Pros And Cons Of Making Psychiatry A Direct Entry School Like Dentistry?

[Edict]

I've heard a lot about the shortage of psychiatrists across North America lately. I've been wondering if it would make sense if Psychiatry was a direct entry school like dentistry instead of a specialty after medical school. 

 

There seems to be a lot of people who are interested in psychiatry but not as interested in the other aspects of medicine. http://forums.studentdoctor.net/threads/medical-school-just-for-psychiatry.1055017/

 

I feel like a lot of people in medicine are also not interested in psychiatry. There seems to be a saying going around that it takes a special kind of person to do psychiatry and many medical students tend to shy away from that because they don't like the field, which does partially lead to a lack of interest in the field. 

 

I feel like interest in the field would go up and more people who are interested in mental health but are unable to get into medical school could pursue the field. 

 

Another argument is that Psychiatry could be combined with Psychology and essentially become one training pathway that would involve getting a Psy.D. that would include medical training that is relevant to psychiatry itself. This would go some way towards eliminating the confusion between the two fields and the current issues of psychology not being covered by OHIP and psychiatrists being pill pushers. These combined specialists would be able to prescribe and would have the same role as both psychiatrists and psychologists combined and different subspecialties can be added to training to make them take the roles of both fields currently. 

 

It just seems like psychiatry itself is a field that is somewhat dissociated from the rest of medicine and since dentistry is an entire school of its own, why can't psychiatry be the same? 

 

Just a suggestion, what do others think? 

[Beacon]

Sounds intriguing, but wouldn't the amount of time required to establish this specialty combination + a new licensing board etc.. be so long that the demand for psychiatry would drastically change by that time? 

[Edict]

Sounds intriguing, but wouldn't the amount of time required to establish this specialty combination + a new licensing board etc.. be so long that the demand for psychiatry would drastically change by that time? 

 

I was under the impression that psychiatry has been in demand since pretty much forever. This is sort of a pie in the sky idea, considering that doing this would require a gargantuan amount of effort and probably a lot more factors driving this than there are currently. 

[Bambi]

Each has their own turf and their separate routes. Won't ever happen (in my opinion for what it is worth).

[Beacon]

I was under the impression that psychiatry has been in demand since pretty much forever. This is sort of a pie in the sky idea, considering that doing this would require a gargantuan amount of effort and probably a lot more factors driving this than there are currently. 

 

Even if the demand doesn't change appreciably, I believe it still would take a significant amount of time/effort/money to establish a psychiatry/psychology combo, mainly due to prescription power and the medical training received by psychiatrists. By the time this happens, who knows what the supply/demand will be like. I am not against this, however, I think the budget can be better spent by allocating more money to decreasing current wait times and revamping the health care system. 

 

This is just my opinion, and I am no psychiatrist. Perhaps someone with psychiatric training can weigh in with their opinions. 

[_ _]

But, if there aren't enough people going into it already, will 'losing' the people who maybe didn't know they liked it negate any benefit?

 

Personally, I don't think that's the way to go because it separates it more from 'medicine' in a way. And that's not necessarily going to improve public perception or care in the field.

 

And let's be honest. Med school is so competitive for entry, you'd likely just end up with people doing it because they didn't get into medical school. And that is not doing any patient a favor, particularly those so vulnerable  

[Organomegaly]

 

 

And let's be honest. Med school is so competitive for entry, you'd likely just end up with people doing it because they didn't get into medical school. And that is not doing any patient a favor, particularly those so vulnerable  

 

 

I disagree. would you say that's why people go into psychology or dentistry or master's programs? 

[_ _]

I disagree. would you say that's why people go into psychology or dentistry or master's programs? 

Sometimes, absolutely. That's been the subject of many threads here, particularly dentistry. 

 

Changing it to make there be an alternative way to be an MD in some field, however, I think is a lot more likely to see this happen. And there's a difference between doing a research masters you don't really care about and dealing with patients they don't particularly care about. 

[loodogg]

I disagree. would you say that's why people go into psychology or dentistry or master's programs?

Yes.

[Organomegaly]

There are plenty of people who go to those schools without having been failed MDs. Psychiatry is already a fairly unpopular residency; with its job prospects people could already be going into it for the socalled wrong reasons.

[Hanmari]

Interesting idea, but I feel that this might hamper the growth of psychiatry as a medical field. A lot of translational research is ongoing in psychiatry that may see clinical application in the next few decades, e.g. neuroimaging and pathobiology of mental disorders. Some are beginning to be applied currently, like rTMS and DBS treatments. While much of psychiatry still relies on the hx and mental status exam (which remain important tools given the uniqueness of presenting complaints), a significant portion of psychiatrists seem eager to bridge the gap between psych and the rest of medicine. Not to mention some psychiatrists are already working intimately with primarily medical pt populations in consult-liaison.

 

Overall I think psychiatry should and will move more towards medicine, not away from it. Does this mean more pill-pushing on their parts? Maybe. But if it's evidence-based pill-pushing and we come to an understanding of the pharmacological mechanisms, why not? Yes, therapy and medication together have better results than either one alone. It doesn't need to be that way forever; therapy takes tons of patient effort, taking pills far less so. If medical treatments in psychiatry are to improve, and if we are to consolidate our view of mental disorders as physical diseases of the brain, I think we need to keep psychiatry as medically oriented as possible. To me this means keeping it an MD specialty and adding new medical knowledge to the curriculum as they become available, not removing it from the medical sphere and combining it with psychology, a field whose primary concern is not the treatment of disease.

[Organomegaly]

Interesting idea, but I feel that this might hamper the growth of psychiatry as a medical field. A lot of translational research is ongoing in psychiatry that may see clinical application in the next few decades, e.g. neuroimaging and pathobiology of mental disorders. Some are beginning to be applied currently, like rTMS and DBS treatments. While much of psychiatry still relies on the hx and mental status exam (which remain important tools given the uniqueness of presenting complaints), a significant portion of psychiatrists seem eager to bridge the gap between psych and the rest of medicine. Not to mention some psychiatrists are already working intimately with primarily medical pt populations in consult-liaison.

 

 

 

I think a lot of psychiatry still requires some degree of physiology. one of the top 5 reasons for visiting a psychiatrist is for complaints regarding side-effects of medications, many of which are not mental health related at all (i.e. extrapyramidal symptoms of anti-psychotics, tardive dyskinesia, impotence from SSRIs - you could write about them for a long time). It's good to have an understanding of the pleiotropic effects of your medications as a psychiatrist. Not to mention your pharmacolology needs to be topnotch, though there's nothing stopping you form learning that in a separate, psychiatry direct-entry program, but it becomes more fluid when you understand physiology.

 

another factor is that many of the very sick patients come from low SES backgrounds and have a variety of other co-morbidities. understanding them will aid in recognizing those issues and referring to the appropriate physician. 

[medisforme]

A couple points I would add that haven't been mentioned yet.

 

1) Psychiatry isn't as unpopular as people make it sound.  In terms of percentage of applicants it has ranked ahead of specialties like ER, anaesthesia and obsy/gyn the past three years.  This year there were 0.86 applicants to every spot, which is getting closer to a 1:1 ratio.  Cities like Vancouver and Toronto are fairly competitive for their psych spots.

 

2) A lot of people I met on the Carms tour, had no intention of pursuing psychiatry when they started medical school.  These are people who likely would not have pursued a separate psychiatry/psychology degree.  You have to have some exposure to mental health and addictions before considering it as a career. The kind of exposure I am talking about can only be obtained during clinical clerkships (as opposed to volunteering/research experience one may have in undergrad which is not the same thing).

 

3) Pre-clerkship psych exposure (at least at UBC) was ridiculously scant, i feel more discussion and exposure to new psychiatry research and treatments could drum up even more interest in this specialty.

[Organomegaly]

i

 

A couple points I would add that haven't been mentioned yet.

 

 

3) Pre-clerkship psych exposure (at least at UBC) was ridiculously scant, i feel more discussion and exposure to new psychiatry research and treatments could drum up even more interest in this specialty.

 

agreed. seems to be the same way at mac. we have a month scheduled for it in november before clerkship but from what I hear it tends to be covered very haphazardly because people are rushing towards clerkship at that point 

[BigM]

As a psychiatry resident, I'd be upset if they made psychiatry a direct entry field.  All of us that are in the field now had to complete medical school and jump through all the same hoops that all of our classmates did.  Just because a number of physicians do not enjoy providing psychiatric care is not a reason to just kick psychiatry out of the realm of medicine.

 

The idea of making psychiatry a non-medical field doesn't make a whole lot of sense to me.  The vast majority of referrals I get from family doctors are for diagnostic clarification and to prescribe/titrate medications that family doctors are not comfortable with.  Do you really want to leave the prescribing of medications with potentially heavy side effect profiles such as antipsychotics to non-medical professionals?  Then take into account that these medications are in many cases prescribed for years.  You really need to understand what you are doing.  In reality, psychiatrists probably have more pharmacology training than almost any other medical specialty.  Prescribing medications is the main reason that we exist so we know our medications inside and out. What other medical specialty (with the exception of clinical pharmacology) spends as much time talking about particular medication interactions and effects of CYP enzyme inhibitors and inducers?  Psychology and psychiatry are extremely different fields.  The vast, vast majority of psychologists will not touch medications beyond answering very basic questions.  In most cases they will quickly refer you back to your prescribing physician as psychotropic medications mainly exist within the realm of family doctors, geriatricians and psychiatrists.

 

If a practitioner is going to provide psychotherapy, then you need to ask how this will be different than the various forms of therapists out there already including social workers and psychologists.  If they are going to be considered specialists in prescribing psychiatric medications then they really aught to have an understanding of medicine. 

 

P.S. this thread reeks of stigma.  It is really unfortunate that the basis of the initial post is saying that psychiatry is basically like dentistry and should be available to people who cannot get into medical school.  Dentistry is an entirely separate field because the vast majority of their work is procedural and contained to a certain body region.  Although they do prescribe some medications, their scope of prescribing is generally limited to a a fairly select set of medications that they are familiar with.  When oral care needs medicine there is oral maxillofacial surgery to back up the dentists.  When eye care requires medicine there is ophthalmology to back up the optometrists.  When mental health care requires medicine there is psychiatrists to back up the psychologists.  

[rmorelan]

My first thought is that making a direct entry ignores where that field is heading as we learn more and more about how the brain works and pathology of mental disorders. This is a field that is going to become more and more complex, and more and more dependent on understanding areas that traditionally were more neurological in nature. Plus many patients have co-morbidities that are extremely complex and also need to be understood in context. It also does as BigM points out ignore the fact that medications are a huge part of the field - tricky medications with complex side effects etc.

 

You can pretty much make the same argues for separation with a lot of fields - say why are all fields in radiology in fact not split off and done by other non doctors trained in their specific area - say mammograms for instance - why does that require the entire host of everything else? Could save a ton of money by just having a 2 year focused program post UG for that. Could make similar arguments for pathology, genetics and sub branches of even more general fields as well. As a side note that is actually a big argument right now - as it really would save the health care system a lot of money as soon as something doesn't require an MD you can bet the income will be cut at least in 1/2.

 

Also it won't really shorten things that much, ha. A clinical psychologist (actually was one of my possible backups to medicine) is a very long program and does of course even include all the medication side of things.