r/Psychiatry

I am a little frustrated that several of my male patients (ages 50+ mostly) keep calling me by my first name. I introduce myself at the lobby entrance and then again in my office as “Dr. X.” I also ask every patient at the start of an intake how they want to be addressed. I thought at first it was because I was inheriting patients from a NP who was going by her first name. However, today a completely new patient did it.

I don’t know whether to correct it, or let it go. On the one hand, I think I should let it go because I don’t want to ruin the rapport. On the other hand, it seems to mostly be people with some cluster-B traits, so I wonder if holding the boundary would actually be better for them / the relationship in the long run.

I also think that it’s important that they know my credentials and that I am a physician. Despite starting with “I’m Dr. X and I’m a psychiatrist,” the patient later asked “wait, you’re my psychiatrist?” Yet then again, still used my first name. Since I do look younger than my age, I think sometimes they really do forget what my role is and I feel like enforcing the title could help.

Thoughts?

After having gone through multiple years of psychiatry residency, I have multiple thoughts that have weighed heavily on me. I wanted to hear your thoughts on the mater.

1. psychiatry continues to do harm in regards to medications. So many times, pts are not fully informed about the side effects of even basic medications like SSRIs. These patients come back wondering why they have libido issues or emotional blunting. Or in CL, pts have poor side effects from SGA despite little evidence supporting its use for delirium

2. poor inter-rater reliability. So many different diagnoses flinging around in a patient‘s chart

3. limited benefits of medications. For example, SSRIs are not going to help with social factors leading to depression/anxiety. Studies show a small effect size compared to placebo

4. combating anti psychiatry stigma. i am finding so many patients or their families that harbor negative perspectives on mental health. This is also not uncommon amongst medical professionals

If so, how come? I'm referring to having it as part of your work to be clear.

I’ve been noticing that a lot of young male pts (early 20s to early 40s) who get referred to my ACT team from inpatient units carry an ASPD dx. Long-term therapeutic work reveals a pathology more consistent with mixed borderline/narcissistic traits, often exacerbated by substance use and chronically poor coping skills. I often find myself frustrated on behalf of my pts—once the ASPD dx shows up in the EHR it just gets copy/pasted during any subsequent hospitalizations, damaging potential therapeutic rapport with clinicians at the hospital and perhaps unnecessarily stigmatizing the pt.

I am starting to consider that traits more consistent with other cluster B disorders can be easily misrecognized as ASPD in men, especially because BPD has a gendered component. Has anyone else noticed a similar phenomenon, especially on the inpatient side? Or do I have a limited conceptualization of ASPD and it is affecting my observations? Or both? Or is there an answer adjacent to my question that could give me better insight into the diagnosis and treatment of PDs? Anecdotes and literature are both greatly appreciated!

My compensation is not tied to admissions and discharges and whether a patient is covered or not so I have no vested interest from that domain, but I hate these peer to peers where coverage is denied for what I believe to be are inappropriate determination by the reviewers. I’ve heard there may be some incentive for reviewers to deny cases. I’ve just recently had a denial after 4 days of coverage for an acutely suicidal pt who just attempted suicide and I was clear in saying discharge is unsafe (and went into explaining why). Are these reviewers held accountable for these decisions? We intend to appeal but the bill gets punted to the patient, which is terrible. I realize the expense of an inpatient stay and the scarcity of needing to scrutinize the need for hospitalization on a daily basis, but there needs to be some accountability and responsibility the reviewer holds on make these decisions about a persons life..anyways, sorry for the vent but if anyone has any tips on how to manage this let me know.

Hi! Non-US psychiatry resident here.

I'm a bit ashamed to ask this late into my residency, but I've been feeling quite disorganized lately when it comes to discussing potential side effects and reassessing them during outpatient follow-up.

Here's what I do: when starting antipsychotics or antidepressants, I usually discuss 1 to 3 of the most common or relevant side effects and I'd say I also provide written information around 60% of the time. However, I realize I rarely revisit these discussions with patients who were started on medication during involuntary hospitalization, which is something I should improve.

Lastly, I think I'm bad at systematically screening for side effects during follow-ups. Do you consistently ask about constipation, dyskinesia, weight gain, etc., at every outpatient appointment? I tend to start with an open-ended question like "Have you noticed any side effects?" but it feels like it can be not exhaustive enough.

Honestly, it feels like i need to structure my approach better. What do you do, and how does that work for you ? Have you changed some things about your process because you encountered a problem?

I am really interested to read your answer, because i'm lacking so far, and it's annoying me. Thanks

Hi Friends!

Which psychiatric medications are most commonly denied by insurance for your patients?

Any top tips on how to help the patient get the medication you feel they need in that situation?

Pgy-4 psych resident here just musing. As a thought experiment, if you had to build a completely new psychiatry residency program didactic curriculum from scratch, what online resources would you use?

I remember in medical school, I felt like our lectures were only mildly useful and attendance wasn’t required, so I just skimmed the lecture slides and mostly studied off of board prep material like boards and beyond, sketchy and first aid (plus anki of course). With that + learning on clerkships, I think I did ok overall.

I’m now luckily at an academic residency program that I think has excellent didactics taught by experts in specific niches, and is very thoughtfully curated so I think that’s really valuable and actually show up. However, for newer psych residencies with limited faculty or community programs where attendings don’t have a teaching obligation, why don’t they incorporate online sources like psychopharm institute, carlat report, etc? Then they could also supplement with required in person workshops/discussion like a flipped classroom model (i know, i know, that word is triggering). It overall seems more efficient to have the lectures be delivered by actual experts in a curated manner, rather than have lackluster lectures from attendings that might not want to be there.

Thoughts?

Thoughts? Right now it's just limited to acne scripts but this definitely opens the door ...I am not overly optimistic.

Hi everyone,

I’ve been following the sub more closely in the past few months, and I’ve noticed that there has been a more downward outlook regarding jobs for psychiatrists. However, per some sources like MGMA, psychiatry salaries were among those that increased the most compared to other specialties in the past year. Anyone with a good pulse on the market and what to generally expect?

Hello,

Does anyone have link (or access) to resources for PPT for didactics targeted for PGY-1 residents in psychiatry?

Like PPTs broadly covering the main DSM 5 criteria, treatment options etc. for anxiety disorders, psychotic disorders, trauma-related disorders and such.

I appreciate the help in advance!

Have any actual psychiatrists who have completed residency actually had any luck with Auvelity? It seems to be very poorly tolerated in my anecdotal experience when pcp’s start it on patients who havent had a full eval to confirm MDD (especially patients with a different diagnosis on differential causing depressive symptoms, who may have significant anxiety, or like ptsd, bipolar, personality issues). I am frustrated with how quick community pcps and APPs are starting people on it and how poorly tolerated and understood it seems to be. Not to mention, patients often not being educated on how you could possibly robo trip if its used while taking OTC cold medicine. Ive seen most people who someone else started it on become very manic or paranoid on it. Looking for anyone else’s experience!!! I feel like SSRIs are better tolerated from a psychological standpoint than this medication (unless the patient has bipolar of course)

I'm in a clinic attached to inpatient hospital for over a year now and I'm struggling with my patient panel. I don't know if it's a me issue, a work issue, or mix of both.

I estimate at least 20% are challenging (at least to me) whether it's due to being high risk, severity of symptoms and illness, difficult circumstances/high social needs. The clinic I work at does not have any case management, RNs, or social work support so it often feels like just me myself and I managing these patients. I get frequent messages for same day appointment requests, severe symptoms arising, paperwork requests, family concerns etc. we have to handle all messages outside of scheduling.

Are most outpatient positions like this, with that mix of acuity and what feels like little support?

I work as a triage nurse for a large outpatient psychiatry department (connected to a hospital). I receive and review about 700 patient messages a week which limits how much I can do for each encounter so I’m trying to find the ways I can maximize the value I can add to the team. It would be very helpful to hear from psychiatrists, NPs, PAs what the most helpful triage support items would be (and maybe things triage nurses have done that were not helpful that I can look to avoid).

Current tasks include (but aren’t limited to) the following:

pend refills which includes PDMP reviews for controlled substances (and pend script corrections per insurance requirements, pharmacy guidance, documented titration plan, etc)

call and sort out issues with fills at the pharmacy
submit medication PAs (and pend appeal letters if denied)

guide patients to local resources (financial support, housing, food, support groups, etc)

Coordinate ECT clearance

call patients to triage medication concerns (side effects, overdosing, underdosing, adverse effects, etc)

Pend general letters (school medication letters)

call patients to triage for safety concerns (and call for wellness checks as needed or coordinate with crisis / ED teams)

call patients to assess worsening symptoms

call and gather collateral from family members or outside clinicians

follow up on labs (clozapine CBCs, med levels, lipids, etc)

coordinate with other care team members (PCP offices, ALFs, nursing homes, etc)

Help patients with medication cost assistance programs

initiate discussion and development of safety plans with the care team

reinforce boundaries with patients when needed (per their physician or NP/PA’s guideline)

Urgent records requests (or calling for report from the ED or outside hospital directly)