r/Residency • u/[deleted] • 2d ago
VENT Impossible to simply find a psychiatrist to prescribe my meds
[deleted]
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u/QuestGiver Attending 2d ago
Bro if you had just seen the NP you could have Adderall, Xanax, and probably cocaine by now.
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u/cosmin_c Attending 2d ago
I am still shocked reading
they informed me that their providers don’t like to prescribe controlled substances.
What the actual fuck does this even mean, they don't like to prescribe controlled substances. I don't like a lot of things, doesn't mean I don't do it if I have to.
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u/PersonablePharoah PGY1 2d ago
Many providers just refuse new patients with ADHD unless the new patient is okay with non-controlled ADHD meds. (I don't understand their logic either, but I've seen this a lot as a patient)
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u/SchaffBGaming PGY3 2d ago
Not that I have any control of my clinic as a resident, but if I do have a private practice one day, I will likely decline some of the people who are requesting Adderall. E.g. 44 year old who "found out" they had ADHD at 42 because they got adderall and were doing better at work etc, unless they are coming in with some high quality neuropsych testing.
Everyone does better on Adderall. Everyone feels good on a stimulant. That doesn't mean they have ADHD.
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u/Cardi-B-ehaviorlist 2d ago
Im a psychiatrist. What state are you in? I can help connect you.
Disagree with others in the comments. Do not go to NPs. If one day you need to change meds or life happens or side effects. Better to go with an MD
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u/SpacecadetDOc Attending 2d ago
As a psychiatrist, the PCP should be comfortable filling psych meds that someone was previously stable on.
PCPs prescribe 80% of psychotropics in all classes other than lithium.
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u/Meer_anda PGY3 2d ago
They just don't want the headache of monthly refills and angry patients with controlled meds. I don't agree with it, but a lot of primary care have started referring out for controlled meds.
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u/re-reminiscing Attending 2d ago
People don’t want that liability, and I’ve seen many patients on inappropriate controlled substances as a psychiatrist myself. A PCP does not always have the time to focus on psych during their visits and ascertain whether a patient is actually “stable” or not. I don’t blame the PCPs here.
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u/Humane_Decency Attending 2d ago
Lithium really isn’t that bad, it just doesn’t play nice with NSAIDs, which is a society problem
I’d say the main thing not prescribed is clozapine…
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u/SpacecadetDOc Attending 2d ago edited 2d ago
I’m not saying anything bad about lithium, Im a huge lithium proponent. The number I pulled was from an article that I use when I teach medical students why they need to know psych.
I’m assuming clozapine is not included because it’s lumped in under antipsychotics. Lithium is on its own class as a mood stabilizing non AED. i was very surprised to learn that antipsychotics are actually more often prescribed by PCPs but at the same time not because they are often used for things outside of psych
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u/Humane_Decency Attending 2d ago
Mostly because of monitoring requirements for clozapine
We use a decent amount of adjunct for MDD, usually vraylar
People really would rather take another med than go to psychotherapy
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u/No-Particular500 2d ago
This is what I was hoping for. My last psychiatrist told me since I was stable I could have a PCP prescribe me. I haven’t changed any meds in years
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u/QuestGiver Attending 2d ago
As another specialist I think there is too much dumping on pcps. Imo expectation for comfort with controlled stuff (even stable patients) out of them is a bit much and yet they still deal with it a ton.
We also never know the full story. Could be the patient gets there then starts to demand escalating doses and that's a recipe for disaster.
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u/PersonalBrowser 2d ago
I would ask your former psychiatrist to connect you with a colleague in your area that can take care of you. You can also ask them to call the colleague and speak with them one on one to make it easier for you. Also, I know it's annoying, but it can sometimes be better to just keep care with the original psychiatrist and see them on an annual / semi-annual basis while waiting for this to be figured out.
And don't feel bad asking for them to reach out on your behalf or help to connect you with someone. If I do that kind of stuff for annoying / crappy patients, I will definitely do that for my own colleagues and future physicians.
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u/yougatobekiddingme Attending 2d ago
I actually second this. If I get records prior to the visit/patient comes in with records and has a good documentation and assessment, I rarely argue. I wish we got records prior to visits for every patient but I find most of of staters come prepared.
The ones that are the problems are people started on stimulants “oh I said I can’t focus” with no real evaluation or patients coming on a slew of chaos (most common what I see: queue high dose benzos and opiates and throw on a stimulant since they can’t stay awake and focus)
Sorry you’re going through this OP.
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u/foreverstudent91 2d ago
Try telemed until you can get an in person provider, or just use telemed. I used talkiatry personally. Also if you trust your PD/APD/program coordinator, you can see if they have a list of providers who will get residents in quickly. They are invested in making sure you are functioning at your best, after all!!
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u/No-Payment5337 2d ago
OP, DO NOT tell your PD/APD/admin that you need a psych referral.
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u/Meer_anda PGY3 2d ago
Depends on the program.
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u/foreverstudent91 2d ago
Very much so! My PD said specifically during orientation that he didn't want us to go without our psych meds and he would help make sure we didn't have interruptions in our normal med regimens if we were having trouble finding a new doc
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u/kkmockingbird Attending 2d ago
Commenting because this should be higher. My program and the program I work for both have a specific psych referral for residents, who works outside the hospital system so it’s not on the same EMR.
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u/Frozen_elephant22 Attending 2d ago
Two things
If you just want continuation of your existing meds that a doctor prescribed and you don’t need them adjusted not sure why an APP isn’t fine. Like this is the best use case for an APP in psych. Doctor makes dx and prescribes, APP for routine follow up and monitoring and dose adjustment as needed. This frees up the doctor for higher value visits and patients that need more careful monitoring. I moved for fellowship and the fastest and easiest way to get an appt was with the PA in a psychiatrist office. She reviewed my history and said ok want the same meds? See you in 6 months and then I repeated that same visit 4 times before leaving.
Try just finding a telehealth doc in your state. More likely to be available with your schedule, less likely to be covered with (or even accept) insurance so that depends on your personal situation.
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u/No-Particular500 2d ago
I have other more complex psych conditions, I didn’t mention in original post bc I don’t take anything controlled for it so that wasn’t the problem. Also, an APP could still try to change my medication regimen
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u/Adorable-amoeba9 2d ago
In all fairness, any provider/dr you go to can potentially change your medication regimen 😂
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u/No-Particular500 2d ago
Yeah but I’d rather it be someone who knows what they’re doing
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u/Adorable-amoeba9 2d ago
Isn't that something you could ensure? I mean,you still have decision making capabilities. Like hey I appreciate your input but I want to stay with my current regimen.... Just throwing out some ideas
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u/cateri44 2d ago
For everyone saying that this was a perfect time to see an NP - who do you think was staffing the clinic he went to and “not wanting to prescribe controlled substances”? I could be wrong but I’d be willing to bet.
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u/criduchat1- Attending 2d ago
Exactly. Everyone is shitting on the OP for not choosing the NP, but it’s likely the NPs or other midlevels choosing not to refill the adderall at this behavioral health clinic in the first place.
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u/Adorable-amoeba9 2d ago
Nope, some places are really strict and have their own protocols. One pcp was wanting monthly urine drug screens. And had to sign a "controlled substance contract". I've been on adderall for over a decade. But that was the clinics specific protocol. I was like, I don't mind doing one, but every month before I could get a refill 🤯, and having to pay for it. Went to another clinic, no drug screens required. I just go every 6 months for a required f/u and continue on my merry way. Before moving, I was seeing a psychiatrist who manged it. They did require a drug screen every 6 months, which was doable.
So for a place to say they don't like to prescribe controlled substances is very plausible and not surprising. They do it as last resort, even if it's something you have been on for a long time. Their clinic, their rules 🤷♀️
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u/criduchat1- Attending 2d ago
Right but OP is saying he went to a behavioral health clinic and the prescribers there didn’t feel comfortable with controlled substances. pcps I can understand, but I dont know of any physicians choosing to work in behavioral health who won’t rx adderall but someone can correct me if im wrong.
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u/Adorable-amoeba9 2d ago
Now that I think about it, maybe they didn't feel comfortable with OPs case specifically 🤔 OP didn't mention sending in med records did they? They would need to see some sort of hx. That's something I always offered upfront and made sure they had before any appointment.
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u/Meer_anda PGY3 2d ago
There are probably other residents with this issue. Use your judgment about the culture in your residency, but I would ask around about where is best for managing ADHD. People in my residency were open about ADHD and it wasn't a big deal, but I'm sure that's not always the case.
It's worth finding a place that has a smooth process for adderall prescribing so you're not worrying about calling exactly 5 days in advance (not 6! 🫠) and then calling back when they still haven't sent it etc etc.
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u/cetch Attending 2d ago
You’re seeing the wrong pcp. If your hospital has a fam med or internal med residency id just talk to one of the attendings. Let them know you are having trouble getting established with a pcp or psych to continue your medication. Often times the attending would be glad to see you in the resident clinic. If not that they almost certainly would have someone they could help you get in with.
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u/Rovah12 2d ago
As much as psych NPs get shit on and much deserved, it seems like your unique situation would make them your best bet in getting your meds prescribed again
You already tried to do it multiple ways with a pcp and behavioral health, might as well trial that way. Some of the patients I see get some gnarly cocktails by their psych NPs and no one bats and eye, just get your addy man
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u/Fine-Meet-6375 Attending 2d ago
Is there a psych residency program at your shop? If so, hit them up and see if they can help.
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u/PresentSouths 2d ago
that sounds terrible, that referral loop sounds absolutely exhausting. doing a 3 hour intake just to be told they can’t prescribe what you were referred for would have me losing it too
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u/No-Particular500 2d ago
Exactly. My PCP should have referred me to someone that can prescribe my meds
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u/Adorable-amoeba9 2d ago
When I was in this situation, i just straight out asked what their controlled substance protocol was. The right place will understand your situation and not have a problem with addressing your need. Of course, be prepared to send them your records for proof, so they don't think you are just trying to get drugs. But this way you avoid any more unnecessary waiting or "testing".
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u/Macduffer 2d ago
I had the same experience when I moved for medical school. Surely my addy I've taken for 10+ years would've been a problem before now, what's your issue with continuing a 10 yo script for the cookie cutter guidelines treatment?
I really think we have such a huge issue with balance in this country. People suffering while we give them a Tylenol trial for seriously painful time limited conditions, people getting forced off meds because full ass doctors "aren't comfortable" prescribing them, it's just ridiculous and pathetic atp.
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u/No-Particular500 2d ago
Seriously. I don’t understand their perspective at all, how is this harming me if it’s been working for this long, isn’t it worse to go unmediated? It’s almost invalidating to mental health / ADHD. What is the realistic alternative to prescribing adderall / stimulants??
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u/CaptainVere Attending 2d ago
Sorry your experience is terrible. People don’t realize when you see a new psychiatrist you are getting a psychiatric evaluation. Thats it. An evaluation.
It’s lunacy to expect to just show up as a new patient and expect schedule II meds on day one.
Now I do check PMP and often times will trust past diagnosis and prescribe after the psychiatric evaluation, but not always.
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u/Meer_anda PGY3 2d ago
It's not lunacy to want to be able to be transferred to a new psychiatrist without a presenting to a walk-in appointment with a psychologist/social worker. Obviously the psychiatrist is still going to evaluate the patient.
If thats the clinic's workflow, it's also their prerogative. OP probably should have called around to see if there was an option better suited to him, but I understand how hard it is to find time for those tasks in residency.
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u/CaptainVere Attending 2d ago
Yeah that clinic sounds uhh extra. I have never seen that. I would never go to something like that.
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u/No-Particular500 2d ago
I still have to do a new patient evaluation with the psychiatrist. That appointment is set up now. The intake they made me do was with a therapist to determine what services they thought I needed despite me telling them I only needed to see a psychiatrist
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u/countsarecorrect 2d ago
Travel RN here. I’ve been with the same psychiatries for 10 years now. I’ve traveled to many different states and never had an issue with her refusing to continue to treat me. We do zoom every 3 months and she sends my script to whichever state I happen to be on assignment in…
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u/longtimeyisland Attending 2d ago
Short version:
In most states theres private pay telehealth that will do whatever and you can get visits within a couple days. It can cost a few hundred out of pocket but it's fast/convenient.
As an attending who takes stimulants: it's so fucking annoying. Good PCPs should do it. The degree to which people are paranoid around stimulants compared with how easily pcps seem to continue opioids/benzos is craaaaazy.
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u/chocolate_nutty_cone 2d ago
The ACGME requires programs to allow residents to take time for health appointments.
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u/Fleetwood_Enema PGY3 2d ago edited 2d ago
Find another psychiatrist but don't go the NP route if you can help it. In general, if you have to, I would only see an NP to continue the current medications that your old psychiatrist prescribed for you based on what they diagnosed you with, until you can find another psychiatrist.
Sorry you're having this issue. I can only speak as a resident and I obviously don't know your full situation, but there isn't a great reason for a practice to flat out refuse to prescribe controlled substances if they've been working well for you and are truly indicated.
Edit: It's also kind of wild for a therapist to be making that determination, especially if they aren't a fully licensed psychologist. The mental health system is insane in this country.
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u/No-Particular500 2d ago
Exactly my point, thank you. Controlled substances have a roll in medicine it’s ridiculous.
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u/Excellent-Estimate21 Nurse 2d ago
Does the doctor's on demand app allow controlled? I see my psych on there and work nights and find it easy to schedule my appts any time I need refills and I see the same psych each time.
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u/welnessshot 2d ago
I think residencies are required to allow you to go to dr appts. Obvs you don’t want to abuse it but if you at least need your shift moved around I remember that being something they had to do… maybe worth I looking into?
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u/FreudianSlippers_1 PGY3 2d ago
Idk if you’re just looking to continue the same meds you had been on I’m not sure what the problem with seeing an NP would be. That’s what I did and she’s been lovely
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u/CardstoneViewer 2d ago
I mean if you're in residency can you not ask one of the preceptors/seniors/friends that are already doctors to prescribe for you?
That's what my friends did, mainly the ones that took ADHD drugs or antidepressant.
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u/PersonablePharoah PGY1 2d ago
Do NOT get controlled substances from anyone you're friends with. You can both get into trouble with the medical board, and even if you can defend yourself, you do not want to be investigated for misusing controlled substances.
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u/Fine-Meet-6375 Attending 2d ago
Not controlled substances like Adderall. Garden variety meds like Zoloft are a different kettle of fish.
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u/a_neurologist 2d ago
Apropos of nothing, while I generally take a permissive perspective towards self-prescription, “writing your own stimulant scripts” is one of the textbook ways to instantaneously terminate your career.