POSTING RULES:

Does a practice’s zip code matter for Medicare / Medicaid reimbursement in states with just one physician fee schedule? How about from insurance reimbursement perspective?

Like California has many fee schedules depending on location but Colorado only has one fee schedule for the entire state.

Just wondering if it would make more sense to minimize expenses by setting up practice location in a very cheap, rural part of Colorado (for example) if the plan was to practice strictly telehealth rather than in an expensive city like Denver.

Does anyone know of residency programs that are particularly strong in outpatient training? For example, some extend outpatient year into PGY4 with half day outpatient clinics/longitudinal electives or just have excellent faculty mentors in this area. If you know if any to avoid bc this is a weakness that would also be helpful.

Now that the telehealth Covid provisions have expired what are your practices around treating and prescribing across state lines?

For example a patient is on vacation or visiting relatives in another state and forgot their meds. Or they get into an anxiety crisis in another state and need meds ordered.

Do you see the patient and prescribe meds to an out of state pharmacy even though you don’t have a license or malpractice insurance in that state?

Anyone familiar with this practice or how they operate? Thanks!!

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https://www.blueskypsychiatrists.com/

Currently finishing up third year of med school with 2 months of surgery rotations. I actually really enjoy surgery and how efficient it can be. Don’t get me wrong, I love BS’ing with patients and getting to know them 😃 but visits can last all of 5 minutes and everyone can be happy and well cared for. I quite prefer being able to keep on my schedule and not feel like I’m being sucked into 28 different problems/complaints or going down unnecessary rabbit holes. Our post-op visits are extremely quick and I enjoy not wasting anybody’s time when possible.

I know psych visits often take longer, but is it possible to structure your patient encounters a bit more focused and to the point in the field? Short and sweet (without missing things/compromising care)? I’m relatively naive to the field but love it and fully intend to apply psych in residency, but just feeling out how customizable the encounters can be in attending/resident life. Thanks yall 😃

I'm a resident in Brazil and around here we are a flooding of tests performed in patients without prior psychiatric evaluation. Some of them are anxious or depressive and are obviously going to have altered scores.

The tests frequently even come with an ICD code for diagnose. I have received some 10 tests and I'm yet to be convinced by the first one of the said very very very discrete autism in adults.

How is this reality in your nation?

Do anyone here actually know a lot about those tests and can clarity to me why do they seem to believe they can really detect such low symptom phenotypes? Am I missing something?

I'm a DO PGY-4 psychiatry resident and was wondering if it mattered which board certification exam I took - ABPN (MD) or AOBPN (DO)? I haven't found any thread explaining the advantages vs disadvantages. The AOBPN certification seems way more convenient, but if anyone could help me out, I'd really appreciate it. Thank you!

Does anyone have a good source/graphic for the receptor profiles (specifically binding affinities) of psychotropics? Trying to find something Stahl's-esque without having to screenshot and make my own.

Does anyone see patients in a traditional office setting and somehow make standing (during appointments) work? Tell me about it.

I'm a forensic trainee in the UK and was listening to the fantastic psychiatry and psychotherapy podcast including the recent Q+A with Dr Richard Cummings. He discussed medical causes for psychiatric presentations.

I felt a little rusty and was particularly taken aback by his case of non-convulsive status epilepticus (which I knew little about) presenting with psychosis. A SPECT scan was done which found a hot focus deep in frontal lobe. Valproic acid cured his psychosis. I imagine this could have easily been missed. Of concern, EEG in this case would be normal as the foci was deep seated. The takehome message was that in this case, suspicions arose when antipsychotics actually worsened his psychosis (reducing seizure threshold).

This made me think 1. Shit I need to do some revision and 2. In forensic, we have so many treatment resistant cases, are we missing anything?

Therefore, I wonder if this sub has any good resources for medical causes of psychiatric presentations, or even if people just wished to share some interesting cases? Maybe I can start with a few that I've happened to come across during my training, keen to hear from everyone!

Wilsons disease - genetic disorder of copper metabolism affecting 1 in 30,000. Copper builds up in liver, eyes and brain (commonly basal ganglia) and can present with psychosis. Symptoms may include liver related symptoms such as vomiting, ascites, jaundice and pruritus. Brain symptoms include parkinsonism, slurred speech, ataxia, frontal lobe symptoms. Examine eyes for brown rings on the edge of iris (kayser-fleisher). Test with MRI (hyperintensities in basal ganglia) and blood test for ceruloplasmin and copper. Sadly the case I saw was a 24yr old who had been in psych units for years with untreated wilsons disease. I saw him in the neuro rehab ward when I was PGY1 and he was significantly disabled. Not sure how he progressed but he really stuck with me

NMDA encephalitis - autoimmune inflammatory condition that frequently presents with psychosis. Caused by auto antibodies targeting NMDA receptors. Patients are often agitated and confused. Autonomic dysfunction is common and seizures can occur. Robust general physical and neurological exams are vital in these cases. MRI brain can be normal but EEG is often abnormal. Around 80% affected are women and its commonly associated with teratomas of the ovary (half of cases).

Phaeochromocytoma - catecholamine producing neuroendocrine tumour. Can present as depression or anxiety. Patient may present with hypertention, tachycardia, headache, tremor, perspiration. ECG may show signs of left ventricular hypertrophy. Test blood and urinary catecholamines over 24h. CT scan gold standard to diagnose

In my country, residency depends on your desired location. For the next two years, I have two options:

1. Joining a smaller private psychiatry practice with a salary ranging from $170k to $300k. The practitioner mentioned the option to work part-time and highlighted a superior quality of life. However, there's uncertainty about the realistic pay and the workload includes seeing on average 6 patients per day. It was sold to me as a dream job.

2. Opting for a larger private practice offering a fixed salary of $150k per year. This involves seeing a minimum of 7-8 patients daily but comes with more benefits and resources due to the larger team.

Both are in central nice cities, think Vienna or similar, so location wise it's perfect. Both are city practices. And I should start at 70-80 % work time. While the first option seems enticing, it's important to consider potential hidden drawbacks. Despite being portrayed as perfect, there may be aspects not disclosed upfront. It's essential to thoroughly evaluate both options before making a decision.

Hi everyone! I’m looking for you must have website that you use that could be useful for people in training? I am trying to create a toolbox of those. Website like switching med or any useful article or guidelines in pratique or even document you like to give to patients! Thank you in advance !

I've been looking at some psychiatrists websites that often cite federal law as prohibiting them from prescribing controlled substances since they are 100% telehealth/virtual (no physical location). However, my understanding is that you can prescribe controlled substances to a new patient that you have not done an in-person medical evaluation on up until December 31, 2024 after the second temporary rule change in October 2023. Here is the text of that second temporary DEA rule change which I'll quote a section of below:

"In light of the need to further evaluate the best course of action given the comments received in response to the NPRMs and the presentations at the Telemedicine Listening Sessions, DEA, jointly with HHS, is issuing this second temporary rule (“Second Temporary Rule”) extending the full set of telemedicine flexibilities regarding prescription of controlled medications as were in place during the COVID–19 PHE, through December 31, 2024. This extension authorizes all DEA-registered practitioners to prescribe schedule II–V controlled medications via telemedicine through December 31, 2024, whether or not the patient and practitioner established a telemedicine relationship on or before November 11, 2023. In other words, the grace period provided in the First Temporary Rule is effectively subsumed by this Second Temporary Rule, which continues the extension of the current flexibilities for all practitioner-patient relationships—not just those established on or before November 11, 2023—until the end of 2024."

Am I right in understanding that a new patient seen today virtually (and only virtually moving forward) can be prescribed controlled substances without an in person medical evaluation through December 31st, 2024? If so, are others referring to federal law just not interested in prescribing these virtually? Not interested in prescribing them at all? Don't want to have to deal with ending care with patients who may not be able to attend in person appointments after 12/31/24? What do you think will happen to these rules after 12/31/24? Or am I just flat out wrong and if you see a new patient now you can't prescribe them a controlled substance until they have an in person medical evaluation?

After fellowship, I’ll be starting my first attending job at the academic institution where I’ve trained. Our team has rotators from our psychiatry residency as well as family medicine PGY-2s, Transitional Year interns, and 4th year med students, both local and visiting.

My question for yall: what tips do you have for me? Not just from other CL docs working in hospitals (your input is also appreciated), but also what do residents want to see from their attendings, same for med students, nurses, psychologists, etc.

Hopefully this is not only helpful for me, but for anyone reading the comments. Thanks in advance!

Hi all. Retiring soon and looking to continue working, albeit at a much slower pace. Maybe a few weeks on and then off so I can take some breaks or part time work prn. Locums seem to be mainly trying to fill full time slots which I don't want.

Any good ideas on part time jobs - maybe accreditation agencies? or chart reviews? Would appreciate any advice on where to start. Thank you!!

How do I make the best out of the APA conference as a medical student? I was planning to attend all the days but trying to see what would be the most beneficial for medical students - the educational sessions look interesting. I know there is a residency fair on the 6th, so definitely was going to attend that but don't know much else.

I was hoping to see if I can potentially get some aways from attending as well. Thank you!

Incoming psychiatry resident and have noticed people nearly always respond with a joke along the lines of “I’ll be your first patient” when they find out what I do. Often these are people I’m speaking to for the first time. What are your favorite responses in these cases?

A somewhat silly but also kind of serious question inspired by the solar eclipse today. Is there literature on this? Have any of your patients commented about any of these rare but predictable natural phenomena?

Anyone ever seen individuals with history of severe alcoholism in recovery see mild withdrawal effects from even small GABA activity?

Young pt ~15mo sober after severe alcoholism (max 30-35 shots hard liquor per day), comes in complaining of a constellation of symptoms that the pt also describes as “feels just like alcohol withdrawals”

Had 2 ER visits with pan-negative workup. On careful history, symptoms started about a month ago after an ER visit for abd pain and headache, pan-negative workup. Discharged with fioricet.

Today pt describes 1wk since last dose and worsening symptoms 3 days later. Symptoms are still present:

• Palpitations
• Tremulousness
• Diaphoresis
• headache
• intermittent nausea

ER visit two days ago included pan-negative bloodwork, and CT head/Abd. UDS with benzos, which I’m suspicious is very likely the Butalbital.

EDIT: I confirmed that I was mistaken and that the UDS was Barbiturates positive, and Benzo negative. I misremembered during my review and typing the post.

What are your thoughts? I’m an FM resident by the way.

Had a patient come asking for our clinic to prescribe this new FDA app approved for depression. I looked into it and do not even see it’s available. Also found a study that showed no differences from placebo. Anyone know anything about this?

What are your policies around terminating patients who No-Show or Cancel an appointment, do not re-schedule, and then do not respond to additional outreach attempts? This is assuming there is no reason to believe the person is any sort of danger or distress, just the simple situation of not returning calls/responding to requests.

How many times do you reach out before sending a termination letter?

How long do you wait between out-reach attempts?

What is your time window for ultimately terminating a patient? Is no response to attempts and 90 days from last appointment too short? Is 6 months too long?

I realize state laws around abandonment vary and will impact these policies, but curious what people are doing.

This thread is for all questions about medical school, psychiatric training, and careers in psychiatry For further info on applying to psychiatric residency programs, click to view our wiki.

Little niche question, for people working in consultation liaison especially if doing organ donation psych evals. Are there definitive guidelines (fitness to donate, abstinence duration) if an alcohol dependent donor wishes to donate (kidney or liver portion)? Would three months' sobriety be adequate to clear, if donor expresses motivation to stay sober? Links to any published guidelines would be greatly appreciated!!

see title :)

https://youtu.be/Jq9-nOEHxIU?si=0Aef76n59f9uSuaT

From my very first rotation, I would happily persuade patients that they needed to take an 'antipsychotic', because their dopamine was too high and thus this drug will help reduce it. 'Like insulin and diabetes' etc.

This is the usual spiel. However, recently I have been wondering how true this statement is...

I like to think that there is something inherent about antipsychotics that is treating the psychosis, but ofc the receptor activity of antipsychotics is extremely variable and clozapine has low D2 affinity.

We know that meth increases dopamine. And we know that meth can cause psychosis, so for a while this was reassuring that we had got it right. But I then thought that meth also upregulates NA and serotonin etc, and many other drugs cause psychosis that are not so dopaminergic (psychedelics, steroids, cannabis).

I went deep into the dopamine synthesis capacity research and id say it is inconclusive, but broadly in favour of psychotic patients having higher dopamine uptake than healthy controls. But this could well be due to increased movement, arousal, anxiety etc during the scan. Also, many of the studies have healthy controls with higher capacity than psychotic patients.

I saw a Dutch study that is ongoing that was looking at dopamine synthesis capacity on borderline patients - if other conditions also exhibit raised dopamine synthesis capacity then I feel that would also make the dopamine hypothesis of schizophrenia less robust.

I'm a trainee psychiatrist so I'm still learning, but it does worry me that I may be saying things to patients that are based on faulty logic (or more likely big pharma marketing). Did we just find drugs that work and then assume the cause must be the reverse of the drugs action...

So I had a few questions - do you have any slam dunk research that makes you fully believe the dopamine hypothesis?

And slightly related, I've struggled to find many decent RCTs comparing benzos monotherapy with antipsychotic monotherapy for schizophrenia. Any links? Has anyone here ever tried to treat psychosis with benzos as monotherapy?

I can see in acute agitation of psychosis benzos often are superior or equivalent to antipsychotics (https://europepmc.org/article/med/33681744), which makes me wonder whether they would have been given the moniker of 'antipsychotic', if they'd been invented first...

In recent decades, various neuro-imaging methods have used in research on ADHD to determine and illustrate brain differences by way of imaging the brain's structure and functioning. While these scanning methods have proven incredibly valuable in studies on the underlying neurological basis of ADHD, they are not useful for diagnosing individuals. This is partly because the brain abnormalities, given their subtlety, only become statistically significant when averaging the results of large groups.

To cite the International Consensus Statement on ADHD:

• Table 1 (71-77):

"Neuroimaging studies find small differences in the structure and functioning of the brain between people with and without ADHD. These differences cannot be used to diagnose ADHD."

• Section 5.0:

"[ADHD] cannot be diagnosed by rating scales alone, neuropsychological tests, or methods for imaging the brain".

• Section 8.0:

"...The second [class] comes from methods that directly examine brain structure or function with neuroimaging scans. Although many of these studies have found differences between groups of people who are and are not diagnosed with ADHD, the differences are typically small and do not dramatically differ between people with ADHD and those with other disorders. They are, therefore, not useful for diagnosing the disorder (Thome et al., 2012). These differences are not caused by drug treatment and, for some patients, diminish or change as patients grow out of the disorder."

Therefore, do not be deceived by popular self-proclaimed experts such as Dr. Amen and his clinics claiming otherwise. I am optimistic that a time will come when a neuro-imaging method will be clinically useful but scientists are not there yet.

Hi all,

I'm a current PGY4, in the midst of attending job interviews. I have no idea about job application etiquette and I'm hoping for some guidance. Basically, I received an offer from a hospital that I rotated at. I generally don't really want to work at this hospital for numerous reasons and I'm treating it as a back up. The compensation seems fair (295k), but it's not PSLF eligible, which is something I need. I received the offer letter about a month ago and the letter itself has a deadline to respond.

The contact at the hospital has messaged me reminding me of the deadline, however I still have interviews coming up at other hospitals that I'd rather work at. The contact at the hospital that extended the offer is aware that I'm still interviewing at other sites. Is it reasonable to ask them for an extension of the deadline to respond to the offer letter? Do I reiterate that I have upcoming interviews and want to have some time to make a more thoughtful decision or do I just not mention that part at all?

Reading up on this after some Googling seemed to indicate that asking for an extension is a huge risk and they may rescind the offer, but is this still the case for physicians (specifically psychiatrists) who are not so easily replaceable? Any insight would be much appreciated!