Sunday, November 11, 2007

Psychiatry's Identity Crisis

Today, the Sunday New York Times has not been inspirational. I suppose I could blog about the pictures they have of the brains of the political candidates, but I just don't want to.

So I surfed around and from KevinMD, I landed on The Medfriendly Blog where neuropsychologist Dominic Carone is talking about how some physicians claim that others-- particularly psychiatrists and physiatrists-- aren't REAL doctors. Dr. Carone goes through the definition of doctor, and his theories on why some docs dis other docs. I added my thoughts to his comment section, specific to psychiatrists, that we may be seen as "less than" because we are less-hands on, our version of an exam is a of mental phenomena and not necessarily of the body, and that part of our treatment is the act of listening/interpreting. Also, many shrinks don't wear a white coat (I'm one of those). Plus we have the Woody Allen view of shrink as psychoanalyst, and pure psychoanalysis can be done by people with several different degrees.

You know, it's a complicated issue because even the term "shrink" is sometimes shared with psychologists, and I generally address anyone with a PhD (even if it's in history, social work, nursing) as "Doctor" and I'm completely comfortable with that, but really, is someone with a PhD in English a "doctor"? No, they have a doctorate degree, but the professional designation is reserved, I think, for those who've graduated from medical and osteopathic schools. Dentists, podiatrists, and vets (and others, for example, neuropsychologists) do the same stuff as "doctors" -- they diagnose and treat illnesses, they have training that's at least as extensive as a people doc, the same prerequisite education, they've dissected those cadavers, they write prescriptions and perform surgery -- in my brain they are certainly doctors, but I bet if you ask them what they do at a party, they say 'I'm a vet/dentist' not I'm a doctor (the podiatrist probably says 'I'm a foot doctor' but hey).

Even without a white coat and a complete physical exam (...ah, I do sometimes check vital signs, ask a patient to walk, hold out their hands to evaluate a tremor, check for cogwheeling, order labs, request that medication vials be brought to the session)'s my view of why shrinks ARE docs.

Psychiatrists must attend medical school. To even get into medical school, certain pre-med requirements must be met and back-in-the-day these included: 2 semesters each of calculus, chemistry, organic chemistry, biology (one semester was biochemisty), physics, and all the sciences included lab courses as well. I believe a year of English is now required, my university back then required it for graduation as well as 2 years of a foreign language and some history/social sciences as well.

Medical School entails a two year pre-clinical course of study. I'm not sure I can remember all the courses I took, but here's a smattering: gross anatomy with cadaver dissection, histology (the study of cells), physiology, pathology, pharmacology, biochemistry, neuroanatomy, embryology, microbiology, immunology. With all the talk around about psychologist prescribing legislation which allows psychologists to prescribe psychotropics after taking a 10-week pharmacology course, I want to point out that pharmacology for medical students is a second year course, begun only after years of science prerequisites are met. That's another rant for another day. In the second year, medical students begin learning to perform physical exams and take medical histories.

The two final clinical years of medical school include for everyone (even shrinks): 12 weeks of internal medicine, 12 weeks of surgery, rotations in pediatrics, OB-GYN, psychiatry, neurology, and I maybe missing some other stuff. Surgery for me included a few weeks of cardiothoracic surgery, and electives in neurosurgery and plastic surgery. The fourth year has lots of elective time and time to interview for internships/residencies. I spent some time doing psych research in California, primary care on a Navajo reservation, psych rotations in hospitals I thought I might want to go to, cardiology, a pain service month, and I can't recall what else.

Before psychiatry training formally begins as a specific residency, a year of internship, hands on, being-a-doc is done-- a transitional year may include 6 months of psychiatry, I did a year of pure medicine and did the whole CCU/ICU/renal transplant unit/AIDS units stuff, no psychiatry.

Okay, then there were 3 years of psychiatry: inpatient, outpatient, electives, mostly just psychiatry except for when inpatients got physically sick and needed work-ups begun before the medicine folks arrived.

Many days, I feel like I've forgotten everything that doesn't have anything to do with psychiatry. Actually, I'm pretty sure I have. I haven't heard of half the meds people are on anymore, I forget the details of how lots of stuff works. My father-in-law asked if you pee less if you have one kidney...? does the second kidney double it's filtration rate? And I need to go look up what a mild decrease in T3-uptake means if the TSH and T4 are both normal.

I titled this Psychiatry's Identity Crisis, and if some surgeon or radiologist wants to fight... but really, amongst ourselves, we don't have a "crisis".
--Dr. Dinah


Anonymous said...

Something to consider: Doctor was originally used to refer to a church leader. Ph.D.s were referred to as doctors 2 years before medical graduates were and medical graduates weren't commonly called Doctor until the late 1500s.

I am a psychology Ph.D. I agree that in the common vernacular people think of "Doctors" as people with M.D.s. But as someone who spend 8 years post-graduate, I earned the title just as sure as medical graduates did. So did lawyers, optometrists, all types of professors, etc. But I don't insist that anyone call me Dr. I wouldn't answer "I'm a doctor" to the question "what do you do?"

c.1303, "Church father," from O.Fr. doctour, from M.L. doctor "religious teacher, adviser, scholar," from L. doctor "teacher," from doct- stem of docere "to show, teach," originally "make to appear right," causative of decere "be seemly, fitting" (see decent). Familiar form doc first recorded c.1850. Meaning of "holder of highest degree in university" is first found c.1375; that of "medical professional" dates from 1377, though this was not common till late 16c. Verb sense of "alter, disguise, falsify" is first recorded 1774.

Bardiac said...

You guys are really uptight about your titles and stuff, aren't you?

You should definitely read more Shakespeare. /nod A little Twelfth Night, perhaps?

Dinah said...

To Anon--
No problem with PhD's being addressed as "doctor"...the issue is more when other MD's say that psychiatrists aren't "real" doctors...

Anonymous said...

You might be a "real" doctor by virtue of all the courses you took but you do not practice real medicine. Too bad ,so sad.

Anonymous said...

Are those of us they are treating not *real* patients then? Are we somehow disqualified from having *real* medical illnesses?

Anonymous said...

IME, other MDs tend to think psychiatrists are not "real" doctors, and other mental health professionals think psychiatrists are not "real" psychotherapists. So, left out of both camps. To me, if you have have the training as an MD, you are a "real doctor." No question about it. Too bad the insurance companies don't always agree.

ClinkShrink said...

I think I still have my signed procedure cards tucked away somewhere from when I was in the ICU. Arterial lines, subclavians, thoracentesis, paracentesis, not to mention the good old lumbar puncture. Non-psychiatric physicians have to do a lot of mean things to their patients in order to heal them. Kind of makes giving medicines look rather tame.

All the 'non-real' doc stuff kind of rolls off me by now. The docs who think like that sure change their tune when they've got a psychiatric patient who needs to be seen.

Anonymous said...

hocus pocus

Dr. Val said...

From one physiatrist to the shrink rap psychiatrists... we should hang out together sometime! At least people have an idea about what you do. My specialty is the victim of the world's worst PR efforts. I'm always asked if I went to medical school or if I'm really a physical therapist or what it's like to treat feet all day long. I'm not sure how to fix this. :) Lately I've resorted to calling myself a Rehab Doctor... but then people think I'm a recovering drug addict. Do you have any advice for me? I need to be rebranded.

janemariemd said...

Unf--king believable! That psychiatrists sometimes aren't considered docs I mean. This may have to do with the spread of information and access to all sorts of info such that lots of folks think anyone can diagnose and treat anything these days.

I still vividly recall some of the patients from my med school days who had severe depression and bipolar disorder, but improved immensely (and relatively quickly) with care from a psychiatrist.

Michael Rack, MD said...

In my opinion, a person becomes a real doctor by completing a real internship. The internship you did qualifies. However, the standard psychiatry internship of 8 months psychiatry, 1-2 months of inpatient medicine, 1-2 months of outpt medicine, and a month in the ER doesn't cut it.

Michael Rack, MD

Anonymous said...

I studied a lot of history but I never heard of unf---king.

Anonymous said...

There are very few real medical illnesses treated by psychs if at all. Mostly people are "treated" for stuff that psychs have worked hard to bring under the umbrella of disease. Psychs invent more diseases than they treat.

FooFoo5 said...
This comment has been removed by the author.
FooFoo5 said...

I wrote about this issue in regard to the Disappearing Patient where the question asked is does psychiatry wish to be known as "neuroradiology-lite.

I am presuming that what we do seems, "easy." The Pharmaceutical industry fills mainstream magazines with "mini-exams" of psychiatric symptoms and suggest you "take this to your doctor." Not to seek specialized psychiatric care, but to your primary care doctor. Depression? Anxiety? Insomnia? Write a script. It's so easy that psychologists who take a state-sanctioned course in psychopharmacology wish to prescribe medications. Yet,the number of missed diagnosis, wrong diagnosis, and mismanaged psychiatric patient care from primary care and ER physicians is well documented.

Is this simply a "territorial" complaint? We are far too accustomed to receiving, without complaint, patients who don't "respond" to a medication, who are "difficult," who are chemically dependent, or whose symptoms are grossly manifest in primary practice. "Let me refer you to..." the "mop-up."

Could I put in a central line? Yes. Would I? In the best interest of patient safety, I would defer to someone who does this much more frequently. Could I assist in a code? Yes, I've been trained to do so. Would I lead? In the best interest of patient safety, I would defer to someone who does this much more frequently. Can I interpret lab results? Yes. Would I attempt to manage HTN? In the best interest of patient safety, I would defer to someone who does this much more frequently. Have I delivered a child? Yes. Would I alone? In the best interest of patient safety, I would defer to someone who does this much more frequently. This, it seems to me, is both ethical and sensible.

I believe that we are here, "connecting patient experiences to social realities," with our specific medical skills. We do not yet possess undeniable confirmatory tests for diagnosis, and thus treatment. So we carefully sort through the spectrum of bio-psycho-social symptoms presented to us, and address them in an evidence-based, medical manner. And far too often, this specialty is judged simply by the misunderstood criterion of "outcome." Some conditions are treated and resolved. But like any chronic, persistent medical condition, many psychiatric conditions are "managed" rather than "cured"; improved functioning, rather than resolution.

I agree completely with Dinah. I have no identity crisis.

ClinkShrink said...

When I was applying for residency I didn't see any programs that had eight months of psychiatry during internship. But lets take it full circle here---we're spending far too much time on the perceived deficiencies of psychiatric medical training when the bigger and more common issue is the lack of psychiatric training for non-psychiatrists. General medical internships don't require psychiatry rotations, or at least they didn't when I was in training. On our last podcast we talked about the current problem where ICU docs fail to recognize and diagnose delirium. This is a real problem and it's a common one. We should be asking: "How can someone be a 'real' doc when they aren't trained to treat brain diseases?"

Anonymous said...

"There are very few real medical illnesses treated by psychs if at all"

Genetics will prove you wrong.

Anonymous said...

Well said, ClinkShrink.

Roy said...

Touche, Clink! As a C-L psychiatrist, it is a common (and sometimes frustrating) occurence to "mop up" unrecognized medical and psychiatric problems after they have festered too long. Delirium is one of these but others include stroke, thyroid, OSA, withdrawal syndromes, seizures, etc.

It would be good to have internists and generalists have more psychiatric training, as they see and treat a lot of it in their practice. I am always willing to teach them.

None of the accredited psychiatric programs would permit 8 months of psychiatry in a 1-year internship. To be accredited in the US, there must be at least 6 months of Medicine, with 2 months being Neurology (see this ACGME Word document for details). We also handle a fair amount of general medicine on the inpatient unit (18 months) and on C-L rotations. Note that most of us do a 4-year residency (compared with Medicine's 3 yrs), though some (like Dinah) do 1 full year of Medicine prior to doing a 3 year Psychiatry residency.

Michael Rack, MD said...

Regarding psychiatry internship requirements: only 4 months of medicine are required for 2008, see (page 13, Four Year Psychiatry Residency Program)

Michael Rack, MD said...

Here's an ACGME link that describes the 4 months of medicine required during an internship psychiatry year:
(see page 3, notice "no more than eight months in psychiatry")
I think that psychiatrists should either be required to do a standard medical internship or to do an internship similar to the one performed by neurology residents.

Anonymous said...

(((((other MDs tend to think psychiatrists are not "real" doctors, and other mental health professionals think psychiatrists are not "real" psychotherapists.))))

Hm....I am learning to be a clinical social worker. I am taking two full time Graduate years to be a counselor. No offense..but in some places social workers and psychologists have more training in that "talky" stuff.

However!!!!! Psychologists and Social Workers should not prescribe meds PERIOD!

I have had some of that biochemically pharmacology stuff from my failed attempt at Pharmacy School. You can become a clinically effective therapist without ever have taken a biology class (or an organic chemistry class).

Psychotropic medications can have some very severe adverse effects. I would not want anyone prescribing Lamictal who would not recongnise Toxic Epidermal Rashy things.

Always thought us mental health people were a team. We all have different roles....but working with the same people.

I think you guys are REAL Doctors (with white coats and everything!!!!)

So where does that leave the D.O.'s? Do they have completely seperate residencies?

Anonymous said...

My New Mental Health Algorism-

Psychiatry: Complete medical history, vitals, determines if any behavior/mood is due to medical issues, prescribe meds, manage adverse effect, make changes...etc

Axis I:
Psychologist: Cognitive Behavior, psychoanalytical, etc etc etc. Good therapist.

Axis II:
Social Worker: Social worker closes office door and bangs her head against the wall fustrated because she has been screamed and leared at by an hormonal borderline teenage girl for the last hour and 15 minutes. All the while telling client that she was overjoyed that her behavior was indeed an indication of her self reliance...blah blah blah

I am just kidding!

Anonymous said...

Ladyk73, I would make a correction to AXIS I. While seeing a psychiatrist on an outpatient basis (and I've seen more than one) I've never had my vitals taken. I think they should considering many of the medications elevate bp. Vitals, therefore, should be taken off the list because they're not being done.


Medicoglia, RN said... psychiatrist always asks about my diabetes management and my asthma; and makes any med changes/reccomendations based on those two issues as well as what I am seeing her for. She also caught an impending asthma attack because I appeared "winded" in her office. Of course she couldn't treat it herself, but she called my GP, actually got her on the phone, explained the situation and when I left pdocs office, went straight to GP's office for asthma treatment. Seems like a "real" doc to me! She was a great chem tutor too! lol

Anonymous said...

It strikes me that those questioning if psychiatrists are "real" doctors are just being obnoxious. It is precisely because I consider them "real" doctors that I am surprised they do not pay attention to things like the effects of the meds they prescribe on a patient's blood pressure, etc., whereas I would not expect the same from a psychologist or social worker.


Anonymous said...

I am a PhD Clinical psychologist with a post doc MS in psychopharmacology. I have also recently completed 4 years of med school, so I guess I am a Dr., Dr.? Silly, isn't it?

On the comment about psychologists prescribing: I am not aware of any 8 week courses in psychopharmacology which supposedly prepare psychologists to prescribe. I completed a 2 year post doc MS program with a 12 month internship in psychopharm. Those are the minimum requirements (in addition to passing a board exam)for psychologists to apply for prescribing privileges.
Significantly more formal education in psychopharmacology than is available in psychiatric residencies. (I was faculty in a nationally renowned psychiatric residency program in the midwest).

Now having completed my MD, I am shocked to have experienced the lack of psychopharmacology education, or for that matter pharmacology for med students. The two semester pharmacology and the TWO WEEKS devoted to psychopharm in my second year was equivalent to the first semester academic didactic in my post doc MS psychopharm program.

Additionally, my psychiatric colleagues in continuing ed institutions such as the Neuroscience Education Institute (faculty consisting of psychiatrists) seminars and academies, display an astonishing and frightening lack of basic medical knowledge (therefore I must agree with some critics who maintain that psychiatrists do not practice medicine).

At the risk of offending my psychiatric colleagues, I would suggest that the best way to fight against the "dangers" of non-medically trained psychologist in prescribing, is to begin by reviewing basic medical concepts; and to make a serious effort in catching up to the clinical, diagnostic and psychopharmacologic training of the "dangerous" non-medically trained psychopharmacologist-psychologists.