Patterns of Adult Psychotherapy in Psychiatric Practice

[TheWowEffect]

Having experienced healthcare in both the US and UK, they each have merits and disadvantages. The US is undoubtedly more technologically advanced, but this seems to have little effect on incidence and prevalence of any illness, since across all measures the British (including the Scots ) are healthier than their American counterparts (even when controlled for SES, education, etc.).
http://jama.ama-assn.org/cgi/content/abstract/295/17/2037
The US also provides healthcare in a much more immediate fashion (no waiting 2 years for a new hip like on the NHS in the UK). However, aside from better outcomes, the true merit of socialized medicine is that it considers healthcare a basic human right. Whatever the financial rewards, I would not be able to scarifice that belief. What's more, US physicians also share that belief, but instead of allowing for a single payer system, they choose to administrate an increasingly complex system of uncompensated free-care for patients who cannot pay/don't have insurance.
The flaw in both systems is essentially the same... the middle man f*cks it up. In the UK it's the government, in the US it's the MBAs at the insurance companies. A truly efficient model would be to have physicians administrate their own healthcare system (as with the original Kaiser Permanente), but this only ends up becoming corrupted b/c 1) Physicans in general would prefer to see pts than administrate, 2) MBAs can't resist the potential profit margin.
So, you're sort of screwed either way, but I still prefer the explicitly stated belief that healthcare is a human right, rather than the idea of "we'll give you charity care because we're so nice."

I agree and would like to add that the problem of so many people being uninsured needs to addressed on a proactive basis.

When you look at the cost of health care in US, its very clear how things that make profit still remain inflated. Why does a CT Scan still cost so much? I'll continue later...........

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[Anasazi23]

When you look at the cost of health care in US, its very clear how things that make profit still remain inflated. Why does a CT Scan still cost so much? I'll continue later...........

Because the CT machine cost the hospital 1.8 million to purchase, costs the hospital close to $500 per scan and interpretation, and costs about $30,000 annuall to maintain. Factor in the fact that about half of CT scans will not be reimbursed by inner city patients without insurance, and you can see why the scan remains expensive.

 

[PsychEval]

But it is different. ECT isn't an ACGME required training experience. Even leaving that aside, you can't treat a psychiatric patient successfully without some psychotherapeutic exchange. Lots of psychotherapy goes on during a 20 minute "med" follow-up, but there's a ill-conceived prevailing idea that we have to distance ourselves from therapy to better fit in with "real" doctors, hence the designation "psychopharmacologist" which ultimately represents nothing. We're all psychiatrists and we all use psychotherapy in one way or another.

What can I say Doc Samson, I’m impressed. I think you are right on target with your comments throughout this thread. Your statements remind me of the type of psychiatrists I respect the most, those who are truly Physicians, Diagnosticians, Psychopharmacologists, and Psychotherapists. These aspects of the collective identity of psychiatry is what makes psychiatry a unique and great specialty. I couldn’t agree with you more that there’s an ill conceived notion that by distancing ourselves from therapy allows us to fit in with “real doctors.” This also applies to psychologists, some of our best and brightest are our neuropsychologists. If you ask some (not all) of these guys, they will tell you they want nothing to do with therapy. They think of themselves as diagnosticians, and although they don’t say it overtly, I get the impression they think therapy is a bit beneath them.


BTW, I look forward to you posting the "The Problem of the Psychopharmacologist" by Kontos, Querques, and Freudenreich. Thanks.

 

[Poety]

As much as I hate breaking away from the topic of psychiatrists disowning psychotherapy so that surgeons might like them more (they don't BTW), I'll chime in on this too. Having experienced healthcare in both the US and UK, they each have merits and disadvantages. The US is undoubtedly more technologically advanced, but this seems to have little effect on incidence and prevalence of any illness, since across all measures the British (including the Scots ) are healthier than their American counterparts (even when controlled for SES, education, etc.).
http://jama.ama-assn.org/cgi/content/abstract/295/17/2037
The US also provides healthcare in a much more immediate fashion (no waiting 2 years for a new hip like on the NHS in the UK). However, aside from better outcomes, the true merit of socialized medicine is that it considers healthcare a basic human right. Whatever the financial rewards, I would not be able to scarifice that belief. What's more, US physicians also share that belief, but instead of allowing for a single payer system, they choose to administrate an increasingly complex system of uncompensated free-care for patients who cannot pay/don't have insurance.
The flaw in both systems is essentially the same... the middle man f*cks it up. In the UK it's the government, in the US it's the MBAs at the insurance companies. A truly efficient model would be to have physicians administrate their own healthcare system (as with the original Kaiser Permanente), but this only ends up becoming corrupted b/c 1) Physicans in general would prefer to see pts than administrate, 2) MBAs can't resist the potential profit margin.
So, you're sort of screwed either way, but I still prefer the explicitly stated belief that healthcare is a human right, rather than the idea of "we'll give you charity care because we're so nice."

Excellent points DS, I think health care in general doesn't bode well for a patient here, or in the UK (I can't speak for any other country at all) Apparently, in the UK mental health care is practically unheard of, which is even sadder. Unless you are SPMI - you're not getting seen, and even then, you're often being treated by a generalist.

 

[Poety]

What can I say Doc Samson, I’m impressed. I think you are right on target with your comments throughout this thread. Your statements remind me of the type of psychiatrists I respect the most, those who are truly Physicians, Diagnosticians, Psychopharmacologists, and Psychotherapists. These aspects of the collective identity of psychiatry is what makes psychiatry a unique and great specialty. I couldn’t agree with you more that there’s an ill conceived notion that by distancing ourselves from therapy allows us to fit in with “real doctors.” This also applies to psychologists, some of our best and brightest are our neuropsychologists. If you ask some (not all) of these guys, they will tell you they want nothing to do with therapy. They think of themselves as diagnosticians, and although they don’t say it overtly, I get the impression they think therapy is a bit beneath them.


BTW, I look forward to you posting the "The Problem of the Psychopharmacologist" by Kontos, Querques, and Freudenreich. Thanks.

Did I miss a post that DS is talkig about? Something about surgeons not liking psychiatrists? Most hte surgeons I know love psychiatrists, especially the trauma guys.

 

[Doc Samson]

Did I miss a post that DS is talkig about? Something about surgeons not liking psychiatrists? Most hte surgeons I know love psychiatrists, especially the trauma guys.

No Poety, you didn't miss anything... The surgeon is my internal representation of the doctor who doesn't think that psychiatry is "real" medicine. Just my own transference issues at play.

 

[Doc Samson]

What can I say Doc Samson, I’m impressed. I think you are right on target with your comments throughout this thread. Your statements remind me of the type of psychiatrists I respect the most, those who are truly Physicians, Diagnosticians, Psychopharmacologists, and Psychotherapists. These aspects of the collective identity of psychiatry is what makes psychiatry a unique and great specialty. I couldn’t agree with you more that there’s an ill conceived notion that by distancing ourselves from therapy allows us to fit in with “real doctors.” This also applies to psychologists, some of our best and brightest are our neuropsychologists. If you ask some (not all) of these guys, they will tell you they want nothing to do with therapy. They think of themselves as diagnosticians, and although they don’t say it overtly, I get the impression they think therapy is a bit beneath them.


BTW, I look forward to you posting the "The Problem of the Psychopharmacologist" by Kontos, Querques, and Freudenreich. Thanks.

Thank you, and to my mind:

Physician + Diagnostician + Psychopharmacologist + Psychotherapist = Psychiatrist

Choose to leave one of those out, and you're forfeiting your professional identity.

 

[Poety]

Thank you, and to my mind:

Physician + Diagnostician + Psychopharmacologist + Psychotherapist = Psychiatrist

Choose to leave one of those out, and you're forfeiting your professional identity.

Physician + Diagnostician + Psychopharmacologist + Psychotherapist - whiney psychotherapy = Psychiatrist

 

[PsychEval]

Physician + Diagnostician + Psychopharmacologist + Psychotherapist - whiney psychotherapy = Psychiatrist

Physician + Diagnostician + Psychopharmacologist + Psychotherapist - whiney psychotherapy + former nurse = A treatment team member you want on your good side.

 

[Doc Samson]

Physician + Diagnostician + Psychopharmacologist + Psychotherapist - whiney psychotherapy = Psychiatrist

I think that I remember having the same trepidation about psychotherapy being "whiney" before I started residency, but I've actually found it to require much more "backbone" than prescribing. No matter which school of therapy you're employing, the general idea is to maintain some emotional distance from the pt in order to help them in a more objective fashion. Psychodynamic therapy probably has the firmest ideas about boundaries, as previously described (but perhaps exagerrated) by Norto on this forum. You do "use" your emotions, in the context of understanding countertransference, but you are expected to remain distant enough from them that they do not adversely interfere with the treatment. CBT actually encourage a cognitive behavioral (hence the name ) formulation and treatment, with emotions sometimes being hypothesized as the result of cognitive distortions. DBT is built around a manualized system of behavioral analysis and skills training.

Ultimately, therapy is oftentimes about purposefully NOT giving the patient what they want, so that they can learn to get it for themselves from other areas of their life. This can take some massive cojones, especially when the pt is provocatively threatening self-harm or employing some other technique to try to hold you hostage. In the world of prescribing, you can all too easily fall in to the trap of giving the pt something, because it's easy to prescribe, and you genuinely want them to feel better. An interesting point here is that SSRIs are probably most responsible for the decline of psychotherapy, since giving a pt a TCA or MAOI engendered a far greater degree of risk and discomfort for the treater, possibly more so than engaging in psychotherapy. The relatively risk/guilt free prescribing of SSRIs has allowed psychiatrists to "wuss out" by providing a path of least resistance.

Real psychotherapy is not touchy-feely, and it is not whiney. It is choosing to willingly expose yourself to human suffering, without allowing yourslef the defense of reducing pain to an intellectualized concept of neurotransmitters and drug interactions. Not for the faint of heart.

 

[Doc Samson]

Sorry, double-post.

 

[Poety]

I think that I remember having the same trepidation about psychotherapy being "whiney" before I started residency, but I've actually found it to require much more "backbone" than prescribing. No matter which school of therapy you're employing, the general idea is to maintain some emotional distance from the pt in order to help them in a more objective fashion. Psychodynamic therapy probably has the firmest ideas about boundaries, as previously described (but perhaps exagerrated) by Norto on this forum. You do "use" your emotions, in the context of understanding countertransference, but you are expected to remain distant enough from them that they do not adversely interfere with the treatment. CBT actually encourage a cognitive behavioral (hence the name ) formulation and treatment, with emotions sometimes being hypothesized as the result of cognitive distortions. DBT is built around a manualized system of behavioral analysis and skills training.

Ultimately, therapy is oftentimes about purposefully NOT giving the patient what they want, so that they can learn to get it for themselves from other areas of their life. This can take some massive cojones, especially when the pt is provocatively threatening self-harm or employing some other technique to try to hold you hostage. In the world of prescribing, you can all too easily fall in to the trap of giving the pt something, because it's easy to prescribe, and you genuinely want them to feel better. An interesting point here is that SSRIs are probably most responsible for the decline of psychotherapy, since giving a pt a TCA or MAOI engendered a far greater degree of risk and discomfort for the treater, possibly more so than engaging in psychotherapy. The relatively risk/guilt free prescribing of SSRIs has allowed psychiatrists to "wuss out" by providing a path of least resistance.

Real psychotherapy is not touchy-feely, and it is not whiney. It is choosing to willingly expose yourself to human suffering, without allowing yourslef the defense of reducing pain to an intellectualized concept of neurotransmitters and drug interactions. Not for the faint of heart.

Come on DS, don't get so sensitive about the subject sheesh - I will argue though that there is an AWFUL lot of therapy that is not exposing yourself to human suffering, its rich bored people with nothing better to do than complain. Perhaps REAL psychotherapy like you say IS NOT, but thats not what i saw in outpatient - it was painful for me, the residents and even the attendings.

ETA: i hope i gain some better therapy experience in residency

 

[OldPsychDoc]

...An interesting point here is that SSRIs are probably most responsible for the decline of psychotherapy, since giving a pt a TCA or MAOI engendered a far greater degree of risk and discomfort for the treater, possibly more so than engaging in psychotherapy. The relatively risk/guilt free prescribing of SSRIs has allowed psychiatrists to "wuss out" by providing a path of least resistance.

Gee--I usually use benzos to grease the path of least resistance...

"Puh-LEEZE Dr. OPD? I'm just SOOO anxious.... I NEVER abused them, I promise. Puh-LEEEEEEZE?????"

 

[Poety]

Gee--I usually use benzos to grease the path of least resistance...

"Puh-LEEZE Dr. OPD? I'm just SOOO anxious.... I NEVER abused them, I promise. Puh-LEEEEEEZE?????"

Please tell me theres a niche I can get into in the field that deals only with spmi's

 

[Psyclops]

THe state is always hiring

 

[OldPsychDoc]

Please tell me theres a niche I can get into in the field that deals only with spmi's

OPD's Rules of Psychopharmacology #2:
"Anyone asking for more lithium or more haldol gets what they want."

 

[Poety]

OPD's Rules of Psychopharmacology #2:
"Anyone asking for more lithium or more haldol gets what they want."

HA! thats great. My mentor used to say, the ones that want to stay here are getting kicked out, the ones that want to leave, have to stay

 

[Solideliquid]

Come on DS, don't get so sensitive about the subject sheesh - I will argue though that there is an AWFUL lot of therapy that is not exposing yourself to human suffering, its rich bored people with nothing better to do than complain. Perhaps REAL psychotherapy like you say IS NOT, but thats not what i saw in outpatient - it was painful for me, the residents and even the attendings.

ETA: i hope i gain some better therapy experience in residency

Yeah c'mon DS! Do we have to up your Chillax™ again?

 

[Doc Samson]

Come on DS, don't get so sensitive about the subject sheesh - I will argue though that there is an AWFUL lot of therapy that is not exposing yourself to human suffering, its rich bored people with nothing better to do than complain. Perhaps REAL psychotherapy like you say IS NOT, but thats not what i saw in outpatient - it was painful for me, the residents and even the attendings.

ETA: i hope i gain some better therapy experience in residency

I can safely say that out of my entire psychotherapy panel, I have not seen one rich bored person with nothing better to do than complain... they're all in my psychopharm clinic (seriously). If therapy degenerates to just "complaining", then that's the fault of the therapist. Poorly done psychotherapy is painful for everyone, most of all the patient.

 

[PublicHealth]

I wish overall there would be a greater emphasis on preventative healthcare, psychiatric and otherwise. The insurance companies can't seem to get the old adage though "An oz of prevention = a lb of cure". That would help alot with the american model's woes. IMO.

Sorry, I was on vacation. Rest assured that my search engine in operating in prime form.

The Banks et al. (2006) study is illustrative. During my MPH days, I recall reading several older articles that examined the same issue and found the same result. There were also some articles that documented higher mortality rates and morbidities associated with private insurance-based systems of healthcare delivery compared to socialized medicine.

Poety, I appreciate your husband's insight into the differences between the US and UK healthcare delivery models. From a public health perspective, however, both systems are flawed. How many tens of millions of people do not have access to basic healthcare in the US? The US system has better technology, but many tests are unnecessary, and in some cases, increase mortality risk (I would look up the link, but I'm lazy today). Doctors are concerned about proper diagnosis and treatment, but are also preoccupied with getting sued. As you pointed out, the waiting lists in countries with socialized medicine are exceedingly long.

Which is the lesser of two evils? Guatemala has more equal access to healthcare than we do. For me, it's a question of accessibility. Solving that problem is a prerequisite for beefing up technology. Our priorities in the US are in the reverse order. I agree that the long waiting lists are a problem. Was there not an effort to combine the US model with the socialized model of healthcare in Canada? In other words, everyone has access to basic healthcare, but if you want to be seen sooner, you can buy private insurance. I recall reading about this somewhere, but admit to not following the literature as closely as I would like. Of course, this would broach issues related to discrimination.

 

[Poety]

I can safely say that out of my entire psychotherapy panel, I have not seen one rich bored person with nothing better to do than complain... they're all in my psychopharm clinic (seriously). If therapy degenerates to just "complaining", then that's the fault of the therapist. Poorly done psychotherapy is painful for everyone, most of all the patient.

You're a real trooper - gotta love your commitment to therapy

As I said, perhaps I had a bad experience, but it was bad. And lets not get started on the parents who blamed everything on the children - ugg.

I'm actually excited to learn more about different therapies that can possibly do good work. Mind you, I was also paired up with a social worker (LCSW) that would do these sessions, so maybe that has skewed my view, we'll see.

 

[Triathlon]

I'm actually excited to learn more about different therapies that can possibly do good work. Mind you, I was also paired up with a social worker (LCSW) that would do these sessions, so maybe that has skewed my view, we'll see.

MAYBE???!!!
Since when are social workers trained in anything even closely resembling psychotherapy? I imagine their insight would be very limited considering their education level. Apple-Oranges or Watermelons-grapes.

 

[PublicHealth]

MAYBE???!!!
Since when are social workers trained in anything even closely resembling psychotherapy? I imagine their insight would be very limited considering their education level. Apple-Oranges or Watermelons-grapes.

Dude, where have you been hiding?

http://www.op.nysed.gov/lcswprivilege.htm

 

[Poety]

MAYBE???!!!
Since when are social workers trained in anything even closely resembling psychotherapy? I imagine their insight would be very limited considering their education level. Apple-Oranges or Watermelons-grapes.

PH is right, at my institute, the LCSW does a LOT of the therapy - in fact shes one of the better ones, however her patients SUCKED, mostly there for that mommy doesn't like my boyfriend, I need to find myself crap that I'm not interested in AT ALL.

Child was somewhat interesting but you need a longer period of time with them to see whats going on, this is the problem with 3rd year exposure, you get the minimum and it usually isn't reflective of what being a psychiatrist will be like, I had to seek out other experiences.

There are MANY psychiatrists that don't like therapy, thats why they have c/l psych.

 

[Psyclops]

Alright, I'm gonna break down and ask, what does c/l stand for?

 

[PublicHealth]

Alright, I'm gonna break down and ask, what does c/l stand for?

Consultation-Liaison. It's one of the subspecialties of psychiatry. Also called psychosomatic medicine.

http://www.psych.org/edu/subspeciaties.cfm

Nice review of C-L Psychiatry: http://www.psychosomaticmedicine.org/cgi/content/full/63/6/896

 

[OldPsychDoc]

MAYBE???!!!
Since when are social workers trained in anything even closely resembling psychotherapy? I imagine their insight would be very limited considering their education level. Apple-Oranges or Watermelons-grapes.

Insight is not equal to educational level.
Hell, sometimes it's not even PROPORTIONAL to educational level!

 

[Anasazi23]

Which is the lesser of two evils? Guatemala has more equal access to healthcare than we do. For me, it's a question of accessibility. Solving that problem is a prerequisite for beefing up technology. Our priorities in the US are in the reverse order. I agree that the long waiting lists are a problem. Was there not an effort to combine the US model with the socialized model of healthcare in Canada? In other words, everyone has access to basic healthcare, but if you want to be seen sooner, you can buy private insurance. I recall reading about this somewhere, but admit to not following the literature as closely as I would like. Of course, this would broach issues related to discrimination.

Hey PH. I'm not as versed on the full aspects of healthcare as some, but I'd like to put out one of my "beefs."

Why do people say that the U.S. has no access to healthcare for the poor?
When I did my rotation at NUMC on Long Island, the vast majority of people had no insurance, no money, and were mooching off the system. The EMTALA laws require this. They get surgeries, neurology appointments, psychiatry appointments, even near-elective surgeries. The tax payors pick up the tab.

The real difficulty is the working class person (usually blue-collar) with minimal to no insurance that has an income, but cannot afford that abdominal CT because they actually [*gasp*] feel responsible to pay the bill when it comes.

 

[PublicHealth]

Hey PH. I'm not as versed on the full aspects of healthcare as some, but I'd like to put out one of my "beefs."

Why do people say that the U.S. has no access to healthcare for the poor?
When I did my rotation at NUMC on Long Island, the vast majority of people had no insurance, no money, and were mooching off the system. The EMTALA laws require this. They get surgeries, neurology appointments, psychiatry appointments, even near-elective surgeries. The tax payors pick up the tab.

The real difficulty is the working class person (usually blue-collar) with minimal to no insurance that has an income, but cannot afford that abdominal CT because they actually [*gasp*] feel responsible to pay the bill when it comes.

As far as know, I did not say anything about the poor not having access to healthcare. It's the working class who have it tough. They're the ones paying taxes to pay for the poor's healthcare, housing projects, prisons, wars in Iraq, etc. All while paying $3/gallon to get to their blue collar jobs in the morning so that they can once again work two days per week to support the poor (and the rich). Lovely system, isn't it?

Some of the most interesting research that I read during my public health training was by Ichiro Kawachi and Lisa Berkman http://www.amazon.com/gp/product/01...102-6781898-4736156?s=books&v=glance&n=283155 They've done some really elegant work showing that social factors such as income inequality underlie health problems in the general population. Everything else is simply a proximate mediator of this relationship. Proximate factors are much more easily addressed than the true, underlying causes, yet sweeping policy interventions have the most direct and dramatic impact on health outcomes.

I'm waiting for social epidemiology to move away from using self-report health ratings to biological measures.

Some reading in this area:

http://www.ncbi.nlm.nih.gov/entrez/...uids=16690902&query_hl=20&itool=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/...uids=16630120&query_hl=20&itool=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/...uids=16505430&query_hl=20&itool=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/...uids=16378349&query_hl=20&itool=pubmed_docsum

 

[Poety]

PH, I think you and Saz just said the same thing, except yours has links

 

[Doc Samson]

There are MANY psychiatrists that don't like therapy, thats why they have c/l psych.

Hate to break this to you Poety, but understanding therapy is a part of C/L too. In ~36 days, I will be a C/L fellow.

 

[pingouin]

MAYBE???!!!
Since when are social workers trained in anything even closely resembling psychotherapy? I imagine their insight would be very limited considering their education level. Apple-Oranges or Watermelons-grapes.

Whoa. Walking into this late but need to speak up here. Not all MSW programs are created equal when it comes to clinical/mental health training.

My MSW program was a clinical program on the East Coast, with an emphasis on psychodynamic theory, object relations, self psychology and ego psychology. My internship was in a program that was based in a CBT brief therapy model, which tends to fit my personality and therapy style better. Our program was so clinical that when my internship supervisor listed my responsibilities, the school tried to discount some of my hours when I was serving on committee meetings, etc (ie, lending a psych-oriented perspective to the workplace violence prevention committee) since it was not individual, group, or family therapy. In class we were taught some (very basic) psychopharm, lots and lots of theory work, and were drilled on psychopathology and diagnostics.

This was the only track or concentration at my school, but other schools have concentrations in policy, children/families, health, community, etc. I have seen non-clinical/mental health MSWs work as therapists, and you're right- it's not pretty. The licensing boards are getting fairly strict about what post-grad experience qualifies one to obtain a clinical license. Many states are moving toward having two levels of MSW license- the traditional LCSW/LISW/LICSW depending on the state, and then a LMSW for people whose backgrounds are more in policy, advocacy, program admin.

 

[Poety]

Hate to break this to you Poety, but understanding therapy is a part of C/L too. In ~36 days, I will be a C/L fellow.

You won't be doing 50 minute therapy sessions with bored rich folks though

 

[PublicHealth]

PH, I think you and Saz just said the same thing, except yours has links

Right. The social epi stuff is an area of research that has the potential to inform healthcare policy. That's what attracted me to public health. Unfortunately, more than 90% of the federal healthcare dollar is spent on tertiary instead of primary or secondary interventions. Simple interventions such as not putting growth hormone in meat and milk, arsenic in chicken, and high fructose corn syrup in everything we eat could make a huge difference. Heinz ketchup in Canada, for example, contains pure cane sugar instead of high fructose corn syrup. I suspect that the government plays a role in regulating what goes into their food.

More on HFCS:

http://www.ncbi.nlm.nih.gov/entrez/...uids=15051594&query_hl=32&itool=pubmed_DocSum

http://www.ncbi.nlm.nih.gov/entrez/...uids=12399260&query_hl=32&itool=pubmed_DocSum

http://www.ncbi.nlm.nih.gov/entrez/...uids=16366738&query_hl=32&itool=pubmed_DocSum

Health insurance companies are slowly beginning to realize that they could save money by preventing instead of treating disease. Did you get any fliers recently from your health insurance company? I was at a conference not too long ago where some HMO psychiatrists and psychologists were talking about screening strategies they were using to identify psychiatric disorders that may exacerbate physical morbidities and increase medical utilization and duration of hospital stays. All in the name of the almighty dollar, but prevention nonetheless.

 

[Triathlon]

I half wanted to get a rise out of my comments, sorry. But really is the therapy the same? Are they coming at it in the same way? Should we give them RxP rights? My point was aimed more at the psychotherapy given by a psychiatrist, it is going to be mingled with psychobiological insight, psychopharmacological insight, and psychiatric diagnostic insight, and plain old medical insight. This is the insight that I was thinking of. Unless none of this is necessary to perform our psychotherapy then I take it all back. I just figured as physicians we have a greater ability to handle the big picture. Maybe my idea of treatment involves too much cohesion of our tools. Please correct me if I am mistaken.

 

[pingouin]

In a perfect world, I'd love to see more psychiatrists doing therapy. In my area, it's pretty rare. I would never pretend to understand the bio- end of biopsychosocial to the level that a physician knows it, and I think you're right, Tri- patients probably do get something different from that experience.

So the next-best option as far as I can tell, is for me to educate myself as much as I can as a non-physician on the subjects you mention, ie, psychopharm, psychobiology, and collaborate with the psychiatrists my patients are seeing. It's mutual- I'll call them about what appear to be med side effects, they call me about something a patient mentioned that they'd like addressed in therapy. Because I have an interest in medicine (doing my post-bacc now), I tend to ask questions about the meds, the mechanisms, the side effects. I really can't speak for how others choose to learn about these things- or if they do at all.

Probably half of my current practice has been referred to me by one psychiatrist, who is fairly fresh out of residency. She told my colleague and I that she has absolutely no interest in doing psychotherapy, only wants to do medication management. She believes strongly in the value of therapy, so she refers almost everyone she sees to our group practice. Her philosophy is that she'll stick to "what I went to school for" (SORRY Doc Samson! her words, not mine!) and let us do "what you're best at".

 

[Doc Samson]

You won't be doing 50 minute therapy sessions with bored rich folks though

But I will be starting a small private practice where I do 50 minute therapy sessions with my patients (not bored, distinctly middle class).

 

[Doc Samson]

Her philosophy is that she'll stick to "what I went to school for" (SORRY Doc Samson! her words, not mine!) and let us do "what you're best at".

No need to apologize, but if psychiatric training was limited to medication management, I would be bored out of my mind. She "went to school" to be a psychiatrist. As I've previously mentioned, that includes, by definition, psychotherapy.

 

[pingouin]

No need to apologize, but if psychiatric training was limited to medication management, I would be bored out of my mind. She "went to school" to be a psychiatrist. As I've previously mentioned, that includes, by definition, psychotherapy.

I wholeheartedly agree with you on this. It's one of the big reasons I'm back in school. I think it boils down to personal preference rather than training milieu- I also work with one of her residency cohorts, and he prefers to do minimum 20-30 min sessions so he can catch up with what's going on with his patients, not just do med checks.

However, Poety- I guess my friend is proof (n=1) that you CAN do a med management-only practice if you so choose.

 

[OldPsychDoc]

I wholeheartedly agree with you on this. It's one of the big reasons I'm back in school. I think it boils down to personal preference rather than training milieu- I also work with one of her residency cohorts, and he prefers to do minimum 20-30 min sessions so he can catch up with what's going on with his patients, not just do med checks.
.

I'm really glad I'm in a system that schedules me for 20-30 minute checks, b/c I NEED to know "what's going on". How can I do a "med check" on the 47 y/o divorced mother of 2 who just found out this week that she has Stage IV adenocarcinoma in both lungs? I'm not exactly "doing therapy", but I'm not doing my job if I'm just "checking" her klonopin dose!!!

 

[Triathlon]

I'm really glad I'm in a system that schedules me for 20-30 minute checks, b/c I NEED to know "what's going on". How can I do a "med check" on the 47 y/o divorced mother of 2 who just found out this week that she has Stage IV adenocarcinoma in both lungs? I'm not exactly "doing therapy", but I'm not doing my job if I'm just "checking" her klonopin dose!!!

That's what I'm talking about.
To be effective we need to combine all of our tools. A med check can be a med check alone if that's all that is needed but how often does that happen?

 

[pingouin]

OPD, I really am with you on this. I love to hear the docs say they want to spend time with their patients.

I have several patients who have case managers who bring them to see me as well as the psychiatrists. From the reports of the case managers (NOT the patients), there are certain private practitioners in our area who routinely spend 4 to 7 minutes with my SPMI patients every 6-8 weeks. They bill for the full 15 minutes, and there are Medicare EOB forms to prove that.

As most of these patients also have multiple medical issues, I would venture a guess that there's not much coordination of care going on with the PCPs, much less any sort of medical workup by those psychiatrists.

Every last one of my patients who is seeing one of these docs also has a comorbid benzo or narcotic abuse problem. A coincidence, I'm sure.

 

[OldPsychDoc]

OPD, I really am with you on this. I love to hear the docs say they want to spend time with their patients.

I have several patients who have case managers who bring them to see me as well as the psychiatrists. From the reports of the case managers (NOT the patients), there are certain private practitioners in our area who routinely spend 4 to 7 minutes with my SPMI patients every 6-8 weeks. They bill for the full 15 minutes, and there are Medicare EOB forms to prove that.

As most of these patients also have multiple medical issues, I would venture a guess that there's not much coordination of care going on with the PCPs, much less any sort of medical workup by those psychiatrists.

Every last one of my patients who is seeing one of these docs also has a comorbid benzo or narcotic abuse problem. A coincidence, I'm sure.

Thanks.

(The cynic in me wants to agree with those practioners billing 15 minutes for 4-7 minutes work...after all, Medicare is only going to pay us for 40% of our value in these visits anyway... I'll try to continue doing what's ethical and what's right in spite of them, though.)

 

[pingouin]

Thanks.

(The cynic in me wants to agree with those practioners billing 15 minutes for 4-7 minutes work...after all, Medicare is only going to pay us for 40% of our value in these visits anyway... I'll try to continue doing what's ethical and what's right in spite of them, though.)

Use the Force, OPD. Don't go to the Dark Side.

 

[Poety]

I wholeheartedly agree with you on this. It's one of the big reasons I'm back in school. I think it boils down to personal preference rather than training milieu- I also work with one of her residency cohorts, and he prefers to do minimum 20-30 min sessions so he can catch up with what's going on with his patients, not just do med checks.

However, Poety- I guess my friend is proof (n=1) that you CAN do a med management-only practice if you so choose.

Hi Jlw, thanks! I think I'd like to do what your other colleague does - those 20 minute "catch up on things" with med checks perhaps. All I know is, even on my interview trail, a residency program said, oh your from xyz, if you plan on moving back there, you can have a very lucrative cash for service practice. I CRINGED at the thought of that since that is NOT why I'm becoming a psychiatrist. I enjoy the people with spmi, but thats me ya know?

As I've always said, I'd love to refer my patients to the ologists in my office for therapy - but thats just MY take on it DS disagrees ofcourse but thats ok.

 

[Doc Samson]

Hi Jlw, thanks! I think I'd like to do what your other colleague does - those 20 minute "catch up on things" with med checks perhaps. All I know is, even on my interview trail, a residency program said, oh your from xyz, if you plan on moving back there, you can have a very lucrative cash for service practice. I CRINGED at the thought of that since that is NOT why I'm becoming a psychiatrist. I enjoy the people with spmi, but thats me ya know?

As I've always said, I'd love to refer my patients to the ologists in my office for therapy - but thats just MY take on it DS disagrees ofcourse but thats ok.

I don't disagree with the concept of split treatments, they're actually indicated in some cases. What I disagree with is the idea that psychiatrists can disown the practice of psychotherapy entirely, it's too important to what we do.

 

[pingouin]

I don't disagree with the concept of split treatments, they're actually indicated in some cases. What I disagree with is the idea that psychiatrists can disown the practice of psychotherapy entirely, it's too important to what we do.

(and until I can get into med school, I'll be making my living off of those psychiatrists who disagree with you!)

 

[OldPsychDoc]

Use the Force, OPD. Don't go to the Dark Side.

I only want to use the power of the Dark Side for GOOD! I swear!

 

[Anasazi23]

I only want to use the power of the Dark Side for GOOD! I swear!

But the Dark Side is only bad if you interpret it to BE bad.

Besides, it's so much easier and more powerful!

 

[maranatha]

Thank you, and to my mind:

Physician + Diagnostician + Psychopharmacologist + Psychotherapist = Psychiatrist

Choose to leave one of those out, and you're forfeiting your professional identity.

Thank God there are psychiatrists like Doc Samson!!! This is why I'm going into psychiatry....To use every skill possible to heal.