Friday, May 27, 2011

To Shrink or Not To Shrink?

Here at Shrink Rap, we often talk about the stigma of having a psychiatric disorder. It's funny, but society has it almost ranked, so that certain illnesses are very stigmatized--schizophrenia and schizoaffective disorder, and borderline personality disorder, to name a few, and others are pretty much socially acceptable: Attention Deficit Disorder, for example, especially among the high school/college crowd where the patient often gets identified (or self-identifies) as the source for those late-night stimulants that so many kids cop.

It's not just the patients. Psychiatrists are also stigmatized, and that doesn't help much when our society talks about the shrink shortage.

Exalya writes:

I'm a first (almost second) year medical student with a strong passion for psychiatry. I love listening to your podcasts; you give me hope for my future when the drudgery of first year classes is getting me down, and I feel like I always learn something useful.

That aside, I am writing to you seeking some advice. At my school, we are required to follow doctors in family practice clinics periodically during years 1 and 2. Frequently I am asked, "What field are you interested in?" to which I reply, of course, "Psychiatry." It seems like every time an attending finds out that I'm into psych, I get eye rolls and flippant remarks. The most common ones are "Psychiatrists just push drugs," "Talk therapy is garbage," and "You'll talk to patients more in family practice." Do you have any advice on how to deal with attendings who do this? Is this the kind of attitude I'll be facing during 3rd year rotations outside psych?

Appreciate anything you have to offer!

From Dinah:

Dear Exalya,

I am so glad you enjoy our podcast! I also got the same nonsense, one of my preceptors told me that I would be more use to society as a plastic surgeon. Great.

The three of us wrote a post sometime back called Who Wants to be a Shrink?...please check it out.

Psychiatry has a lot of options: it is what you make it. You can have a low volume practice and focus on psychotherapy, you can have a high volume practice and madly write prescriptions, or you can mix it up. You can teach, do basic research and never see a patient, be a chairperson or administrator, focus on public health or private health. I do promise you, if you want to, you will talk so much more to your patients than in family practice. I also promise you won't make the money that you would in a surgical subspecialty. There is always the advise the financial aid adviser gave me when I graduated from medical school heavily in debt and insisting I was going in to psychiatry: "Marry rich."

What should you do? Ignore these turkeys. Do what you love and have a career where you enjoy your days. We took a survey recently: 90% of the shrinks in our state said they would do it again (at least of those who answered the survey).

From Roy:
I agree with Dinah. You will have lots of flexibility in what you can do. And you do not need to marry Rich or any other guy. As for the flip remarks, you Will get them. Shrug them off as uninformed comments, or as just trash talk to get you to go to their specialty. Just smile and tell them that you hear all the smart people go into psychiatry ;-)


From Clink:
Yes, I heard comments like that when I was a medical student too: if you become a psychiatrist you'll lose your medical skills, why bother being a doctor if you're just going into psychiatry, psychiatric disorders mean there's nothing "really" wrong with the patient, etc. Twenty years later, I still occasionally hear comments like that---even from friends and family. It's a hazard of the biz. You'll eventually have the last laugh though, the first time you get called to consult on a delirious patient and you can lecture the "real" doctors about forgetting their basic psychiatry skills. You'll also see how the karma plays out during residency: all the surgery and internal medicine docs will be miserable while the psych residents love their work and their patients. And really, psychiatry IS a lot more fun than any other specialty. Don't be too hard on the docs making ignorant comments. They're jealous.


Rob Lindeman said...

Just curious: you didn't mention institutional psychiatry or forensic psychiatry. I don't know for sure, but I suspect there are positions to be filled in these fields as well.

Sideways Shrink said...

I completely agree with Dinah, Roy and Clink: ignore what the attending and other students say. What I used to say when I was in training was "Mental health is a growth industry." and "You will see the same patients in your practice." I trained at Columbia University 10 year ago and saw psychiatry residency seats at various hospitals empty because no one was there to fill those residency positions. Insurance reimbursement mirrors this lack of regard for psychiatry. However the demographic/retirement changes in psychiatry will create a scarcity of prescribers that will perhaps increase reimbursement rates. As with other specialties, this will logically create interest in psychiatry when it comes to match day.

moviedoc said...

Rob may have a point about forensic psychiatry at least, but the real reason I might recommend avoiding psychiatry applies to some extent to medicine in general: More of the work will be relegated to non-physicians, and physicians will continue to face eroding respect and reimbursement and increasing demands for administrative busywork. Become a nurse instead.

jesse said...

Unfortunately, I don’t think there is anything much to say in response. We are sensitive people, otherwise we might have gone into some specialty in which sensitivity is a detriment rather than an advantage. I heard, when I said I was going into psychiatry rather than cardiology, “that is a real waste of a medical education.”

We think about why we would be interested in a retort. To whom is it really for, the person who belittled us or for us ourselves? I assure you surgeons as a whole do not ask themselves these questions.

So ask yourself why you are interested in psychiatry. It is truly fascinating, and one can make of it what one wants. I find something interesting in most every medical specialty (and law, history, science...). If you think about thinking, psychiatry and psychology would fit you fine. If you are comfortable with ambiguity and empathize with others psychiatry might be a good career choice.

No matter what you choose there will be those who do not understand it.

Anonymous said...

As someone who has chronic mental illness (depression, PTSD) and who is a nurse approaching 55, and who works with elders in the community - there is a HUGE need for psychiatrists who are skilled and comfortable working with elders. Physiological aging affects drug metabolism often before the person FEELS old or considers themselves old, so drugs that previously worked well may not work so well, or interfere with medications added to treat other diseases that develop (HTN, NIDDM,acute and chronic pain).Many elders develop psych sx (if not full blown disorders, usually depression and anxiety, with or without dementia.) PCPs do what they can, but often mistreat or undertreat, in my opinion. Lots of opportunities to work with elders for talk therapy in addition to med management, opportunities to teach, work w/ families, educate community, and forensic work too - the process of determining need for the court to appoint a guardian or conservator hinges on neuropsych assessment of competence. I'm less than 30 miles from Boston, one of the big medical education/research hubs.I know of 2 board certified geriatric psychiatrists - one works only parttime, one is nearing retirement age - in the community. A couple of others do inpatient unit only, or are not board certified in geriatrics. The growth is definitely there, as much more weight is given to the biological aspects of MH sx, and the interplay of "medical" and "mental" diseases.

Anonymous said...

It's nice knowing that this isn't just an issue in my area. I was honestly quite shocked to find so many attendings who were antagonistic towards an aspiring psychiatrist, and really, it's sad for both them and their patients. I suppose it makes some sense, as I have found general medical culture to be far more intellectually conservative than I ever expected.

Anonymous said...

Perhaps those attendings have seen some of the many profoundly mediocre (at best) psychiatrists who abound. There are wonderful psychiatrists but there are also terrible ones, and they are essentially not held responsible for the lack of care if not damage they do -- far too often, their lack of medical knowledge or inability to provide decent therapy is brushed off as the patient's resistance.

There are truly wonderful psychiatrists out there. But my guess is they're outnumbered by the ones who more closely match your attendings' associations with psychiatry. Perhaps they too started off with genuine interest and discovered how little was really expected. Who knows.

Dinah said...

Last anon:

I think a great deal of it is that people (meaning both doctors and psychiatrists) buy into the insurance company concept that psychiatry should be practiced on people who are lined up on a fast-moving conveyor belt. The finances of the system demand quick care, and that's just not good medicine for every individual in every circumstance.

Maybe it's time people kicked back?

Anonymous said...


I don't even know what to respond. the "people" have no standing to "kick back." those utilizing mental health services are either bound completely to health insurances strictures or spending huge percentages of their income on private practice doctors.

perhaps if psychiatrists began to kick back, the system could be functional. An insurance company does not care if a person with depression or bipolar or (i assume even more so someone with a personality disorder) thinks the reimbursement rate to a psychiatrist is low. The psychiatrist always has the option to choose to not take insurance. that leaves me with the option of either quick-fix psychiatry covered by my insurance or paying hundreds of thousands of dollars for private treatment.
Yes, if insurance reimbursed you guys at a rate comparable to "medical" doctors, then the problem would be essentially fixed.

But honestly -- the "people" kicking back?? there's no valid "kicking" I or any of my compatriats could do because my using or not using insurance to see a mental health professional does not make one bit of a difference to my HMO or PPO. Should I write them a letter? Suggest they reimburse you at a higher rate? Seriously.

Maybe you guys should think about some "kicking back." Perhaps if you all refused to accept low reimbursement rates and while not providing other options (ie private practice), insurances would have to respond and there would essentialyl stop being such an absurdly high market value for an hour of therapy. I mean, really. You have to go out of your way to find a gynecologist who doesn't take insurance and I'm sure my upper east side manhattan gyn is reimbursed well. It should be the same for psychiatrists.

But if you think it's the patients who can change that....???? don't blame the fact that insurance companies underpay you and as a result you overcharge me on my not "kicking back" far as I can tell, psychiatrists are the only ones here with any real choice in the matter.

Dinah said...

Anon: Psychiatrists are people. I meant perhaps the psychiatrist people could kick back. I don't know exactly what that means.

It's about the money with the insurance companies, but it's also about the hassle and the loss of control. Maybe less now than when I participated years ago now that parity decreases the need for preauths (I hope). But the amount of work is incredible, I know psychiatrists who see patients for free rather than deal with the submissions, rejections, figuring out what the copay and deductibles are, how many visits are allowed for just how long, and fifth time the insurance company loses or rejects the claim because the doc put his name in box 22 but not again in box 23.

The patient people can ask their employers/HR people to drop an insurer if the mental health benefits are poor.

Out-of-pocket fee for service outpatient psychiatric care does not cost hundreds of thousands of dollars. Let's say a session with psychiatrist costs roughly $200 (come to maryland, I can find you good docs who charge more and less). Let's say you come weekly for a couple of months (minus your vacation, minus the doc's vacation, minus the week your car is in the shop., then every two weeks, once a month. so say roughly 20 appointments at roughly $4000,for almost hour long therapy appointments and meds. Then you submit it to your insurer as out-of =network and they pay "some"....maybe 80% (yes, some of my patients get back 80% of the fee), or less, maybe $80 a session, leaving you with $120--or $2400 for a year's worth of attentive treatment. If it makes a difference in the quality of your life (like if it gets you back to work, or to not being in a place you are suffering so much)...then you're left to decide if it was worth it. If it doesn't help, it wasn't worth it.But it's not hundreds of thousands of dollars. And I see many people who are not rolling in dough.

Anonymous said...

Forget the pressure from other specializations. There are limitations and advantages to every flavor medicine. Remember instead what you enjoy doing, because it will be hard regardless of the job so it better feel worthwhile remember also the patients who desperately need more skilled and available shrinks. My father is a child psychiatrist and is one of only a handful in his isolated state. I know too personally that it took me 20 years of suffering from depression and undisguised complex PTSD to find a gifted shrink who provides therapy as well as psychopharm. This doctor has truly saved my life and helped me develop the skills and strength necessary to live my life fully, joyfully, and meaningfully. I'm grateful to my allergist, orthopedist, etc, but I can't say the same about their gift to me.

Unknown said...

Those doctors who make snarky comments about psychiatry do so until they need one. And when they do need one, it is always an emergency.

That will be when they are grateful you chose psychiatry.