Combined internal med/psychiatry programs?

[Leonardsean]

Are there any combined IM/psych programs to steer clear of? Programs with a toxic environment, etc. I'm currently doing my 3rd and 4th year clinical rotations at a site where the residency director creates a particularly hostile environment. Just want to avoid 5 years of a similar experience.

On the other side of the coin, are there any great programs?

Which ones provide training in psychotherapy as well as psychopharm.?

--Sean

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[Shikima]

Honestly, if you want to do it, just do it. Personalities are a large quotient in determining "toxic" environments (speaking from experience) and if you want to do it, then go forth and apply broadly. Think about FP/Psych also.

 

[notdeadyet]

Which ones provide training in psychotherapy as well as psychopharm.?

Combined residencies by their design do not have strong psychotherapy training. The cost of combining a 3 year IM residency and 4 year psychiatry residency into a single 5 year residency is that you cut the training in each down to the minimum to compensate. For the psych side you lose continuity of care, lots of hours that other programs devote to basic psychotherapy, and much significant exposure to many modalities that you could get at other programs.

Combined residencies are great if you want an academic career at a combined residency. It's also great if you are going to be literally in the middle of nowhere and spend your career doing basic medical and psych care and spending a fair bit of time catching up on each (and in this practice you'd likely be doing only psychopharm anyway). You could make a good case for ccombined if you were going hospice (though most folks back away from this later). Combined residencies are not the direction traditional integrated care is going (obviously, as their numbers are dropping as integrated care is going).

It's a godsend for a very, very small niche of potential applicants who want to practice in very, very rare environments. For many, it's an appeal to folks still struggling with the proverbial "hanging up the stethoscope." But if you have a strong interest in psychotherapy, combined residencies would be pretty near the bottom of places I'd apply.

But these programs are so low in number, I'd contact them directly and ask. You want to ask:
- which years of program will I have devoted psychotherapy patients and how much continuity will I have with them (e.g.: will I only be doing it a few months each year or have longitudinal time carved out)
- how many hour long protected psychotherapy slots in any given year?
- how many hours of psychotherapy training and (more importantly) supervision will i have?
- how much structured training and supervised psychotherapy will I have in modalities that interest me beyond CBT? Maybe in PE, CPT, TLDP, IPT, DBT, ACT, open-ended psychodynamic, couples, family, child, etc.

That's how I'd approach it. And did. I was going to go combined until late in the process and took a good look under the hood.

 

[Shikima]

Not dead, you have the caveat that not all pure Psych training programs are going to have strong psychotherapy training. Perhaps this would be a good jumping off point for going into Geropsych, Sleep Medicine, and/or Pain Medicine/Addicitions training?

 

[notdeadyet]

Not dead, you have the caveat that not all pure Psych training programs are going to have strong psychotherapy training.

True. But for a given applicant's abilities, there will be a multitude of psych programs that offer more psychotherapy exposure than the combined programs. You could probably argue that even many of the less therapy oriented psych programs will have more time devoted to therapy just due to schedule (can't say because I don't know those programs well).

Perhaps this would be a good jumping off point for going into Geropsych, Sleep Medicine, and/or Pain Medicine/Addicitions training?

It would be a good jumping off point to any fellowship that doesn't allow psych but allow IM. For programs that do allow psychiatrists but make it hard to get in (thinking sleep or pain), you could make a good case (though you could also argue you'd be better off getting the absolute best psych training you can, doing sufficient electives in your field to satisfy the programs, and make your case that way). For most fellowships that it would be just handy (like Geri, c/l or addictions), you'd be better off getting the absolute best psych training you can, as you will not be the primary caregiver for your folks physical maladies anyway and it does not take a residency in IM to learn which meds cause depression and such.

 

[Shikima]

Ah, I see where you're going..

 

[vistaril]

Combined residencies by their design do not have strong psychotherapy training. The cost of combining a 3 year IM residency and 4 year psychiatry residency into a single 5 year residency is that you cut the training in each down to the minimum to compensate. For the psych side you lose continuity of care, lots of hours that other programs devote to basic psychotherapy, and much significant exposure to many modalities that you could get at other programs.

Combined residencies are great if you want an academic career at a combined residency. It's also great if you are going to be literally in the middle of nowhere and spend your career doing basic medical and psych care and spending a fair bit of time catching up on each (and in this practice you'd likely be doing only psychopharm anyway). You could make a good case for ccombined if you were going hospice (though most folks back away from this later). Combined residencies are not the direction traditional integrated care is going (obviously, as their numbers are dropping as integrated care is going).

It's a godsend for a very, very small niche of potential applicants who want to practice in very, very rare environments. For many, it's an appeal to folks still struggling with the proverbial "hanging up the stethoscope." But if you have a strong interest in psychotherapy, combined residencies would be pretty near the bottom of places I'd apply.

But these programs are so low in number, I'd contact them directly and ask. You want to ask:
- which years of program will I have devoted psychotherapy patients and how much continuity will I have with them (e.g.: will I only be doing it a few months each year or have longitudinal time carved out)
- how many hour long protected psychotherapy slots in any given year?
- how many hours of psychotherapy training and (more importantly) supervision will i have?
- how much structured training and supervised psychotherapy will I have in modalities that interest me beyond CBT? Maybe in PE, CPT, TLDP, IPT, DBT, ACT, open-ended psychodynamic, couples, family, child, etc.

That's how I'd approach it. And did. I was going to go combined until late in the process and took a good look under the hood.

the big advantage of doing psych-med is that you will be trained as an internist.....for someone who wants a career who deals with the 'medical', this is obviously a big deal. But for someone who wants that, they should just do internal medicine in the first place.

 

[notdeadyet]

Ah, I see where you're going..

I don't want to seem anti combined residency. I came very close to going that route unto I had a couple honest conversations with two great combined PDs who laid out on the table the very, very small subset of applicants they thought the combined residencies are good for and I realized I wasn't it. And neither were most people who were looking at it.

Many combined residency alum I've met ended up in regular psych careers. And although they still have some of the residency knowledge up in the noggin years later, almost all of it gets lost without repetition (heck, ask me questions about coverage for most antibiotics and I only graduated med school a few years ago). So if you're not going to be doing a job where you use both residency skills directly and daily, it's hard to argue that the training you learn is worth the training you lose.

 

[Shikima]

Right. It was the purist vs jack of all trades argument.

 

[MacDonaldTriad]

Are there any combined IM/psych programs to steer clear of?

--Sean

All of them would be the honest answer. I don’t want to sound anti combo either, but the truth is I am. I have never met a combo graduate who isn’t doing 100% psychiatry. The few times our program has had a mid-training opening, we were flooded with excellent candidates who were trying to get out of their combo programs. I’m sure the combo route is right for some people, but these people are not common and a lot of combo residents change their minds.

 

[michaelrack]

Med/psych used to be a good gateway into sleep medicine (back when sleep medicine was a good field to go into)

 

[masterofmonkeys]

The combo would make a lot more sense if our opportunities for flexibility weren't so completely obliterated by CMS (and by extension private insurance). Med/psych for outpt makes a ton of sense since people sick in one area tend to be sick in both. I think that a med/psych doc would make a KILLING in the private practice cash market in a big enough city but that's about the only place where I see it offering a true competitive advantage.

I think it's possible to be a psychiatrist who doesn't lose their medicine. And if we think about what an FNP or a primary care PA sees, I don't see why we couldn't do at least that much as psychiatrists (provided you spent the continuing ed time to maintain your chops).

I WISH there was a place for med/psych. There isn't, which is one of the reasons I didn't do it.

 

[michaelrack]

I agree with most that has been said on this thread. Psychosomatics becoming an official subspecialty/certification put the final nail in the coffin for med/psych. Med/psych does have some marginal utility for those who have certain specific academic interests (performing research in areas like heart disease/depression, etc). However, many of these interests can also be accomodated by just doing a general psychiatry residency (plus/minus psychosomatics fellowship)

 

[nitemagi]

Check out Duke & UCDavis.
http://residency.medicine.duke.edu/medicine-psychiatry

 

[vistaril]

I agree with most that has been said on this thread. Psychosomatics becoming an official subspecialty/certification put the final nail in the coffin for med/psych. Med/psych does have some marginal utility for those who have certain specific academic interests (performing research in areas like heart disease/depression, etc). However, many of these interests can also be accomodated by just doing a general psychiatry residency (plus/minus psychosomatics fellowship)

On a day to day basis psychosomatics(C-L) has very little to do with medicine. maybe psych C-L in the real world would be run and done differently(and maybe the consulting service would expect something different from people with training in medicine) if it was common to see dual boarded people do C-L, but that's not the case.

 

[michaelrack]

On a day to day basis psychosomatics(C-L) has very little to do with medicine. maybe psych C-L in the real world would be run and done differently(and maybe the consulting service would expect something different from people with training in medicine) if it was common to see dual boarded people do C-L, but that's not the case.

I agree. My point was that psychosomatics took away a niche from med-psych.

In academics, med/psych does have a little utility- it gives a doctor more credibility when operating accross departments. When I was with the univ of MS dept of psych, I was able to get involved in a few research projects with the dept of medicine (analysis of the Jackson Heart Study data)- things like inflammatory markers/depression/heart disease. My IM cert wasn't absolutely necessary, but it did help.