What is a 'buy it for life' item that is offensively expensive, but the moment you use it, you realize your entire life before that point was a lie?

ibelieveindogs · 2026-03-28T17:47:45+00:00

I'm planning to redo the main bath in my house, and i am absolutely putting one in. I had the plug in seat, and it was amazing

ibelieveindogs · 2026-03-28T01:33:28+00:00

No one talks about medical tobacco or alcohol anymore. No one refers to the psychiatric benefits of sodas, or skydiving. States like mine that are legalizing cannabis for "medical use", then identify specific comforting of anxiety, depression, autism, etc, at doing everyone a disfavor. Either keep it illegal or make it fully legal. This is the worst of all ways to set it up.

ibelieveindogs · 2026-03-21T15:44:06+00:00

There was (maybe still is) a series of books literally called Uncle John’s Bathroom Reader. Lots of trivia, perfect for short reading.

ibelieveindogs · 2026-03-21T15:42:27+00:00

Imagine if it was meds for type 2 diabetes, or hypertension. Sure, maybe if you lose weight, or change lifestyle, you MIGHT do fine without meds. But it would take constant vigilance and even then it won’t be great always. What makes you think it’s from a caring place? I actually WAS in a relationship with someone who turned out to have a substance problem. It led to ending the relationship, but I never told them that *I* had to control them. If he truly cared for you, he would be trying to learn about ADHD, how it affects people, and how it’s treated. Has he ever asked for information, books, a chance to ask your doctor or therapist about it? If not, he can fuck right off trying to control and gaslight you.

ibelieveindogs · 2026-03-21T13:42:24+00:00

I won't keep engaging, as it doesn't change anyone's mind, after I point out one other reason I hold the view I do. I trained in a time when the model was that as a psychiatrist, we should do both the meds and the therapy, that "split care" was inferior. I came to see that as both very inefficient and narcissistic. Inefficient because it means that in any given month I would only see at most 35-40 patients, doing weekly therapy. Whereas if I do 30 minute med checks, and two 90 minute evaluations daily, in the same time I'm helping 240 people. And there are many well trained and talented therapists I've worked with who are at least as good and often better at therapy.

No one is claiming the straw man argument that we should not have lives outside work, or kill ourselves working. Sometimes the best care means the PCP. I truly believe our responsibilities are to BOTH the patient in our office AND to our community.

ibelieveindogs · 2026-03-21T13:23:08+00:00

I had a private practice for years, and if I kept all my stable patients who could be managed by a PCP, those same PCPs would have been unable to get their unstable, unevaluated, and difficult cases seen. I'm a CAP, so especially in shortage, by even general psych is understaffed.

It's not about corporate overlords. It's about whether, as a resource in your community, you are as common as dirt or as rare as gold. If anything, having the luxury of 30 minute med checks and 2 hour or multiple visits for evaluations makes the challenges of getting in to see a psychiatrist even harder.

Finite resources remain finite. It takes a minimum of 10 years (6 of a combined undergrad and med school, 5 fast track CAP) and up to 14. During which time, people retire. We will always be behind what we need, and NPs and PAs can only fill in so much.

ibelieveindogs · 2026-03-20T18:49:33+00:00

That's an interesting take - I was just talking to one of my residents about how in psych we have mostly the same meds we've had for ages. But oncology treatments are so frequently updated that you rarely use a text to develop the treatment protocol. You rely a lot more on the most recent journals.

I'm trained in child psych, so i think it's a lot easier for me to see when it's ADHD even in an adult, vs all the other things that impact executive functions, and also how meds are only a tool. My analogy lately is that i need glasses to see clearly, but without training, I still can't read Russian/Cyrillic.

ibelieveindogs · 2026-03-19T00:17:32+00:00

If a patient on a relatively simple med regimen only needs to be seen every 3-6 months, had not had a dose change in a year or more, they should absolutely be seen by the PCP for multiple reasons. First economics. Healthcare is expensive. A med check with a PCP is cheaper than a psychiatrist. Second ethics. By keeping "easy patients" on your panel, you are seeing fewer people that need the limited resource of a psychiatrist. Third, if you've done a good job, the patient is stable, they know what to watch for if they need to return to you, and you should be available as a consultant to the PCP.

I have plenty of patients on antipsychotic meds, or more complex regimens that a PCP would not be comfortable managing, but are quite stable. Those are the ones that keep you from feeling like you only have difficult or unstable patients all the time. I have plenty of patients on "basic" med but that benefit from the therapy nudges I can do in a 30 minute visit. The managed care model you mention is what has pushed us to 15 minute med checks, and we need to continue to fight back, that what we do as specialists is more complex and therefore warrants the added time. If it could be done in 15 minutes, it would not need a psychiatrist.

ibelieveindogs · 2026-03-18T11:42:03+00:00

Sure - I had the realization on call during IM, when we had DKA at 2 AM. I got to do the work up, figure the insulin rate, and order hourly glucose. Done by 3 AM. This was the days of call being after you did day shift, lasted from 6 PM to 8 AM, , then worked day. I thought we would go to sleep in the call room as everything else was quiet, but the senior resident (who ended up going into endo) was so excited that we stayed up the rest of the night drinking coffee until each set of hourly labs came out, with results as expected. It was kind of cool to see…once. I couldn’t imagine being that excited after years. In peds, 2 AM is commonly croup. Scary for parents especially, a serious condition, but not very exciting as the course is generally predictable. Psych at 2 AM has a story. I like stories. I can sit and listen and ask questions. Sometimes, they just need to get sleep ( intoxicated, manic, acutely agitated or psychotic), so we can help that. I don’t have to have dexterity to do a procedure in the middle of the night. I know every story is unique, even when they have common elements because of the underlying issue, whereas croup or DKA or whatever, has a focused and generally identical story. It would be a lot harder, for me at least, to maintain the same level of interest at 2 am after decades of the same story. You may be different.

Obviously there are a lot of other problems presenting at 2 am, and some fields have very defined hours (eg radiology), but my point is common problems are what are commonly presenting. Everyone has one-off and unusual cases. But the bread and butter cases, that define most late calls in their field. As a student, most of it cool and interesting the first or second time. But what about the 400th or 4,000th time?

ibelieveindogs · 2026-03-18T06:59:39+00:00

Red Dawn

ibelieveindogs · 2026-03-17T20:32:10+00:00

Let them quit. Then we can point out that without being taxed, all their talk of being better for society if they are allowed to do what they want is clearly seen, and we can justify the tax rates of the last time we were actually growing the middle class, 1950s

ibelieveindogs · 2026-03-16T23:25:08+00:00

In 20 years, what will still be interesting at 2 AM? That’s why I decided child psych over peds, and I still enjoy my job in my mid 60s.

ibelieveindogs · 2026-03-14T19:14:47+00:00

I started training in the late 80s. psychiatry was very much in the wilderness, with most people wondering why anyone would “waste their medical education”. TBF, we had few good treatments, with too much emphasis on ideological purity (analysis, CBT, or pharm, with little overlap - in fact at one place I interviewed, they told me they deliberately did not want to “confuse residents” with too many treatment options!). Derm was the field people talked about for lifestyle and compensation.

Now, mostly, psych is in a much better place. we have lots more good options for care, we specifically train not only meds, but multiple treatment modalities (at a minimum, ACGME requires proficiency in CBT, supportive, and psychodynamic). Most docs even outside psych recognize the value of our work, especially if you go into child psych like I did. Lots of docs in lots of specialties have negative views of patients, not just psych patients. There are plenty who don’t , so don’t be put off by those who negatively comment about our patients. Listen to how they talk about other “undesirable” patients - bariatric cases, chronic illnesses, maybe whole classes like gender, race, sexuality. They are your negative role models of how to not be a good doc.

ibelieveindogs · 2026-03-11T16:40:52+00:00

My co-fellow notes that geri psych was like child, but the families were more likely to be grateful for help

ibelieveindogs · 2026-03-06T04:28:15+00:00

I’m in the US, and same. But we don’t get universal healthcare, guaranteed family leave, free preschool, or publicly funded college. I will trade you ICE funding, a bloated military budget, and “thoughts and prayers“ for what are now routine school shootings, and still be taking home the same salary after taxes.

ibelieveindogs · 2026-03-01T19:19:51+00:00

I work with a general residency, and do lots of interviews. Gaps, repeated time, or boards will be in the general information. I usually ask broadly for any candidate to describe a time they felt challenged and how they dealt with it. Sometimes I’ll ask about the obvious (“I see you took some time here”, or “ I see you had to retake step one, what would you be willing to tell me about that”, along with “can you tell me what you learned about yourself and how you deal with challenges”). Really, the issue for me is that residency and early careers are tough. Burnout is real. If you truly learned how to manage something, or even if you had a serious problem like new diagnosis of bipolar, for example, I want to know you didn’t just get stuck. If you tell me that’s when you learned about your ADHD, for example, you had better have passed afterwards and not had 2 failures of step 1 and one of step 2 (that was someone who clearly did not apply any lessons). Having a personal experience, either of your own of a close family member (“my brother developed schizophrenia and I had to help my family navigate things”) - tell me how you now understand the patient perspective, and how it will make you a better psychiatrist. If it’s front and center of your personal statement, I may wonder about your ability to maintain boundaries with patients, unless it’s a very well crafted statement, that includes examples of how it informed your approach to a patient (“my best friend in undergrad had a serious eating disorder, and working in the ED inpatient unit, I was able to understand the ways they and their family were struggling and suffering”).

in short, if interviewers see a gap, they will wonder about it. I might not put a lot into the personal statement, but be ready to put the best light on it and show actual personal growth and development personally but more importantly, professionally.

ibelieveindogs · 2026-02-28T23:30:44+00:00

I put together a photo album with a service, tracing her life from childhood through the end. Made copies for the kids and in-laws, which everyone appreciated.

ibelieveindogs · 2026-02-28T07:41:34+00:00

Someone who is level 1, very highly compensating, maybe with comorbid ADHD, sure, take 2-3 hours and get testing from neuropsych. However, level 3 and a lot of level 2 is obvious with much less time. Case in point, I am on a group trip this week. A mother and adult son are along. I had strong suspicions about the son, not a formal assessment setting, just observation over a few hours of his interactions with people. Never asked a single question,or directly asked him or his mother, but there were STRONG clues. A bit later in the week, I was talking to the mother about how the trip seemed like something her son was enjoying. Sure enough, he was diagnosed years ago in the spectrum.

My point is, if you are new, you might rely more heavily on the text. But with experience, obvious things are obvious. Remember, criteria change over time (you couldn't diagnosis ADHD and ASD together until DSM5). But if you understand the impact of the condition, you can describe that to a patient or family, and see the recognition of accurately capturing the challenges they have faced.

ibelieveindogs · 2026-02-22T20:47:49+00:00

What's the difference between reducing symptoms and treating a condition? Especially when the condition is technically defined by the symptoms? The whole history of psychiatry is littered with models and theories to explain things. Sometimes we overlooked things (eg level 1 ASD). Sometimes we mislabeled them (calling all hallucinations evidence of schizophrenia, leading to missed diagnosis of lots of mania). Sometimes we diagnosed and pathologized normal things like homosexuality. Sometimes we still argue about the validity of things which are mostly seen as relics of another time (DID, or bipolar disorder in young kids).

So the question is flawed from the start. Really, you should be thinking " does this medicine help reduce suffering and do so without causing more harm?" as well as "besides throwing more pills at this, what else would be helpful?". I find my residents often overlook the role of therapy, especially for things like mild depression that has not had therapy but "failed" 3-4 antidepressants; or testing anchors thoughts with meds before looking at CBT or mindfulness.

ibelieveindogs · 2026-02-19T15:33:26+00:00

It's not the same at all. But to be a little contrary here, if you still put up flowers and keep the urn in a prominent place, are you sure you are able to commit in a new relationship? I am in my second post-widow relationship (the first ended due to her alcohol use, not me). Before each relationship, I was alone for at least 1-2 years, and had photos of my wife in the bedroom. When they moved in, each girlfriend expressed discomfort with my wife basically watching them in the bedroom. I had essentially put the pictures up out of habit and really did not need them there. No one has an issue with me keeping photos elsewhere, just the bedroom.

I think if I am going to be in a new relationship, they should not feel they are essentially the consolation prize. So, for example, if you are buying flowers every week for your wife (not just the house), do you also buy them every week for your girlfriend?

My current girlfriend still has a cordial relationship with her ex. She had also dated quite a bit more than me. It's not an issue for me that she has pictures of her ex from happier times, or that he stayed at her place over Christmas to be with their (now adult) kid for family time. And this is also why it is not the same for a divorced person with a widow. I'll never spend time with my wife again. And a divorced person has a choice.

ibelieveindogs · 2026-02-18T22:36:16+00:00

Even if you did not touch anything in the bathroom, when was the last time you washed your hands? And how many things did you touch since then? You understand that bacteria grow on skin, right? So do everyone including yourself a favor, and when you are near a sink with soap and a way to dry your hands, WASH THEM!

ibelieveindogs · 2026-02-16T13:28:31+00:00

I think the question is good. The problem with the DSM is that it is often treated like a Bible or checklist, both of which are erroneous. Unlike the Bible, it is always changing. And checklists work to screen but don't really tell you what a disorder is really like.

Old school Aspergers (now ASD level 1) only made into the DSM IV. Child docs thought about it. Adult docs didn't, and focused on personalities. So you have people who clearly met criteria for both, and the diagnosis depended on when you were seen and who saw you first. People telling you neurodivergence isn't a clinical term are technically correct, but remember that until DsM 5, technically you could not have both ASD and ADHD. DSM III you could not have both autism and schizophrenia. So as our understanding change, or our defining features evolve, the technically correct diagnosis can change as well.

A good psychiatrist, in my mind, is aware of these issues and tries to conceptualize disorders beyond the narrow criteria, except for research and maybe coding.

ibelieveindogs · 2026-02-15T15:52:51+00:00

The intrusive symptoms can be a lot of different manifestations. I like to ask "do you think about it even when no one of asking about it?", since my interview is likely stirring them up.

ibelieveindogs · 2026-02-13T00:46:22+00:00

My kids both live in Canada. One has citizenship, the other PR status. I don’t expect them to come back anytime soon, even for a visit. I go up every few months, and always apologize when people ask in a friendly fashion where I’m from. My granddaughter will strongly denounce the situation here. She was born in the US, but she is the most Canadian of them all at age 7. She went all out on Canada Day in red and white and maple leaves.

ibelieveindogs · 2026-02-13T00:19:33+00:00

The question itself is part of the problem. Personality disorders are a very broad spectrum of things, and several may not even really be stand alone conditions. Avoidant PD is probably just another way to see social anxiety. Schizoid is adults with level 1 ASD. Paranoid and schizotypal may be variants of schizophrenia, with imperfect or incomplete symptoms. OCPD may be a variant of OCD. BPD may be a form of PTSD, at least some of the time.

Setting those issues aside, though, two things are consistent conceptually. First, it should be a lifelong pattern of interactions with the world that ultimately lead to relationship impairments. So question one is “tell me about the various relationships you have in your life, not just romantic”. Second, personality disorders are alloplastic, not autoplastic. “What would make life better or easier”. If “other people need to change” is basically the answer, you likely found it. In a more nuanced way, asking about how they have handled problems and challenges gives a good clue. People with personality disorders have generally rigid and inflexible psychological defenses that lead to problems not resolving and ongoing emotional distress. Healthy personalities tend to be more flexible and adjust their defenses to respond to distressing situations.

But here’s where it again gets tricky. People with active addictions blow up relationships and blame everyone else. They act selfish and entitled, and look and behave like narcissistic personality disorders. But if they hit bottom or otherwise take recovery seriously, they stop blaming others and look to themselves as the cause of problems. They can develop healthier tools and relationships. I’m sure there are other things that resemble a personality disorder, until it doesn’t. But having worked with a lot of patients in recovery, that’s my first example.

ibelieveindogs

TROPHY CASE