According to a recent USA Today article, a U.S. physician-recruiting firm received a 47% increase in the number of requests for psychiatrists between April 2009 and March 2010. This was a 121% increase from 2006-2007.

Psychiatrists were the third-most-requested physicians, trailing only family practice and general internal medicine.

How can this trend be explained?

By both supply and demand.

Although the number of medical students choosing to enter psychiatry residency has gone up slightly, many more have chosen more lucrative specialties. The number entering the profession will not compensate for the fact that more than half of all psychiatrists 55 and over are nearing retirement.

Demand is expected to increase 19% between 1995 and 2020 (for child psychiatry 100%).

I’m thankful to work in a field with excellent job security. In terms of demand, it’s a great time to be a psychiatrist. Unfortunately, it’s not a great time to need the services of a psychiatrist—access is likely to remain a problem in many places.

What is your response to this?

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There is a natural conflict of interest that occurs when a psychiatrist who is providing treatment to a patient agrees to perform an evaluation or render an opinion about something of a legal nature regarding the same patient.

In treating patients in the community, I’ve turned down requests from attorneys on several occasions when they wanted me to provide expert opinions about my own patients. I simply did not feel comfortable doing so as I believed that it was going to interfere with my treatment relationship with them.

This viewpoint is endorsed by the American Academy of Psychiatry and the Law in their Ethics Guidelines for the Practice of Forensic Psychiatry (PDF).

Here’s an excerpt:

Psychiatrists who take on a forensic role for patients they are treating may adversely affect the therapeutic relationship with them. Forensic evaluations usually require interviewing corroborative sources, exposing information to public scrutiny, or subjecting evaluees and the treatment itself to potentially damaging cross-examination. The forensic evaluation and the credibility of the practitioner may also be undermined by conflicts inherent in the differing clinical and forensic roles. Treating psychiatrists should therefore generally avoid acting as an expert witness for their patients or performing evaluations of their patients for legal purposes.

Psychiatrists can be compelled to testify in court as fact witnesses regarding their own patients, but not as expert witnesses. Fact witnesses can verify the dates of treatment, the diagnoses made at those visits, statements that patients made, and the treatment rendered, but they cannot be asked to speculate or render opinions.

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I recently published a post asking for readers to submit questions to me that they might have (primarily about my profession). I’ve paraphrased when necessary:

1. “Why do people who truly do have mental issues despise taking their medicine-often times going off of it and landing themselves back into the hospital due their condition? They say they don’t need the medicine-but obviously they do. And those who fake an illness love their medicines and will fight, steal and lie to have these medications.”

A: Most people do not actually want to have a mental illness. For various reasons they resist it and can be in some degree of denial. One aspect of some mental illnesses is also a lack of insight (or varying insight depending on how sick they are). People who fake illnesses for secondary gain (entitlements, attention, etc.) have a large incentive to stay in the illness role to obtain what they seek. The better they play the part, the less likely their cover will be blown.

2. “Do you have any risk management tips? What are some practical things correctional medical and mental health providers can do to minimize lawsuits by inmates?”

A: Excellent questions. And they require answers too lengthy to write here. Therefore I’m going to do a post on risk management issues in the next week or so.

3. One reader recently sent me an e-mail expressing frustration that I do not publish posts on transference issues. Specifically she was interested in material about patients who have romantic feelings toward their psychiatrists.

A: As a male psychiatrist who currently spends much of his professional time treating male inmates and who is not formally practicing psychotherapy, you’re not likely to find articles about patients and psychiatrists having romantic feelings for each other. I’m just one person doing what I do here for free (actually I pay money for my blog; I spend hours each week writing for free). I simply can’t and am not interested in covering everything. Readers interested more in psychotherapy issues with psychiatrists may want to check out Shrink Rap, a psychiatrist blog by 3 psychiatrists (2 females and 1 male). Dinah, one of the psychiatrists there, has a psychotherapy practice and often posts about therapy issues.

4. How could a librarian (presumably in a correctional facility) help inmates to better understand their health conditions?

A: That’s a tough one. I’m vaguely familiar with the library resources that have been available to inmates in the institutions in which I’ve worked–what’s available seems to vary quite a bit from one place to another. Given the less than high school education that many inmates have, I would say that helping them to find books that would be appropriate to their reading levels would be most helpful.

5. “How do you keep from getting frustrated with recalcitrant/dense/reluctant to take your suggestions types, and how do you keep your cool at the times you’d really just like to reach across the table or whatever and shake your patient and say “WHY AREN’T YOU GETTING THIS?!?!!?”

A: I do get frustrated at times. I wouldn’t be human if I didn’t!  But,  I guess that over the years I’ve learned to be more patient with patients, even difficult ones. What helps me is that I see myself as a consultant to my patients. I’m not there to rescue them or save them from themselves. I do my best to establish rapport with them, assess them, educate them, and provide my opinions and recommendations. If they choose to ignore my recommendations, then I document everything and move on. If they change their minds down the road and  want to work with me, then I’ll gladly do it. I don’t take it personally. It’s about them, not about me. As far as patients “getting it,” some people never will. But I believe that establishing a good therapeutic alliance is one of the keys to being able to make a difference. Patients care much less about what you have to say until they know they can trust you.

6.”Particularly in the setting you work in, how do you manage to avoid coming down with, for lack of a better term, secondary PTSD? It’s got to suck to sit and listen to what are undoubtedly some pretty horrible stories for hours on end and I can’t imagine it’s possible not to be affected by what you hear.”

A: Honestly, it’s very draining at times. For me personally, having variety in my schedule (I don’t just work in corrections) is key. I do think I’ve learned to cope with it better over time. However, I’ll have to say that I also think it’s something that some people can naturally do more easily than others. It may sound like an oxymoron to be able to be a sincerely caring person and at the same time realize that you need to do your little part each day to try to help others and then forget about it when you walk out the door, but that’s what I try to do. You can’t save the world. I’ve come across some very caring health care professionals in non-correctional settings who could never survive working in a jail or prison. They would get so emotionally wrapped-up in all the drama and trauma that they would lose their ability to objectively assess their patients. They’d run into boundary issues (they’d become enmeshed) because they’d want to rescue all the unfortunate patients they treated. And that’ s just not healthy for the patients or health care workers. I know that may be difficult for some people to understand, but it’s so true. And these would be the ones, in my opinion, most likely to be traumatized from their work.

Thanks for your questions. I hope some of my answers made sense! Feel free to leave your comments.

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I’m getting tired of hearing myself talk. You’re probably getting tired of it, too. So, it’s your turn!

Seriously, I really want to hear from you.

Ask me whatever you want about my profession, and I’ll do my best to answer (as long as the questions aren’t too personal or about my employers!).

You may leave your question(s) as comments to this post, or you may e-mail them to me (click on Contact at the top of the page to quickly send me a message).

I look forward to your questions and appreciate the time you take writing them. Please help me make this interesting! Thanks.

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Psychiatrists treating patients who can’t talk: Sounds fishy, doesn’t it?

Well, I do it 2-3 days per week, and as strange as it may sound, it makes perfect sense.

Let me explain.

I provide psychiatric consultation services in a facility for people with intellectual and developmental disabilities. (Intellectual disability is the newer term for mental retardation.) Some of my patients are short-term admissions from the community, and others are long-term residents of the facility. Over the past couple of decades as community living has become the norm, many long-term residents have moved to the community. Those who are left are quite fragile and very medically complex. About 70% have seizure disorders. Most have severe or profound intellectual disabilities and are completely non-verbal. Being dependent on others for assistance with activities of daily living is the norm.

One of the old myths about persons with intellectual disabilities (ID’s) is that they cannot develop mental illnesses. You may have heard the term “dual diagnosis.” Usually that term refers to persons who have both mental illness and substance dependence. However, in the field of developmental disabilities it also refers to persons who have both an intellectual disability and mental illness. Patients with any level of ID, including those with no expressive communication skills, can develop mental illness.

Since these severely intellectually disabled individuals who can’t talk can develop mental illness, how does one determine whether mental illness is present and which diagnosis is most likely?

Not the traditional way that medicine is practiced in the U.S.

It takes a multidisciplinary team approach and careful data collection. Our team is comprised of primary care, psychiatry, nursing, psychology, occupational therapy, physical therapy, speech and language pathology, dietary, pharmacy, social work, Qualified Mental Retardation Professionals, recreational therapy, vocational services, and direct care staff (CNA’s).

The good news is that not only do we have access to all of these disciplines, but every team member is experienced in evaluating and treating intellectually disabled patients who have minimal communication skills.

One of the advantages of being in a system without fee-for-service medicine is that we can seamlessly involve as many disciplines as necessary without having to deal with administrative or reimbursement barriers. For example, as a psychiatrist, I can contribute my expertise (and learn a great deal as well) to cases that do not strictly involve mental illness. And my involvement transcends prescribing psychiatric medications.

When evaluating a new patient, our team will review outside records and then meet with the patient’s stakeholders from the community: parents/guardians, case managers, group home staff, etc. We will all sit around a table together and have an admission staffing meeting, a rare entity in health care these days.

The various disciplines will perform their assessments. If there are problem behaviors identified, then psychology will perform a functional assessment of the behavior. They will collect objective data of the relevant behaviors throughout the patient’s stay.

As a psychiatrist, I rely a great deal on the patient’s history as reported both in outside medical records and at the admission meeting. Then I consider the results of the assessments of the other disciplines with significant attention to the primary care physician’s and psychologist’s workup.

Many behavioral problems in this patient population are caused or exacerbated by non-psychiatric medical issues. Constipation and pain are a couple of common examples. Patients with such issues may begin to exhibit or show an increase in already-present behaviors such as agitation, yelling, aggression, or self-injurious behavior.

It is crucial not to be too quick to make a psychiatric diagnosis–one does not want to make the mistake of treating pain with psychiatric medication, for example.

Once I am able to consider the patient’s history and clinical signs in the context of the other team members’ assessments and objective behavioral data, I determine whether the clinical picture resembles established psychiatric diagnoses. This is where understanding “the art” of psychiatry and having previous experience treating verbal, developmentally normal patients is vital.

The longer I have to work with a patient, the better I am able to make an accurate diagnosis. Sometimes the diagnosis is fairly clear on the day of admission, but in some cases (such as with some of the long-term residents), it may take a couple of years or more.

When I do make a diagnosis, if I believe medication is warranted, then I typically prescribe very cautiously, starting only one medication at a time, using low doses, and making only one change at a time. If psychology wants to try a behavioral intervention, then that is considered a change. If primary care wants to start a medication for pain or reflux, then that is considered a change. Working collaboratively it is usually possible to stick to the “one change at a time” approach.

We all rely on the objective data that psychology tracks combined with each other’s observations of the patient to track the patient’s progress and to guide our treatment. This integrated approach allows me to provide much higher quality psychiatric care than I could in the traditional outpatient setting of the fragmented U.S. health care system.