Forget the Politics...Sorry....Doctor vs Provider what is difference between a psychiatrist and a psychologist??

"Uhm same thing?" psychiatrist or psychologist? Nope. "Uhm ( from the sophisticated smarty pants of society) a psychiatrist can prescribe meds and a psychologist can't. True but is that the only difference, is that the defining divergence?"
As you probably know I am now from what I can see the most politically incorrect PRO-PHYSICIAN Blog I can find on the world wide web in the English Language. As you know I don't side step stuff by providing the same constant SAFE-helpful information on common medical problems that you can find in a thousand places on the Internet. Granted my blog is true honest and candid, it is highly opinionated, and I like to think I speak for a lot of doctors whom are simply terrified to say some of the things I say about the adversity a physician is up against in this day and age in the practice of medicine. Of course I don't provide SAFE blog posts on all the latest medical technology ipod and ipad apps and all that BS. Another good clean and SAFE fun topic for doctors to blog about.
So I have an opinion on this question and some facts. I even discuss  it somewhat in When Can I Go Home?
Yes psychiatrists are physicians and they can prescribe medication,
But so can Clinical Nurse Specialists and Nurse Practitioners, and Physician Assistants, all have varying degrees of prescribing authority and autonomy and this varies by state. In a couple states psychologists can ever prescribe psychiatric meds.
The honest to God truth is that this physician extender, or mid-level practitioner model had its origins and motivations in necessity. No one wants to go into the Field of Psychiatry. There is a shortage of psychiatrists.

(I did a recent interview for the Minnesota Medical Associations monthly journal talking about the recession and the effect on depression. The sophisticated and educated Free-Lance Writer hired by the Association to conduct interviews had no idea that psychiatrists were just about the lowest paid specialty in Medicine.)

Okay so we know people don't go into psychiatry to make money and if they think they are , then they are misguided and ignorant, no big issue there.

I won't get into all the reasons why there is a shortage of psychiatrists, it isn't about the money, it is a host of reasons.

Now when you take the shortage issue and you couple it with that fact that politically and perceptually doctors are arrogant SOB's whom only care about making money and therefore just not good people, than you have the legitimization and flourishing of mid level prescribers in psychiatry.

Let me illustrate my point further by example.: I had a student nurse once, whom was getting a masters degree and essentially then getting her license to prescribe psychotropics, I was supposed to teach and train her. She was a good person and quite bright and caring toward patients. I asked her, "What is the difference between a physician and a nurse prescriber?" She advised spontaneously, " nurses are different than doctors. Nurses talk to their patients"
I will never forget that. To this day it irks me and hurts my feelings to no end. She truly believed that and was indoctrinated into believing that, She was not stupid just politically brainwashed.
All I do all day is talk to patients and give and give and give my energy all day. It has nothing to do with the biological mechanism of the meds. It is what a doctor- a good psychiatrist does, Nurses and psychologists do not have a monopoly on talking to patients.

So once I was at a music shop and buying my son some guitar strings the quintessential music story pony-tail guy saw my credit card signature and he said "Ahhh... MD making decisions"  he actually had it right. No one has ever signed anything since the day I graduated form medical school below my signature, An MD always gets to sign at the most bottom line, I swear to God. The signature underneath everyone Else's assures that individual is the master of all liability and assumes all responsibility when the rubber hits the road,

Now the reason I talk about liability and responsibility goes to making decisions. By the nature of training the physician is really not allowed to have a comfort zone for making decisions, Decisions imply ultimate responsibility and liability. Sure you can have colleagues to consult get second opinions, but in the end the physician really has no where else to go. By the nature of the training doctors make life and death decisions in the middle of the night after no sleep for forty hours. That is pressure. Psychologists don't have that kind of training,
I may have blogged about this in the  past but the point got driven home to me a couple weeks ago. Talking to some psychologists and one in training, this therapist trainee was overwhelmed and intimidated by a patient. She wanted to pass the patient off to someone more experienced, she did. no problem right? So how does that work. Will there always be someone more experienced and how did they get that way?
Training more Training and supervision.
Okay here's the bottom line as a psychologist in your training it is ethical and appropriate to give the patient away to someone Else if you are scared and over your head. No problem sounds like the right thing and it probably is, especially for the patient (psychologists call em' clients like lawyers and accountants and advertising executives have 'clients') I don't want someone who does not know what they are doing.

Now jump back 20 years, I'm in my residency I am overwhelmed and intimidated by a patient, I don't even want to see the patient behind a closed door. "Please someone more experienced take this patient off my hands. PLEASE! I'm just a resident,.... a doctor in residency training.
So an old supervisor long dead now says to me, you will have lots of patients over the years who are overwhelming, frightening, you have to learn to work through it, accept it deal with it, get good at treating them. There may be no one in the end more competent to fall back on. Get supervision guidance. Learn. I did, the patient lived and got through the year and things went okay, I did all right, and actually helped the patient. I did not have the luxury to dump the patient on someone more experienced.
Therein lies one of the most fundamental difference between psychiatrists and psychologists and nurses.
If a  doctor does not know what they are doing, they damn well better get some supervision and figure it out, they don't get to send the patient somewhere else because "ohh it's too hard"

Anyway I hope and pray for all of you blog readers caregivers around the world that you had a Blessed Christmas or Happy Hanukkah and have a wonderful and prosperous New Year.  And thanks for Reading my blog in 2011. I know most people are looking for the difference between delirium and dementia and depression, or questions about Alzheimer's being a mental illness. I will keep blogging in 2012.
I do not forget all of you caregivers world-wide, and we will hope and pray for some SIGNIFICANT Alzheimer's progress in 2012.

New Blog: Medical Fiction Writer and other updates

Good Day. Long time no blog. I have been busy with some Health Care Issues lately. In fact I have been down to Mayo Clinic twice since I last blogged. (Great Venipuncturists at Mayo, also fairly decent restaurants in Rochester, MN) I won't bore you with the details right now, needless to say it sucks, but then you go on as best you can,  as time keeps marching on.

Also I have been busy trying to survive as a Private Practice Physician in the State of Minnesota, despite the best efforts of  many bureaucracies and agencies to annihilate entities like myself: all done of course shouting the Battle Cry and in the name of health care "REFORM".  When it is all said and done, we will still need doctors to take care of patients and patients who need to be cared for and cared about by their doctors.
It is absolutely astounding how many people are now employed (with really good employee health benefits I might add) to hinder, hamper, occlude and basically prevent physicians from simply spending their time taking care of their patients. ASTOUNDING

On the lighter and more fun side of things, I started a new blog.
It is called MEDICAL FICTION WRITER CHECK IT OUT. Not too much there yet, but it will get there. Over the last couple if years I wrote another book. very different than When Can I Go Home?. This one is a work of - you guessed it-medical fiction.  It is sort of a drama, action, crime, romance, with chaos, violence, doctors, lawyers, courtrooms, lots of things. Stay tuned. I'm in the process, a very grueling process of doing the first edit.
The blog will be for writers and readers and about writers and readers of medical fiction. and of course Medical Fiction Books.

For all you Alzheimer's caregivers, it is Summer at least in the Northern Hemisphere, if that's where you are. Try to get outside for some warmth, even for a little while. Keep the faith, do your best, I know you didn't sign on for this, but I am sending you my positive thoughts, hopes and wishes and energy right now. What I still have of that positive energy, it is there just below the surface of my cynicism! I promise though, that positive energy and hope is real in me, just as it is in you, whether you know it or not.  So don't get too lost in losing the daily battles, overall by caring for your loved one, with your devotion and dedication, you are winning the war on this thing.
God Bless.
 

On Being a Psychiatrist

Here is a little story I wrote, depicting some musings on being a psychiatrist. I wrote it a couple years ago, for a Minnesota Medical Association little writing contest. They did not see it as a winner and therefore not fit to print. If you still wear Birkenstocks, raise Llamas, vote a certain way, and present a certain, non-disquieting view of medical practice, well that may make for a better and potential printable winner, so that rules me out. We do like our realities to be in a certain way up here. The stuff we know:  we know The stuff we don't know: does not exist. Its mostly the stuff we don't want to know: does that exist?

"ON BEING A PSYCHIATRIST" 

Joseph J. Sivak MD

            "The shiny brown leather couch glistens in the late afternoon sunlight. The couch envelops the supine patient. A bespectacled gray-bearded man in a brown herringbone tweed three-piece suit sits in a cherry-spooled rocking chair a few feet behind the patient, frantically taking notes. The psychiatrist directs the patient, “Tell me how you feel about that.”

            The patient a perpetually shy woman of about forty years shifts on the couch and obsessively twirls her pearl necklace and chews on the white beads, as a grandfather clock on the other side of the room seems to tick more loudly than ever. The patient struggles with her analysis. The psychiatrist pulls out a gold-chained pocket watch from his vest. “Hmm…times up for today. See you tomorrow at four.”

            The patient hastily rises from the couch, walks out of the room and pays her bill to the receptionist, handing her cash from her purse. It is a bill for services to have ones head shrunk, to become actualized.

This archetypal image has little resemblance to the modern day twenty first century practice of psychiatry. Hollywood holds dearly to this quintessential image, as does a vast portion of society. It is a romantic, classic, yet profoundly irrelevant image. In fact I don’t even have a couch in my office, let alone a grandfather clock. I do own a three-piece suit somewhere, but have not worn it since the eighties.

The patient scowls across the room at the harried doctor. The doctor has fifteen minutes with the patient and unfortunately has three people waiting in the crowded waiting room and he is already 45 minutes behind. The patient barks, “You better give me some klonopin or adderall dude, cause if you don’t, I don’t know what’s gonna happen. I might violate my probation and I’m not going back to prison. I’m gonna hurt somebody if you don’t give it to me dude.” The patient is agitated and twirls the chain on his wallet in one hand and beats a cell phone against his leg with the other.  The psychiatrist hears someone in the waiting room loudly swearing at the receptionist for having to wait so long.

This scene may be somewhat more realistic for many modern day psychiatrists, but not as classically romantic as Hollywood wishes for.  When I was in medical school and I chose a residency in psychiatry, I still held on to a bit of the classic archetypal image. The image implied that the patient actually wanted to be there, and happily paid their bill. I liked the idea where the patient developed new insights into their unconscious and became healthier. The idea that almost everything had a meaning and was precisely interpreted was most appealing.

Many myths and misnomers abound in regard to the modern day practice of psychiatry. Many people believe that psychiatrists are extremely wealthy. They stare in disbelief during conversation, when I advise them that psychiatry is the second lowest paid specialty in medicine. They are shocked when I advise them that most medical students don’t choose a residency in psychiatry because there is relatively little pay compared to other specialties. They are dumbfounded when I advise them that 90% of my patients don’t pay in cash or check or credit card and that the vast majority of my patients don’t pay anything at all for their psychiatric care.  It seems that it is much simpler to hold on to the classic romantic view of psychiatry.

Another popularly held myth is that most psychiatrists are a bit crazy and simply go into psychiatry to figure themselves out.  Sometimes I ascribe to that view, but I can honestly say that the rate of craziness is probably not any higher in the field, than say surgery, or the legal world or carpentry or any other line of work. The psychiatrist just hangs around professed psychopathology all day. But you can’t really catch mental illness per say in the same way you catch a cold.  Most psychiatrists are actually rather humane, empathic individuals that chose the profession because they were interested in truly helping their fellow human being.

Ideally, in medical school, I felt psychiatry may have bridged the gap between the art and the science of medicine. It starts at an infinitely tiny point, namely the human brain and explodes into every scholarly domain. It touches philosophy, sociology, art, history, biology, chemistry, anthropology, linguistics and psychology to name a few. 

            After practicing for fifteen years, it is so very different from what I idealized back when three piece suits where still in style. The pressure like most areas of medicine nowadays can be ungodly. Idiosyncratic pressures in the field are abundant. For example psychiatry is the only field where one might be sued for malpractice, for failing to protect someone you never knew existed.  Depending on circumstance, the psychiatrist may be held liable if their patient harms someone else. The degree of violence in society is astounding and dictates the scope of many psychiatric practices in America today. Violence often stems directly from early abuse and neglect and a lack of human regard and connectedness.  A large percentage of my patients grew up around violence and abuse with very little familial nurturance. Simply having no other option, be it determined by nurture or nature, they continue to perpetuate the cycle and are often predisposed to anger and impulse problems. Unfortunately for some the psychiatrist often becomes the displaced object of that anger. Every year in this country a significant number of psychiatrists are assaulted and one or two actually murdered by their patients. The threat rivals that of a busy emergency department, but the psychiatrist’s office is usually not equipped with armed security, unlike a busy intercity ED.

            It is often common for a patient to visit a psychiatrist’s office for some reason other than coming to get treatment for an illness. This was something never taught much in training. Reasons range from: staying out of jail, to getting ones children back from social services, to getting disability income, to improving their divorce outcome, or to keep their job.  Often when there is some primary reason for being there other than getting treatment, the person may feel everyone else, including the psychiatrist has a problem.  Pulling the psychiatrist out of the role of physician and into a role of manipulating ones social environment can often have little to do with true patient advocacy or treating ones mental illness and making the patient healthier.

            Another strongly ascribed to fallacy is that psychiatrists are all just “pill-pushers”.  The truth of the matter is that most medications can and do eliminate psychiatric symptoms and alleviate suffering, but in 2008 most medications do not essentially cure or heal mental illness. There are fascinating breakthroughs in the understanding of the plasticity of the human brain and discoveries of such substances as brain derived neurotropic factor. The mapping of the human genome also has profound implications for psychiatry, but we are still hard pressed to prescribe a medication that heals psychological wounds and cures psychopathology. Yet in our fast–food, Madison Avenue Based society there is much pressure and unrealistic expectation to simply prescribe a “happy pill” or a “normal pill”.    

            At this point in time till proven otherwise, the healing component directly relates to and takes place in the relationship between the patient and the doctor. The psychiatrist often becomes the only safe and stabilizing figure in a patient’s otherwise chaotic, entropic life. The doctor often becomes a nonjudgmental empathic entity that the patient can depend upon. In this sense there is almost a re-parenting process that takes place, in the transformation towards psychological healing. Indeed some strictly biological psychiatrists would scoff at this idea, while at the other end of the spectrum non-physician psychotherapists often believe that the psychiatrist does not even talk to their patient in lieu of simply pulling out the prescription pad and begin scribbling on it. Most good psychiatrists, the ones that actually take care of patients all day know better. The medication prescription often takes on more than biological implications. It takes on metaphorical proportions as a symbol of the most ancient of archetypes the physician patient relationship and the healing that takes place.

            The ultimate loss of a patient comes in the form of suicide. When a patient walks out the door of the office, the doctor can never be 100% certain that a patient will be safe from harming themselves. Even when the psychiatrist does everything within their clinical capabilities, they can not always save a patient from themselves. This is in the context that depending on the practice, a psychiatrist may treat hundreds if not thousands of patients a year who are chronically suicidal.

            The academic challenge can be more elusive. It is true that there is little that surprises or necessarily intrigues me about human behavior anymore. Another Hollywood misnomer is that the average psychiatrist finds human psychological aberrations so very interesting. Indeed at a dinner party when the conversation turns to some strange behavior in someone’s uncle, all eyes turn to the psychiatrist for a response filled with alacrity to hear more. I suspect this is true for the psychiatrist that sees three patients a week. Most see many more. Many psychiatrists would rather discuss baseball or Beethoven or bookstores when away from work.

It is true that I have heard tens of thousands of narrative life stories filled with anguish, terror and pain, and after one or two pieces of information I can usually fill in the rest quite accurately in the narrative. This can lead to a cynical attitude in the psychiatrist, or conversely it can be used as a gift to help patients feel cared about and understood. The understanding comes from a perception of an uncanny clairvoyance on the part of the doctor and empathy for the patient by making the patient feel that their story is unique. When they are sitting in the office, their life story is the only thing that matters to the doctor.

Over the years it has also become apparent to me that the mentally ill can not always speak for themselves or stand up for themselves. The current health care climate continues to perpetuate this phenomenon. There is a greater responsibility than ever for the psychiatrist to advocate and help fight the stigma of mental illness. This can only help each of our individual patients that struggle with these issues.

So from that ideal image I conjured up almost 20 years ago to today, my perceptions have changed a bit. I felt the job would be energizing if not invigorating. What I have learned is that the human psyche and spirit only has a certain amount of positive energy to give and so much negative energy it can absorb. The end result can sometimes be a daily mental and physical exhaustion.  It is a job in which one is obligated to give 100% of their spirit and psychological energy in treating their fellow human beings. The real joy comes from the fact that we have a gift in the responsibility to give and to care for our fellow human being. This joy touches not just psychiatry but all physicians. Despite the pragmatic realities of health care and our technological fast-paced world, and the continued reduction of human connectedness in society, the ancient archetype of healer will remain as long as human beings remain.

I know of nothing else that I could do now. It is in my blood and in my soul. Perhaps the joy also comes from the exhaustion of giving ones positive goodness and energy in the name of healing on a constant basis in the physician’s daily professional life. Anything short of that and we should not call ourselves a physician. Perhaps the joy of giving is actually invigorating. Perhaps that gray-bearded man in the tweed suit with the pocket watch felt that exhaustion or maybe that joy."

                                             ©2008 Joseph J. Sivak MD

To Dr. Joe

Doc,
I am having some problems with your posts. For me they are not simple enough. We with this disease really have problems with professional type language. This is not a complaint, just telling you my side when I read your posts. I know your site is for caregivers and to help them. But I know a few of us with AD that read your blog, they may also have this problem. I still consider you a friend, even is you are a shrink. That does not make you bad. My day today is, I sucked up my blog, brain is shrinking and so is my understanding of what I read or attempt to.



God Bless You My Friend,
Joe
http://living-with-alzhiemers.blogspot.com/

Is Alzheimer's A Mental Illness?

This is more of a political question in many ways than a scientific one. When we speak of a psychiatric disorder we often use the term "functional" as opposed to "medical". Functional essentially means without an organic cause.

We know that AD has a specific course, with specific and non-specific signs and symptoms. It has demonstrated changes in the brain at a microscopic cellular level as well as a macroscopic level when it is advanced. The gross brain of a victim with advanced stages of AD looks different than the gross brain of a person without the disease.

In many psychiatric disorders you can not find the physical changes in the brain. That does not mean they do not exist, it is just that science has not caught up in certain psychiatric disorders.

For a long time when AD was first becoming known in our conscious awareness some twenty or so years ago, the issue of a psychiatric disorder or not was a hotly contested and emotional issue by many advocates and groups. It really stemmed from the fact that we have terrible biases and stigmas associated with mental illness. In fact we still do. We did not want to classify our AD victims with 'those' kind of disorders.

In fact there are many psychiatric disorders where you can find differences in the brain. It is well-established that people suffering with schizophrenia for example, have larger ventricles in the brain compared to people without schizophrenia.

The debate was further compounded by the fact that the Diagnostic and Statistical Manual (DSM) which is still on its 4th edition and goes back to the early 1950's in the first edition, lists Alzheimer's Disease. This manual is sort of the "Bible" of psychiatry developed by committees of experts that have time, and published by the American Psychiatric Association. It lists diagnosis and criteria to make the diagnosis. It has two actual practical purposes besides academic (and political). lawyers and judges love it, in a court of law, because it is in black and white and considered dogmatic, and insurance companies like it because they recognize some diagnosis of which they will actually reimburse for.

Many people do not like that Alzheimer's disease is listed in the DSM.

The fact of the matter is there are many personality changes and behavioral changes in AD. A victim can develop depression or display irritability, aggression, or speak in a delusional fashion (for example become paranoid) and even develop hallucinations- seeing or hearing things that are not real.

These are all signs and symptoms we generally reserve as conventional psychiatric symptoms.

Sadly we really don't treat our mentally ill with much respect or dignity in our 21st century world. The stigma abounds. It is not unlike how society stigmatizes AD, whether we want to admit it or not.

As families we often don't like it when the psychiatrist gets involved in the treatment of our loved one with AD. The psychiatrist is usually associated with the prejudices we have about mental illness.

In the end the question is irrelevant. Mental illness is real and people suffer with it, just like AD. both need to be treated and they both need to be treated with more compassion, no matter what way you look at it.