Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Tuesday, June 24, 2003

    Medrants has an excellent post on depression and primary care. I especially agree with his comments as follows:

    Many patients do not want to see a psychiatrist or psychologist. Many health care plans do not allow appropriate mental health referrals. We can manage much depression in our offices. For many patients, the generalist is indeed the best (and sometimes only) choice.

    One thing I still hold against my med school and residency training, which focused on primary care, is that I was never told how much mental health diagnosis and treatment I'd be doing. My psychiatry rotation in med school consisted of a series of lectures interspersed with six weeks on a locked psych ward at the VA, and two or three shifts in the ER on the psych team. Now, these were indeed learning experiences, but they held no relevance for any mental health issues I encounter in the course of my day as an internist. And as for my residency experiences... my teaching hospital also had a psychiatry residency program, which meant that the psych residents saw every patient who had any sort of mental health problem, and we were not allowed to prescribe any psychotropic drug. The psych residents had a lock on all pharmacologic orders. The upshot is I was let loose into the world of medicine with no idea of how to prescribe antidepressants - any antidepressants - at a time when Prozac was at its peak and new serotonin reuptake inhibitors were being developed at a rapid pace. I consider this almost criminal.

    Generalist programs are spending more time considering depression diagnosis and management every year. The residents that I work with are clearly better at considering the diagnosis of depression than their predecessors from 5-10 years ago. They also are becoming more comfortable with pharmacotherapeutic options.

    Good! They won't have to spend ten years making up for lost time, as I have been doing. The good news is that now I'm pretty good at figuring out who needs meds, who doesn't and what might work best for them. I just wish it hadn't taken so long.



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