Are We Training Psychiatrists to Provide Only Medication Management?
By S. Weissman, MD;June 27, 2011; Psychiatric Times. Vol. 28 No. 6

In reviewing the practice patterns of psychiatrists today, it can be clear that numerous provide mostly medication checks or medication management for their patients. The conventional wisdom just for this model of practice is that it's based on current strategies to payment for clinical service, which places reasonably limited on brief interventions by psychiatrists. Medications must be prescribed with a physician, while a non-MD mental health worker can provide psychotherapy and stay paid by an insurer at a lower unit cost than that paid with a psychiatrist to complete the same kind of treatment.

Although it can be true that today’s economics encourage the practice of medication management by psychiatrists, the existing structure of clinical experiences in residency training programs could also serve to implicitly encourage and support this model of practice.

The practice of psychiatry is the merger of scientific disciplines that reveal in understanding behavior and taking care of our patients. The science of psychiatry is taught effectively in most, if not all, psychiatric residencies by a graded curriculum that addresses the biology, psychology, and social factors of human behavior. Resident performance about the psychiatric resident training examinations (PRITE) taken during each year of residency along with the written examination in the American Board of Psychiatry and Neurology for certification concur that current graduates are very well versed in the varied aspects from the science of psychiatry.

The art of psychiatric practice is learned by residents during various supervised clinical rotations. Each rotation carries a number of stated learning objectives and related competencies which a resident must master. But once the resident masters the required competencies, is she or he in fact able to perform these required competencies? The ability to perform in a clinical rotation might not exactly mean that this resident gets the competence to apply unsupervised. In assessing performance during or following a rotation, we must see whether the resident will be able to practice within the field. While one learns science in the academic framework, the art of psychiatry is learned experientially, in graded supervised settings. The set of skills grows to comprehend experience. In psychiatry a lot more than any other medical specialty, ale being a psychiatrist is most crucial. The psychiatrist’s core knowledge, skills of interviewing, and her or his empathic capacity function as the diagnostic imaging and laboratory tests of other medical specialties.

The psychiatrist performs a diagnostic assessment by actually talking to the patient and individuals within the patient’s life. After completing the diagnostic interview, the psychiatrist may obtain information business professionals and from laboratory results. A unique kind of information for psychiatrists regarding their patients, which can be frequently not acknowledged in the the diagnostic and therapeutic process, could be the psychiatrist’s empathic sense of the patient. Using all of the collected data, the psychiatrist produces a DSM diagnosis and answers any special concerns regarding the person. At this point, a treatment plan is developed. Assessing patients and developing and instituting a therapy plan will be the essence in the psychiatric residency.

Once the psychiatric resident completes the main care and neurology rotations, he'll almost certainly start to operate on psychiatry inpatient units. Typically, the resident in concert with an attending psychiatrist and sees 7 or 8 patients daily. Attending psychiatrists must see the patient and play an integral role in the patient’s treatment or they cannot bill because of their services. This is a vary from 20 to forty years ago, once the resident was the only real doctor to see the person.

Today, the resident along with the attending psychiatrist come up with a joint diagnosis and help other members of the team, like a nurse plus a social worker, to develop a treatment plan. Frequently, the only role for that resident is for that medication treatment in the patient. The resident may take part in family interventions, but work with the patient’s family is usually left on the social worker. Because with the rapid turnover of inpatients (6 or 7 days on average), psychotherapy is often not an important part of the treatment. Stabilization with medications and group therapy are the core from the treatment. In the course of his rotation, the resident may see more than 300 patients. Once the patient is discharged, the resident can often be unable to telephone him and will not know the outcome in the treatment unless an individual is readmitted. At the end in the rotation, the resident are capable of doing diagnostic assessments, use others to develop remedy plan, and direct the medication management of the patient. The resident might not exactly, however, be knowledgeable about the extended impact in the medication on the individual.

The resident will then move on to a psychosomatic medicine rotation for two months, consulting on patients in medical or surgical units. The resident’s primary responsibility is to create a quick diagnosis and propose a fast intervention along with the medical or surgical team and nursing staff. During the supervised consultations, the resident participates in the psychiatric subspecialty, where he may be more associated with an observer than an active participant. Once again, due to today’s short amount of hospital stays, the resident has limited knowledge from the outcome of his treatment interventions. On child psychiatry rotations, the resident’s active role when controling children could possibly be limited. The resident functions primarily just as one observer. Clinical work is usually heavily supervised and observed. A similar experience may occur on the 2-month rotation in geriatric psychiatry.

In most residencies, outpatient jobs are a minimum of 12 months inside resident’s third year. The resident is offered diverse supervised responsibilities and it is required to produce abilities in a number of psychotherapies, including dynamic psychotherapy. Residents generally have between 3 and 5 dynamic psychotherapy cases at the time. If we assume each patient is in treatment about 4 months, the resident might have between 12 and 15 patients in psychotherapy during the course from the year. Many of these patients would also be taking medication, plus a significant amount of other patients will be seen limited to medications.

Residents can easily demonstrate in formats constructed by their teachers that they may perform a number of tasks. However, on their own—outside with their residencies—their skills might be limited. One masters a form of art by the repetition and studying oneself and one’s abilities. Unfortunately, in many residency programs, the sole activity the psychiatric resident is in a position to master in this fashion is at prescribing medication. Experience using a handful of patients in dynamic psychotherapy might not be adequate to the resident to believe he has mastered psychotherapeutic skills. It is not surprising that on graduation, many residents pursue work in which their main role is medication management.

Many of today’s residencies reinforce mastering only the skill of applying knowledge with the biology of behavior, which informs the use of medications. The unanswered question for you is, can modern clinical psychiatry survive if training programs provide clinical experiences that may produce expertise in only one of psychiatry’s core disciplines? Residents have to be given adequate time in their training to find out and incorporate the psychological and social elements critical to like a psychiatrist. If psychiatry reduces or abandons its engagement with psychology and social science in understanding and treating mental disorders and focuses predominantly about the biological factors of mental disorders, after that our role as psychiatrists be? Other physicians may assume the responsibility for medicating patients with mental disorders, while others may take around the role of integrating the biological, psychological, and social forces that have an impact on behavior.




“Under the care of Leo J. Borrell, M.D. since December 2001, I have seen a remarkable improvement in my mother’s condition. She is responding dramatically to the new regiment Dr. Borrell has prescribed”

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Feb 3, 2008

The Interdisciplinary Team; The Role of the Psychiatrist

by Dr. Leo J. Borrell, featured in Assisted Living Consult for November/December 2006. A HealthCom Media Publication