Infectious diseases vs. Psychiatry

[Darkskies]

Hi everyone,

I've been a member of this board for quite some time now. I'm currently a third year medical student and although I haven't yet had my IM rotation, by far my most favorite subject from the basic science years has been microbiology. I'm still transitioning into third year as I had expected medicine to be more like detective work(kind of like how the board exams were) in that a patient presents with a variety of symptoms, you diagnose the patient based on their history, physical exams, and labs, and then give them the appropriate treatment. Instead on the rotations I've had so far medicine seems to be far more about paperwork like disability forms, prior auths,etc., managing diabetes, hypertension, cholesterol, musculoskeletal pain, and referrals(especially in family medicine). I hate admitting this but sad to say I think I might even prefer the basic science years now looking back than third year so far.

I really hated musculoskeletal anatomy and I find treating back pain, neck pain,etc. is nearly 50% of all of what family medicine consists of. Just shoot me lol.. What's even more upsetting is that these patients don't even seem to get better.

I don't think I want to do a heavily procedure based specialty and I haven't had internal medicine yet but I have heard that the residency is very overwhelming even if the subspecialties you have access to afterwards are far more enjoyable. Does general IM have as much inane paperwork and managing musculoskeletal pain as family medicine? Also, I know finances shouldn't really come in the way of my decision but I will have upwards of 300k in loans and average ID salaries are one of the lowest across the board, even lower than family medicine! It doesn't make sense that an ID doc who has 2 years of fellowship on top of 3 years of general medicine ends up making less than a hospitalist or family med doc. Still, like Psychiatry it's supposed to be a field where no day is ever boring. Someone did mention to me that ID has a restricted job market and that a better reason for choosing ID is if you want to do research in the field rather than clinical practice. Also, as I've noticed on rotations, perhaps the study of the subject might actually be rather different than what it's like in the applied field.

I think I would greatly enjoy Psychiatry as you get to treat just one area of a patient's health concerns instead of having to manage 10-15 different conditions in all organ systems and multi-tasking while likely doing it only superficially since you have around 10 minutes to see each patient. The qualms I have with the field are the usual in that it is a more subjective specialty, many of the psychiatry medications' mechanisms are still unknown, and some in the field are indiscreet pill pushers/med managers. I was thinking that if I do choose to pursue Psychiatry, I would focus more on the severely mentally ill since that is where I think I could do the most good, but I remember reading a post by splik on one of the threads where he states that psychotherapy is even just as effective or more effective on unstable schizophrenics than antipsychotics are. I'm fine with this but the majority of Psychiatrists don't engage in psychotherapy so would that mean many patients in the field aren't getting proper care? I also don't appreciate that the DSM at times is trying to medicalize normal behavior as pathological and that you really need to be able to distinguish what constitutes true mental illness instead of blindly following the DSM. Here's an article by Theodore Dalrymple, a retired British Psychiatrist, to illustrate what I mean:http://www.city-journal.org/2013/23_4_otbie-psychiatry.html

Since the majority of one's life is spent at the workplace, and whatever field I enter I will likely be practicing in it for the next 30-40 years, I just want to be assured that my work will be meaningful and that I can gain satisfaction from it. Do you feel that you help many patients every day and that without your work input, these patients would be far worse off?

I wonder if I'm too cynical since sometimes when patients have stated that they were depressed, they just appeared 'unhappy' to me or in the case of their life circumstances, I would be 'depressed' too. On the other hand maybe this is a good trait to have and would let me more objectively treat patients?

On my Psychiatry rotation on an inpatient unit, the entire staff including the Psychiatrist, would relentlessly gossip and laugh daily about the patients behind their backs even in the case of legitimately depressed elderly women with no drug abuse problems. It rubbed me the wrong way and I was wondering if this is the norm across the board. It surprised me since you would think in the field of mental health, the practitioners would be less likely than the general population to engage in this sort of thing. It makes me wonder now if people working in mental health are attracted to the field since they get to sort of be voyeurs into patients' dysfunctional lives similar to watching daytime soap operas/jerry springer rather than to help get people back on their feet and treat mental illness.

If I choose to do C/L would that be a more surefire way to have a firmer footing in general medicine while being a Psychiatrist? I also like toying with the idea of being a Psychiatrist and engaging in microbiology research on the side but that's likely a pipe dream due to all the bureaucracy right?


Thanks for reading and I greatly appreciate all responses!

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[splik]

I was very torn between ID and psychiatry too! There are some similarities - you are dealing with the consequences of social inequality, poverty and injustice in both specialties, and both have a large degree of detective work in complex cases to try and make sense of the problems at hand. They are both very cognitive specialties and may attract people who are interested in humanitarianism. One main difference is that you can cure many many diseases in ID and radically control others, whereas the same cannot be said for psychiatric illnesses (though the prognosis for the latter is not as bleak as has been claimed). I have met many people who were similarly torn, and also know 1 ID doc who became a psychiatrist (an analyst no less) and 1 psychiatrist who became an ID doc!

This is probably the wrong forum to ask about ID vs psych of course because most psychiatrists don't know anything about ID. The main problems are there is a glut of ID docs and not enough work to go around so most of them are glorified primary care docs. Also ID docs are more likely than other specialists (except nephrologists) to provide the totality of primary care to their patients. This may be appealing but it may also be exceedingly dull. Unless you're doing research it is unlikely you will be spending all of your clinical time doing infectious diseases, and most of it is not those juicy cases of working up fever of unknown origin, but managing barn door things like osteomyelitis, cellulitis, HIV, hepatitis, TB.

They get paid less because a) the people who go into ID are do-gooders and they can get away with paying them less b) people will work for less to do the work they love c) there are too many of them and d) most importantly the patient population has a higher level of uninsured, underinsured and medicaid given the high levels of poverty and other inequality/deprivation markers in this population.

And yes it is certainly possible to combine the two with research or be a researcher in an area that has nothing to do with psychiatry (but you will then almost certainly need to have a PhD in that field). There are people exploring neuropsychiatric effects of lyme disease and other CNS infections for example, or looking at HIV's effects on microglia and development of dementia, and that bizarre psychiatrist Fuller Torrey who believes that cat **** is the cause of schizophrenia has spent years looking a Toxoplasma, lots of research into EBV and mechanisms of post-viral fatigue etc

Also to clarify I didn't say that psychotherapy was as effective as drugs from "schizophrenia". There are no head-to-head RCTs (surprise surprise), and of course for acute psychosis drugs are going to subdue the patient much more quickly. I was merely pointing out that 60 years of research had showed it was both possible and often very helpful to use psychotherapeutic approaches to psychosis, especially in those patients who did not benefit from drugs or do not want them, and adds a dimension of meaning and agency to the lives of people experiencing psychosis, and that psychotherapeutic options should be more available for those who want it.

Edit: also HIV psychiatry is a burgeoning research area as well one of the more established areas of psychosomatic medicine. The patient population is extremely challenging, with complex medical and psychiatric comorbidities, lots of addiction, personality pathology, but also more unusual and interesting pathology including complications of ARV treatment, opportunistic infections, and HIV-associated neurocognitive disorder and other HIV-associated syndromes. You are not going to be fiddling about with patient's ARVs but you will be working closely in a multidisciplinary team, find the psychiatric issues directly affect adherence, functioning, and aspects of their disease management. You do have to be very comfortable spending a lot of time talking about gay sex though!

 

[hamstergang]

I can't help much answer your question, but I can help correct some misconceptions you have about psychiatry.

What's even more upsetting is that these patients don't even seem to get better.

Happens a lot in psych too. Most of what we treat are chronic illnesses that don't have cures yet.

some in the field are indiscreet pill pushers/med managers.

Why would that deter you from the field? You can practice good medicine even if others aren't. There are bad doctors in every field, so should you not be a doctor at all?

I also don't appreciate that the DSM at times is trying to medicalize normal behavior as pathological and that you really need to be able to distinguish what constitutes true mental illness instead of blindly following the DSM. Here's an article by Theodore Dalrymple, a retired British Psychiatrist, to illustrate what I mean:http://www.city-journal.org/2013/23_4_otbie-psychiatry.html

Like above, just because some may blindly follow a flawed book doesn't mean you would have to. Despite its flaws, a lot of people seem to forget that the DSM has a requirement on nearly every disorder that it must cause significant functional impairment or distress. If you just read the other criteria, you will pick up too many people. But with this caveat, you should only be diagnosing those that are in need of help.

And don't forget too that psychiatrists don't drive around looking for patients. They come to us because they think something's wrong or because the police see that something's wrong.

As for that article, I feel that it seems to think psychiatry is more unique than it actually is compared to the rest of medicine. How do you diagnose someone with hypertension? Well, you need 3 separate blood pressure readings that are elevated (and according to wiki NICE says they need to be done 1 month apart). But why 3 and not 2? Why 1 month and not 3 weeks? And what defines elevated? Is that actually indicative of a disease process, given that over 90% of the time we never identify a cause? When people meet the given criteria for htn or a psychiatric disorder, we know that they do worse on some number of measures than those who don't meet the given criteria, and so while the criteria may seem arbitrary they do serve a purpose.

On my Psychiatry rotation on an inpatient unit, the entire staff including the Psychiatrist, would relentlessly gossip and laugh daily about the patients behind their backs even in the case of legitimately depressed elderly women with no drug abuse problems.

Would it be ok to laugh if she did have a drug abuse problem?

This has been discussed here before. I think everyone agrees that there is a line somewhere that shouldn't be crossed, but having some degree of fun behind a closed door isn't so bad and is certainly normal in more than just psychiatry. The work can be incredibly draining if you don't make fun of it sometimes.

 

[Darkskies]

I can't help much answer your question, but I can help correct some misconceptions you have about psychiatry.

Happens a lot in psych too. Most of what we treat are chronic illnesses that don't have cures yet.


Why would that deter you from the field? You can practice good medicine even if others aren't. There are bad doctors in every field, so should you not be a doctor at all?


Like above, just because some may blindly follow a flawed book doesn't mean you would have to. Despite its flaws, a lot of people seem to forget that the DSM has a requirement on nearly every disorder that it must cause significant functional impairment or distress. If you just read the other criteria, you will pick up too many people. But with this caveat, you should only be diagnosing those that are in need of help.

And don't forget too that psychiatrists don't drive around looking for patients. They come to us because they think something's wrong or because the police see that something's wrong.

As for that article, I feel that it seems to think psychiatry is more unique than it actually is compared to the rest of medicine. How do you diagnose someone with hypertension? Well, you need 3 separate blood pressure readings that are elevated (and according to wiki NICE says they need to be done 1 month apart). But why 3 and not 2? Why 1 month and not 3 weeks? And what defines elevated? Is that actually indicative of a disease process, given that over 90% of the time we never identify a cause? When people meet the given criteria for htn or a psychiatric disorder, we know that they do worse on some number of measures than those who don't meet the given criteria, and so while the criteria may seem arbitrary they do serve a purpose.


Would it be ok to laugh if she did have a drug abuse problem?

This has been discussed here before. I think everyone agrees that there is a line somewhere that shouldn't be crossed, but having some degree of fun behind a closed door isn't so bad and is certainly normal in more than just psychiatry. The work can be incredibly draining if you don't make fun of it sometimes.

Thanks for the reply. I should have worded my post better but no I do not think it would have been ok to laugh if she did have a drug abuse problem. I was just trying to convey how the staff at this unit would pretty much search for any reason whatsoever to laugh at the patients. It almost gave you the feeling that they don't take the patients seriously and aren't really there to help them get better. TBH, I think hardly any of the patients we saw even got better.

I'm not attempting to take a holier-than-thou attitude and I understand that we're only human and that this sort of thing is bound to happen. Heck, I'm sure I've done the same in the past. I can see the humor if the staff were laughing at the ridiculous things a schizophrenic had said or done recently as this isn't attacking his character but the manifestations of his illness. I also realize that there is a need to blow off steam since it is an emotionally taxing environment but I actually found it MORE draining to see how with at the end of nearly every patient encounter, the staff would unfailingly laugh and make fun of the patients. It almost seemed like they were playing a game to see who could make the best jokes or the meanest comment.

The only reason I mention this is because I would like to know if making fun of patients to the extent that it happened in this unit, is the norm in Psychiatry. I'm fine with it on a certain level and if it happens every now and then considering the types of patients one encounters in the field and the nature of the work, but not if it happens with every single patient encounter on a daily basis. I think that would make me lose faith in the patients and in what my purpose at work is supposed to be.

As you stated, I suppose even if it is the norm, that doesn't mean I would have to act that way.

I think splik hit it spot on as I'm interested in ID because of the detective work and the fact that you can truly cure people who are suffering from their illnesses or at least control them to a much greater extent. I also greatly enjoyed microbiology and like the idea of working with lower socioeconomic groups who may really need and benefit from my care. I suppose the latter is also what attracts me to psychiatry apart from the fact that you are also dealing with one area of illness and not trying to manage multiple medical problems while only knowing very little about all of them(as you would in primary care).

I don't know if it's worth it on my part to have as much in loans as I do to pursue ID via IM when there is a glut of ID doctors and a limited job market where I will mostly be doing primary care. What made you choose to pursue Psychiatry in the end, splik? With regards to psychotherapy, as a resident I'm sure you get adequate time to hone your skills in that direction but how do you plan on incorporating that into your practice when you are an attending? Is it possible to provide psychotherapy as well as manage medications and still make a decent income to chip away at one's loans?

The downside to Psychiatry is long term prognosis. Do many patients get better? I guess it comes down to what I wrote before: "Since the majority of one's life is spent at the workplace, and whatever field I enter I will likely be practicing in it for the next 30-40 years, I just want to be assured that my work will be meaningful and that I can gain satisfaction from it. Do you feel that you help many patients every day and that without your work input, these patients would be far worse off?" If someone would answer, I would really appreciate it. Thanks!

 

[nitemagi]

The downside to Psychiatry is long term prognosis. Do many patients get better? I guess it comes down to what I wrote before: "Since the majority of one's life is spent at the workplace, and whatever field I enter I will likely be practicing in it for the next 30-40 years, I just want to be assured that my work will be meaningful and that I can gain satisfaction from it. Do you feel that you help many patients every day and that without your work input, these patients would be far worse off?" If someone would answer, I would really appreciate it. Thanks!

Meaning is an individual experience. No one can answer that for you.

I do help my patients every day, and many even "graduate" from my treatment. You need a broad toolbox, an open inquisitive mind, and a lot of persistence.

 

[Darkskies]

I'm bumping this thread because I was curious to know what other opportunities are available in Psychiatry when it comes to treating patients with Infectious diseases. I understand that as a Psychiatrist most roles would involve addressing the mental health aspects of such patients. Is there any capacity to work as a Psychiatrist who also treats infectious diseases? I've realized that the only thing I'd miss from IM would be the bugs and antibiotics as I simply find the subject matter fascinating and there is a lot of opportunity to make a difference.

 

[Abby_Normal]

I'm bumping this thread because I was curious to know what other opportunities are available in Psychiatry when it comes to treating patients with Infectious diseases. I understand that as a Psychiatrist most roles would involve addressing the mental health aspects of such patients. Is there any capacity to work as a Psychiatrist who also treats infectious diseases? I've realized that the only thing I'd miss from IM would be the bugs and antibiotics as I simply find the subject matter fascinating and there is a lot of opportunity to make a difference.

Have you looked at HIV psychiatry? You wouldn't be handling the patient's HIV treatment, rather helping them with the psychiatric sequelae of HIV (coping with disease, but also possibly some CNS manifestations of the bug itself, like dementia) but a knowledge of and interest in microbiology and antivirals would probably be a plus.

 

[Shikima]

I'm bumping this thread because I was curious to know what other opportunities are available in Psychiatry when it comes to treating patients with Infectious diseases. I understand that as a Psychiatrist most roles would involve addressing the mental health aspects of such patients. Is there any capacity to work as a Psychiatrist who also treats infectious diseases? I've realized that the only thing I'd miss from IM would be the bugs and antibiotics as I simply find the subject matter fascinating and there is a lot of opportunity to make a difference.

Not a whole lot. You could consider a fellowship in C&L with an emphasis on CNS infections.

 

[Darkskies]

Not a whole lot. You could consider a fellowship in C&L with an emphasis on CNS infections.

Thanks for the replies. Isn't it a little ridiculous that after 4 years of medical school plus a year of internship, you're restricted to only treating illnesses that are within the realm of your specialty? Is there really no arrangement where you can practice psychiatry but then also dabble in treating infectious diseases, even if only tangentially related? I was hoping that since there is so much flexibility in medicine, an option as such would exist..

 

[smalltownpsych]

Thanks for the replies. Isn't it a little ridiculous that after 4 years of medical school plus a year of internship, you're restricted to only treating illnesses that are within the realm of your specialty? Is there really no arrangement where you can practice psychiatry but then also dabble in treating infectious diseases, even if only tangentially related? I was hoping that since there is so much flexibility in medicine, an option as such would exist..

If you were to see a way that integrating the two areas could benefit patients and/or the community, or even other doctors, then maybe you could create something along those lines. The line between the medical and the psychological is not so clear although the line between infectious disease and psychological is clearer than the line between chronic pain and depression or gastric complaints and anxiety.

 

[Armadillos]

As others mentioned, psychiatrists are embedded in many university HIV/ID clinics, but your obviously not going to be managing their HIV meds. So this would be a great option if you like the patient population, but a bad option if all you care about is treating infections.

Realistically about the only time a psychiatrist is going to prescribe abx would be occasionally treating UTIs on a inpatient unit.

If squashing bugs is your thing, then psych would be a strange choice.

 

[Shikima]

Thanks for the replies. Isn't it a little ridiculous that after 4 years of medical school plus a year of internship, you're restricted to only treating illnesses that are within the realm of your specialty? Is there really no arrangement where you can practice psychiatry but then also dabble in treating infectious diseases, even if only tangentially related? I was hoping that since there is so much flexibility in medicine, an option as such would exist..

There is an option. You can do IM/Psych combined residency. Or FP/Psych..... or you could a Neuro/Psych combined residency program. There are other programs where you do Peds/Psych/C&A residency combined.

Alternatively you could do a FP or IM residency, complete a Psych Residency and then complete an Addictions and pain management fellowships.

Your imagination will drive the future.

 

[MacDonaldTriad]

I'm bumping this thread because I was curious to know what other opportunities are available in Psychiatry when it comes to treating patients with Infectious diseases. I understand that as a Psychiatrist most roles would involve addressing the mental health aspects of such patients. Is there any capacity to work as a Psychiatrist who also treats infectious diseases? I've realized that the only thing I'd miss from IM would be the bugs and antibiotics as I simply find the subject matter fascinating and there is a lot of opportunity to make a difference.

Lymes disease

 

[notdeadyet]

Isn't it a little ridiculous that after 4 years of medical school plus a year of internship, you're restricted to only treating illnesses that are within the realm of your specialty?

Nope. 1 year of intern level training managing diseases would be a scary thing. No one wants someone who is "dabbling" to be responsible for their disease....


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[hamstergang]

Isn't it a little ridiculous that after 4 years of medical school plus a year of internship, you're restricted to only treating illnesses that are within the realm of your specialty?

As you continue on in your education and training, you'll see that 4 years of medical school and 1 year of internship are really not sufficient for you to safely practice independently. It is far from ridiculous.

 

[Darkskies]

Nope. 1 year of intern level training managing diseases would be a scary thing. No one wants someone who is "dabbling" to be responsible for their disease....


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I didn't mean to exaggerate and I apologize for my poor choice of wording.

When researching combined residencies, it seemed that on most threads, people argued against embarking on that route since you usually end up practicing in only one field so I guess that's out of the picture, then.

I liked the first two years of medical school but the only subjects that I truly enjoyed were Microbiology/Immunology and Psychiatry. I liked other aspects of medicine such as GI, Endocrine, Repro, and Nephrology. I disliked Anatomy, especially musculoskeletal. Now that I'm on rotations, it seemed that on family medicine, a lot of complaints involved musculoskeletal pain, managing diabetes, hypertension, cholesterol, GERD, asthma, etc. I haven't yet had my IM rotation but I don't know how much I'd really enjoy it if it's anything like family medicine. Also, being a 3rd year medical student, I'm often confused as to what my role is supposed to be and find that it is a big transition from the didactic years. Much of the material learned in the first two years oftentimes doesn't really seem to apply in the clinic especially since many patient complaints are vague. I think this contributes to the stress and uncertainty I had when I was on some of my rotations.

I like diagnosing patients and thinking up treatment plans. On some of the rotations I've had thus far, it seems that most of the time the diagnosis is already made, and you are only adjusting medications, making sure patients are getting routine exams, and filling out paperwork and forms.

Threads on the IM forum are a bit pessimistic and many commenters complain about how stressful IM residency is and how certain job positions are also not that much better. How do I know if I can handle IM residency? When I brought up the fact that I might want to do ID, some informed me that it was not a good choice if I will have a heavy loan burden and ID doctors also make the lowest income across the board. Hospitalists and Primary care physicians earn more. They are also not in the highest demand in the current climate and it could be hard to find a position. I don't really care too much about income but it does start to matter when you consider I will have around 300k in loans or more with interest once I graduate.

Most infectious diseases are managed by general IM and FM docs, so I suppose I could just pursue a 3 year IM or FM residency without specializing but then that would also mean most of the time I would be managing patients' non-ID issues.

 

[heyjack70]

You could do IM and take extra electives in infectious disease in residency. This might satisfy your interest in the field. Then become a hospitalist to make better money, and have a good handle on infectious disease. In smaller/community hospitals, you might actually be the infectious disease expert because they don't have any fellowship trained ID docs.