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When I think of residency, I'm reminded of this;
Luke: There's something not right here... I feel cold. Death.
Yoda: [points to a cave opening beneath a large tree] That place... is strong with the dark side of the Force. A domain of evil it is. In you must go.
Luke: What's in there?
Yoda: Only what you take with you.
I disagree. There is enough medicine to know and understand when doing psychiatry.Reminds me of the months of Internal Medicine during my prelim year. Ironically enough, Psychiatry also has to do some months of Internal Medicine as well, which I believe to be utterly useless for that specialty.
Disagree. Good general medicine knowledge/experience is what separates the good psychiatrists from the dangerous ones…Ironically enough, Psychiatry also has to do some months of Internal Medicine as well, which I believe to be utterly useless for that specialty.
I disagree. There is enough medicine to know and understand when doing psychiatry.
Gone are the days where we have people laying on couches asking, "Und, tell me ov your mother, ja?"
You need to be at least somewhat competent at medicine to be a good psychiatrist in this day and age, unless you somehow decide that prescribing lithium, antipsychotics, Depakote, et al. are not important in this field.
I disagree. There is enough medicine to know and understand when doing psychiatry.
Gone are the days where we have people laying on couches asking, "Und, tell me ov your mother, ja?"
You need to be at least somewhat competent at medicine to be a good psychiatrist in this day and age, unless you somehow decide that prescribing lithium, antipsychotics, Depakote, et al. are not important in this field.
I had a patient recently who had a history of psychosis and ended up getting admitted to psych because of a decompensation of the psychosis. She also had a lot of other problems that made it hard for her to communicate her symptoms - I won't go into detail due to risk of revealing her identity. The ED did everything correctly and she ended up getting admitted to psych. She subsequently spiked a fever, and on further workup, she turned out to have severe bacterial meningitis. Her nuchal rigidity was very mild, and even the neurologists weren't able to pick it up conclusively. Head CT was normal. Luckily, the psych resident on call was clever enough to do a thorough medical workup and start appropriate antibiotic therapy while we were waiting for the results of the workup. If it hadn't been for our IM/neuro training, she probably would have died.
I had a patient recently who had a history of psychosis and ended up getting admitted to psych because of a decompensation of the psychosis. She also had a lot of other problems that made it hard for her to communicate her symptoms - I won't go into detail due to risk of revealing her identity. The ED did everything correctly and she ended up getting admitted to psych. She subsequently spiked a fever, and on further workup, she turned out to have severe bacterial meningitis. Her nuchal rigidity was very mild, and even the neurologists weren't able to pick it up conclusively. Head CT was normal. Luckily, the psych resident on call was clever enough to do a thorough medical workup and start appropriate antibiotic therapy while we were waiting for the results of the workup. If it hadn't been for our IM/neuro training, she probably would have died.
I'm hoping she did that with the assistance of the medicine and neurology services. While we might have a really strong background in IM and neurology, we don't have the same expertise as infectious disease and neurology services in dealing with something like meningitis.
I'm hoping she did that with the assistance of the medicine and neurology services. While we might have a really strong background in IM and neurology, we don't have the same expertise as infectious disease and neurology services in dealing with something like meningitis. Based on that, you owe it to your patient to consult those other services for a critically ill patient.
Not to say your fellow intern isn't great and didn't do an appropriate job, and if she had less training, she might not have known to be concerned and ask for help. However, I get worried about providers being cowboys.
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Also, for psych interns and residents who are used to doing things like tinkering with someones bp meds or metform dose on inpatient psych, community/pp inpatient world is a completely different animal. You're not expected to manage htn, dm, hld, etc..at ANY level.......if it's completely stable you would just resume their meds in a training program perhaps, but in most community psych units you wouldn't. You will almost certainly have a hospitalist group who consults on these patients to increase revenue. You wouldn't be allowed to say "well due to my excellent pgy1 medicine training I feel good about restarting this pt's metform at the current dose, so no assistance is needed"....
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Yes, of course he consulted neuro. But it wasn't an obvious consult... the patient wasn't able to communicate her symptoms, so he had to have a pretty good understanding of bacterial meningitis in order to suspect it. She didn't have neck stiffness or leukocytosis and wasn't able to communicate her headache. And she really didn't look that sick. But he thought that she might have some meningismus on physical exam, she had some risk factors, and she was spiking a fever. You don't consult neuro every time a patient spikes a fever, and most psychiatrists don't check for meningismus when admitting a patient, even if they do have a fever. Even the neuro team had a low suspicion for meningitis until the LP results came back. It wasn't a classic textbook picture of "fever, headache, neck stiffness."
Anyway, the whole story is complicated, and this is mostly a digression. The point is that the medical training is useful. We can spend forever debating the extent of its utility.
Spiking a fever for unexplained reasons sounds like a good time to consult the medicine service. Good for your colleague, though, for suspecting the right diagnosis and consulting neuro as well.
Anyway, about medical training -- we don't refresh those skills with ongoing training in IM and neurology, so they get dated and atrophied regardless of how much we try to keep up. The medicine folks and the neurology are almost always going to be able to do it better than us, so I think having a low barrier to consult honestly makes sense, especially with an acutely ill patient. I agree that we should be comfortable with things like treating hypertension and basic diabetes management. We also need to be able to know when to consult -- perhaps that's the real benefit of those IM and neuro months.
When's the last time you checked a patient for meningismus? The point is to be able to detect the meningeal signs. I don't think even a medicine consult would have picked that up... it was neurologist-level stuff. Also, a medicine doc probably wouldn't have realized that the patient's AMS was atypical for a chronic psychosis. That's why the patient ended up getting admitted to psychiatry instead of neurology.
But again, this is a digression. There have been a thousand debates about the necessity of medical training in psych. Personally, I think that I use it a fair bit. The most recent example (yesterday) was when I had a patient admitted who had a BP of 120/90 and was on a large antihypertensive regimen and we suspected noncompliance, and he was too demented to clarify things on his own... if I didn't know about hydralazine dosing, I could have started him on his home meds and he would have gotten dangerously hypotensive. But I'd used enough hydralazine on the medicine service to know that a person if a person has a BP of 120 despite not getting his hydral for several hours in the ED, he clearly doesn't need the amount of hydral that he was taking. It seems silly to call a medicine consult to ask whether to start a patient on his home meds, and if I hadn't done a medicine rotation, I probably would have just started home meds with the assumption that his dosing was appropriate. I run into similar situations with insulin all the time... i.e. the thought that "this patient is on a LOT of insulin, and I don't have any particular reason to suspect noncompliance, but I just find it hard to believe that they need this much... I'm guessing that the NP at their outpatient free clinic is just uptitrating the insulin because of a high A1c, and it's not working because the A1c is still high, so the insulin gets uptitrated again (which happens ALL THE TIME, especially in patients whose psych illness limits their ability to provide a reliable history to their outpatient IM doc). I'd better put them on a sliding scale and recalculate their actual insulin requirement from scratch, and then I'll call a diabetes consult in the morning just to be safe." I learned that on my intern year IM rotation, not in med school.
Many of those situations could be replaced by calling a medical consult on any patient with chronic medical illnesses, but I think that'd be an unnecessary burden on the medical service.
When's the last time you checked a patient for meningismus? The point is to be able to detect the meningeal signs. I don't think even a medicine consult would have picked that up... it was neurologist-level stuff. Also, a medicine doc probably wouldn't have realized that the patient's AMS was atypical for a chronic psychosis. That's why the patient ended up getting admitted to psychiatry instead of neurology.
But again, this is a digression. There have been a thousand debates about the necessity of medical training in psych. Personally, I think that I use it a fair bit. The most recent example (yesterday) was when I had a patient admitted who had a BP of 120/90 and was on a large antihypertensive regimen and we suspected noncompliance, and he was too demented to clarify things on his own... if I didn't know about hydralazine dosing, I could have started him on his home meds and he would have gotten dangerously hypotensive. But I'd used enough hydralazine on the medicine service to know that a person if a person has a BP of 120 despite not getting his hydral for several hours in the ED, he clearly doesn't need the amount of hydral that he was taking. It seems silly to call a medicine consult to ask whether to start a patient on his home meds, and if I hadn't done a medicine rotation, I probably would have just started home meds with the assumption that his dosing was appropriate. I run into similar situations with insulin all the time... i.e. the thought that "this patient is on a LOT of insulin, and I don't have any particular reason to suspect noncompliance, but I just find it hard to believe that they need this much... I'm guessing that the NP at their outpatient free clinic is just uptitrating the insulin because of a high A1c, and it's not working because the A1c is still high, so the insulin gets uptitrated again (which happens ALL THE TIME, especially in patients whose psych illness limits their ability to provide a reliable history to their outpatient IM doc). I'd better put them on a sliding scale and recalculate their actual insulin requirement from scratch, and then I'll call a diabetes consult in the morning just to be safe." I learned that on my intern year IM rotation, not in med school.
Many of those situations could be replaced by calling a medical consult on any patient with chronic medical illnesses, but I think that'd be an unnecessary burden on the medical service. It makes more sense for the psychiatrist to have that basic level of training, especially since patients with serious psychiatric illnesses often have such poor management of their general medical problems. I'll call a medicine consult if first-line management isn't working. Akin to a PCP starting 20mg of celexa for depression, and referring to a psychiatrist if that doesn't work.
There are two different things going on here. Should psychiatrist know basic medicine? Sure. Will they use basic medicine skills? Sure..