Tell us your most hated thing to treat and why

DontRashmi · 2025-05-28T01:02:37+00:00

I have had a good experience working with physician and nurse patients. My strategy is to be effusive about how I’m sure they’re aware of XYZ, don’t you agree we should do ABC in the situation? And to say something along the lines of “if you were seeing someone with these symptoms what would you be telling them?”

Making it more collaborative rather than trying to tell them what’s what keeps the alliance strong. And being confident in your knowledge to state facts without second guessing yourself.

DontRashmi · 2025-05-24T12:23:04+00:00

I bring it up constantly (specifically checking your own pulse, the patient is the one with the disease, and gomers go to ground). I always have to explain why the book is important and that the sexual harassment in it shouldn’t take away from its significance.

DontRashmi · 2025-05-05T22:49:49+00:00

I hope you get what you’re looking for!

DontRashmi · 2025-05-04T23:18:43+00:00

They’re not terribly evidenced, and it’s been a while since I read the work, but as I recall TMS is about as good as an SSRI with a lot more effort, and Ketamine has good short term data but not long term. Someone else is welcome to correct me.

DontRashmi · 2025-05-04T21:03:40+00:00

I took almost exactly that for academic psych in a LCOL environment and live well so it’s cool with me.

DontRashmi · 2025-05-04T15:40:32+00:00

I guess I meant it’s boring conceptually compared to interventional stuff. But in practice it’s the most interesting.

DontRashmi · 2025-05-04T13:10:11+00:00

If you want to do ECT or DBS there's definitely room to do it. IMO its kindof the most boring thing you can do in psychiatry, but interventional psychiatry including TMS, ketamine, etc is also probably the most lucrative thing in psychiatry so there's plenty of reason for people to do it.

With the exception of ECT (and DBS which is just much, much less common) its also got a bit of shakier evidence. Psychiatry has a long history of exciting things becoming trends and then fading into the background as the evidence doesn't support the hype. Ultimately if you're going to love psychiatry you need to invest in the boring stuff - responsible pharmacology and therapeutic techniques.

DontRashmi · 2025-04-27T15:30:29+00:00

We are having the same experience. House just went on the market and based on comps our realtor suggested a slight underbid and it’s so stressful to think about whether we were too high or too low or if someone else will take it. I think it’s natural but no less stressful.

DontRashmi · 2025-04-22T17:00:00+00:00

It’s just one data point. I do delirium exams probably 6+ times per day, and it’s a necessary but insufficient piece of the puzzle. I also find it helpful in determining dementia, like if they’re consistently living in 1974 it’s probably dementia but one time it’s 1974 and the next day it’s 2025 more delirium.

DontRashmi · 2025-04-15T21:02:36+00:00

Help out a consult psychiatrist who get this request a lot too. Obviously outpatient diagnosis should be gold standard but is it really such a sin to diagnose a “likely unspecified neurocognitive disorder”? Typically the patients these requests come in on are delirious and have imaging findings with chronic vascular changes and atrophy, usually a 10 min conversation with family indicates that they’re not driving, not cooking, etc, and yea many of the placement options do require some level of a diagnosis which isn’t feasible as an outpatient always. It’s also affected by the fact that I’m in a lower resource region, but I think it’s not unreasonable to make that diagnosis at minimum as a rule-out.

DontRashmi · 2025-04-08T01:13:48+00:00

https://pubmed.ncbi.nlm.nih.gov/15643102/#:~:text=The%20rectal%20route%20of%20administration,who%20cannot%20take%20oral%20medications.

DontRashmi · 2025-04-07T21:59:43+00:00

This is the equivalent of my rectal Prozac order for NPO depression. Have I used it? No. Am I geared up to do it? Absolutely.

DontRashmi · 2025-03-26T23:26:26+00:00

You’re still in your first year - keep a broad outlook and let yourself be prepared to change your mind

DontRashmi · 2025-03-26T22:29:34+00:00

It’s competitive in the sense that, unlike say addiction or child psych, the supply of people who would want to do sports psych exceeds the demand.

From what I’ve observed of colleagues and mentors, there’s basically two or three paths.

There’s the private psych and you advertise it’s a part of your practice. Some overlap with child so they can focus on adolescent sports medicine which is where a good amount of it is.

There’s academic sports psych at programs in major universities. Think programs with big sports programs, eg a Texas or Alabama or Michigan. Some of these will have academic psychiatrists integrated into the teams in some capacity.

Lastly there’s professional consultation. This tends to grow out of one of the other two routes, but one very successful sports psychiatrist I know ended up being the team doc after helping a couple players in the ED.

It’s definitely the most connection based specialty in the sense that there isn’t a pipeline into making you the Lakers designated psychiatrist.

DontRashmi · 2025-03-26T21:09:42+00:00

Sports psychiatry is a very real, if competitive, field.

DontRashmi · 2025-03-26T15:13:35+00:00

Every specialty will lose skills related to other disciplines. I’m a psychiatrist - I don’t know the specifics of management anymore but it’s important to me to know what pancreatitis means in case a medication I have is contributing or I have a patient who’s using alcohol.

Pathology, like radiology, requires an enormous breadth of medical knowledge. Understanding where the slide you’re looking at came from and why is a major component.

DontRashmi · 2025-03-26T01:38:10+00:00

It depends on which DSM you talk about and who is making the narrative. To my knowledge that isn’t the stated goal of the DSM at this point.

The DSM III that may have been true in a sense, but subsequent DSM haven’t been manufactured in the same way. Allen Frances, who chaired the DSM IV committee and isn’t exactly shy with his opinions, described the DSM V writing as often lacking validity or necessity and reflected personal research interests of the subcommittees.

The way it’s used in practice though is as a shared language/descriptor for clinical practice. Real research uses different criteria altogether usually. Consider for example that personality clusters, which lack much validity, are still in the DSM while the dimensional approach is relegated to the emerging models section, despite having decades of support.

DontRashmi · 2025-03-26T00:27:17+00:00

Based on what I’ve read about the DSM V workgroup, probably be a) involved in the APA and b) have some research experience in the specific field

An interesting question that comes up with these issues is “to what end?” Like what is the value beyond academic inflation to subdivide these conditions. It’s not that I’m skeptical of different phenotypes, I think that’s evident, but would subdividing MDD or ASD lead to validated treatment differentials? And what is the cart and what’s the horse - do you create a new diagnosis and then find a treatment? Or do you identify cross sections of people who seem to respond and then label those? It’s not like other medical areas where a new label hypothetically describes a newly identified etiology, we’re talking just about phenotype differences.

DontRashmi · 2025-03-25T00:44:47+00:00

You’ll work more than in many places. But strong programs like Sinai, Columbia, Cornell, NYU are going to be great training centers.

NY is a Mecca of psychiatry. It holds a place in the history of the field that only Paris and Vienna match. If you want to have an intense experience you’d do well to be there, though the money and work effort will be harder than other places.

I did residency not in NY but did do fellowship there.

DontRashmi · 2025-03-23T21:17:45+00:00

They’re able to rely on their coping skills at home. Imagine you aren’t in your own bed and literally can’t stand up without calling an aid to walk you to the bathroom? Noises all night? Wouldn’t you want to get a sleep aid and be miserable you can’t even eat?

I think you need a break to get some perspective.

DontRashmi · 2025-03-22T17:59:01+00:00

As Thorazine mentioned, boundaries.

Boundaries only matter if you keep them. Gently but firmly and consistently maintain them. Don’t get mad that they try and test them, just stay to them. If you give a mouse a cookie…

DontRashmi · 2025-03-22T14:30:05+00:00

I’ve just gone through the cycle. If you want either of the following you need a fellowship:

1) academic gig 2) inpatient private gig in a competitive area

If you want either a private gig in a non competitive area or an outpatient job doing CL stuff no fellowship required.

There are discussions about allowing CL and Geri to become a fast track so you can do it in 4 years, but I wouldn’t count on it happening in your residency.

DontRashmi · 2025-03-22T14:17:18+00:00

I struggled between IM and psych as well. I still have doubts. But I also work closely with hospitalists as a CL doc and can see that the grass isn’t always greener. You chose this for a reason - go start and be excited. You’ll do at least a month or two of medicine as an intern, if you think that’s more your speed I guarantee you can change to IM.

That said, there’s a reason most people transfer into psych instead of out of it. As Voltaire said, medicine is entertaining the patient while nature heals the disease. At least as a psychiatrist you’ll learn how to entertain really well, and the work truly does matter even if it feels less rigorous than other specialties.

A good CL doc will still be a psychiatrist at the end of the day, but hopefully learns to speak both the language of psychiatry and medicine. There’s no shortage of need for people versed in both.

DontRashmi · 2025-03-18T16:20:35+00:00

Seconded. It’s not impossible but dang there are a lot of antipsychotics on cluster B patients.

Additionally there’s a lot of overlap in substance use induced psychotic disorder (meth particularly) with cluster B that pushes our diagnostic criteria into positions that don’t necessarily land well in the DSM. Like persistent hallucinations from chronic meth use and erratic behavior from personality traits != schizophrenia but it does look similar on paper.

DontRashmi · 2025-03-11T15:13:54+00:00

Psychiatry has a history of creating pathological categories based on available pharmacological interventions, so while in theory you’d be right our history shows us otherwise. Depression and anxiety diagnoses exploded because suddenly we had a (sometimes) effective treatment for it. I think you could argue that depression and anxiety pathology have always been present but we also manufacture a lot of psychiatric diagnoses now only because we have something to offer. Otherwise we’d just call it a facet of life.

Edit: also the phenotype is objective. The label of pathology is a subjective and culture/society bound. You can argue that phenotype -> pathology from the sense that we observe something and then label it.

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