Psych vs. Rheum

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rgerwin

rgerwin

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I am having a of a specialty choice struggle. I have always loved neuroscience, and doing something like a behavioral neuro fellowship and psych residency seemed like a natural fit. I love my psych rotation. I like the family-friendly lifestyle, and I feel my personality fits with others in the field.

However, I also love immunology and autoimmunity, so my rheum elective has thrown me into a quandry. Also a good lifestyle, after the IM residency. I know it's an open-ended question, but thoughts on the pros and cons to each?
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You can go cash only with psych and IM, but not likely Rheum.

You'll need to like most I'm subspecialties to deal with those 3 years of residency. And if you discover you don't like rheum, well you'll be stuck in rheum or IM. If you don't like psych you can always do a fellowship in sleep, pain, palliative, or the traditional fellowships.

More practice setting variability in psych than rheum. This is a plus if you are likely to get restless after a few years in one setting. Better chief complaints in psych than in rheum. Psych doesn't really touch fibromyalgia!! Greater range of living ability with psych. In otherwords, you can live in smaller town than rheumatologist, and I would venture to say there are more openings for psych across the country, too.
 
Psych doesn't really touch fibromyalgia!!
Click to expand...

I have found this to be a weird overlap between us and rheumo because Lyrica drug reps were trying to push to treat fibromyalgia with Lyrica. Also, IMHO, fibromyalgia is one of those disorders that has some heavy overlap with psychiatry.

In addition to the above, rheumatology, as you likely know, requires an internal medicine residency. I've seen several people who wanted to specialize but considered more than one type of field, a bit hesitant because they didn't want to do IM.

e.g. a buddy of mine from years ago didn't want to do IM, but wanted to do GI or surgery. Since a GI fellowship is competitive, he was stuck. He didn't know whether to go into surgery or risk IM on the chance that he might not get into a GI fellowship.
 
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whopper said:
I have found this to be a weird overlap between us and rheumo because Lyrica drug reps were trying to push to treat fibromyalgia with Lyrica. Also, IMHO, fibromyalgia is one of those disorders that has some heavy overlap with psychiatry.
Click to expand...

And then there's this:

http://www.savella.com/about-savella-snri.aspx

An SNRI used as an antidepressant elsewhere in the world, but marketed only for Fibromyalgia in the US so the patient doesn't have to be on "a psych med".
 
I was torn between psych vs. IM fellowship as well (I liked heme/onc a lot as a med student, and could have been quite happy in rheum or endo too).
Ultimately though I decided against IM because I decided that bread-and-butter psych was much more interesting to me than bread-and-butter IM.
I decided it made no sense to tolerate 3 years of misery (which inpatient IM wards represent to me) to hopefully finally get to something I really enjoyed when general psych was something I would like right out of the gate. Especially since many people who start off residency interested in fellowship ultimately end up deciding not to bother pursuing it in the end.

The personality issue was a factor in my decision too. My experience has been that IM people are more likely to be malignant or unhappy people (probably due to the lifestyle), whereas psych people are more likely to be eccentric but generally nicer and happier. I can tolerate eccentricity. :)
 
First of all, psych should be involved in fibromyalgia, if not the primary specialty working with it, IMO. I have seen little to no evidence that it is anything but a somatic manifestation of primary psych illness. Not saying it is pure somatization, but that it is rooted in an abnormal stress response and/or psychiatric dysfunction.

As for the dilemma. I understand all too well. I went to med school knowing I would go on to psych. But PM&R and cardiology are huge loves of mine.

I am now doing my medicine months and it kinda sucks. Because I really do love general medicine. A lot. Even though I'm at a super malignant, obnoxious, and slave-driving site for my medicine months, I am still feeling the pangs of anticipatory loss that in a month and a half, I will never again be a general medical doc.

I think in the end you have to weigh the pros and cons. You have to ask yourself if you really could enjoy doing one thing for a lifetime. In the end, I know that internal medicine would not be intellectually or personally fulfilling enough for me to do it for the rest of my life. Same goes for cards.

But psych is something that in and of itself I feel will still be as rewarding 30 years from now as it is today. *shrug*
 
masterofmonkeys said:
First of all, psych should be involved in fibromyalgia, if not the primary specialty working with it, IMO. I have seen little to no evidence that it is anything but a somatic manifestation of primary psych illness. Not saying it is pure somatization, but that it is rooted in an abnormal stress response and/or psychiatric dysfunction.
Click to expand...

Agreed. :)
 
rgerwin -

4th yr here. Kind of. I'm really done, so I'm kind of in limbo until June when psych residency starts. For reference. Not trying to speak from a position of any authority on this subject, that is, but sharing my thoughts.

Career advisor of mine once stated, to paraphrase horrifically yet misleadingly use quotes, "I'm Rheum-trained but an internist first" -- and this is my impression of Rheum at its best. I have been taught that any IM subspecialist is supposed to think this way, always an internist first...

Now psych, you can have your healthy respect for IM and keep your principles of medicine always in mind, but you get to be a part of the revolution. You know, the one where we once and for all dissipate the stigma of mental illness, make human suffering of all forms exempt from the insult of shame, uhh.. what else is there, oh yeah, shatter the narrow and destructive paradigm of the concrete treatment of "disease", see the person as more than a collection of cells in an era where we are in danger of all being dismissed as Erlenmeyer flasks full of transposable elements...

But maybe I'm biased.
 
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I've seen several doctors try to treat fibromyalgia with benzos and opioids. The texts I've read on the subject recommend against that because the disorder is likely life-long, and those meds are only designed to be temporary. If used long-term, the problems could get worse.

Another problem with benzos and opioids is some speculate that fibromyalgia is a type of disorder that can push a patient into feeling they have little control over their life. Adding a substance abuse problem certainly isn't going to help. Many of the therapies I've seen are aimed at trying to mentally empower the patient in a manner that will increase their threshold to pain such as excercise, a mental attitude that fibromyalgia will not hold that person down, etc. SNRIs, for that reason, are helpful in the treatment of fibromyalgia.

So then, the patient comes to me for a comorbid problem, often treated with a benzo or opioid. No one tried an SNRI. I found that surprising given that some of the doctors were rheumatologists, and this is something that's usually considered "their" disorder. Some, though, have given out amitryptaline, though studies indicate that SNRIs are just as effective, and with less side-effects.

And none of the other doctors recommended any of the lifestyle changes recommended in the texts such as excercise, a limit on excuses to not go to work, etc.

Several doctors, for some strange reason think lifestyle changes is only the avenue of psychiatry. Where this idea developed I don't know.
 
My "rant of the year" for 2010 is directed toward my primary care colleagues who have FORGOTTEN than amitriptylline IS the prototypical "SNRI". I've had 3 patients referred to me already on duloxetine 120 mg "for pain" AND amitrip, anywhere from 50-200 mg nightly "for sleep". One of them was even ALSO on fluoxetine "for depression", which was of course antagonizing amitrip's metabolism and raising the levels to toxicity! :eek: And NONE of them had been told--"This could kill you if you overdose on it", nor had ANY effort been made to check a level...
 
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Sneezing said:
You can go cash only with psych and IM, but not likely Rheum.

You'll need to like most I'm subspecialties to deal with those 3 years of residency. And if you discover you don't like rheum, well you'll be stuck in rheum or IM. If you don't like psych you can always do a fellowship in sleep, pain, palliative, or the traditional fellowships.

More practice setting variability in psych than rheum. This is a plus if you are likely to get restless after a few years in one setting. Better chief complaints in psych than in rheum. Psych doesn't really touch fibromyalgia!! Greater range of living ability with psych. In otherwords, you can live in smaller town than rheumatologist, and I would venture to say there are more openings for psych across the country, too.
Click to expand...


I actually don't mind dealing fibromyalgia. Maybe b/c my mom has it.
Your point about being stuck in IM really resonates. I mean, I think I'll like rheum, or even endocrine, but what if I hated them both. I also sometimes have pangs about leaving manipulative medicine behind, but I'm interested in neuropsych. I could always do some cervical treatments with headache pts, etc etc. or just keep it up on the side for fun , help teach at a medical school, and provide low-income treatment sometimes somewhere, or whatever.


Thanks everyone! Very helpful.
 
masterofmonkeys said:
First of all, psych should be involved in fibromyalgia, if not the primary specialty working with it, IMO. I have seen little to no evidence that it is anything but a somatic manifestation of primary psych illness. Not saying it is pure somatization, but that it is rooted in an abnormal stress response and/or psychiatric dysfunction.

As for the dilemma. I understand all too well. I went to med school knowing I would go on to psych. But PM&R and cardiology are huge loves of mine.

I am now doing my medicine months and it kinda sucks. Because I really do love general medicine. A lot. Even though I'm at a super malignant, obnoxious, and slave-driving site for my medicine months, I am still feeling the pangs of anticipatory loss that in a month and a half, I will never again be a general medical doc.

I think in the end you have to weigh the pros and cons. You have to ask yourself if you really could enjoy doing one thing for a lifetime. In the end, I know that internal medicine would not be intellectually or personally fulfilling enough for me to do it for the rest of my life. Same goes for cards.

But psych is something that in and of itself I feel will still be as rewarding 30 years from now as it is today. *shrug*
Click to expand...

I considered PM&R as well.
 
Sneezing said:
And if you discover you don't like rheum, well you'll be stuck in rheum or IM. If you don't like psych you can always do a fellowship in sleep, pain, palliative, or the traditional fellowships.
.
Click to expand...

If you find you don't like IM/rheum, you could do a sleep fellowship.


Another option is doing an IM/psych combined residency and making up your mind about a rheum fellowship later.
 
OldPsychDoc said:
My "rant of the year" for 2010 is directed toward my primary care colleagues who have FORGOTTEN than amitriptylline IS the prototypical "SNRI". I've had 3 patients referred to me already on duloxetine 120 mg "for pain" AND amitrip, anywhere from 50-200 mg nightly "for sleep". One of them was even ALSO on fluoxetine "for depression", which was of course antagonizing amitrip's metabolism and raising the levels to toxicity! :eek: And NONE of them had been told--"This could kill you if you overdose on it", nor had ANY effort been made to check a level...
Click to expand...

I agree with you about the potential for toxicity with these combo's. However, I think of amitriptyline as much more than an SNRI. It is a very dirty drug that acts at multiple receptors; probably some of it's anti-pain effects come from Na+ channel blockade.
 
michaelrack said:
I agree with you about the potential for toxicity with these combo's. However, I think of amitriptyline as much more than an SNRI. It is a very dirty drug that acts at multiple receptors; probably some of it's anti-pain effects come from Na+ channel blockade.
Click to expand...

Oh I agree with it being "more than an SNRI"--but it is enough of an SNRI in its own right that one shouldn't need to be prescribing both a TCA and SNRI. Seriously, can you think of a scenario in which that would be appropriate?

Adding Cymbalta to amitriptylline is truly just "gilding the Lilly". ;)
 
OldPsychDoc said:
Oh I agree with it being "more than an SNRI"--but it is enough of an SNRI in its own right that one shouldn't need to be prescribing both a TCA and SNRI. Seriously, can you think of a scenario in which that would be appropriate?

Adding Cymbalta to amitriptylline is truly just "gilding the Lilly". ;)
Click to expand...
:thumbup:
 
There is definitely a way to link your two fields of interest in psych research. Lots of cool stuff...

- inflammation and autoimmunity in schizophrenia
- cytokines in depression, schizophrenia
- (my favorite) cytokine-induced sickness behavior
- SSRIs modulate TH1 response and levels of proinflammatory cytokines
 
michaelrack said:
If you find you don't like IM/rheum, you could do a sleep fellowship.


Another option is doing an IM/psych combined residency and making up your mind about a rheum fellowship later.
Click to expand...

There aren't that many of those programs, though, so it wouldn't be top on my list. I am throwing out a couple of applications though, and we'll see what happens. Plus, that's 7 years of training to end up going into rheum. Not really what I want.
 
If you really can't decide, you could go into IM and then switch after the intern year into Psych if you decide that you really prefer psych. You can switch from IM to Psych after the first year and still graduate on time, but the same is not true for switching from Psych to IM.
 
If you really can't decide, you could go into IM and then switch after the intern year into Psych if you decide that you really prefer psych. You can switch from IM to Psych after the first year and still graduate on time, but the same is not true for switching from Psych to IM.
Click to expand...

This option could work.

The person, however, needs to take in consideration that making the switch to psychiatry after some IM is difficult. Not just because transfers themselves are extremely difficult once residency starts, but also because going through the application process again, while working about 80 hrs a week is horrendous.

IMHO, if someone starts IM, yes the options are still there, but the doors now are much harder to open.
 
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