency. It was extremely frustrating.
always odd to me that people **** on ortho when psychiatry is rejecting admissions for a glucose of 135 or sodium 134. Psych are way way bigger offenders of "i dont know anything, just admit to IM".
This is also a dumb benchmark. The medical complexity a psychiatric unit is willing to accept is highly variable and institution (or unit) dependent.
Where I trained, plenty of patients on our units were getting IV medications including antibiotics, had various drains, had multiple chronic conditions, etc. We would insert NG tubes, remove sutures, etc. Most of our eating disorder patients were in active refeeding syndrome. This is not the case everywhere but it has very little to do with the doctors. Some psych units are part of free-standing psychiatric hospitals with minimal or no in-house med/surg services. Obviously the ceiling of acceptable medical complexity for these units is going to be low.
Even on a psychiatric unit that is part of a med/surg hospital, many things can get in the way of us taking patients. To begin with, there may be institutional policies that could prevent us from taking certain patients. Beyond that, depending on the unit/institution, the psych nurses may not be experienced in certain types of care. Examples of this might be wound care, managing pumps or administration of certain types of medications, or maintenance of certain types of medical equipment. Even if the nurses are comfortable, the staffing and resources are usually different on a psych floor than a med-surg floor. It might not be a problem for a medical floor nurse to draw q6 labs, but this creates staffing problems on a psych floor when there are limited nurses and several of them might be unavailable for patient care because they’re acting as 1:1s for patients at high risk of suicide or violence. At some places, phlebotomy may be less predictable than at other places in the hospital because there may only be a couple of phlebotomists for all of the psych floors. This can be a problem if your patient really requires morning labs that will result that morning.
The physician staffing after-hours can also be different. Where I trained, one psychiatry house officer would be responsible for up to 80 beds, including any admissions to the units. And even so, as I said, we probably accepted some of the most medically complex patients of anywhere in the country. But you can imagine what it’s like being responsible for that many patients on call, all while trying to admit and respond to behavioral codes. A couple of patients going into hypertensive urgency or DKA or whatever really messes up our ability to do our job, including by admitting patients from the ED and clearing room for medical patients.
Furthermore, whether a patient is appropriate for psychiatry often has to do with their motivation and history during prior inpatient admissions. If someone with a severe mood disorder had a serious suicide attempt, in most situations, most psychiatrists will agree that person will need an admission once medically stable, or at least ongoing psychiatric consultation to recommend treatment during their medical hospitalization. But not every case is as clear cut. Someone is an alcoholic and often tries to kill themselves when they’re drunk, but has no suicidal intent when sober and does not want to engage in substance abuse treatment? That person might be unlikely to benefit from an inpatient psychiatric admission and the fact that they’re homeless and your social worker is having difficulty finding a place for them to go does not modify their appropriateness for a psych admission. We see this stuff all the time and it often comes out of a fundamental misunderstanding of what we do and what the role for a psychiatric admission is. It is not psychiatry’s job to assume custodial care of homeless or chronically mentally ill people and try to manage their social barriers to discharge. That is a social work problem. The job of inpatient psychiatry is to treat people with an acute presentation of psychiatric illness for whom treatment is likely to result in transition to a lower level of care.
There is also the milieu to consider. It might be fine to place a patient in a room on a medical floor, but if you take that same patient and put them on a psychiatric floor it might pose an unacceptable level of risk. Some frail elderly woman who is a fall risk may not be appropriate for a unit with several severely psychotic individuals that is having regular seclusion events.
I’ll also just add that everybody has a degree of discomfort with stuff they don’t handle regularly. We get more than our share of consults along the lines of “placing psych consult because patient has a history of schizophrenia” or similarly ridiculous requests. I could list them all and drag every other specialty through the mud but, ultimately, everybody is just trying to do their best for patients and I’m generally happy to help if I can figure out what it is that people actually need help with.
Suffice it to say: even if psych does not admit your patient, it’s likely that they’ve put a lot of thought into why they are or are not appropriate for admission. Maybe you should ask them to explain it next time and actually listen to what they’re saying. It’s unlikely that the psychiatrists are just refusing to take patients they could otherwise help without a good reason.
