What do you guys hate about psychiatry?

[sunlioness]

As for not treating the real problem . . . Yeah. Happens all the time. Where I am now, the real problem is poverty. I find myself actually telling people a lot, "I wish I could actually help you with the real problem." They seem to both understand and appreciate that.


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[clausewitz2]

As for not treating the real problem . . . Yeah. Happens all the time. Where I am now, the real problem is poverty. I find myself actually telling people a lot, "I wish I could actually help you with the real problem." They seem to both understand and appreciate that.


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Isn't this pretty typical of any specialty that manages chronic issues, though? Dude with COPD at 45 who continues to smoke two packs a day is going to benefit from inhalers, sure, but, uh, not the real problem that is causing limitations in his life.

Better example: dude with SBP over 200 who takes his BP meds only when he has a headache because he can't swing them on a regular basis.

 

[F0nzie]

Doesn't anybody think it's weird that psych is rarely seen collaborating with other doctors in multispeciality practices where having a psychiatrist on board would seem ideal? I will sometimes see a psychologist in the practice with the FPs or Peds managing the meds or Nps doing the psych stuff. We kinda do our own thing in the corner. Are we are the red headed stepchild of medicine? lol

 

[Shikima]

I really hate this whole issue of "parity diagnoses." No other field, as far as I know, has to deal with this.

But for psychiatry, we have to put a diagnosis from a certain list "otherwise we won't get paid." So if the true issue is a substance-inducted mood disorder, I can't put that as the first diagnosis and be done with it (except at the VA), but have to list some other closely-related but not 100% true diagnosis so that "we can get paid." Ugh.

I can't even bill for dementia related processes which are G codes..... I need to use F codes. I'm exploring this issue with my PHO and involving hospital leadership. Utter nonsense.

 

[Shikima]

Doesn't anybody think it's weird that psych is rarely seen collaborating with other doctors in multispeciality practices where having a psychiatrist on board would seem ideal? I will sometimes see a psychologist in the practice with the FPs or Peds managing the meds or Nps doing the psych stuff. We kinda do our own thing in the corner. Are we are the red headed stepchild of medicine? lol

Yes. Even in the VA system, where it is easily 60-70% emotional based, hospital leadership and VACO really do not tolerate mental health services nor value it.

 

[smalltownpsych]

Isn't this pretty typical of any specialty that manages chronic issues, though? Dude with COPD at 45 who continues to smoke two packs a day is going to benefit from inhalers, sure, but, uh, not the real problem that is causing limitations in his life.

Better example: dude with SBP over 200 who takes his BP meds only when he has a headache because he can't swing them on a regular basis.

Not a very good analogy IMO. The patients with life problems causing depressed mood are also those who are less likely to benefit from medication other than the placebo effect. They are not happy pills and they don't increase mood in non-depressed people. In fact, they are reported to reduce emotional experience in many which is also a benefit for some of my patients. Of course, this doesn't include benzos and stimulants which can make almost anyone feel better.

 

[notdeadyet]

It's changing. Only recently has the APA embraced the idea of collaborative care, and once they did, they still need to figure out how to do it.

I think you'll see it happening more and more at the VA first. There are a lot of pilot programs going on right now. The politics of vets waiting so long to establish psychiatric care is such that there is a big influence on cutting that down and while they are opening new Access to Care clinics, they are also trying to reach out to vets where they already have services, which makes a lot of sense.

I'm waiting for when this roles out into community health, where it makes even more sense.

 

[DD214_DOC]

There are several collaborative/consultation type models out there, mostly to help PCM/PCP's handle psych stuff with consultation if necessary. The biggest shortcoming of these models is that PCM's/PCP's have neither the time nor the interest to do any of it, and I think they prefer the referral model if only to make their time-consuming psych patients go away so they can forget about them.

 

[sunlioness]

That and it's hard for the consulting psychiatrist to bill. I did a bit of that kind of work at my last job. I really enjoyed it. It was a nice break from direct patient care.


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[smalltownpsych]

That and it's hard for the consulting psychiatrist to bill. I did a bit of that kind of work at my last job. I really enjoyed it. It was a nice break from direct patient care.


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Not being able to bill for consultation is a big problem. I spent about ten minutes discussing a case with a psychiatrist last month, but that was unusual circumstances because of Tarasoff considerations. Most of the time, we don't talk at all and it could be helpful for the treatment, but I can't bill for it and neither can she. I can't bill for phone calls to patients either under any treatment code although they are obviously not social calls. Also, many insurances won't pay for a family session without patient present which is what a parent coaching session would have to be billed as and is often more indicated than a session with the kid themselves.

 

[Information Underload]

My answer is simply documentation. It's the thorn in my side. Part of that is trying to establish my professional reputation early in my career, but notes in psychiatry realistically must be longer than those in most other fields. I hate this part of my job more than any other. Just hours of mindless nonsense.

 

[DD214_DOC]

FYI, there are interprofessional collaboration codes but I think they apply only to physicians. I will have to dig them out. They are relatively new. The problem is that the reimbursement is kinda crappy, and in the 10-15 minutes you collaborate you could have seen a patient for a medication f/u and received considerably more reimbursement.

In a system where providers are salaried, it makes sense as it theorectically potentially prevents your panel from growing and saves you time in the long run and decreases overall workload. If, and only if, it doesn't disrupt other patient care. (which it does since time is never actually carved out for it). In pp, it probably doesn't make sense.

 

[sunlioness]

I've learned that in institutions where providers are salaried, they seem to be more about generating the billable income. Less flexible with scheduling. More about cramming people in there. If they have to pay you regardless, they're going to make sure they're getting paid too.

I'm wondering if that's why my current gig brushed me off when I asked them about doing work with primary care and my last gig loved the idea. Having said that, they gave me imputed RVU credit for doing it. So it wasn't just that.


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[Shikima]

You're only as good of a work horse as long as you generate revenue and other services which are important to that institutions leadership. You are not a valued member of the team......

 

[Shikima]