Tuesday, January 22, 2008

Obligatory Comment Induced Post

In reflection on my post dealing with Psychiatry I found the responses completely perceptable. Of course, having dealt with similar forms of misunderstanding or degrees of complete arrogant ignorance directed towards my chosen specialty I can understand the knee-jerk reaction towards my apparently incendiary comments.

They were expected. I anticipate more, perhaps as others are directed towards the jerk med student who knows nothing about psychiatry. Imagine if I’d bashed acupuncturists or homotherapeutics – we’d be swimming in the assaultive commentations.

Yet the fact remains – my experiences, my teachings in a school of medicine by residents, attendings, and social workers demonstrated a very sad state of affairs. The social workers were more involved in talking with patients than the doctors who, instead, spent a great deal of their time reading or leaving early. Patients improved here and there, but there were very rare circumstances where a physician actually worked hard at understanding the patient’s needs or point of view. Unfortunately, this is all too common in other areas of medicine, but damnable from a psych perspective. If my exposure has been insufficient to truly warrant a degree of opinion, I am aware.

Yet, even friends entering the psychiatric field have expounded on the degree of psychiatric training they've tried to avoid. They agreed with my perceptions of the residency we rotated through and noted some others where they'd interviewed whose residents actually would state: "we need to get a real doctor's opinion". That's where my concern for Psychiatry lies - in the apparent loss in some training programs in keeping their residents grounded in their medical school knowledge.


There have been discussions regarding the desire of psychologists to receive training to begin prescribing medications. If what I’ve heard, that being drug management is more lucrative than couch talk, I can understand their wishes. However, and let me be clear on this, I do not think that psychologists should be giving out drugs, regardless of my perception of the state of Psychiatry. If for what little medical treatment and disease pathophysiology psychiatrists actually recall, they received 4 years of post-graduate training revolving around the medical needs of patients in all arenas. Their understanding of pharmacology, side effect profiles, and dosing have been inculcated during this process and they are, therefore, more likely to be able to understand the toxic-therapeutic ratios, effective dose over lethal dose, and other nuances that a physician must evaluate when prescribing medication.

As little of the understanding of psychologist training I do know I don’t feel that they are as well prepared to be able to understand, nor be able to review, drug interactions and potential dangers as a psychiatrist. And perhaps it is the 4 years of residency training that I bemoaned earlier, focusing on the drug management more than psychoanalytical jargon, which further qualifies the psychiatrist from those who want to be included.

But what of the additional year or two that psychologists have suggested that will enable them to understand these concepts? They still lack the fundamentals, ingrained throughout 4 arduous years of medical school, that all physicians rely upon. Rather than being on the same footing they've already started behind and, worse yet, have years of training that have narrowed their mental process towards what they studied.

Overall, medical training allows the students and residents more capacity to understand where, when, and how to obtain vital information – regardless of specialty. What's more is the fact that these same students and physicians have a less focused perspective as they've been trained in broad strokes from the getgo.

Yes, we all forget how to manage certain diseases (I can’t for the life of me recall how to classify Salter fractures from surgery nor what the management would be), but we have studied them before and understand enough to be able to review with better efficacy. It's like riding a bike - you never really forget, but it's harder to teach an old dog new tricks.

What’s more is that through this process we’ve been able to interpret more readily what we don’t know. I’ve felt that a PhD enables someone a great deal of knowledge about a very precise and minute area of science. Truly they are experts in a small area. The problem that occurs is all too often someone with a specific focus begins to believe that they can do more without realizing their limits. I do not agree that a PhD enables anyone the option of performing as a physician – the training is to myopic. In fact, I find it disturbing to know that some professions are actively trying to erase or blur the fine line between the physician title of “doctor” and their own within medical settings. Because, unlike a rose, a doctor by any other name is not the same.


social worker said...

MSG: Thanks for addressing this. I used to be on the other side of the argument, but I now agree with you. My thought process used to be that psychologists know their patients (or clients or whatever they're called in your agency) mental health status much better than anyone else and with the right training they could prescribe meds and I think it would work. However, I failed to take into account that when MDs prescribe meds, they're not just thinking of mental health. They're considering the patient's entire medical history, the medications they take for other disorders, and a whole host of other factors. Minimal training cannot teach someone how to do that. And that's why there are medical schools and residency training.

If these laws go into effect, I think because med management is more lucrative than psychotherapy, psychologists will turn into med managers. For my sake and the sake of the social work profession, I'm glad social workers have not tried to jump on this bandwagon. And I hope they won't.

Thanks for addressing this, MSG.

#1 Dinosaur said...

I recently had a psychiatrist ask me to prescribe and monitor a patient's psych meds. He explicitly told me that he believed he and other psychiatrists didn't have sufficient medical expertise to do so safely. More power to him for recognizing his limitations.

Ladyk73 said...

I agree 100% that only medical doctors (NPs and PAs as lawful) should write scripts. Agree on all counts.

I am a MSW student!!!
From working/ interning in the mental health field.... Money is a big issue. Mental health is not well funded, many mentally ill patients have medicaid. Good doctors say the hell with it an go into private practice...and you will never see them during a med school education.

First, like any profession...there will be fruitcakes. Giggles Oh my...anyways!

Good Psy-blogs:

Shrink rap:


Turn Your Head and Scoff:

Make shrink or fade:

Roy is a super smart consultant.
Clinkshrink and FooFoo are correctional skrinks
and Dinah does therapy and meds..
And the guy from vermont is just really silly.

Check them out!

Old MD Girl said...

To clarify something.... It's not that Psychiatrists prescribe drugs because drugs make them more money. It's that insurance doesn't pay for counseling beyond a certain number of visits, and that they can make more money if they see more than one patient an hour based on the way they're currently compensated.

social worker said...

OMDG: You're right; insurance companies pay for very limited visits for therapy and that's unfortunate. Everyone loses--MDs and Therapists lose income potential and the ability to practice their craft and patients lose because they get limited care. If a patient is lucky they get 20 visits a year. And that's if they have "good insurance." Many plans don't cover outpatient mental health at all.

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