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Dr. Stan Giudici - The University of Iowa, 2003

Do not listen to anyone who says that after combined residency, you must eventually choose between psychiatry and internal medicine. That is a lie. On occasion, I heard this during my residency, but I refused to believe it. After finishing residency at the University of Iowa, I joined a multi-specialty group outside of New York City. I immediately began earning my keep working in the Urgent Care until I was on the various insurance plans. That took 3-6 months. Once I got onto the plans, I began billing under psychiatry because insurance reimbursement is higher under psychiatry than internal medicine. Insurance companies classify psychiatry as a specialty. Though I bill under psychiatry, in my patient encounters I practice both medicine and psychiatry. My knowledge of medicine makes me a better psychiatrist; my knowledge of psychiatry makes me a better internist. Where they both meet, I fill that niche in pain management. Our training is unique and enables us to enter into various niches, and therefore, we can function in any area where internal medicine and psychiatry interface.

My clinical notes are entitled Psychiatric/Pain Management Diagnostic Evaluation or Psychiatric/Pain Management Follow-Up. This way, the insurance company will know that this is a psychiatric note and billed as such. My initial evaluation of a patient includes both a complete psychiatric diagnostic evaluation with the addition of a pain history as defined by the American Academy of Pain Management. In addition to a formal mental status exam, the clinic note also includes a physical exam, results of diagnostic imaging studies and laboratory studies. I do all the work-ups, and order labs, imaging studies, and neurophysiologic studies. As in psychiatry, treatment begins with a diagnosis; likewise, in pain management, treatment rests on a diagnosis. Often times the patient has been to numerous doctors and “no body can find why I am in pain” or “no body can find what is wrong with me.” Sometimes it is straightforward such as diagnosing inflammatory arthritis, diabetic neuropathy, and nutritional deficiencies such as B12 deficiency. Other times I diagnose conditions that are easy to miss such as restless leg syndrome, somatization disorder, or even generalized anxiety disorder as a source of muscle tension and tightness. These latter disorders lead to what the patient often refers to as “total body pain”: a complaint that I have found tends to be beyond the training of a physiatrist or an anesthesiologist. This complaint is quite common in our practice.

For nearly three years, I have been practicing in this area. I started with zero patients and now have well over 600 active patients. As varied is my practice is the variety of my patients: I see those with mental retardation, children over age 12, adults, those with chronic pain, the elderly and those with dementia. Moreover, I take overnight call from home once a week admitting medicine patients for the group. I have now established my own private practice. My patients have followed me in droves. Again, key is that they recognize your value, they see you as having a wealth of information, and grow to rely upon you and trust you in all aspects of medicine and psychiatry.

In the academic world, we med/psych folks sometimes find ourselves misunderstood. However, in the real world, people recognize the breadth and depth of our knowledge and training. They definitely recognize our uniqueness. Once they learn of you, they will seek you. I have no regrets and see myself as extremely fortunate. My training at UIHC was top notch and I see this coming through in how I handle clinical problems in psychiatry and medicine in both inpatient and outpatient settings. Moreover, my colleagues have come to recognize me as an “expert” in my field of psychiatry and pain management and seek me out with their clinical questions. I find it rewarding because I can piece together the different elements of a clinical picture and come up with a composite, and I am helping people who really have no where else to go in the community. I believe only one uniquely trained in internal medicine/psychiatry can handle these more challenging patients.

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