Should I do psychiatry?

[BigBear123]

Time is running out and I need to decide pretty soon!! I'm an MS3 going on MS4. I got interested in psych mostly because I LOVE psychopharmacology. I think mental illness is interesting, especially the bread and butter mood disorders, anxiety, and psychotic disorders. I also really like the people in psychiatry and would love to have them as future colleagues.

However, I have found that I do not like outpatient work in general, and the options for doing non-outpatient psychiatry are more limited. I also have very little interest in psychotherapy... I know that psychiatrists nowadays usually refer out their psychotherapy (at least in big cities such as where I am), but I understand that I would still have to learn to do psychotherapy in residency. I did enjoy C/L psych, but I am wondering if it is worth it for me to do go into psych with the goal of doing this one subspecialty.

I am just wondering if I should go into psychiatry given all of the above, and if my dislike of outpatient settings and my lack of interest in psychotherapy should stop me...

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[OldPsychDoc]

You sound like you'd do well with inpatient, consult, or emergency psych. There are LOTS of non-outpatient, non-therapy options. And hospital-based psych tends to be more team-centered and collegial than outpatient, which would hit your "like the people" criterion. Now the pathology is likely to be a bit beyond "bread and butter" a lot of times, but psychiatrists do not live by bread alone!

 

[northernpsy]

You hate doing therapy in particular and don't care much for outpatient in general? Welcome home, my brother/sister. I felt the same way in psych residency (though my view on outpatient became more positive once I graduated).

Different residency programs emphasize psychotherapy to different degrees. In some places, the training is mostly veery biologically focused while others expect you to make a serious effort and carry a good number of therapy patients. Ask lots of questions about the therapy training at whatever programs you're interested in.

When I looked for jobs after residency, I was specifically avoiding outpatient work and didn't have ANY trouble finding job offers. If you tell hospitals you want to do inpatient work or CL work, they will find a way to use you. Most places are desperate for psychiatrists, so they aren't going to be too picky.

Honestly, I didn't realize that the program I wound up at was very therapy focused until I got there (I was more focused on other issues during the interview) and while the extensive training in psychodynamic psychotherapy wasn't my favorite experience I don't think it was a total waste either. I do incorporate a few things I learned from my therapy experience in my work in consult-liaison and inpatient psychiatry (though I definitely don't think that an interest/background in therapy is critical to do well in these areas).
I also found that the experience of getting to know patients in that way (through weekly or q2weeks therapy appointments over the course of several years) actually turned out to be more interesting than I expected. Even though I still don't enjoy therapy overall, I did end up becoming fond of my patients (NOT in an erotic countertransference way, thank you very much) simply because I saw them so frequently and learned so much about their lives. It was actually a bit emotionally moving for me when the day finally came when I had to talk about termination with some of the patients I had gotten to know so well. I will never again have a therapy clinic, but I don't regret getting the experience of seeing what it was like in residency. Very few other specialities allow you to have such a deep relationship with a patient, so it was an interesting life experience if nothing else.

 

[splik]

If you like the "bread and butter" stuff (which I personally find kinda boring) then psychiatry could be a great fit. I will say that you have likely not had any meaningful exposure to outpatient psychiatry as a medical student. I know at least here our outpatient med student rotation is mind-numbing because the students get very little in the way of hands on experience or ownership of patient care. You will also presumably have had very little/no exposure to psychotherapy. Thus I am not sure you would be able to accurately assess how interested you are in these things. You want to go into any field with a healthy skepticism and an open mind. Psychopharmacology is very interesting but ultimately it is connection that heals. You certainly do not have to do psychotherapy as a psychiatrist and most no longer do psychotherapy proper, but understanding principles and knowing how to talk with and be with patients is an important part of the work we do and can be enriched by the principles of psychotherapy - but it doesn't mean you have to be a beardy-weirdy analyst type. I also liked psychiatry as a med student because I liked C/L psychiatry and that was partly because it was fun, but also because it was the rotation that I got the most meaningful experience and got to be useful. I think that makes a difference to whether you enjoy something as a student. There are fewer inpatient vs outpatient gigs, but there are still plenty of inpatient jobs and not many people are queuing up to work with the most disturbed individuals in those settings. Psychiatry is a broad field with multiple different specialties and settings spanning everything from degenerative brain disease to problems of living. There is something to suit many different personality types. Not everyone likes working with patients long-term and may prefer briefer encounters with patients (such as what you get in an inpatient on general hospital setting) and you will figure this stuff out as you go through your training.

 

[HarryMTieboutMD]

To the original poster- YES, you should do psychiatry. This was exactly my mindset in med school, though I was- and still am- into the zebras, but as a resident I have come to find the bread and butter cases (including personality disorders) fascinating as well. Even though people like to rip on psychopharmacology ("it hasn't changed that much in 60 years",, "most midlevels can manage it", etc) it takes a fair amount of training and thought to really treat some of the more complicated cases. My program is one that has traditionally de-emphasized (or even minimized) therapy exposure, but this has changed in recent years. I have no intention of being a therapist, but principles of the different psychotherapy modalities are extraordinarily useful.

So in short, yes, you should psychiatry. Everything else will bore you.

 

[notdeadyet]

Another pitch for psychiatry is that you are not committed to any particular field. You may finish residency and do C/L work at a hospital for two years, then become a full time emergency psychiatrist, then transition over to working on an inpatient unit, then do a part-time psychotherapy practice, then work in addictions, then work with veterans, etc.

There is a LOT in the way of variety in this field.

 

[smalltownpsych]

What's wrong with psychotherapy? Learning how to deal with peoples crap in a productive way will be a necessary skill. You probably just are more of an Albert Ellis person than a Carl Rogers type of person. Not all of us spend agonizing hours listening to boring people drone on and on about how the world done them wrong. I am working outpatient now and am hating a lot of it because I do have to sift through too many of those folks. Inpatient settings, much faster pace and briefer therapeutic interactions that are informed by actual behaviors and observations of patients interactions with others on the unit as opposed to the patient's biased and limited perspective in outpatient setting.

 

[Shikima]

What's wrong with psychotherapy? Learning how to deal with peoples crap in a productive way will be a necessary skill. You probably just are more of an Albert Ellis person than a Carl Rogers type of person. Not all of us spend agonizing hours listening to boring people drone on and on about how the world done them wrong. I am working outpatient now and am hating a lot of it because I do have to sift through too many of those folks. Inpatient settings, much faster pace and briefer therapeutic interactions that are informed by actual behaviors and observations of patients interactions with others on the unit as opposed to the patient's biased and limited perspective in outpatient setting.

ACT Therapy?

 

[BigBear123]

There's nothing "wrong" with psychotherapy, it's just not for me. I don't care for analyzing people's thoughts and behaviors. It reminds of me of English class. I'd rather be doing something more "active" and less cerebral.

 

[MacDonaldTriad]

Now ACT is Acceptance and Commitment Therapy, before it was Assertive Community Treatment. Just like BPD is no longer Bipolar Disorder. I hate change.

 

[Merovinge]

Now ACT is Acceptance and Commitment Therapy, before it was Assertive Community Treatment. Just like BPD is no longer Bipolar Disorder. I hate change.

I hate that the funding for some of the most vulnerable folks in the world has dried up so much that ACT isn't even Assertive Community Treatment. Having gotten to train with a founding father of the ACT model im med school and already seeing it slowly disappear in such a short time despite the strong evidence base for cost-effective and human-effective care is so sad.

To answer the OP - Absolutely. I love psychopharm and have a pretty inherit bias against MDs doing dedicated psychotherapy and I still loved residency. The training, while a bit tedious at time (particularly the therapy didactics), has been absolutely helpful in making me a better physician and it was remarkably moving to leave my long-term therapy patients for fellowship. Inpatient hospitalist/CL/ED psych is all the rage for hospital systems lately and there are a ton of job opportunities for these jobs if you want them.

 

[MacDonaldTriad]

The best thing about Assertive Community Treatment cost effectiveness research is that unless you can find matched controls, all you have to do is pick the very most expensive subjects and regression to the mean does all the work for you. Most systems want you to just take the most costly subjects and not just half of them so guaranteed success. Mind you I'm all about ACT and do believe it's numbers are a lot more than regression.

OP, there are an infinite amount of inpatient jobs that are hard to fill because there are also almost an infinite amount of outpatient jobs and most of us prefer outpatient. Keep an open mind about therapy and go for it. You may like it, nothing in medical school gives any sense of what it is like anyway.

 

[swifteagle43]

I don't like outpatient either. Inpatient compensates better also.

 

[Shikima]

The best thing about Assertive Community Treatment cost effectiveness research is that unless you can find matched controls, all you have to do is pick the very most expensive subjects and regression to the mean does all the work for you. Most systems want you to just take the most costly subjects and not just half of them so guaranteed success. Mind you I'm all about ACT and do believe it's numbers are a lot more than regression.

OP, there are an infinite amount of inpatient jobs that are hard to fill because there are also almost an infinite amount of outpatient jobs and most of us prefer outpatient. Keep an open mind about therapy and go for it. You may like it, nothing in medical school gives any sense of what it is like anyway.

A more cost effective solution compared to ACT is to hire retired military snipers with rifles loaded with Invega Sustenna.

 

[Bartelby]

Just chiming in to agree with the other posters that your interests (non-outpatient, low interest in psychotherapy) align well with inpatient and CL work. I think even if you don't change your mindset over time (which happens to many/most of us) that you can find a happy fit in psychiatry.

 

[HarryMTieboutMD]

Back to the original topic... everyone above has offered variations on the same theme: at most programs, you will not be trained to be a therapist explicitly, and unless you have a direct in to the blueblood analytic market in NYC you will likely not solely be practicing therapy. Nevertheless, skills learned in therapy training are important for dealing with personality disorders (large %of patients), addiction (I use MI/structured 12 Step facilitation/CBT basics all the time), and pretty much every other illness. It's useful for getting patients to take their meds/follow directions, establish trust, and really, just having an ally in treatment. Also, certain concepts, especially fundamental psychodynamic ideas, have really helped me maintain positions of neutrality and objectivity when dealing with patients who have a proclivity for drawing out counter transference. I used to think all therapy was unnecessary for a physician until I became a resident and realized its utility- and incidentally I am at one of the most "bioloigical" (though this is a meaningless term in 2016) programs in the country...

 

[MacDonaldTriad]

Some of the most "biological" psychiatrist who would never identify with being a therapist are the most talented therapists I know. All psychiatrists use therapy principles and do therapy even if they don't recognize it as such.

 

[Nasrudin]

A more cost effective solution compared to ACT is to hire retired military snipers with rifles loaded with Invega Sustenna.

Either you read my mind. Or I'm under hypnosis. I've had that same thought. But lacked the executive planning and insight to not say it out loud.

Also in the company of overly sensitive, triggered, virtue signaling, New York liberals.

You'd have thought I was Nazi. The look of terror was utter and and complete.

 

[Nasrudin]

OP, there are some really good points in this thread. Which I agree with. Welcome to Pscyhiatry.

I share your aversion to traditional stylistic ideas of psychotherapy. Or even the current vying for the stage for mindfulness and whatever The Next New Thing is or will be.

Action is one of the missing parts.

So join us.

 

[smalltownpsych]

There's nothing "wrong" with psychotherapy, it's just not for me. I don't care for analyzing people's thoughts and behaviors. It reminds of me of English class. I'd rather be doing something more "active" and less cerebral.

Maybe you're thinking of old school analysis with symbology and all that garbage. However, you do need to know what is producing the behaviors and symptoms that you are targeting. I conceptualize most of my psychotherapy from a neurobiological standpoint myself. For me, it is all about the orbitofrontal cortex and how that interacts with the limbic system. Also, if the only tool you have is pharmacological, then you might be limiting yourself a bit.

For example, a couple weeks ago, I had a consult with a patient with Borderline PD and extensive trauma history who was in for medical reasons and this had activated her trauma response and interpersonal difficulties, shall we say , and she was hurling obscenities and objects at staff who were at the point where they were giving it right back. She was politely refusing all medications, "you f'ers aren't going to poison me with your crap." I spoke with her for about 45 minutes and staff for about 5 minutes and with no medications she was completely calm and able to work with the medical staff. I was able to do this because I understood exactly what was going on and how to communicate that effectively to the patient and it had nothing to do with any deep interpretation or analysis.

 

[OldPsychDoc]

Either you read my mind. Or I'm under hypnosis. I've had that same thought. But lacked the executive planning and insight to not say it out loud.

Also in the company of overly sensitive, triggered, virtue signaling, New York liberals.

You'd have thought I was Nazi. The look of terror was utter and and complete.

Just target the lawyers and ethicists first...

 

[Nasrudin]

Just target the lawyers and ethicists first...

Benevolent national socialism. What could go wrong?!

 

[Shikima]

Benevolent national socialism. What could go wrong?!

In before Godwin's Law.