Shirah Vollmer MD

The Musings of Dr. Vollmer

When Should Psychiatry Residents Learn Outpatient Psychiatry?

Posted by Dr. Vollmer on May 7, 2015

Most psychiatrists leave academic medical centers and practice in the outpatient setting, and yet, many four-year training programs do not begin to expose residents to outpatients until year three. Medical education has typically been skewed towards the notion that if you can treat the sickest patients, then treating less acute folks will follow easily. This has never made sense to me, as although I think it is critical to see severely ill patients to learn the scope of illness, it is also critical to learn the skills of dealing with less intense, but still troubling symptoms. More specifically, in psychiatry, outpatient psychiatry is a very different skill set than inpatient psychiatry. With hospitalized patients, the goal is to stabilize them so they can leave the hospital, typically in three to five days. Stabilizing means getting symptoms under control. By contrast, with outpatients the goals are to improve functioning at work and at home. Here the skill set requires stimulating the patient to care about himself such that he makes good decisions which yield a sense of fulfillment, or “to love and to work,” as Freud would say. The goal post changes over time, as the patient gains greater self-esteem and confidence. To learn outpatient psychiatry one needs to take a longer view of health, and as such, continuity of care is critical for learning. If outpatient work began in year one, then the resident would have the opportunity to watch both patients grow, and watch themselves grow as a clinician. Utilizing time, the four years of training, as a way to emphasize that change takes time and as such, time is critical to professional development. Psychoanalytic training adds on, with a high-intensity clinical demand, but it is not a substitute for the challenging transition from medical student to psychotherapist. My rant continues. Psychotherapy needs to be a valuable part of psychiatric training and more pointedly, it needs to start when the student becomes responsible for patient care. I dream of this world where psychotherapy returns to psychiatric training in a way which builds confidence in the residents. I know it is a dream, but maybe, just maybe, it can get some traction.

2 Responses to “When Should Psychiatry Residents Learn Outpatient Psychiatry?”

  1. Shelly said

    What you write makes sense, of course. My issue is with something else you write: “With hospitalized patients, the goal is to stabilize them so they can leave the hospital, typically in three to five days.” With someone who has had a psychotic break or is having a manic episode, is it really the case that 3-5 days is enough? Can you really send them home in so short a time? Are their caregivers ready to handle them on their own?

    • The short answer is -it depends! Some patients benefit from quick hospitalization whereas other patients just use it as a revolving door. The problem is that the insurance companies are determining when a patient should be discharged, as opposed to the physician. Thanks, as always.

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