Yet another ask a resident thread - psychiatry edition

[Jalby]

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No, I still think your recurrent bumping of that thread is ridiculous, and I'm convinced you're just a slow-play troll. But you say some funny stuff sometimes, so I have to give you props on that.

It's been 2 and a half years since I last bumped it up. I'm trying to cut back. And troll implies I am saying something I don't believe. I believe everything I post.

 

[Dr. In Formation]

Do you refer patients to other health care professionals like endocrinologists, dieticians, nutritionists or medical social workers prior to medication management?

Do you use cognitive behavioral therapy or other psychological therapy techniques?

Do you believe there is a certain "type" drawn to choose psychiatry as opposed to the other specialties?

 

[Pusheen]

Sorry if this is a controversial question, but do you think inpatient psych wards deserve the negative reputation they sometimes have? I have come across stories/experiences of people who claim to have been treated badly/unnecessarily harshly in these facilities..how much of it is legitimate?

 

[NickNaylor]

Last question. Tips for dealing with angry patients and family members?

This can be tough.

I think there are two important things. First, you are The Expert - whether you feel that way or not. As a physician, you command a certain sense of authority with lay people. You must be comfortable in that role and use it to your advantage. Families may disagree with your assessment, plan, whatever, but ultimately you are the one that is most trained to come up with these things. Trying to explain your rationale and the reasons for your decision will assuage the majority of people. Sometimes people get upset because they don't understand why certain decisions are being made. Taking a few minutes to sit with your patient and/or their family and explain what is happening can be immensely helpful. Yes, it takes time, but that time is an investment that can help build your alliance with your patient and pay dividends down the road.

Second, you need to be aware of your own emotions and try and control them. It can be very easy to escalate things when you're interacting with angry patients, families, or other medical staff. You absolutely must avoid doing that. One thing I've found that has helped me on this point is to realize that people do not get angry for no reason. Some people just do not have sophisticated ways of dealing with their emotion. For example, a family may be upset that they feel like their family members needs aren't being attended to and take it out on you. A patient may feel like they aren't being listened to and act out by refusing treatment, refusing to cooperate with the medical team, and generally being a pain in the ass. The point is that there is always a cause for the behavior. People do not get randomly angry for no good reason. Trying to understand where that anger comes from - and accepting that they are angry at something - can help you approach a patient compassionately and humanely even though they may not be doing the same to you. They may not be forthcoming with what is making them upset. Hell, they may not even recognize that something is making them upset or that they are even upset. It is your job to understand that and try and figure out what is making them angry and addressing it as compassionately as you possibly can.

There's an old article titled Taking Care of the Hateful Patient by Groves JE (NEJM 1978 298(16): 883-7) that, as the title implies, discusses taking care of the hateful patient. It's old but still relevant. Perhaps look that over for some extra insight on this issue. It's pretty short and an easy read.

 

[NickNaylor]

Do you refer patients to other health care professionals like endocrinologists, dieticians, nutritionists or medical social workers prior to medication management?

Do you use cognitive behavioral therapy or other psychological therapy techniques?

Do you believe there is a certain "type" drawn to choose psychiatry as opposed to the other specialties?

1) Yes, at least on the inpatient units an interdisciplinary approach is critical. On all of the units that we work at, every patient on admission gets:
- PT, OT, and KT consults
- an H&P done by a hospitalist to evaluate for physical complaints and for recommendations regarding physical medicine management
- consults as needed to address more complex medical issues
- nutrition/dietary consults

As for the question of doing this before medication management, they are usually done in tandem. The one exception to this is if we feel that a psychiatric complaint is due to a primary medical problem (in which case they likely shouldn't be on a psychiatric unit to begin with). In those cases, we will generally attempt to address any underlying medical issues and using psychotropic medications only if absolutely needed.

2) I do not personally use them as I do not have any training in them. Well, that's not true - there are components of these therapy techniques that we routinely use all the time. Supportive psychotherapy is something that manifests in one way or another in almost every patient encounter (and, in fact, most physicians do supportive psychotherapy as well, whether they realize it or not). In my program (and all psychiatry programs), we are also required to see certain numbers of patients for certain psychotherapeutic modalities only as a therapist (i.e., without medication management). For example, I just had my first session with a patient that I will be seeing for long-term psychodynamic psychotherapy. So yes, we get training in psychotherapy during residency. It is not nearly sufficient enough to go out on your own as a psychotherapist, and anyone interested in doing therapy for a significant amount of their practice will get additional training - either in therapy-focused electives or in training programs outside of residency. However, by the end of the residency it is expected, at least in my program, that you will be competent in at least three basic psychotherapeutic modalities: CBT, supportive psychotherapy, and psychodynamic psychotherapy. In my program, there are plenty of opportunities to also get training in other modalities as well (e.g., group psychotherapy, marriage psychotherapy, DBT, etc.).

3) To a certain extent, sure. Psychiatric patients are so different compared to most medical patients that I think a willingness to work with them does require a certain personality structure and approach to work that is different than the other fields. But really, being a competent psychiatrist is no different than being another type of physician: you must be compassionate, be capable of really listening to what your patient is telling you, and be thoughtful in coming up with your assessment and plan. We just do that in different ways - through interviews, observation in behaviors, and psychotherapeutic techniques - compared to other specialties (e.g., objective investigations of physiological function, physical exam, and direct interventions to correct physiological abnormalities).

 

[NickNaylor]

Sorry if this is a controversial question, but do you think inpatient psych wards deserve the negative reputation they sometimes have? I have come across stories/experiences of people who claim to have been treated badly/unnecessarily harshly in these facilities..how much of it is legitimate?

I cannot comment on what happens at inpatient units generally since I don't have the experience necessary to make such a judgment. I can say that at the units I work at our patients are treated very well (they may disagree, but that's often because they aren't interested in psychiatric treatment, are admitted involuntarily, etc.). I have never witnessed or seen "unnecessarily" harsh treatment at any of the units that we work at. Physical holds (i.e., touching a patient for any reason with the intent to restrict their behavior), the use of seclusion/restraints (which is extremely rare - I have only seen these used a couple of times during my time on inpatient units), and involuntary administration of medications are Big Deals and are used only when absolutely necessary. Examples in which those interventions might be used include when a patient is an imminent danger to themselves (e.g., harming themselves while on the unit - things I have witnessed include a patient banging their head on the wall, slamming their hands on tables [such that they have gotten wrist fractures], etc.), an imminent danger to others (e.g., attempting to assault staff, attempting to assault other patients, etc.), and unable to be "redirected" (essentially, being talked to to try and deescalate their behavior without the use of restrictive interventions).

More generally, I do think there is something to this idea of inpatient psychiatric treatment being traumatic. Think about it: you're experiencing a first-break psychosis, you don't think your treatment team has your best interests at heart, you think that the medications that are being offered to you are poison, and you're forced to stay their involuntarily by court order. How would that make you feel? Ideally, treatment - voluntarily or not - would improve insight such that the patient would be able to reflect back on these experiences and realize that they were acutely ill, but nonetheless I imagine some of these sentiments remain with them, even if they do start to feel better. I do think there is something to the idea that inpatient psychiatric admission - particularly under involuntary conditions - may result in an increased risk of non-compliance with psychiatric treatment down the road (why would I want to be honest about my complaints if I thought I might have to return there? For that matter - why would I even want to go back to see a psychiatrist if there is a possibility of me being admitted again to an inpatient unit against my will?). As far as I know no one as really looked at this issue, but it's something I would like to look into at some point.

In short: I have never seen or heard of anyone being abused (let's call it what it is) at any of the units I work at. I have heard about it at other psychiatric hospitals in the local area. One hospital in my city is currently being sued by a group of patients that are alleging abuse during their stays on their inpatient unit. The seriously mentally ill population is a vulnerable group for whom I think there's a higher-than-baseline risk of abuse. Oftentimes, this population is poor (due to having poor functioning due to their mental illness), has limited or no social support (so no one to tell about perceived abuse), and remain stigmatized such that their complaints may not be taken seriously. So, would I be surprised if these things happen? Unfortunately, no - and that is a huge tragedy and something that must be corrected. But again, that is not something that I have seen first-hand.

 

[hubbsbubbs]

What qualities and characteristics do a successful psychiatrist have? Similarly, what qualities do unsuccessful psychiatrists have?

I've been aiming for psychiatry, but have recently been worried that I might not do well in the field.

Also, do many psychiatrists start their own practice/clinic?

 

[NickNaylor]

What qualities and characteristics do a successful psychiatrist have? Similarly, what qualities do unsuccessful psychiatrists have?

I've been aiming for psychiatry, but have recently been worried that I might not do well in the field.

Also, do many psychiatrists start their own practice/clinic?

I addressed this in a couple of places above, but I think the most critical things are 1) being able to listen to patients (and take the time to listen well without getting frustrated if there is "wasted time" during the course of an interview), 2) being compassionate, and 3) being willing to work with the population of psychiatric patients. That last point is a bit of a euphemism for a variety of behaviors that can make acutely ill psychiatric patients difficult to work with. This can include being verbally assaulted, physically assaulted, working with, at times, threatening patients, working with patients that have absolutely no interest in seeing you or receiving psychiatric treatment (yet are there by third-party order, namely, law enforcement and/or the judicial system), and working with patients that fail to improve over the long-term because they lack the insight necessary to understand that they need medications, should go to substance treatment, etc. etc..

The mind is a tricky thing. In general, most medical patients are interested in getting some kind of treatment. At the end of the day, most people don't want to die, and while they may not be the most compliant with outpatient regimens, they are generally not going to actively oppose your attempts to help them if they are acutely ill. There are exceptions, of course, but in general I think that's more or less true. Psychiatric patients are different, and many times the situation is the exact opposite (generally unwilling to accept help when acutely ill but perhaps more likely to understand the importance of treatment when they are not acutely ill): many of our patients don't understand that anything is wrong, don't understand that their behavior is abnormal, and lack the ability to understand that we are actually trying to help them. This can oftentimes make the interaction between patient and psychiatrist adversarial, particularly in the inpatient setting. You must be able and willing to work in those circumstances. I will admit that it can wear on you after a while. In spite of that difficulty, you must continue to show genuine compassion and continue to do everything that you can to help the person in front of you in spite of the abuse, threats, and unwillingness to get involved with treatment. Doing so requires a great deal of patience. Improvement in psychiatric patients is measured in millimeters, and in general people do not improve dramatically over the short-term. Thus, you must also be willing to "stick with" cases for a while (in contrast to, say, surgery, where treatment is generally limited to operating, immediate post-op care, and relatively brief, continued outpatient follow-up). Not everyone is interested in that kind of relationship with patients, but again this is something that interested me, thus I like it.

With respect to outpatient practice, I'm not sure what the statistics are but I would say that it is not uncommon for many psychiatrists to start a solo practice. The most common career path seems to be complete residency -> do inpatient work for a few years -> start your own practice. Again, there are obviously exceptions, but I would say that is the most common "track" that is followed by many psychiatrists. In general, it is fairly easy to start a psychiatric practice compared to other specialties, and I think psychiatry is one of the few remaining fields by which it is possible to start - and be successful running - a solo private practice. That possibility is one of the reasons that I got into psychiatry as I'm drawn to the entrepreneur aspect of starting and running a practice.