@hardasnails1973 442 wrote:

I am just curious in the amount of training that MD’s get in SSRI and related drugs who are not specialists The reason being that so many GP are handing out SSRI’s and other related drugs like it was candy with what I see as no specialize training. One time I asked a my GP about and SSRI and its interaction with brain chemistry. He had to go look it up in the medical book to its function. When I saw this it kind of made me lose respect for a Dr that should have known about it off the top of his head.

Medical school training in pharmacology is at the level of a Ph.D pharmacologist. It is that good. No lower level medical professional receives this level of training.

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A physician is a person who has learned to teach him or herself. Almost all of a physician’s knowledge is self-taught.

The pre-medical education, medical school and residency education provides a unique knowledge framework, medical method of thinking, and initial modeling and experience that a physician will use as a foundation to build his or her knowledge-base with their post-graduate continuing education and work experience.

A key concept is that medical education is a continuous lifetime experience. It never stops.

Medicine is a craft. A physician is a craftsman, who continuously hones his or her skills.

What makes a medical doctor different and empowered is the foundation that their education provided. It is a perspective that is different from other fields.

Today, the difference in extent of my knowledge-base between now and medical school is like the difference between psychiatry residency and the 6th grade. It is amazing how simple medical school is in comparison to what I am doing today. Of course, medical school, to me was a ton of fun. So it was very much like elementary school as an environment.

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One of the biggest problems in medicine is that physicians (such as family physicians and general practitioners) are given very little time to provide care for their patients.

For example, the average family physician I know, has only about 6 minutes to give to a patient before having to move on to the next patient. This is largely an outcome of managed care. A family physician has to do this in order to break even and not go out of business.

This time-limited model for medical care has warped the field of medicine in that physicians have developed cookbook style assessments and treatments to allow a quick diagnosis and treatment of a patient.

As a result of managed care, cookbook style thinking, unfortunately, has become, endemic in the field of medicine. Since it works “O.K.”, allows them to make a living, and poses relatively little risk, physicians have gravitated to this practice. It certainly allows one to have personal time and a lifestyle outside of medicine.

Cook-book style thinking also has allowed lesser-trained medical providers to provide medical care. Nurse practitioners and physicians assistants rely on cook-book thinking to practice. From my point of view, it is a huge drop in the quality of care, but there are so many patients, someone has to do it. There simply are not enough physicians.

Unfortunately, cook-book style thinking also dumbs-down the craft of medicine. It lulls physicians to stop developing their craft.

These days, physicians often engage in category thinking. They give category medications for category diagnoses. This is classic cookbook thinking. They often don’t think below the surface – to actually ask what is causing the patient’s illness. They stopped asking why or how a patient came to be ill. Just give the category medicine for the category diagnosis then shoo the patient out of the room in order to bring the next one in.

Unfortunately, medical illnesses often are highly complex entities. For example, diabetes and heart disease are complex entities. To get a person “well”, it takes much more work than to simply given them a category medicine.

The watchword is “wellness”. This is an ideal which is not being achieved. Instead, more people are becoming sick.

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To repeat: Medical school training in pharmacology by the 3nd year of medical school is at the level of a Ph.D pharmacologist. It is that good. No lower level medical professional receives this level of training.

With the dumbing down of physician skills from cookbook thinking, however, physicians often forget their pharmacological training. They forget how they got pimped about how Propranolol works. Rather, too easily, they give a category medicine for a category diagnosis.

For example, if a person is depressed, give a depression medicine. Thus, you have the GP handing out an SSRI without thinking about what it actually does. Since SSRIs are “relatively safe”, this is possible, though often not effective. But then, if the patient believes it will work, the placebo effect reigns supreme. The powerful effect of a father-figure physician given a medication also enhances the placebo effect of the medication.

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To ask the question of how an SSRI interacts with brain chemistry is actually not a fair question to ask of a GP. I would not think less of him or her if he did not know.

I certainly would not expect a GP to answer that question. A GP has breadth but not depth of knowledge. Using chess as an analogy, they can think only one or two moves ahead. Cookbook thinking predominates. After all, they only have 6 minutes to see a patient. What can one expect in 6 minutes?

Even a well-trained psychiatrist would have difficulty answering that question. I know. I ask.

The reason I say this is that very few people actually have more than a rudimentary understanding of brain circuitry – psychiatrists included.

Fewer still have an understanding of how the signaling systems interact.

Even fewer people have an understanding of how the nervous system interacts with the endocrine and immune system.

Brain circuit interaction is actually not taught well in psychiatry in more than a rudimentary way. (wow!). The teaching in other fields is even worse.

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Why? How did this happen?

A contributing factor to this problem is what I call the problem of Occam’s Razor.

Scientific thought in medicine has always followed the idea that one should search for the simplest solution to a problem. The simplest solutions is thought to be the correct or right solution.

Thus, mental illness has been dominated by attempts to find the single explanation, the single cause of mental illness.

This has lead to gross oversimplifications – such as mental illness is a “chemical imbalance”, or that depression is a serotonin deficiency, that schizophrenia is a dopamine-excess problem, etc.

The idea that multiple systems interact to cause an illness is not in the forefront of medical thinking – outside of some alternative forms of medicine. Medical scientists forever look for the panacea for an illness. Unfortunately, a single intervention cannot usually cover all of the pathology that contributes to the development of a complex illness.

When I read about the pathophysiology of a mental illness, such as Bipolar Disorder, many of the causes are listed. But the treatments discussed seem to forget about the pathophysiology. Few people, it seems, can put it all together, even when the information is right in front of them.

The tenet of Occam’s Razor blinds medical thinking.

A mental illness is a highly complex illness – physically. Unless it is approached that way, we only have partial treatments that work at best little more than placebos.

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Some closing thoughts:

Primary care physicians and their extenders (Nurse practitioners and Physician Assistants) provide more than 75% of all mental health care. Nurse practitioners and Physician Assistants have nearly zero mental health training. This includes a large amount of often inappropriately prescribed medications.

About half of the visits to a primary care physician involve mental health issues.

A good rule of thumb is that a person whose medical chart is thicker than 1-inch has a diagnosable major mental illness. Period.

Combine all of the psychiatrists, psychologists, licensed clinical social workers and marriage-family-therapists together and you find they provide only 25% of mental health care.

It is important to provide primary care physicians with better mental health training so that they can provide better care for patients. since there are not enough allied mental health specialists to provide care.

Ideally, family practice residents and other GPs should do rotations in the psychiatry department just as psychiatry residents do rotations in internal medicine and neurology. Unfortunately, I did not see the family practitioners do this in my program.

Ideally, family nurse practitioners and physician assistants should have a psychiatry rotation as part of their training.

Family practice residency should do a year rotation in psychiatry – and thus should be a four year residency rather than a three year residency as it is today.

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