You don’t need to go to residency to prescribe Risperdal

[Psychic Meep]

Recently heard an attending psychiatrist telling med students that she believed nurses and PA’s provide equivalent care to physicians and snorted “You do don’t need to go to residency to be able to prescribe Risperdal!” She claimed that in her view the majority of our training was extraneous and that the ”literature” backed her claims of equivalency. She (the attending) is too high up in the food chain for me to critique face to face but I did feel pretty frustrated that she was trying to undermine her profession. In my mind since she’s close to retirement and holds some high positions in the hospital, I figure that her attitude is one of “I’m almost retired, to heck with the consequences of what I say!” and also heavily influenced by PC hospital politics.

If we follow her logic to its conclusion, wouldn’t a 3rd or 4th year medical student be superior to a PA in knowledge base? If she’s comfortable believing that a PA could replace us, would she be comfortable letting a med student run the service? I also find the reduction of what we do to simple brain dead prescribing a bit galling.

Thoughts?

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[Sushirolls]

You've already determined there is a deficiency in the logic. Let it enter one ear and flush it out the other. Try to observe and learn what you can with this person, but take everything else said with an extra helping of skepticism.

Resist all urges of retort or sarcasm or humor or pointing out their flaws / errors in thinking. It will only serve to bite you. Smile, nod, survive the rotation and remember this as an example of what not to emulate when you are further down the training process.

A person who is so vocal in not knowing their field, the quality differences, the care differences, etc, etc, is also some one who is likely to not care about you or your career and tear it apart in a second.

Good luck. Keep your head down.

 

[nexus73]

“But I’m irreplaceable... because I’m an academic?” Maybe? I don’t know this seems either completely irrational, or someone at the end of their career. If this is an employed doctor it’s mind boggling they would push for this, as they would themselves be replaced if the right (wrong?) administrator was convinced they were right.

I’ve seen this more from old psychiatrists within a few years of retirement, or well past 65 years old and still practicing. It’s like they’ve been lying to themselves their entire career but now they’ve got a few million in the bank let’s just start trashing the field. Often seems they’re tired of being busy and are ok letting mid levels take the burden off them. Just retire already.

 

[Bartelby]

You for sure don't need to go to residency to prescribe Risperdal, though prescribing it appropriately might be another matter.

 

[NickNaylor]

Most of the medications that we use are not particularly complicated to manage, so in some sense I guess I agree. Treatment algorithms can get complicated as you move further down the line, but sure, "prescribing Risperdal" isn't complicated.

As mentioned above, though, the trick is the diagnostic process and figuring out when to use what medications. Clearly that's something that some attending psychiatrists can't do properly - much less a medical student, PA, or NP - based on some of the silliness that I see coming to our inpatient unit on a fairly regular basis.

 

[When is graduation again?]

As my name states, i agree that training has a lot of unnecessary redundancy and is too long...

But I disagree about everything else. It's pretty lazy logic. I find that psychiatry is actually in a tough spot in terms of what we are expected to know. Depending on who you ask, you're expected (or are able) to be a master of psychopharm, therapy, and primary care, which clearly no-one can do and if you don't do these things you are not "practicing at the top of your license." Once you start digging into all the knowledge, you become overwhelmed with all the things you don't know. It seems like you're attending is just comfortable not knowing. Seems like the Dunning-Kruger effect to me.

 

[SmallBird]

Recently heard an attending psychiatrist telling med students that she believed nurses and PA’s provide equivalent care to physicians and snorted “You do don’t need to go to residency to be able to prescribe Risperdal!” She claimed that in her view the majority of our training was extraneous and that the ”literature” backed her claims of equivalency. She (the attending) is too high up in the food chain for me to critique face to face but I did feel pretty frustrated that she was trying to undermine her profession. In my mind since she’s close to retirement and holds some high positions in the hospital, I figure that her attitude is one of “I’m almost retired, to heck with the consequences of what I say!” and also heavily influenced by PC hospital politics.

If we follow her logic to its conclusion, wouldn’t a 3rd or 4th year medical student be superior to a PA in knowledge base? If she’s comfortable believing that a PA could replace us, would she be comfortable letting a med student run the service? I also find the reduction of what we do to simple brain dead prescribing a bit galling.

Thoughts?

Its pretty lame for sure, and transparently defensive. Instead of saying "I don't get sufficient self-worth from clinical practice alone, and now that midlevels can do it, its been important for me to distinguish myself in other ways" she has to project her own process onto the entire field. I take a lot of pride in what I do and think its quite difficult to do well. There are plenty of psychiatrists who think there job warrants the training they did, and there are plenty of patients and hospitals who agree. So don't worry too much. She should just by a Harley Davidson and impose herself on others in that way.

 

[psychacad]

Bear in mind that psychiatry training in the US is shorter than in most Western countries. If anything I don't think many programs get sufficient exposure to therapy, eating disorders...etc.

It's easy to take for granted what we do. But the actual work isn't really that simple. I moonlight at an ER where SW see patients and present them to MDs. They probably have more clinical contact than many NPs, and still, most of them do a terrible job clinically (to the point where I try to see the pt on my own and have them help with collateral, d/c..etc). That's because the soft interviewing skills and the necessary patient exposure to develop a clinical feel only come with intensive training. So yes, if you want to do a shoddy job, don't do residency to prescribe risperdal.

 

[Stagg737]

“You do don’t need to go to residency to be able to prescribe Risperdal!”

As others have said, I think this is probably the only accurate statement she made. And it's really only conditionally accurate as once we get past the first 2-3 lines of therapy a lot care gets really messy and straight up bad. Even many psychiatrists do a poor job with more complex cases, thinking that most prescribers population with a fraction of the training a resident has can manage them adequately is pretty ignorant.

 

[dl2dp2]

I have a different take: I suspect that if people who went to MD route had instead trained in the NP route, they'd be pretty competent.

People who trained through the NP route had a much higher variation in both training and in personal competence in other domains. For certain more mission-critical tasks, service provider quality variation is not acceptable.

Why do bulge bracket investment banks only pick candidates from top 10 schools? The average MD program is about as competitive as the top 10 MBA and JD programs in the country. People who end up as MDs are #different. Everyone knows this. Every behaves knowing this and assuming this. Nobody says this out loud because it's not PC. It doesn't really MATTER what this senior person says.

 

[Old&InTheWay]

I have come to appreciate that most individual things that occur in medicine (even many procedures) are not terribly difficult to learn to do. The real challenge is deciding when, and often more importantly when not, to do them. So sure, a 1st day resident or new NP/PA "can" prescribe the same as an BC/BE psychiatrist, but whether they have the wisdom to make the right decision is the real skill.

The attending mentioned in the original post must be quite burned out to feel that their only value is in writing prescriptions. It's kind of sad and shocking that they have reached the point of openly talking to traininees in this way. This is certainly good info to give when you are asked to provide feedback on your rotations as this person should not be involved in medical education.

 

[clausewitz2]

I have a different take: I suspect that if people who went to MD route had instead trained in the NP route, they'd be pretty competent.

People who trained through the NP route had a much higher variation in both training and in personal competence in other domains. For certain more mission-critical tasks, service provider quality variation is not acceptable.

Why do bulge bracket investment banks only pick candidates from top 10 schools? The average MD program is about as competitive as the top 10 MBA and JD programs in the country. People who end up as MDs are #different. Everyone knows this. Every behaves knowing this and assuming this. Nobody says this out loud because it's not PC. It doesn't really MATTER what this senior person says.

This is one of those things that I think is definitely true but can't prove. I've met some MDs who were...intellectually incurious to say the least but none who were straight-out unintelligent. This has not been uniformly true of NPs. I think MD training also selects for conscientiousness and desire to excel more so than NP training despite the fact that medical school does not directly increase these things. We don't want to go back to the bad old days of doctor always knows best and we all know people who aren't especially interested in excelling and aren't especially pressed to keep up their skills but when it comes down to it for complex tasks that. cannot. fail. well-functioning systems are still likely to go to MDs first.

 

[clausewitz2]

I have come to appreciate that most individual things that occur in medicine (even many procedures) are not terribly difficult to learn to do. The real challenge is deciding when, and often more importantly when not, to do them. So sure, a 1st day resident or new NP/PA "can" prescribe the same as an BC/BE psychiatrist, but whether they have the wisdom to make the right decision is the real skill.

The attending mentioned in the original post must be quite burned out to feel that their only value is in writing prescriptions. It's kind of sad and shocking that they have reached the point of openly talking to traininees in this way. This is certainly good info to give when you are asked to provide feedback on your rotations as this person should not be involved in medical education.

In Aristotelian terms, psychiatry is relative low on techne but very sensitive to phronesis, partly because there often isn't a clearly objectively and universally correct answer for most questions. Definitely a craft more than anything else.

 

[Attending1985]

Recently heard an attending psychiatrist telling med students that she believed nurses and PA’s provide equivalent care to physicians and snorted “You do don’t need to go to residency to be able to prescribe Risperdal!” She claimed that in her view the majority of our training was extraneous and that the ”literature” backed her claims of equivalency. She (the attending) is too high up in the food chain for me to critique face to face but I did feel pretty frustrated that she was trying to undermine her profession. In my mind since she’s close to retirement and holds some high positions in the hospital, I figure that her attitude is one of “I’m almost retired, to heck with the consequences of what I say!” and also heavily influenced by PC hospital politics.

If we follow her logic to its conclusion, wouldn’t a 3rd or 4th year medical student be superior to a PA in knowledge base? If she’s comfortable believing that a PA could replace us, would she be comfortable letting a med student run the service? I also find the reduction of what we do to simple brain dead prescribing a bit galling.

Thoughts?

Maybe her comment, especially if she’s an older psychiatrist, is referring to the fact the profession has carved a very narrow niche for itself thats limited to prescribing which you don’t need 4 years to learn. She’s certainly not alone or even wrong with that sentiment. I’m a big fan of Sami Timimi a British psychiatrist who says the same thing. Essentially that psychiatry used to be a beautiful and useful mix of medicine, psychotherapy and psychology but the profession has narrowed it’s scope to prescribing with extremely poor results. Statistically we can’t argue this. He warns that those in other roles will likely take over for us which we already see happening. He says it way better google him if interested.

 

[AD04]

Did you tell her that you agree with her, which is why you're prescribing invega instead of risperdal?

I'm almost two years out of residency and I'm still learning new things. I love how I am able to blend psychopharmacology with psychotherapy with psychology with philosophy with religion with business. It's really a treat for me to treat deep thinkers and high performers. You cannot explore the finer aspects of practicing psychiatry (i.e. diving deep into the patient's mind) if it is just medication management.

 

[FatherPsychiatry]

Hmph. If she needs mental health care, I bet she'll be the first to demand to "talk to the manager" if she gets an NP.

 

[Old&InTheWay]

Hmph. If she needs mental health care, I bet she'll be the first to demand to "talk to the manager" if she gets an NP.

When you say "mental health care" you mean "Risperdal," right?

 

[sloh]

Maybe her comment, especially if she’s an older psychiatrist, is referring to the fact the profession has carved a very narrow niche for itself thats limited to prescribing which you don’t need 4 years to learn. She’s certainly not alone or even wrong with that sentiment. I’m a big fan of Sami Timimi a British psychiatrist who says the same thing. Essentially that psychiatry used to be a beautiful and useful mix of medicine, psychotherapy and psychology but the profession has narrowed it’s scope to prescribing with extremely poor results. Statistically we can’t argue this. He warns that those in other roles will likely take over for us which we already see happening. He says it way better google him if interested.

Thanks for sharing. This was a good read.

“Brands that target mood, stress, and insecurities about the self in adults have enormous potential. Similarly, brands that target the behavior and development of children also have enormous potential (unless they are associated with blame for the care givers, the main group of customers). Thus, strong brands like bipolar disorder, depression, ADHD, and autism demonstrate their popularity by their rapid expansion in the absence of any scientifically tangible discovery that supports the existence of these constructs in an empirically identifiable form in the bodies of those labelled, and beyond the imaginations of those who label individuals with these brands.

Instead, unnecessary identity insecurity coupled with (for some) the more profitable pretense that we are as technically advanced as other branches, has led psychiatry astray. On the lack of technical advances, we will be found out

It is sad that psychiatrists have been pushed into being primarily viewed as the prescribers in mental health services. Our representative institutions and academics have been complicit in this. The flimsy appeal that our models and practices are biopsychosocial (apart from not really knowing what this looks like in practice) is a smokescreen to what much of practice as a psychiatrist has become.”

Psychiatry and the Shores of Social Construction: Sami Timimi, MD

Are current systems of mental health care alienating children and adults from the meaning inherent in their own emotional difficulties?

www.psychiatrictimes.com

 

[SmallBird]

There is no denyi

Thanks for sharing. This was a good read.

“Brands that target mood, stress, and insecurities about the self in adults have enormous potential. Similarly, brands that target the behavior and development of children also have enormous potential (unless they are associated with blame for the care givers, the main group of customers). Thus, strong brands like bipolar disorder, depression, ADHD, and autism demonstrate their popularity by their rapid expansion in the absence of any scientifically tangible discovery that supports the existence of these constructs in an empirically identifiable form in the bodies of those labelled, and beyond the imaginations of those who label individuals with these brands.

Instead, unnecessary identity insecurity coupled with (for some) the more profitable pretense that we are as technically advanced as other branches, has led psychiatry astray. On the lack of technical advances, we will be found out

It is sad that psychiatrists have been pushed into being primarily viewed as the prescribers in mental health services. Our representative institutions and academics have been complicit in this. The flimsy appeal that our models and practices are biopsychosocial (apart from not really knowing what this looks like in practice) is a smokescreen to what much of practice as a psychiatrist has become.”

Psychiatry and the Shores of Social Construction: Sami Timimi, MD

Are current systems of mental health care alienating children and adults from the meaning inherent in their own emotional difficulties?

www.psychiatrictimes.com

While there is no doubt that the trend you and others have referred to is real and tragic, you don’t have to let it drive your practice. My training had a very prominent focus on psychotherapy and psychosocial interventions more broadly, and that is how I practice, and that is how I insist the other providers on my team practice. Because you can bill for psychotherapy we all meet our targets despite spending more time on fewer patients. We spend equal time on rounds discussing biological, psychological and social aspects of the patients formulation and associated treatment plan. I’ve never had an administrator tell me to stop doing that.

 

[Bartelby]

Seconding SmallBird, in my setting I participate in a range of interventions (psychotherapy, collaboration on diet and exercise plans, milieu interventions, addressing social issues including homelessness / problematic interpersonal dynamics / unemployment, connecting with improved management of non-psychiatric medical issues, appropriate prescribing, etc). If you don't like grinding out brief med checks then don't agree to work somewhere where that is the expectation (or if you do at least verify that a good interdisciplinary team will be working on other issues in tandem with you). It still remains entirely possible to provide quality care in psychiatry, even in employed positions.

 

[Attending1985]

There is no denyi


While there is no doubt that the trend you and others have referred to is real and tragic, you don’t have to let it drive your practice. My training had a very prominent focus on psychotherapy and psychosocial interventions more broadly, and that is how I practice, and that is how I insist the other providers on my team practice. Because you can bill for psychotherapy we all meet our targets despite spending more time on fewer patients. We spend equal time on rounds discussing biological, psychological and social aspects of the patients formulation and associated treatment plan. I’ve never had an administrator tell me to stop doing that.

That’s wonderful and I do the same. We unfortunately are the silent minority in the psychiatry machine. The general trends Dr. Timimi so very well describes are the prevailing force driving general mental health care in the US. I think it’s important for us, even if our practice is antithetical to this, acknowledges that and is a voice for change. We certainly can’t escape it as we see countless patients harmed by this care in our practices. For the record he would criticize psychology as well for medicalizing the human experience and extracting meaning from it.

 

[SmallBird]

That’s wonderful and I do the same. We unfortunately are the silent minority in the psychiatry machine. The general trends Dr. Timimi so very well describes are the prevailing force driving general mental health care in the US. I think it’s important for us, even if our practice is antithetical to this, acknowledges that and is a voice for change. We certainly can’t escape it as we see countless patients harmed by this care in our practices. For the record he would criticize psychology as well for medicalizing the human experience and extracting meaning from it.

I think one thing we can do is bravely and directly calling it out when leaders emphasize the important of us making new breakthroughs in brain-based treatment as the indisputable priority for our field. It’s is unconscionable that we would direct so many of our resources towards such efforts when we have extremely effective behavioral treatments (like behavior activation which has a dramatically larger effect size than antidepressants) that are not available to the vast majority who could benefit.

I have no way of knowing if I’m a good or bad psychiatrist but whenever I’ve received positive feedback or achieved a good outcome with a difficult patient it has been a result of drawing on a range of strategies to communicate with somebody and help improve their attitude towards their own role in recovery. It is difficult and requires the use of diverse knowledge. When NPs I work with are asking for my help it’s not to tell them to pick risperdal over trileptal (although that’s a seperate problem) but because they are spinning their wheels with a patient who is not recovery oriented and need help thinking of a more effective approach. If you don’t have these skills and can’t get patients to be more motivated, resilient, and with a more adaptive treatment concept you’re going to end up moving people between levels of care and driving the overdiagnosis of treatment resistance.

 

[Attending1985]

I think one thing we can do is bravely and directly calling it out when leaders emphasize the important of us making new breakthroughs in brain-based treatment as the indisputable priority for our field. It’s is unconscionable that we would direct so many of our resources towards such efforts when we have extremely effective behavioral treatments (like behavior activation which has a dramatically larger effect size than antidepressants) that are not available to the vast majority who could benefit.

I have no way of knowing if I’m a good or bad psychiatrist but whenever I’ve received positive feedback or achieved a good outcome with a difficult patient it has been a result of drawing on a range of strategies to communicate with somebody and help improve their attitude towards their own role in recovery. It is difficult and requires the use of diverse knowledge. When NPs I work with are asking for my help it’s not to tell them to pick risperdal over trileptal (although that’s a seperate problem) but because they are spinning their wheels with a patient who is not recovery oriented and need help thinking of a more effective approach. If you don’t have these skills and can’t get patients to be more motivated, resilient, and with a more adaptive treatment concept you’re going to end up moving people between levels of care and driving the overdiagnosis of treatment resistance.

I suspect you’re a good psychiatrist 😀

 

[Old&InTheWay]

This turned in to such an encouraging conversation. Gives me hope.

 

[birchswing]

On the lack of technical advances, we will be found out

I liked reading this, but this part struck me as wish fulfillment.

Anyone who cares to know, knows.

 

[Candidate2017]

I have a different take: I suspect that if people who went to MD route had instead trained in the NP route, they'd be pretty competent.

People who trained through the NP route had a much higher variation in both training and in personal competence in other domains. For certain more mission-critical tasks, service provider quality variation is not acceptable.

Why do bulge bracket investment banks only pick candidates from top 10 schools? The average MD program is about as competitive as the top 10 MBA and JD programs in the country. People who end up as MDs are #different. Everyone knows this. Every behaves knowing this and assuming this. Nobody says this out loud because it's not PC. It doesn't really MATTER what this senior person says.

I disagree about MD competitiveness vs top MBA/JDs.

The number of spots at top 10 MBA and JD schools are much, much less than the number of spots at MD schools. Med schools and med training select for test taking abilities and brown nosing superiors. These are all individualistic pursuits that serve to stunt physicians from effective teamwork, even at a small scale level of teamwork. While top 10 MBA and JDs are also skilled at test taking and brown nosing, there is a heavy emphasis on teamwork and achieving organizational goals and success on a massive scale.

Even non-top 10 MBAs and JDs can put a hurting on MDs. Who do you think the CEOs of hospitals, insurance, EMR companies etc are? Who do you think are pushing for more midlevels? Even just a few of them can get together and change the landscape of medicine, whether swooping in to take over telepsych, derm clinics, or emergency medicine or radiology contracts.

 

[SmallBird]

This turned in to such an encouraging conversation. Gives me hope.

As it should! I think a student reading SDN would hear three loud messages, and be at risk for taking them as fact. 1) It doesn't matter where you train, its all the same; 2) Quality is entirely subjective and not really a thing, and 3) The job market is crazy and you need to push insane volumes to avoid being replaced. I think these things go together, as do the opposite. Everyone I trained with cared about getting good training, and tried to learn as much as possible. They believe quality is a thing, and they now have jobs that care about that too, and don't see 25 patients a day. I know that this isn't a fringe minority because we have data showing the average RVUs worked by a psychiatrist and it works out at around 10-11 inpatients a day. My boss (at the hospital, not my MD supervisor) is happy with the work I do and has no interest in replacing me with someone that will see 25 patients because thats just not what will support the mission of the hospital. I am sure that I don't work in the only humane environment left and its important that trainees don't despair.

 

[clausewitz2]

My boss (at the hospital, not my MD supervisor) is happy with the work I do and has no interest in replacing me with someone that will see 25 patients because thats just not what will support the mission of the hospital. I am sure that I don't work in the only humane environment left and its important that trainees don't despair.

I think it's worth bearing in mind also that if payment models in mental health start to look more like the medical side of things and bouncebacks start getting heavily penalized suddenly the treat'n'street places are going to have to change up. Brief admission with durations based mainly on insurance's willingness to pay without a fuss and abrupt discharges with minimal aftercare planning is a good way to get unfortunate repeat business.

 

[dl2dp2]

I disagree about MD competitiveness vs top MBA/JDs.

The number of spots at top 10 MBA and JD schools are much, much less than the number of spots at MD schools. Med schools and med training select for test taking abilities and brown nosing superiors. These are all individualistic pursuits that serve to stunt physicians from effective teamwork, even at a small scale level of teamwork. While top 10 MBA and JDs are also skilled at test taking and brown nosing, there is a heavy emphasis on teamwork and achieving organizational goals and success on a massive scale.

Even non-top 10 MBAs and JDs can put a hurting on MDs. Who do you think the CEOs of hospitals, insurance, EMR companies etc are? Who do you think are pushing for more midlevels? Even just a few of them can get together and change the landscape of medicine, whether swooping in to take over telepsych, derm clinics, or emergency medicine or radiology contracts.

This is not true, btw. Check your facts. Harvard has 930 biz school and med school 170. This is roughly the proportion for every other biz vs. med school. Med school is also longer. There are about 150 med schools in the US. If you have a proportion of 1 to 8, then top 10 biz school is around the median med school in terms of competitiveness, assuming the same type of applicants.

In general, though, med school applicants have higher GPA/scores and widely thought to be more conscientious than typical JD/MBA applicants. Many healthcare organizations are "physician-led", and there's fairly substantial evidence to the point that it's taken for granted that physician-led organizations perform better. Non-healthcare organizations also often have physician leaders, though they typically take the role of Chief Medical Officer, and often command a higher salary than the CEO, depending on the context. You don't want to be the CEO of a garden variety community non-profit hospital---their role is typically to manage ancillary staff and other assets/liabilities. You typically want to be a partner at the physician organization that provides services to the hospital. Very often community hospital non-MD CEOs get paid less than a senior orthopedic surgeon (or even a senior psychiatrist).

 

[the5thelement]

"Precision is the difference between a butcher and a surgeon"​

 

[AD04]

I think a student reading SDN would hear three loud messages, and be at risk for taking them as fact. 1) It doesn't matter where you train, its all the same; 2) Quality is entirely subjective and not really a thing, and 3) The job market is crazy and you need to push insane volumes to avoid being replaced.

I would add to point #1: If you're solely trained in academic institutions, not matter how top-notch the brand is, you're getting less training compared to someone who trained all over. Academia tends to self-select for a certain type of personality that doesn't resonate well outside the ivory towers. And training shouldn't stop after residency. Explore what's out there and make mistakes and gain experience.

 

[AD04]

The average MD program is about as competitive as the top 10 MBA and JD programs in the country.

I would bet the median MD income is more than the median income of graduates from top 10 MBA or JD program.

 

[Stagg737]

I think it's worth bearing in mind also that if payment models in mental health start to look more like the medical side of things and bouncebacks start getting heavily penalized suddenly the treat'n'street places are going to have to change up. Brief admissions with durations based mainly on insurance's willingness to pay without a fuss and abrupt discharges with minimal aftercare planning is a good way to get unfortunate repeat business.

This would also likely have the added effect of less short-term admissions for personality disorders and substance detox as well. The former would likely be a good thing, I'm not as sure on the latter.

I would add to point #1: If you're solely trained in academic institutions, not matter how top-notch the brand is, you're getting less training compared to someone who trained all over. Academia tends to self-select for a certain type of personality that doesn't resonate well outside the ivory towers. And training shouldn't stop after residency. Explore what's out there and make mistakes and gain experience.

Have an extra like. Part of what I looked for when interviewing was diversity of practice environments. My program rotates through an academic center, VA, CMHC, and has electives available in the community/PP. I think it's pretty hard to gain experience with PP during residency, but I still think being in as many environments as possible during training is only beneficial in the long-run.

 

[clausewitz2]

This would also likely have the added effect of less short-term demons for personality disorders and substance detox as well. The former would likely be a good thing, I'm not as sure on the latter.

Holy crud that autocorrect tho. Admissions was what I meant, fixing above.

EDIT: tested a few variants and apparently SDN specifically renders 'ad+missions' without the plus sign as 'demons', but 'admission' is fine. Who is setting up these filters?

EDIT': i see now that med+ical schoo+l is turning into Easter basket above, this must be an april fool's prank

 

[Stagg737]

Holy crud that autocorrect tho. demons was what I meant, fixing above.

EDIT: tested a few variants and apparently SDN specifically renders 'ad+missions' without the plus sign as 'demons', but 'admission' is fine. Who is setting up these filters?

Lol, I have ad missions typed in the quote, but it keeps showing up as "demons". @Lee Wut? lol

 

[Liquid8]

How interesting – here in Australia we’ve recently had a Royal Commission into Aged Care where one of the recommendations was that only psychiatrists or geriatricians should be initiating antipsychotic treatments like risperidone. The investigation has obviously found lots of cases where elderly patients have been over-sedated (probably intentionally and pushed by care staff to manage BPSD) with adverse outcomes. This of course has upset our GPs, the medical work force that treat the majority of nursing home patients.

 

[hamstergang]

Lol, I have ad missions typed in the quote, but it keeps showing up as "demons". @Lord of the Bunnies Wut? lol

I believe it's an April Fools (Apr1l F00ls) thing and that tomorrow all the words will go back to normal, making your post quite odd at that point.

 

[LimpSpatula]

You've already determined there is a deficiency in the logic. Let it enter one ear and flush it out the other. Try to observe and learn what you can with this person, but take everything else said with an extra helping of skepticism.

Resist all urges of retort or sarcasm or humor or pointing out their flaws / errors in thinking. It will only serve to bite you. Smile, nod, survive the rotation and remember this as an example of what not to emulate when you are further down the training process.

A person who is so vocal in not knowing their field, the quality differences, the care differences, etc, etc, is also some one who is likely to not care about you or your career and tear it apart in a second.

Good luck. Keep your head down.

How do we get people like this out of leadership positions?

 

[dl2dp2]

How do we get people like this out of leadership positions?

You are not thinking about this correctly. People end up in [certain] leadership positions BECAUSE they think in this way. This is also institution-dependent. Quality--especially low variance high-quality care--has a cost: doctors with the most dependable and highest quality people are extremely expensive and not affordable by the average patient. The point of systems-level innovation is to create a context where people and their available resources can be matched to the feasible and acceptable level of quality. If you think that the institution in which you reside is a mismatch of the level of quality you provide, there are a few things you can do--either you can persuade actual stakeholders that the institution at hand has a quality-resource mismatch, or you create a new entity in which you can provide the kind of quality that you would like to deliver. Plenty of people in America have the means and the demand to pay for high-quality mental health care. It's just that you are not finding them in your care-providing context. Plenty of leadership of systems cares about [actual or perceived] quality.

 

[FlowRate]

I’m a big fan of Sami Timimi a British psychiatrist who says the same thing.

Did a bit of a deep dive and yeah, I'm a fan.

(Attachment is critical analysis of the concept of adult ADHD)

 

[LimpSpatula]

You are not thinking about this correctly. People end up in [certain] leadership positions BECAUSE they think in this way. This is also institution-dependent. Quality--especially low variance high-quality care--has a cost: doctors with the most dependable and highest quality people are extremely expensive and not affordable by the average patient. The point of systems-level innovation is to create a context where people and their available resources can be matched to the feasible and acceptable level of quality. If you think that the institution in which you reside is a mismatch of the level of quality you provide, there are a few things you can do--either you can persuade actual stakeholders that the institution at hand has a quality-resource mismatch, or you create a new entity in which you can provide the kind of quality that you would like to deliver. Plenty of people in America have the means and the demand to pay for high-quality mental health care. It's just that you are not finding them in your care-providing context. Plenty of leadership of systems cares about [actual or perceived] quality.

I didnt mean that part. I meant the part where it was advised this person would destroy OPs career. Why do we have those people there? Ive mentioned this before but doctors are the worst about this.

 

[WisNeuro]

Did a bit of a deep dive and yeah, I'm a fan.

(Attachment is critical analysis of the concept of adult ADHD)

Has some interesting points, but they seem to gloss over some key, well-known points that don't fit their narrative.

 

[dl2dp2]

I didnt mean that part. I meant the part where it was advised this person would destroy OPs career. Why do we have those people there? Ive mentioned this before but doctors are the worst about this.

I don't see how this person would destroy OPs career. Many hospital admin's promote NPs in public and then behind backdoor ruthlessly slash their salary to increase the physician group's bottom line and dividend yield. You just don't know *what* is going on. If you are really interested in what this person is doing or thinking you can have a private conversation with them. And even then you don't really know. It's probably a good idea to tell NPs what they want to hear if you want to keep them happy, which might, ultimately, be beneficial to your "career" (if you ever get to the partnership stage).

People need to learn to tell the difference between propaganda meant for someone else, marketing material, people's genuine beliefs and motivations, mentorship-speak, etc. The understanding of the content of the information needs to be modulated by the audience. What this professor says is uninterpretable, for example, if the audience is mainly a group of NPs. Learn to read a financial statement and do your own math to truly gain an appreciation of how systems of care works and the incentive structure within different institutions.

 

[FlowRate]

Has some interesting points, but they seem to gloss over some key, well-known points that don't fit their narrative.

If you'd be willing to expand, even in short form, I'd be interested.

 

[WisNeuro]

If you'd be willing to expand, even in short form, I'd be interested.

I'll go back over it later when I have more time, but one example would be them criticizing what they describe as different symptom sets, noting that hyperactivity is not included in some adult symptom measures. There are a good number of longitudinal child studies that showed the hyperactivity component to be the symptoms most likely to decrease as the child grows into adolescence and early adulthood. This is fairly well known feature that they authors do not acknowledge, I assume because they would have to edit their criticism. There is no way that they could claim to have done a review of ADHD and not know this issue.

 

[sloh]

Did a bit of a deep dive and yeah, I'm a fan.

(Attachment is critical analysis of the concept of adult ADHD)

Thanks for sharing, good read.

"The reason that adult ADHD is so appealing to drug companies can be readily deduced from official symptom lists and proposed diagnostic criteria, which consist of multiple experiences and behaviours that are practically universal.

Although DSM-5 proposals and other criteria specify that symptoms must impair ‘social, academic, or occupational functioning’,5 it is difficult to think of circumstances in which someone seeking help would not fulfil, or believe they fulfil, these criteria. There is also no empirical or logical basis on which such diverse phenomena should be grouped together.

The extent of promotional material aimed at women suggests that companies may be targeting markets previously occupied by other psychotropic drugs, in the same way that pharmaceutical marketing helped transform anxiety into depression in the 1990s to market the new antidepressants. According to this view, adult ADHD is one of the latest frameworks being offered to women through which to perceive their distress and dissatisfaction."

 

[clausewitz2]

.

There is also no empirical or logical basis on which such diverse phenomena should be grouped together.

Look, it doesn't prove that ADHD is a natural kind or anything, but executive control is not a concept made up by drug companies. The cog neuro/cog sci literature has had a lot of work involving this concept over years. It is absolutely the case that there is a logical and obvious connection between most of these symptoms and the idea of a deficit of the mental faculty responsible for deciding on and maintaining persistence in goal-directed behavior.

I don't think the authors are stupid so I have a hard time not seeing this as disingenuous. This is my need with a lot of critical psychiatry; they are the most rigorous and conservative EBT fundamentalists when it comes to anything supporting mainstream mental health but are content to base their positive arguments on conjecture and gestures towards marxist analysis.

You either get to be liberal in accepting evidence or not, not pick and choose

 

[SmallBird]

Look, it doesn't prove that ADHD is a natural kind or anything, but executive control is not a concept made up by drug companies. The cog neuro/cog sci literature has had a lot of work involving this concept over years. It is absolutely the case that there is a logical and obvious connection between most of these symptoms and the idea of a deficit of the mental faculty responsible for deciding on and maintaining persistence in goal-directed behavior.

I don't think the authors are stupid so I have a hard time not seeing this as disingenuous. This is my need with a lot of critical psychiatry; they are the most rigorous and conservative EBT fundamentalists when it comes to anything supporting mainstream mental health but are content to base their positive arguments on conjecture and gestures towards marxist analysis.

You either get to be liberal in accepting evidence or not, not pick and choose

I agree entirely. Why would it be that attention and executive function are the only functions in the entire body that can't be impaired in adults, only in children?

 

[sloh]

I agree entirely. Why would it be that attention and executive function are the only functions in the entire body that can't be impaired in adults, only in children?

Moncrieff and Timimi, in the paper, seem to also challenge the childhood diagnosis of ADHD. The discrepancy between adult ADHD and the childhood disorder just puts the adult diagnosis more into question.

"The concept of adult ADHD derives its face validity from its supposed similarity with the childhood condition. There have been many challenges to the validity of the childhood disorder, but even if these are set aside, it is not clear that the two diagnoses are related, since there appears to be a consensus that people with adult ADHD have a different spectrum of symptoms from children, and it is purely on the basis of symptoms that the two disorders are identified or diagnosed.

The current concept of adult ADHD is also incompatible with the previous view that ADHD is a developmental disorder, which the majority of children will mature out of as their development catches up. Follow-up studies and some imaging studies were believed to support this hypothesis, which also explains the preponderance of boys with ADHD, since development in boys, including neurological development, is slower than in girls. It is now claimed, however, that 60% of children diagnosed with ADHD continue to show symptomatic impairment into adulthood.29 Follow-up studies report rates of persistence as widely varying as 4–70% after age 18, with differences likely to be explained by the criteria used and the nature of the cohort, including comorbidity.29 Data on prescribing in the UK, however, found that most young people had stopped taking stimulants by age 21, and although the authors of this paper concluded this was evidence of inappropriate under-treatment, it may also reflect the natural reduction of symptoms with age, consistent with the developmental hypothesis of ADHD."

 

[SmallBird]

Moncrieff and Timimi, in the paper, seem to also challenge the childhood diagnosis of ADHD. The discrepancy between adult ADHD and the childhood disorder just puts the adult diagnosis more into question.

"The concept of adult ADHD derives its face validity from its supposed similarity with the childhood condition. There have been many challenges to the validity of the childhood disorder, but even if these are set aside, it is not clear that the two diagnoses are related, since there appears to be a consensus that people with adult ADHD have a different spectrum of symptoms from children, and it is purely on the basis of symptoms that the two disorders are identified or diagnosed.

The current concept of adult ADHD is also incompatible with the previous view that ADHD is a developmental disorder, which the majority of children will mature out of as their development catches up. Follow-up studies and some imaging studies were believed to support this hypothesis, which also explains the preponderance of boys with ADHD, since development in boys, including neurological development, is slower than in girls. It is now claimed, however, that 60% of children diagnosed with ADHD continue to show symptomatic impairment into adulthood.29 Follow-up studies report rates of persistence as widely varying as 4–70% after age 18, with differences likely to be explained by the criteria used and the nature of the cohort, including comorbidity.29 foolishness on prescribing in the UK, however, found that most young people had stopped taking stimulants by age 21, and although the authors of this paper concluded this was evidence of inappropriate under-treatment, it may also reflect the natural reduction of symptoms with age, consistent with the developmental hypothesis of ADHD."

I guess we are making slightly different points. As to the question of whether the DSM defined syndrome of ADHD has 'validity' - I find that to be a very unimportant question and its possible that it is or isn't. But ADHD amongst all of our diagnoses is the one that least needs a syndrome and can be understood in terms of basic brain functions. In clinical practice it is easy to detect attentional deficits, executive function deficits and increased impulsivity. It is also possible to assess the level of environmental stimulation that someone needs to feel calm and function well. These deficits are frequently responsive to biological treatments and environmental modifications. Adults can have these issues as well.