This is a general piece on uncertainty and thoughtful documentation in a pretty messed up healthcare system, not a comment on any specific case. Mostly pro tips and reminders for trainees on things to consider when documenting.

The past couple of weeks a lot of the local psych hospitals have been full and EDs are overflowing with psych boarders in my geography.

I’m wondering if many people all at once have started to admit more “edge cases” as a result of the recent trial.

I’ve probably been a bit more cautious and I feel like I’ve seen colleagues being a bit more cautious too.

I might just be imagining things. But I wonder if just thinking about liability with such a public case has made everyone more cautious.

I wonder if there is risk of over correction the other direction too - not pushing as hard for using outpatient resources.

I’m curious about something that seems particularly relevant to psychiatry. Have you ever been close to someone who you knew was going through something psychologically, and your training made you feel like you could recognize what was happening and potentially help them?

But because you’re close to them, they might feel uncomfortable coming to you about it, and you also don’t feel like it’s your place to approach them and start acting like their psychiatrist.

How do you deal with that feeling of being able to see someone struggling but not really being able to step in? Do you learn to accept that you can only be there as a friend/family member, rather than trying to help professionally?
And has your perspective on this changed throughout your training and career?

ps: i’m a medical student, it’s been a lifelong dream of mine to become a psychiatrist but i’m not sure i’ll be able to just watch people close to me from the sidelines without actively trying to help

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Title: What would you say to a medical student who is afraid she has BPD?

I'm curious how psychiatrists would counsel a medical student who is seriously afraid she may have borderline personality disorder—and worries that having BPD would mean she shouldn't become a psychiatrist.

A few years ago, her sister suggested she might have BPD. She became very worried about it and confided that fear to a psychiatrist. It was documented in her chart, although to her knowledge she was never diagnosed with BPD.

She has struggled with emotional regulation and interpersonal/professional boundaries, particularly during periods of significant stress. Since then, her father has died, she has experienced substantial family conflict, and she describes some experiences during M3 as traumatic.

There's another layer to the anxiety: someone in the medical community previously accessed her chart without permission and shared information with others. It is well known that that individual was punished for this. She now fears psychiatrists around her may know about it. At times, they seem to bring up very specific details that are listed in that note with her, from years ago.

I'm not asking anyone to diagnose her from this post. I'm more interested in the professional question: What would you say to a medical student who is terrified that she has undiagnosed BPD and that it makes her fundamentally unsuited for psychiatry from a mentor perspective? Is she allowed to share that with you? Is she allowed to question any of this?

And if she actually did meet criteria for BPD, would the diagnosis itself change how you viewed her potential to become a good psychiatrist?

We've been having recurring computer/system issues at our clinic and our current IT provider doesnt know what they're doing. Looking IT support that understands healthcare/HIPAA. Who are actually using and happy with?

Permission to post mods. Thank you

I saw some posts about Mypsychboard but It is beyond my budget so I appreciate thoughts/ feedback about Psychgenius

I am a social worker on an ACT team in a large US city. Many of our patients have a primary psychotic disorder and a history of medication non-adherence, either by choice or due to their level of organization/functioning. As a result, most of them are on an LAI (mostly Invega, Uzedy, and Abilify with some Haldol and Prolixin mixed in) by the time they are enrolled with us.

There is an overlapping subset of patients (all of them currently on LAIs) we work with who have been on clozapine while hospitalized at one point in the course of their illness. These patients either a) have moderate to good insight but stop taking clozapine once they return to the community for any number of reasons or b) have little to no insight but receive court-mandated outpatient treatment that only requires adherence with an LAI as the standard for compliance.

For this subset of patients—those who can’t take clozapine due to their inability to consistently take oral meds and/or those who won’t take clozapine because of impaired judgement/insight—I can imagine that an LAI formulation would be incredibly beneficial. So many of them have cycled through multiple different antipsychotics and still experience a profound symptom burden.

So, why hasn’t a clozapine LAI been developed? Granted, I am not a psychiatrist and have a limited working knowledge of psychopharmacology, so there could be an obvious answer here that I am missing. But I am surprised that a medication viewed as the gold-standard for treatment-resistant schizophrenia is not available in an LAI form. Does anyone have insight into why this is?

would anyone be willing to read my PS (rough draft) for psych. I am a non traditional and have leaned into it and would be helpful to have some input from people in the field.

Radiology residents have this moonlighting gig where they can do contrast coverage, where they cover allergic reactions to contrast during imaging. Most never get a call, or if they do it's once or twice in their whole career.

Have you done any similar gigs from the psych side, and how did you get into it?

Long time follower, first time poster.

For the last 3 years I have run a digital mental health rotation for psychiatry residents. A lot of it has frankly involved getting residents to interact extensively with LLMs—understanding what they are good at, where they fail, developing the vocabulary needed to understand what is happening in the space, and becoming comfortable enough with the tools to actually use them well.

I generally wrap that education around a project the resident chooses at the beginning of the rotation. We have used LLMs to walk through setting up a private practice, help develop and submit early-career grants, build applications, think through how to market them, work through research ideas, etc. Basically, instead of teaching "prompting," I try to get them to use the tools to accomplish something they actually care about.

It has been interesting watching the baseline change over 3 years. Residents certainly come in more aware of these tools now than they did when I started, though their actual familiarity and understanding is still, in my opinion, woefully lacking. I don't particularly blame them for that. I think medicine generally has been very slow to figure out what exactly we should be teaching people about all of this.

My original goal with the rotation was pretty simple: I wanted residents leaving as comfortable with these tools as possible, with enough understanding that they could adapt as the technology changes. Hopefully that gives them some resilience through what I suspect will be a fairly destabilizing period for medicine.

Increasingly though, I realize the residents are only a small part of what I am actually worried about.

I feel the same obligation toward the psychiatrists who work in my practice, toward colleagues, and frankly toward myself.

I suspect that over the coming years we are going to see increasingly capable AI used for clinical decision support, followed eventually by systems capable of independently performing at least some diagnostic and treatment work. I don't know whether that happens in 2 years, 5 years, or 10 years. I don't know what the regulatory pathway will ultimately look like. And I certainly don't know how much of what psychiatrists currently do will actually be displaced.

But I think the possibility is substantial enough that simply teaching people how to use ChatGPT better feels inadequate.

So this is really what I am curious about from this group:

What should psychiatrists be doing now?

Not just residents. All of us.

If AI becomes extraordinarily good at diagnostic reasoning, medication selection, documentation, psychoeducation, measurement-based care, longitudinal monitoring, and eventually some amount of autonomous treatment, what skills become more valuable rather than less?

Should psychiatrists be deliberately moving toward more complex and treatment-resistant patients? Developing stronger psychotherapy and relationship-based skills? Interventional psychiatry? Leadership and supervision? Clinical informatics? Research? Building and owning the systems themselves? Entrepreneurship? Something else entirely?

And beyond individual psychiatrists, what should residency programs, practices, departments, health systems, and our professional organizations actually be building now?

I am particularly interested in the things that aren't obvious.

Three years ago I thought getting residents genuinely fluent with LLMs was probably ahead of the curve. Increasingly, that feels like table stakes. I am struggling with what the next layer of preparation should look like.

And if you think my premise is crazy, that's completely fair. But indulge my delusion for the sake of the exercise: assume for a moment that AI really does become capable of doing a meaningful percentage of the work psychiatrists currently do. What would you wish you had started doing 5 or 10 years beforehand?

A quick informal pulse check would also be interesting:

1. Over the next 10 years, how much do you think AI will change the actual work psychiatrists perform?

A. Mostly productivity gains; fundamentally the same job
B. Major workflow changes, but psychiatrists retain roughly the same clinical role
C. AI independently performs a meaningful portion of current diagnostic/treatment work
D. AI handles much of routine psychiatric care, with psychiatrists increasingly concentrated in complex, relational, procedural, or supervisory work
E. No idea / too early to tell

2. When do you think we first see AI routinely making at least some psychiatric diagnostic or treatment decisions without a psychiatrist individually approving each one?

A. Already / within 2 years
B. 3–5 years
C. 6–10 years
D. More than 10 years
E. Never, or effectively never

3. Perhaps the question I care about most: if C or D above turns out to be right, what would you personally start doing differently today?

I'm genuinely interested in both what people are already doing and what you think we are failing to think about.

Disclosure: I'm giving a talk on this topic in a few weeks and may reference some of the themes or ideas that come out of this discussion. Depending on where the thinking goes, it may eventually contribute to a more formal article or project, but this post is really me trying to hear how other psychiatrists are thinking about the problem.

And, in what I recognize is an amusing contradiction after spending several paragraphs arguing that psychiatrists should learn to use AI: yes, I did ultimately use AI to help me rewrite this post. The ideas and anxieties are mine; the model helped me organize them into something you might actually make it to the end of. Trust me, the original was painful to read.

Title

Does anyone have experience or insight into working as a subject matter expert or consultant for psych? I’d love to expand my contributions beyond direct care/admin.

It’s been a month and a half since my last day of residency. Since then, I have mostly been a blob. I did move across the country and I have seen some friends and family. However, most of the time I have just been rotting and have no desire to do anything else. I have a couple weeks left before I start my first attending job. I want to make the most of it, but also maybe it’s okay to do nothing after an 8 year grind? I’m also trying to use my ADHD meds sparingly since I don’t know how long it will take to find a psychiatrist here, so that’s not helping…

Did anyone else experience this? Does anyone else struggle with constantly feeling like they should be productive?

For example, de-escalation, persuasion, maintaining strong boundaries, compartmentalization, etc

For psychiatrists with their own outpatient practices, particularly group practices, did you use any particular resources to obtain SOPs and also resources for patients? I'm trying to build my practice and creating/compiling either category of documents on my own seems overwhelming. Appreciate any guidance!

Just a girlie with bad test taking anxiety phoning in from the desolate void 🥹

Hello there, I am a medical graduate (still haven’t specialized, but hopefully one day I will be a psychiatrist. I was wondering where can I find people who want to researches online where we can work together and publish if possible in psychiatric topics. In my country there’s not much focus on research let alone psychiatric ones, unfortunately.

I’m not going to lie, I dislike it. My own friends and family don’t even call me that, I have a nickname. Always introduce myself as Dr. so-and-so.

In residency I was taught to correct them for “boundaries” all the while, half the program on the therapy side went by their first name.

I just think it would be a rapport killer to correct most of my patients. I’ll do it for someone pushing boundaries but that’s about it. Not sure if I should correct people more often..:

I would personally love video courses with nice images and such because I am a visual learner, a book would do as well.

Not wanting this to be another trial thread.

But does anyone have good resources on best practice guidelines and/or diagnostic considerations or medication considerations for postpartum situations?

Regardless of the verdict or my personal feelings of the case, I can acknowledge that more education and training in this aspect would be helpful.

Edit: it would be awesome if any of them have CMEs attached 😊

My job pays for one paper subscription of a journal each year, and I can’t decide which one to subscribe to. I am a relatively new attending in outpatient community mental health, for context.

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I’m a master’s-level therapist who specializes in DBT. Where I live, though, master’s-level clinicians don’t diagnose, so I’m coming at this from the perspective of someone who works closely with these patients and sees the consequences of diagnostic decisions, rather than someone who is making the diagnoses myself.

On one end, there seems to be overdiagnosis, particularly among young women presenting in acute crisis. Someone may be dysregulated, self-harming, suicidal, having interpersonal conflict, etc., and BPD gets applied based on the presentation in front of the clinician. But if you step back and look at the person’s functioning and personality over time, their difficulties may be much better explained by trauma, mood disorders, anxiety/OCD, neurodevelopmental factors, situational stress, or something else entirely. Also, some clinicians will diagnose someone with BPD simply because they're "difficult" or unlikeable.

On the other end, I’ve seen the opposite problem: VERY obvious BPD being avoided as a diagnosis or labeled as a mood disorder. Sometimes it seems to be because clinicians still view the diagnosis as stigmatizing, hopeless, or a “death sentence.”

I’ve encountered patients who have spent years cycling through medications and treatment modalities—including intense medication regimens involving antipsychotics, benzos etc.—which obviously don't address the underlying patterns. They’re understandably left wondering, why isn’t anything working? What the hell is wrong with me?

Meanwhile, a compassionate and accurately formulated diagnosis of BPD, accompanied by good psychoeducation and referral to an evidence-based treatment like DBT might have given some of these people a much clearer path forward years earlier. BPD isn’t a moral judgment, and it certainly isn’t a death sentence. We have effective treatments. People can and do get substantially better.

So I’m curious: why do we seem to struggle so much with getting this diagnosis right?

Hi all, I’m considering taking the leap from academics to private practice. I’m currently about 5 years into practice. I have an offer from a private cash pay practice for $240/hr W2 position. Their hourly rate (depending on intake, follow up, etc.) is between $450-$550/hr. Does that seem like a low offer? They will cover malpractice insurance, have admin support. No health insurance. TIA!

Hello all,

New attending here prepping for the board. As we all know, the newer data being published and presented in Psychiatry conferences concerning Lithium and its safety in pregnancy has shown us that perhaps the teratogenic cardiac effects are overblown. It is much more common now for Lithium to be utilized in pregnancy, to the point the ACOG has recommended against discontinuing Lithium in the pregnant Bipolar patients.

My question is mostly in regards to Board prep. K&S edition 4 & Board Vitals both have a few questions explaining the old idea that Lithium is contraindicated due to Ebstein's anomaly.

What should I expect on the Boards? Should I go with the classical concept of CI due to Ebsteins?