Wednesday, March 09, 2016

What Do The Kids Need to Know?

That's a great title for a post, isn't it?
Unfortunately, this isn't going to be about anything all that juicy.  I'm giving a talk on Access to Care next week to 60 or so psychiatry residents in training.  I thought I would ask our readers: What should young psychiatrists know about finding a psychiatrist?  Are there things that make it harder or easier to find someone?  What should they know about health insurance participation?
Write something I hadn't thought of  and I'll read it at my presentation!
Thank you for your help.


Zoe Brain said...

All mental health professionals are not created equal. There are many professing to be "Christian Counselors" - or "Spiritual Advisors" or whatever who claim to be psychiatrists - and some indeed got psychiatric qualifications 40 or 50 years ago when there was no place for evidence-based medicine - who have left a pile of corpses behind them.

If I can quote from the WPATH Standards of Care v7, which applies to Gender Dysphoria, but has application in principle in other areas:

Ethical Guidelines Related to Mental Health Care
Mental health professionals need to be certified or licensed to practice in a given country according to that country’s professional regulations (Fraser, 2009b; Pope & Vasquez,2011). Professionals must adhere to the ethical codes of their professional licensing or certifying organizations in all of their work with trans-sexual, transgender, and gender-nonconforming
Treatment aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with sex assigned at birth has been attempted in the past(Gelder & Marks, 1969; Greenson, 1964), yetwithout success, particularly in the long-term (Cohen-Kettenis & Kuiper, 1984; Pauly, 1965).
Such treatment is no longer considered ethical.

Now the bit with general application:
If mental health professionals are uncomfortable with, or inexperienced in, workingwith transsexual, transgender, and gender-nonconforming individuals and their families, they should refer clients to a competent provider
or, at minimum, consult with an expert peer. If no local practitioners are available, consultation may be done via telehealth methods, assuming local requirements for distance consultation are met.

Young Shrink - or Old Shrink - if you're out of your depth helping with a client due to lack of expertise, or moral qualms regarding the issue = pedophilia comes to mind - then call in someone who knows their onions, please. Bear in mind there are a lot of Charlatans out there, so research their competence and track record carefully.

Joel Hassman, MD said...

"Are you ready to primarily treat substance abuse and personality disorder as at least a third if not more than that in your outpatient travels?"

'Cause that is what it is in CMHCs in my travels these past 5 plus years, and even in private practice now, over 25% are just primarily controlled substance seeking if not just medication seeking as sole intervention.

Are you ready to at least face questions that psychotherapy is a dead art? It is what it is from my experiences. Good thing you don't have me up at the podium, because I would have to honestly and sincerely ask these colleagues if they are ready to give up most of their independence and autonomy.

Yeah, that would be a conference killer, eh?

Joel Hassman, MD said...

I had a minute this PM after my earlier comment and offer this to you, both the author here and any colleagues interested, I wrote an "open letter to graduating psychiatry residents" a little less than three years ago at my blog, and offer people Google it just by that above phrase in quotes, it should be the first link in the search. I am not linking it here outright for two reasons:

1. I am not selling my blog as a resource or reference overall, and
2. I like people to work a bit in tracking down things.

If you do read it, read all of it, it is positive at the end, but, certainly not at the beginning! I finish with this, if you really are a doctor for all the right and responsible reasons, you as a clinician should be beyond outraged and annoyed. Take it from me and 6 years of temp work, almost every place I have worked at is at the very least quick to overlook drug seeking and be accepting of just med checks as primary interventions. And in Community Mental Health Care Clinics, the psychosocioeconomic issues alone could keep a 10 person clinician staff of therapists busy full time at 30-35 hours a week and get fair reimbursement for it.

But, i ain't seein' dat!

And if most of the people at this talk allude they don't care if that is the status quo, then I hope readers who are the patients pay attention to that as well!!!

PseudoKristen said...

I think the best (and probably safest) way to find a good psychiatrist is through word of mouth. I would tell new psychiatrists to get to know therapists and other physicians who will refer patients to you. I was very reluctant to see a psychiatrist, but I finally did because of all the good things my therapist said about this particular psychiatrist. She told me that he had really helped the patients she had referred to him and that the patients really like him. She refers all of her patients to this one psychiatrist because of his reputation.

If patients don't hear of a psychiatrist through word of mouth they are going to get on Google and look. So, it would be smart to have a website which says a little bit about yourself so they at least know something about you which may lead them to make an appointment. Another option (assuming they live in a big enough city) is to sign up with ZocDoc, which I hear is kind of expensive but it might help you get new patients in the beginning and fill empty appointment slots. I found my internist and dentist through ZocDoc, so I'm a fan.

Dinah said...

Zoe Brain: Thank you!
Joel: I imagine the residents in an inner city hospital have discovered that many psychiatric illnesses come with co-morbidities. It puzzles me that you sound to be angry at people for their problems?
P-K: very few psychiatrists in Baltimore on ZocDoc-- docs just aren't having trouble getting patients, and the clinics are simply closed to admission. It's not easy.

Joel Hassman, MD said...

No, and frankly, I don't get that conclusion from you, I have never judged or been critical of patients who are interested in care and genuinely want the expertise of a provider, even if they struggle with the care interventions. I think you are a bit out of touch with the realities of what is going on in CMHCs, and even in the average private practice of late, Dinah. And some of your posts reflect that to me, and your compatriots of this blog I think are equally out of touch at times with the day to day realities that general providers like me face.

There is more Axis 2, even if comorbid, which by the way go under if not un-diagnosed, and there is certainly a helluva lot more substance abuse, misuse, and self medicating going on with patients that would drive any concerned and boundary maintaining clinician a bit overwhelmed at least.

So, you go to this "talk" and make an effort to hear what these "new" clinicians have to offer as much as yourself, and then I challenge you to step back and think where you were at in their shoes about what, 25 years ago, and then wonder whether things in psychiatry are fairly fine, or, clinical standards and baseline expectations for appropriate interventions have strayed, if not irrevocably lost!

Hey, yeah, just my opinion, but, do you hear that I have been a temp working in various clinics and other psychiatric programs these past five plus years and am seeing a deterioration in the level of not only psychiatric care, but the support and ancillary services we as psychiatrists DEPEND on to supplant what we hope to accomplish in helping people help themselves?!

I don't live in a bubble, and sometimes caring leads to hurting. And, I think I am a fierce advocate for mental health, hence why I was ostracized for taking on a hospital in a small Maryland town that crapped on the chronically ill. Can you claim that same experience in your clinical travels over the years?

Sorry, but sometimes some people are full of sound and fury but signify nothing, and that is not aimed at me...

PseudoKristen said...

Oh, I know it's not easy to find a good psychiatrist who is available. It took me a long time and it also took resources that I have now but didn't have in the past. I'm just saying that the way patients (who want to see a psychiatrist and who have resources) tend to find a psychiatrist is through either word of mouth or searching the internet. If you search the internet and all you see is a name and phone number, not too many patients are going to be all that interested. I would think most patients want to know something about the psychiatrist they're signing up to see.

For patients who need to use insurance or who have no money it's a whole different ball game altogether (I've been there, too, and I never did find a good one who was available when I was in that situation). One thing I've learned is that it's better to have no psychiatrist than a bad one.

Joel Hassman, MD said...


I would cautiously agree with your conclusion that it is better to have no psychiatrist than a bad one, as neutrality is better than negativity, BUT, watch out you are not at least inadvertently advising chose a PCP or other Non Psychiatric provider for psychiatric care. Because it is even more damaging for people to offer services they don't have the expertise to render specific care interventions, as such providers often think they can fall back on that as an excuse, "well, the patient knew I wasn't a psychiatrist, so he/she accepted the risks."

I have heard that in my travels by physicians who are not psychiatrists, and that is not just astounding, but, irresponsible. Oh, and then these same physicians are quick to try to dump their messes on us. And, I think readers who are patients or concerned loved ones to those who are patients, need to start asking why are physicians being so nonchalant if not dismissive of such bad judgment by their colleagues. Because that is what I dealt with in that small town I noted in prior comment, physicians and other health care professionals who had the audacity, the unmitigated gall, to tell me they knew of careless and shameful clinical care and did NOTHING about it.

I would offer people look up the term "complicity" and wonder if it applies to some of your travels with health care professionals. Over at, I subtly raised that question at his most recent post. I know this: there is still a helluva lot of power in marginalizing, and then ostracizing incompetent, irresponsible, and blatant negligent care, but, it starts with taking a stand.

Anyone would like to debate otherwise???

Unknown said...
This comment has been removed by a blog administrator.
PseudoKristen said...

Dr. Hassman, you're right a PCP is not necessarily any better. The PCP I had where I used to live treated me for a while but realized when he was in over his head.

tracy said...

None od you care anyway....I know from experience