- Joined
- Feb 7, 2007
- Messages
- 826
- Reaction score
- 22
I have no plans to move back to N.J. at this time
Based on the 10 min of Jersey Shore that I've seen, the new 10% tax on tanning is going to force a lot of people to move out of NJ
I have no plans to move back to N.J. at this time
I think that practicing medicine is much more than simply writing out a prescription. Practicing medicine, to me, implies a comprehensive biological understanding of disease
I maintain that psychiatry as we now practice it it fundamentally different from medicine. Unlike every other specialty, we do not have a fundamental biological understanding of what we are doing. Instead, we rely on a psychological understanding. That is, diagnosis proceeds exclusively based on a series of psychological procedures, including interviewing, observing behavior, and making judgments about how behavior and responses to questions relate to the array of diagnoses available to us in the DSM. Sure, we order labs and sometimes MRIs, but this is all in order to rule out a medical condition, and not to diagnose a psychiatric condition.
If we heal without a biological understanding of what we are healing, we are certainly healers, but can we really call ourselves medical doctors in the way that other specialists can? I wonder.
While therapy training in residency can vary, therapists training can also be a mixed bag in the community as pretty much anyone can do it. At times, I am appalled to learn what type of 'therapy' these non-MDs have been doing with my patients.
Although I agree with nearly everything Snarfer wrote (no big surprise, since it was in agreement with me), I want to caution against the argument that "since some in your profession do a less-than-perfect job, you have no place criticizing mine." That argument cuts both ways, and of course, "one bad apple don't spoil the whole bunch, girl."
.
Thanks Kugel. The last paragraph was in response to a post by therapist4change. No offense intended.
Though not the intention of his post, it is hard not to feel discouraged when reading Dr. Carlat's comments. As a medical student who has chosen psychiatry as his future field, a sliver of doubt is raised when a well-educated, well-spoken psychiatrist explains why I won't be a real doctor and will be effectively wasting my medical school education. So, that being said, I'd like to thank and applaud Kugel, Nancysinatra, and Snarfer for reminding me and other potential students who read these forums that psychiatrists are in fact medical doctors, too.
It is all plumbing. Plumbing also explains why I like being mean to people.
Though not the intention of his post, it is hard not to feel discouraged when reading Dr. Carlat's comments. As a medical student who has chosen psychiatry as his future field, a sliver of doubt is raised when a well-educated, well-spoken psychiatrist explains why I won't be a real doctor and will be effectively wasting my medical school education. So, that being said, I'd like to thank and applaud Kugel, Nancysinatra, and Snarfer for reminding me and other potential students who read these forums that psychiatrists are in fact medical doctors, too.
I totally agree that my argument sounds silly at face value. But I'm driving at an issue that (I think) is a profound problem for psychiatry. One of the arguments I commonly hear against psychologists prescribing, or in favor of the idea that medical school is essential for prescribing, is some variation of: "writing out a prescription is, in fact, practicing medicine."
I disagree, because I think that practicing medicine is much more than simply writing out a prescription. Practicing medicine, to me, implies a comprehensive biological understanding of disease, and a series of technical procedures and decisions based on that understanding. Thus, when I did my medical internship at St. Mary's hospital in San Francisco, I really practiced medicine. For example, I remember admitted many elderly women with pneumonia. I listened to their lungs for crackling, I ordered chest X-rays to look for signs of lobar pneumonia, I ordered blood tests to look for elevated WBCs, I got blood cultures to decide which antibiotic was most appropriate, and then I prescribed a drug based on that medical work.
I maintain that psychiatry as we now practice it it fundamentally different from medicine. Unlike every other specialty, we do not have a fundamental biological understanding of what we are doing. Instead, we rely on a psychological understanding. That is, diagnosis proceeds exclusively based on a series of psychological procedures, including interviewing, observing behavior, and making judgments about how behavior and responses to questions relate to the array of diagnoses available to us in the DSM. Sure, we order labs and sometimes MRIs, but this is all in order to rule out a medical condition, and not to diagnose a psychiatric condition.
If we heal without a biological understanding of what we are healing, we are certainly healers, but can we really call ourselves medical doctors in the way that other specialists can? I wonder.
Daniel Carlat said:I totally agree that my argument sounds silly at face value. But I'm driving at an issue that (I think) is a profound problem for psychiatry. One of the arguments I commonly hear against psychologists prescribing, or in favor of the idea that medical school is essential for prescribing, is some variation of: "writing out a prescription is, in fact, practicing medicine."
I disagree, because I think that practicing medicine is much more than simply writing out a prescription. Practicing medicine, to me, implies a comprehensive biological understanding of disease, and a series of technical procedures and decisions based on that understanding. Thus, when I did my medical internship at St. Mary's hospital in San Francisco, I really practiced medicine. For example, I remember admitted many elderly women with pneumonia. I listened to their lungs for crackling, I ordered chest X-rays to look for signs of lobar pneumonia, I ordered blood tests to look for elevated WBCs, I got blood cultures to decide which antibiotic was most appropriate, and then I prescribed a drug based on that medical work.
I maintain that psychiatry as we now practice it it fundamentally different from medicine. Unlike every other specialty, we do not have a fundamental biological understanding of what we are doing. Instead, we rely on a psychological understanding. That is, diagnosis proceeds exclusively based on a series of psychological procedures, including interviewing, observing behavior, and making judgments about how behavior and responses to questions relate to the array of diagnoses available to us in the DSM. Sure, we order labs and sometimes MRIs, but this is all in order to rule out a medical condition, and not to diagnose a psychiatric condition.
If we heal without a biological understanding of what we are healing, we are certainly healers, but can we really call ourselves medical doctors in the way that other specialists can? I wonder.
.
You're not wasting your education--far from it. As someone who has chosen psychiatry already you're in a good position, though I imagine you might be wondering how some of your rotations are relevant to your chosen field. When I was at UCSF, my residents knew I was the future psychiatrist and would often assign me to cases that involved heavy psychosocial components. I did plenty of extra reading etc....Though not the intention of his post, it is hard not to feel discouraged when reading Dr. Carlat's comments. As a medical student who has chosen psychiatry as his future field, a sliver of doubt is raised when a well-educated, well-spoken psychiatrist explains why I won't be a real doctor and will be effectively wasting my medical school education. So, that being said, I'd like to thank and applaud Kugel, Nancysinatra, and Snarfer for reminding me and other potential students who read these forums that psychiatrists are in fact medical doctors, too.
Medical Mimics of Psychiatric Disorders.
There are actually many excellent psychologists who work on consult-liaison services. See, for example, the training for psychologists at the Henry Ford Hospital. No, I do not accept the notion that one needs to go through clinical rotations in these fields in order to treat the psychiatric problems of patients with medical illness.You don't think you need the rest of medical school to understand this? I can't see very many successful CL psychiatrists being produced by a system that focuses on psychiatric education at the detriment of IM, surgery, OBGYN, neurology, etc.
There are actually many excellent psychologists who work on consult-liaison services. See, for example, the training for psychologists at the Henry Ford Hospital. No, I do not accept the notion that one needs to go through clinical rotations in these fields in order to treat the psychiatric problems of patients with medical illness.
There are actually many excellent psychologists who work on consult-liaison services. See, for example, the training for psychologists at the Henry Ford Hospital. No, I do not accept the notion that one needs to go through clinical rotations in these fields in order to treat the psychiatric problems of patients with medical illness.
You're not wasting your education--far from it. As someone who has chosen psychiatry already you're in a good position, though I imagine you might be wondering how some of your rotations are relevant to your chosen field. When I was at UCSF, my residents knew I was the future psychiatrist and would often assign me to cases that involved heavy psychosocial components. I did plenty of extra reading etc....
But it is true that much of the med school curriculum is overkill for psychiatry, which is why I hope that we can put our heads together and create a hybrid of medical school, psychology training, and psychiatry residency. This would involve harvesting the most relevant of the medical school didactic courses and tweaking them to make them more useful to future psychiatrists; getting rid of courses that just aren't at all relevant (I would put gross anatomy, histology, pathology in that pot); adding a slew of new courses that are currently absent from or lightly covered in med school, such as Principles of Psychopharmacology, Medical Mimics of Psychiatric Disorders, Pharmacokinetics of Psychiatric Medications, The History and Clinical Use of DSM, Psychiatric Interviewing, Cognitive Behavioral Therapy, Practical Psychodynamics, etc....
I think all these didactics would fill about 3 years of this new Psychiatry Graduate Program, then all students would go into a two or three year psychiatric residency. The total training would last 5 to 6 years. The final degree: Psychiatric Physician, or Psychiatric Doctor, or Doctor of Mental Health, or other title.
If the American Psychiatric Association created and endorsed such a revision of training, obtaining the required legislation to ensure prescribing privileges and hospital admitting privileges would be a breeze, though would have to be done on a state-by-state basis.
If we started to plan this program now, we could enroll the first students within a couple of years, and the first graduates would start practicing in 2018 or so.
I can't decide if the MGH fight or the puppy scolding is winning the thread...
I have often used psychologists for testing on a CL service, and they are valuable - but I wouldn't want them opining on the differential of a delirium.
While not all psychologists would be suited to address complicating medical factors that may mimic psychiatric / cognitive conditions, a boarded neuropsychologist would be an asset in that setting. They could speak to how the patient's presentation and level of functioning is impacted, and back it up with objective data, and provide more information for differential dx.
They could speak to how the patient's presentation and level of functioning is impacted, and back it up with objective data, and provide more information for differential dx.
You're not wasting your education--far from it. As someone who has chosen psychiatry already you're in a good position, though I imagine you might be wondering how some of your rotations are relevant to your chosen field. When I was at UCSF, my residents knew I was the future psychiatrist and would often assign me to cases that involved heavy psychosocial components. I did plenty of extra reading etc....
But it is true that much of the med school curriculum is overkill for psychiatry, which is why I hope that we can put our heads together and create a hybrid of medical school, psychology training, and psychiatry residency. This would involve harvesting the most relevant of the medical school didactic courses and tweaking them to make them more useful to future psychiatrists; getting rid of courses that just aren't at all relevant (I would put gross anatomy, histology, pathology in that pot); adding a slew of new courses that are currently absent from or lightly covered in med school, such as Principles of Psychopharmacology, Medical Mimics of Psychiatric Disorders, Pharmacokinetics of Psychiatric Medications, The History and Clinical Use of DSM, Psychiatric Interviewing, Cognitive Behavioral Therapy, Practical Psychodynamics, etc....
I think all these didactics would fill about 3 years of this new Psychiatry Graduate Program, then all students would go into a two or three year psychiatric residency. The total training would last 5 to 6 years. The final degree: Psychiatric Physician, or Psychiatric Doctor, or Doctor of Mental Health, or other title.
If the American Psychiatric Association created and endorsed such a revision of training, obtaining the required legislation to ensure prescribing privileges and hospital admitting privileges would be a breeze, though would have to be done on a state-by-state basis.
If we started to plan this program now, we could enroll the first students within a couple of years, and the first graduates would start practicing in 2018 or so.
I am sure you see patients with multiple medical issues, on multiple meds for these issues with complex psychiatric presentations. What makes you believe a training at a lesser level than a medical school will be adequate to take good care of these patients?
The tens of thousands of NPs and PAs prescribing, and the already practicing prescribing psychologists?
This is just plain silly. There are components of psychiatry that are firmly medical and have biological understanding of the disease process. Certain practice settings more so than others. But this is also today, the present, of psychiatry. Look back 50 years ago. How much was clearly understood then? And how much is understood now?I totally agree that my argument sounds silly at face value. But I'm driving at an issue that (I think) is a profound problem for psychiatry. One of the arguments I commonly hear against psychologists prescribing, or in favor of the idea that medical school is essential for prescribing, is some variation of: "writing out a prescription is, in fact, practicing medicine."
I disagree, because I think that practicing medicine is much more than simply writing out a prescription. Practicing medicine, to me, implies a comprehensive biological understanding of disease, and a series of technical procedures and decisions based on that understanding. Thus, when I did my medical internship at St. Mary's hospital in San Francisco, I really practiced medicine. For example, I remember admitted many elderly women with pneumonia. I listened to their lungs for crackling, I ordered chest X-rays to look for signs of lobar pneumonia, I ordered blood tests to look for elevated WBCs, I got blood cultures to decide which antibiotic was most appropriate, and then I prescribed a drug based on that medical work.
I maintain that psychiatry as we now practice it it fundamentally different from medicine. Unlike every other specialty, we do not have a fundamental biological understanding of what we are doing. Instead, we rely on a psychological understanding. That is, diagnosis proceeds exclusively based on a series of psychological procedures, including interviewing, observing behavior, and making judgments about how behavior and responses to questions relate to the array of diagnoses available to us in the DSM. Sure, we order labs and sometimes MRIs, but this is all in order to rule out a medical condition, and not to diagnose a psychiatric condition.
If we heal without a biological understanding of what we are healing, we are certainly healers, but can we really call ourselves medical doctors in the way that other specialists can? I wonder.
Hi, Student Doctors--This is my first posting, and I am long past my student days! But I felt it important to comment on the controversy created by (among others), my friend and Tufts colleague, Dr. Daniel Carlat. I believe Dr. Carlat intended the issue of "prescribing privileges" for psychologists to serve as a kind of goad for the internal reformation of psychiatry; unfortunately, his seeming defense of the "medical psychologist" argument has created a good deal of dismay among many of us in the field of psychiatry. I hope you will take a look at the editorial I published on the psychiatrictimes.com website:
.http://www.psychiatrictimes.com/display/article/10168/1545667?CID=rss.
There, I argue that there is no such thing as "prescribing" apart from the practice of medicine; and that the practice of medicine requires a level of scientific knowledge that cannot be achieved through the proposed curriculum for "prescribing psychologists." The absence of systematic data on the practices of current "medical psychologists" is another huge problem, and this is not simply a matter of a "turf battle." It is a matter of defending the public safety, and insisting on scientific standards as the foundation for granting medical practice privileges.
For those of you going into psychiatry, don't despair! We have our internal problems as a medical speciality, to be sure--but we have always been and will always remain "real doctors", in the best and most comprehensive sense of that term: treating the "whole person" by integrating biological, psychological, social, and cultural knowledge into a coherent framework of care.
--Best regards, Ronald Pies MD
But it is true that much of the med school curriculum is overkill for psychiatry, which is why I hope that we can put our heads together and create a hybrid of medical school, psychology training, and psychiatry residency. This would involve harvesting the most relevant of the medical school didactic courses and tweaking them to make them more useful to future psychiatrists; getting rid of courses that just aren't at all relevant (I would put gross anatomy, histology, pathology in that pot)
I think we should all remember that, despite the utter absurdity of his stance on this issue, Carlat's writings otherwise are some of the most important and accessible things produced outside of journals. He's made it cool to hate pharma influence, and generally, he writes with intellectual rigor and honesty. The Carlat Report, and his blog (where he gives us a bit of a shout-out, btw), are incredibly worthwhile.
He also runs the risk of becoming the Ralph Nader of psychiatry.
He's also got the cojones to post under his real name, so let's argue the issue at hand rather than casting aspersions on his motivations.
Beyond that, in outpatient settings, practices vary widely. Some "go-getter" psychiatrists see themselves as primary care doctors, and check blood pressures, check lipid levels aggressively and institute statin treatment. Unless the psychiatrist is double-boarded in medicine and psych, I find this practice worrisome. Medicine is getting more and more complicated and I would not want my child being treated medically by a psychiatrist.
I think we should all remember that, despite the utter absurdity of his stance on this issue, Carlat's writings otherwise are some of the most important and accessible things produced outside of journals. He's made it cool to hate pharma influence, and generally, he writes with intellectual rigor and honesty. The Carlat Report, and his blog (where he gives us a bit of a shout-out, btw), are incredibly worthwhile.
He also runs the risk of becoming the Ralph Nader of psychiatry.
The Status Quo for many is viewed negatively, so in that sense it would be seen as quite complementary.He might well consider that a compliment!
Wasn't it not that long ago that a "general practitioner" was someone with one year of internship who worked in a family-type practice and did almost everything? I realize medicine is much more complicated and regulated now, but not all aspects are equally more complicated. I don't think being boarded in IM is necessary to start a HTN medication, even nowadays. Of course there is a limit where you have to refer the patient or call a consult.
Plus if you restrict what "psychiatrists" do to only "mental health" and really want to limit it, then what about when we use medications like beta blockers for anxiety? Are we practicing "medicine" or "psychiatry?" If a medication is used off label that comes from, say, neurology, but it works, for, say, depression, well, what about that situation? (If I didn't go to medical school, but had only studied "psychopharmacology"--I sure wouldn't feel right using it then!) If I admit an inpatient who's on a bunch of cardiac medications, am I "practicing medicine" because I start all his heart medications? Do you expect me to call cardiology? Personally I think that would be ridiculous. And I would have numerous more similar questions.
And patients may bring medical matters to a psychiatrist's attention. If the psychiatrist is not knowledgeable, they may fail to make the correct referral.
I totally agree that my argument sounds silly at face value. But I'm driving at an issue that (I think) is a profound problem for psychiatry. One of the arguments I commonly hear against psychologists prescribing, or in favor of the idea that medical school is essential for prescribing, is some variation of: "writing out a prescription is, in fact, practicing medicine."
I disagree, because I think that practicing medicine is much more than simply writing out a prescription. Practicing medicine, to me, implies a comprehensive biological understanding of disease, and a series of technical procedures and decisions based on that understanding. Thus, when I did my medical internship at St. Mary's hospital in San Francisco, I really practiced medicine. For example, I remember admitted many elderly women with pneumonia. I listened to their lungs for crackling, I ordered chest X-rays to look for signs of lobar pneumonia, I ordered blood tests to look for elevated WBCs, I got blood cultures to decide which antibiotic was most appropriate, and then I prescribed a drug based on that medical work.
I maintain that psychiatry as we now practice it it fundamentally different from medicine. Unlike every other specialty, we do not have a fundamental biological understanding of what we are doing. Instead, we rely on a psychological understanding. That is, diagnosis proceeds exclusively based on a series of psychological procedures, including interviewing, observing behavior, and making judgments about how behavior and responses to questions relate to the array of diagnoses available to us in the DSM. Sure, we order labs and sometimes MRIs, but this is all in order to rule out a medical condition, and not to diagnose a psychiatric condition.
If we heal without a biological understanding of what we are healing, we are certainly healers, but can we really call ourselves medical doctors in the way that other specialists can? I wonder.
There are actually many excellent psychologists who work on consult-liaison services. See, for example, the training for psychologists at the Henry Ford Hospital. No, I do not accept the notion that one needs to go through clinical rotations in these fields in order to treat the psychiatric problems of patients with medical illness.
Anasazi - could you clarify your rationale for distinguishing between physicians and psychiatrists?
"a physician first, and psychiatrist second"
This is a common differentiation, particularly when discussing the differences between psychiatry and psychology. In psychiatry you are first a physician and then you train as a psychiatrist. In psychology you are a scientist first and then you train as a psychologist.Anasazi - could you clarify your rationale for distinguishing between physicians and psychiatrists?
"a physician first, and psychiatrist second"
Some psychologists (neuropsychologists and rehabilitation psychologists w/ a neuro focus) have a firm grasp on neuroanatomy, neurophysiology, etc....though the average psychologist does not. This is actually one of my biggest pet peeves about psychology. I'd most trust boarded neuropsychologists and neuro-focused researchers, but that is just my opinion.Psychologists also focus on the study of the brain very comprehensively and not only pathologies am I correct? Psychiatrists seem to be there to help mental health issues, mostly.
Maybe I'm wrong. I'm an ignoramus dog.
This is a common differentiation, particularly when discussing the differences between psychiatry and psychology. In psychiatry you are first a physician and then you train as a psychiatrist. In psychology you are a scientist first and then you train as a psychologist.