Yet another thread about stigmatization of Psychiatry...

[LEdaddy]

Read this and thought I'd share it with you all:

http://www.medscape.com/viewarticle/739615

The moment I saw the title "Forsaken Specialty" I knew exactly what it was going to be about. I have recently experienced a lot of Psychiatry-bashing on my current Peds rotation, so this article struck a chord.

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[toothless rufus]

Read this and thought I'd share it with you all:

http://www.medscape.com/viewarticle/739615

The moment I saw the title "Forsaken Specialty" I knew exactly what it was going to be about. I have recently experienced a lot of Psychiatry-bashing on my current Peds rotation, so this article struck a chord.

Nice article.

 

[notdeadyet]

I have recently experienced a lot of Psychiatry-bashing on my current Peds rotation, so this article struck a chord.

I think that you might find that "Psychiatry-bashing" is pretty institution dependent. I think you see a lot less of it at schools with strong psychiatry departments. You still get a lot of docs who shudder at the thought of treating mental illness, but you don't hear as much bashing of the profession as a whole if the Psych department is one of the bigger guns.

And it's not unique to Psychiatry. You get a lot of Emergency Medicine and Family Practice bashing at different places too when the programs aren't as prevalent.

 

[LEdaddy]

True. I've heard a lot of ED-bashing on the wards (even sometimes from psychiatrists...).

 

[whopper]

Most places I've seen hate ERs because it's the ER calling up the other units to admit patients.

Does that make ER bashing legit? Of course not. Patients, of course, have to be admitted.

Other doctors focus so much on the physical and the labs, so something involving other disciplines such as behaviorism is foreign to them. Add the narcissim and egocentricism with the hypereducated, and that IMHO explains this phenomenon.

In other countries, where they cannot afford labs out the wazoo, behaviorism is much more emphasized. I did, for example, some work in the UK, and while doing a physical examination, a doctor remarked that I neglected to mention the full plate of food next to the patient, and that the fan was on even thought it was not a hot day and remarked that he immediately suspected hyperthyroidism. That is something outside the paradigm of so many American doctors.

 

[Ibid]

Other doctors focus so much on the physical and the labs, so something involving other disciplines such as behaviorism is foreign to them. Add the narcissim and egocentricism with the hypereducated, and that IMHO explains this phenomenon.

In other countries, where they cannot afford labs out the wazoo, behaviorism is much more emphasized. I did, for example, some work in the UK, and while doing a physical examination, a doctor remarked that I neglected to mention the full plate of food next to the patient, and that the fan was on even thought it was not a hot day and remarked that he immediately suspected hyperthyroidism. That is something outside the paradigm of so many American doctors.

I feel that is a brilliant point.

Just to flesh that out from a UK perspective it’s not just about affordability. The US is plagued with defensive practice so ordering tests that range from barely to only slightly indicated is much more common, even in the worst case irrelevant but whose counting when an insurance company is paying? Obviously it’s understandable in a context where being sued is much more of a live possibility. In the UK if a doctor orders up the same battery of tests they are likely to be thought of as rather lacking in basic skill rather than someone covering all the bases.


I have some papers on another drive that show 56% of diagnoses are made after history alone in general medical clinics, rising to 73% after physical examination in the UK. (not recent, research into history taking seems to be out of favour)

 

[whopper]

Physical exams, from "real" doctors in the UK was on the order of Sherlock Holmes doing his thing, while in America, I've noticed even good doctors doing what would be considered substandard physical examinations compared to a good doctor in the UK.

I emphasize "real" and "good" because as we all know, there are terrible doctors out there. When you are forced into a position where you cannot order a lab...you have to use your other options to a greater degree of mastery.

The guy it turned out, did have hyperthyroidism. Most American doctors, from my experience, wouldn't have even ordered a TSH based on the physical examination alone if they were in that same situation with the guy because hyperthyroidism symptoms was not his chief complaint, and he didn't bring up any complaints about it unless asked. He was in the hospital due to a physical injury.

In America, his hyperthyroidism I figure would've been caught, but only because a TSH is a standard lab everyone orders here. I don't recall if it is a standard lab ordered there, but I do recall the diagnosis was spotted due to superb clinical examination.

 

[Ibid]

I don't recall if it is a standard lab ordered there,

Essentially the answer to that is no. The expectation is that in A&E for instance a junior doctor would think about what was required, not least avoiding the circumstance of getting back a batch of borderline results for irrelevant tests that divert attention. There "should" not even be a notion of routine or standard labs.

Pushing the envelope of my personal knowledge here.

Edit: A long way off topic but the flip sid of this is that the UK will never have the cancer survival rates that the US achieves because the US culture of testing for everything leads to a small but significant and very expensive it must be said early detection of some cancers. Early detection being crucial. The UK government is always saying the UK will match the the US but its not going to happen. The government is trying population based screening and finding out what everyone else already knows. You spend a lot of money and only detect a few cases.

 

[whopper]

True, but IMHO the best doctor masters the physical exam and appropriate use of labs.

Bringing this into the psychiatric, If I ever notice a patient's mental status getting worse after administration of Valproic acid, I order a serum ammonia test. It's not standard to order one when a patient is on that medication, but about 50% of the time I've ordered them based off of the above criteria, turned out the patient had hyperammonemia.

Anyways, just to add a little more data to the story making it more impressive, while I was in the UK and the above story happened, the doctor acting my instructor knew nothing about the patients. While I was a medstudent, we went through each patient in the unit one by one, and he had me do a physical examination and present it, and he did one on another. I felt this was very fair given that so many attendings demand so much from students and residents but don't show how they'd do in the hotseat themselves.

The guy's skills IMHO were far better than even some of the best clinicians I've seen in the states. They have to do more with less, and it really does sharpen their clinical skills. Yes, of course, I'd rather have more labs available, but IMHO this was like swinging the bat with the weight attached, then swinging it for real without the weight. It was nice to have that type of exposure. To see it happen to that degree of skill makes people, IMHO, more likely to be able to obtain that skill themselves.

 

[Mattchiavelli]

In other countries, where they cannot afford labs out the wazoo, behaviorism is much more emphasized. I did, for example, some work in the UK, and while doing a physical examination, a doctor remarked that I neglected to mention the full plate of food next to the patient, and that the fan was on even thought it was not a hot day and remarked that he immediately suspected hyperthyroidism. That is something outside the paradigm of so many American doctors.

I hope one day I can be that good. It's just a different culture here... the litigation boogeyman motivates too much of our practice here. Even with published data about not needing to order certain tests/images they still get ordered. I think too many in the US view medicine as a science which equates to tests when it's really an art with scientific media which equates to clinical acumen [a subset which is knowing when to order/not order stuff].

 

[CTR]

I have recently experienced a lot of Psychiatry-bashing on my current Peds rotation, so this article struck a chord.

I actually find it surprising you'd be getting that much flack on a peds rotation. I seem to have had the opposite experience in that the pediatricians I have rotated with all seem to say the same thing when they learn of my interest in psychiatry: "You'll definitely be busy." One of them even commented that these days pediatricians are becoming more like mental health care providers, with all the anxiety, depression, and ADD they treat on a daily basis. Similarly, I have also received positive comments from other primary care providers, including internists and family physicians. Surgeons and anesthesiologists, however, are a different story, but this makes sense considering their jobs don't really involve as much talking with their patients.

 

[CTR]

True. I've heard a lot of ED-bashing on the wards (even sometimes from psychiatrists...).

LOL, I have seen this too. One of the psychiatrists I rotated with would often say that his job was mainly to treat the doctors who consulted him.

 

[whopper]

The comment about the pediatricians is ironic because, at least where I'm working, I feel too many pediatricians (even psychiatrists at times) diagnose ADHD without doing some type of formal diagnostic method.

No Conners, no DSM, no systematic way of diagnosis, just mentions of the kid being unruly. Then often-times, no EKG, no start of a non-stimulant medication first etc.

I'm having quite a few patients that I'm taking off of ADHD medications and they feel just fine without them.

The profession bashing thing IMHO is idiotic. If someone wants to bash a bad psychiatrist, that I have no problem with. There are bad doctors in every field. The only thing I can possibly say in defense of some of what I'm hearing is perhaps there are so many bad psychiatrists in that one particular area that other doctors are frustrated with that situation, and now think it is the standard for the whole profession. That's a leap because I've seen this type of bashing everywhere and with almost every field--just depends on which specific branch you're in. The IM docs bashed the surgeons because they never got their post surgery meds ordered right and the IM doc had to fix it, everyone bashed the ER doctors because they hated admissions, the infectious disease doctors bashed all the doctors that freely gave out antibiotics without the usual restrictions, etc.

Psychiatry just happens to get it more because of what I mentioned: lack of behaviorism in American medicine, egocentric paradigms, narcissism, most doctors being too right-brained and all about labs and little else, ignorance etc.

 

[JabsterL]

I think that you might find that "Psychiatry-bashing" is pretty institution dependent. I think you see a lot less of it at schools with strong psychiatry departments. You still get a lot of docs who shudder at the thought of treating mental illness, but you don't hear as much bashing of the profession as a whole if the Psych department is one of the bigger guns.

Just out of curiosity, could you please name some schools/institutions in which Psych is one of the bigger guns and thereby there's less psych bashing?

Thank you!

 

[Daftrage]

Just out of curiosity, could you please name some schools/institutions in which Psych is one of the bigger guns and thereby there's less psych bashing?

Thank you!

I can say my home institution of UAMS fits this bill. One of the newest and nicest buildings that is on the main drive of campus is the Psychiatric Research Institute. I was freely open about my desire in Psychiatry on every rotation and never received any flak just some good natured ribbing that I was allowed to dish back.

This was a factor I also took in deciding my new residency at MUSC and felt comfortable that they were well respected too. Their department brings in a lot of research funding which brings respect at the top levels and all the department appears to be run in a very professional manner with good people which should bring respect more at the resident level. I will be able to say more tho about MUSC later tho as I haven't actually started there yet.

I'm sure there are more out there these are just the ones I have been lucky enough to be a part of.

 

[LEdaddy]

I can say my home institution of UAMS fits this bill. One of the newest and nicest buildings that is on the main drive of campus is the Psychiatric Research Institute. I was freely open about my desire in Psychiatry on every rotation and never received any flak just some good natured ribbing that I was allowed to dish back.

This was a factor I also took in deciding my new residency at MUSC and felt comfortable that they were well respected too. Their department brings in a lot of research funding which brings respect at the top levels and all the department appears to be run in a very professional manner with good people which should bring respect more at the resident level. I will be able to say more tho about MUSC later tho as I haven't actually started there yet.

I'm sure there are more out there these are just the ones I have been lucky enough to be a part of.

Secondhand information, but I've heard that at both Columbia and MGH, the psychiatry programs garner respect within the greater institutions. I think it also has something to do with the culture of the surrounding environment (NYC and Boston).

 

[notdeadyet]

Just out of curiosity, could you please name some schools/institutions in which Psych is one of the bigger guns and thereby there's less psych bashing?

Thank you!

UCSF, UCLA, and UC Davis, from what I've seen in California. Probably others within state as well.

Strong psych departments --> better utilization --> better reputation --> less bashing.

This trend seems typical with all departments. PM&R docs get written off as "glorified Physical Therapists" in places where there's weak PM&R departments. The list of examples is pretty long.

 

[whopper]

Just out of curiosity, could you please name some schools/institutions in which Psych is one of the bigger guns and thereby there's less psych bashing?

There was an article a few years ago in Psychiatric News (the newspaper of the APA) mentioning a particular medschool as having an exceptionally high # of students going to psychiatry and they chalked it up to the rotation being taught better than the usual at most schools.

I know where I did residency that was the case at least for a few years when a particular attending was the program director and medical school rotation director. At that point in time I felt my program was particularly superior in one on one teaching compared to several other schools in the area, but the golden goose attending I'm speaking of moved to a different part of the country my PGY IV year.

 

[Doctor Bagel]

There was an article a few years ago in Psychiatric News (the newspaper of the APA) mentioning a particular medschool as having an exceptionally high # of students going to psychiatry and they chalked it up to the rotation being taught better than the usual at most schools.

I know where I did residency that was the case at least for a few years when a particular attending was the program director and medical school rotation director. At that point in time I felt my program was particularly superior in one on one teaching compared to several other schools in the area, but the golden goose attending I'm speaking of moved to a different part of the country my PGY IV year.

I think psychiatry representation during basic sciences is important, too. My medical school sends a lot of people into psychiatry, and we had a really strong human behavior curriculum during basic sciences. Psychiatrists were also fairly prominent in the university (for example, the dean of students was a psychiatrist, and the president of my clinical campus was a psychiatrist). Where I'm at now, students get pretty much no exposure to psychiatry during 1st and 2nd year, and they've all reported to me feeling very poorly prepared for the human behavior part of Step 1 (which is a shame because it's a pretty prominent part of the exam).

 

[beegirl22]

LOL, I have seen this too. One of the psychiatrists I rotated with would often say that his job was mainly to treat the doctors who consulted him.

LOL, that's a good one! But seriously, I'm not too sure the ED bashing is unfounded. On another private forum (not health related) highly respected member posted this re: someone asking what to do with friend expressing thoughts of suicide:

But anyone in any type of healthcare willl tell you that anybody who wants to die never tells someone else. And the person who does tell it and then attempts it is not making a serious attempt. And then if they die because of the attempt, it is generally accidental so to speak... As an ER nurse, I see this lots and have training in this.

Subsequently found this study describing a bias belonging to EDs. http://www.suicidology.org/c/document_library/get_file?folderId=236&name=DLFE-331.pdf