I've been going back and forth about whether to do a child fellowship or not and I can't seem to make up my mind. For every reason I give myself to do it, I can give myself a reason not to do it. Has anyone had this same problem? I figured it would be helpful to hear the opinions of others in regards to pursing this fellowship. Do you think it's worth it? Why did you or didn't you pursue a fellowship in child? Thanks!
Thoughts about Child and Adolescent Fellowships
- Thread starter Dr1216
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Worth the investment? BIG TIME. Your practice will fill twice as fast. Demand is higher and far less susceptible to encroachment from mid levels.
Why I didn't do it? Too stressful. Parents are difficult to work with. Too heart breaking to see abused/neglected children.
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Also interested in this. I see a lot of upside for C&A fellowship but not many talk about the down sides. Any other negatives that current fellows, or maybe attendings familiar with the fellowship (even general psych attendings), are willing to share?
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The downside to child psychiatry is child psychiatry. If you love it, it's a great field, but it's not a field I would do for the extra money or convenience of easier practice filling.
I thought I was CAP bound but ended up opting not after actually doing rotations. The whole practice dynamics is not to my liking and this puts me in the majority. I'd say about half of incoming residents express an interest in child psychiatry but we lose many to most along the way. God bless 'em, but it's not for everyone.
I thought I was CAP bound but ended up opting not after actually doing rotations. The whole practice dynamics is not to my liking and this puts me in the majority. I'd say about half of incoming residents express an interest in child psychiatry but we lose many to most along the way. God bless 'em, but it's not for everyone.
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I'm applying to child next year. We have a lot of people in my class that want to do child and stay at our program. Likely more than the program can take. So, in my case, I've considered what will happen if I don't get in...which will be that I just do adult. I'm too old to reapply and waste more time.
That thought process has led me to consider that I could just do adult, be done, and take the "easy" way out. 4th year and done is certainly easier than 2 years of child fellowship. When you're done you can get an adult job, still see a few older teens, and get on with life. What made the decision for me to still apply was imagining what would happen if I didn't get into the fellowship. I would/will be beyond mad about it. Which tells me it's the right thing to do. If that makes sense.
So, imagine yourself not getting in. Not doing child. Being stuck in adult-land forever. How does that feel to you?
Thanks to those who've shared their thoughts so far!
Some of what has been brought up echo some of my thoughts. Like on the plus side, it would make me more marketable in the future whether I do PP or not and the income potential is higher. I do enjoy working with children and have a huge soft spot for children that are victims of abuse (though I sometimes wonder if this would make it harder to work with that population). I like the idea of trying to help these people get a grasp on their mental illnesses at a younger age and even if not, maybe training will help me understand how some of my adult patients came to become how they are. But on the negative side, it can be frustrating working with parents, there are so many layers of social work involved, and at times I honestly feel that unless these kids are given a parental transplant, there isn't much to do in terms of helping them. I also feel that at times, medications are pushed too heavily on this population when therapy should be the primary treatment for some.
@digitlnoize You pose a good question; one that I hadn't asked myself. And now that I think about it, I think I would honestly be more than content if I didn't get in and was stuck in adult land forever......I guess I have my answer. Thanks a lot!
Some of what has been brought up echo some of my thoughts. Like on the plus side, it would make me more marketable in the future whether I do PP or not and the income potential is higher. I do enjoy working with children and have a huge soft spot for children that are victims of abuse (though I sometimes wonder if this would make it harder to work with that population). I like the idea of trying to help these people get a grasp on their mental illnesses at a younger age and even if not, maybe training will help me understand how some of my adult patients came to become how they are. But on the negative side, it can be frustrating working with parents, there are so many layers of social work involved, and at times I honestly feel that unless these kids are given a parental transplant, there isn't much to do in terms of helping them. I also feel that at times, medications are pushed too heavily on this population when therapy should be the primary treatment for some.
@digitlnoize You pose a good question; one that I hadn't asked myself. And now that I think about it, I think I would honestly be more than content if I didn't get in and was stuck in adult land forever......I guess I have my answer. Thanks a lot!
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When I think about working with children I feel inspired to do C&A psychiatry, but when I think of working with bad parents I feel turned off from it. From people who are pursuing or did C&A, how do you get past the difficult parent part?
I didn't pursue a fellowship in child psych because I don't believe that medicating bad behavior and/or bad parenting is a good thing.
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Hmm, seems like a good reason for you to go into CAP, so you can give these kids the proper treatment they need instead of letting them go to someone who will do it wrong.
I just started my C/A fellowship this week. Liking it so far, but it's way too soon. I'm doing it because I like working with this younger population and don't find the negatives mentioned to be so bad (obviously, it's subjective). Also, I dislike working with geriatrics.
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You might be surprised to learn that you don't have to practice bad medicine just because you're able to.
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Well there's a whole spectrum of child psychiatric disorders that have nothing to do with "bad behavior." Autism comes to mind. I'm sure many children benefit from treatment to live better lives thanks to their doctors.
I have one patient with autism and the medication has worked to improve her sleep and eliminate her outbursts. It's been such a clean therapeutic outcome that it's one of the pure joys I've gotten from psychiatry thus far.
I have one patient with autism and the medication has worked to improve her sleep and eliminate her outbursts. It's been such a clean therapeutic outcome that it's one of the pure joys I've gotten from psychiatry thus far.
I don't see how one could do the kind of systems based/education oriented/time intensive outpt work in pp with the Medicaid c/a population with those reimbursement codes......how would you keep the lights on?
oh yes antipsychotics and mood stabilizers have shown such amazing efficacy(in general, not this particular pt I can't comment on) in controlling outbursts of autistic adults. The evidence is almost as good for that as Topamax in controlling affective instability in borderlines.
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Wow that's incredibly insensitive to the children who can live better lives because of it. You're heartless man. Your sarcasm is so thick at the expense of what helps people. Very poor taste.
The medicine is working, the child can function well and is doing better in school. What more evidence do you need? I can't tell if you are Aspergerish and just have poor social skills, or are cold hearted.
One of the biggest pitches for CAP is that while people generally don't pay for themselves, they'd go into bankruptcy to take care of their kid. Obviously, thats not true for every case, but it means that Medicaid clinics are less of the default in most markets. Also, there are opportunities consulting/contracting for schools, residential programs, etc. where a system is already in place and you're working to coordinate care with counselors (not the norm for adults, excluding maybe forensics/jails).
oh please....you'll note that I made a special point to say I don't know the particulars of your patient. I most definitely stand by my point that using antipsychotics for adolescents and adults with autism prone to outbursts does not have a great deal of evidence that it helps a bunch. Do we do it? Of course. But that is more a result of there not being any effective pharmacologic treatment, so we just throw what we have at it. I was more poking fun at the use of an example for something that in generally has a crappy evidence base. You'd think you would have at least picked an example that has a better evidence base....like someone with actual ADHD who is now doing much better at school an on effective stimulant.
1) a disproportionate % of the worst kids from the most messed up environments have families with no access to funds of any kind.....so it's not as if these parents can simply make sacrifices to get their kid real care.
2) A lot of the school/agency type jobs where you are being paid decent money per hour to serve in a consulting role.........well they are paying you to do exactly that. What they are not paying you is to do the time intensive nuts and bolts time non-pharm management. They're paying you to sign off on treatment plans implemented by other people essentially, or direct an overall care plan. And that's fine if you like that work(heck if I did child that's what I would do), but let's not pretend it is an ideal care model or all that rewarding in terms of the patient interaction for the child psych.
Either you don't know the literature or have not worked with enough ASD patients. Antipsychotics, while not treating core symptoms, have large effect size (0.9) with aggression and disruptive behaviors.
Leo keep up with the good work. I have worked in and ID clinic before doing child and found you can do a lot of good for both families and patients with ASD.
thanks but I have the literature open right now. Here is the Cochrane money quote on Risperdal:
Although this review reports encouraging improvement in some
behavioural aspects of autism spectrum disorder, carers and clinicians
should be aware of the paucity of evidence in administering
this drug in such a vulnerable group of people. This patient
group will inevitably continue to present challenging behaviours
overmany years; therefore, it is vital to consider issues surrounding
long-term use.
Sorry, but I'll pass on things like 'paucity of evidence'. Furthermore, most of these studies are very short term(autism is a longterm thing.....not an 8 week thing)
Furthermore, there have been a bunch of studies for non-Risperdal/non-abilify antipsychotics which show no benefit at all. This leads me to believe it's a lot of garbage in/garbage out.....what's the reason Risperdal might work some in these patients but not Geodon for example? If it's an affinity of binding thing why risperdal and Abilify?
There will always be cheerleaders in psychiatry for throwing whatever drug Pfizer or GSK or whatever is pushing on vulnerable patients and hoping something sticks.
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I just wanted to chime in that we need more competent child psychiatrists. Just remember that for many, if not most, of the issues that we deal with when working with kids, there is no medication to treat it, but there is a huge amount of pressure from schools and parents to "fix it" with a pill. I would also suggest that it will be helpful to work closely with a good child psychologist to help resist this pressure to to medicate symptoms without treating the cause. It has been my experience that otherwise the kids will almost invariably get worse and be prescribed more and more medications.
I think this goes back to the original point that it is what you make of it. CAP offers pretty dramatic poles between good and bad medicine, but my point is that there are generally more resources available when it comes to children. The expectation is that you use these resources, which can be enjoyable or a drag (and gets to the core of this thread). It may or may not be an ideal care model, but its attractive to people whose goal is to make it one. I just wanted to point out that the default career wasn't Medicaid clinics (if anything, the worst offenders of throwing pills at bad behavior are at some of the best academic institutes).
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Almost everyone I know in child psychiatry is in it because they love it. Almost everyone I know not in child psychiatry is not in it because they hate it. Very few are on the fence for some reason. Most medical students applying to psychiatry say they want to do child. Most residents don’t go into child. The demand is higher, the pay is better, but for most of us, no amount of money could make us do it. If you have done some of it and you don’t hate it, you are more qualified than most of us. Be careful, almost everyone who applies gets in. The unmatched positions list tends to be long.
I really enjoyed C&A psych, but didn't want to have to treat a normal child of sick parents and didn't want to spend the extra year.
If going into private practice, it is definitely a huge asset, but like anything, has its drawbacks.
If going into private practice, it is definitely a huge asset, but like anything, has its drawbacks.
You are wrong on so many levels. First off, there are numerous trials done with Risperidone indicating its effectiveness dealing with these behaviors. Some are short term, but some are longer. One was 2 years long.
http://www.ncbi.nlm.nih.gov/pubmed/16768634
Abilify has also had short and long studies with one as long as 1 year. http://www.ncbi.nlm.nih.gov/pubmed/21813076
As far as the other antipsychotics. There have been trials done using Seroquel and Zyprexa with good effects, but not enough studies to get the FDA approval. Show me the trials where they don't work? I can provide links if anyone is interested about the positive trials I have read. Haldol has also been used effectively, although I will rarely start it. Geodon failed an RCT when used at low doses.
That's what the data says. Medications can help.
Now the clinic I worked at had people waiting 4-6 months to see us. Often times patients were over medicated or seeing a provider for the first time. Even though the data is limited, we have agents we can use to help these patients and change families' lives. The important part is to do it in a thoughtful way, not just throw a cluster of meds at the patient. I have had training working in every possible field in psychiatry and I will say that ID patients are the hardest to treat because of the co-morbidities they can't express. Well...eating disorders are hard too haha. The families were so grateful for the care we gave because so many clinicians are inept at it or won't work with that population.
Vistaril sounds like someone who has had minimal experience in this field and even less desire to help these patients because "how would you keep your lights on".
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I guess the struggle I have is that I rarely get to see medications administered in a thoughtful way, more often than not I see clusters of meds thrown at the difficult patients and it becomes especially problematic with children. Which could be an argument for why we need more highly trained doctoral level prescribers. I would rather have them be psychiatrists, because I have enough work to do already, but don't know if we can get enough med students to choose this specialty.
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Going into psychiatry is kind of like going into child psychiatry. If you doubled the pay tomorrow, I think more medical students would go into it, but I think some of them probably shouldn’t. A lot of talented doctors shouldn’t go into psychiatry, because they just wouldn’t be good at it. There are some parts of the skills needed that you just can’t teach.
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The majority of the time, seeing the situation as "bad parenting" is a woefully inadequate assessment of the situation. The fellowship helps you understand that better, if you're a thoughtful person. Often the situation is one of incompatibility between a child and a family. You'll see tons of families who have one "bad kid" and several "okay kids." They didn't suddenly become massively different parents for that one. The unfairness of genetics is often such that the neurocircuitry of the parent and the neurocircuitry of the child express the same vulnerabilities, and those are often incompatible.
I'd recommend Judith Warner's "We've Got Issues" and Ross Greene's "The Explosive Child" (though they have somewhat different takes on child psychiatry) as being a really nice place to get a feel for the field.
Doesn't mean there aren't "bad parents," but no more than there are just "bad people" in the rest of psychiatry, medicine, on your street, etc. And if that's the case (such as in so many trauma cases), the kid is still suffering and needs an advocate. That can be you. I'm not sure what higher calling there is than that.
As for "medicating bad behavior," again, if that's the way you see it, then child isn't for you. It also shows a massive misunderstanding of what's going on. A kid is suffering. A kid is suffering because he has lagging skills that are inadequate to meet the demands of his life, and there are countless episodes of incompatibility. The world isn't going to stop having expectations because a kid has lagging skills. Medications are used when a) a clear illness is present for which medication is an established treatment, or b) a clear dysfunction and suffering exists, of which one of several ways of ameliorating is using medication with responsible monitoring and discussion of risks and benefits. Medications aren't always ideal, but they are consistent, and given our political culture that does not particularly support families, often one of the best options.
Child psychiatry is awesome. Child psychiatrists tend to be a much cooler group of people than general psychiatrists, though psychiatrists in general are a pretty cool group most of the time. The worst thing that happens is that you lose some income. You can always go back to treating adults or treating a mix of ages if the issues inherent to child psychiatry become overwhelming. And even if you do, the added perspective on development will make you a much better adult psychiatrist than you might otherwise have been.
If it feels good, do it. If it doesn't, don't. It's one of many great ways to spend a life.
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Fixed that for you.
It's perfectly fine not being a child psychiatrist. Obviously. The best reason is "I did not feel as happy doing child psychiatry as I felt doing other things." Making a thoughtless assessment of the field outside the trenches is not valuable, even if it's fun and makes you feel clever and superior.
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The most often quoted study in this field is called the (research unit of pediatric psychopharmacology) RUPP study, which is a multi-center study published in NEJM, sponsored by NIMH (not pharma), had a largeish sample size for this kind of study ~ 100 children, and showed a rather dramatic effect size (57% ABSOLUTE, not relative, symptom severity resolution on CGI relative to placebo)
The way you interpreted the summary paragraph of a Cochrane review does not reflect the actual tone of the review, which is cautiously optimistic. Is there sufficient evidence to initiate a trial of antipsychotic in this group clinically? Existing practice guidelines say yes. Does everyone respond to treatment? No. Do you often see a dramatic effect? Yes. Do we have enough evidence to figure out who responds and who doesn't? No. Hence the "paucity" of evidence clause.
Let's not confuse treatment heterogeneity with therapeutic nihilism, which is what you describe yourself to be. I think it's disingenuous to use the Internet as a place to spread unnecessary hopelessness and the mistaken belief that meds never work, which is false--and which you know as well as all of us do is false.
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This is problematic because the training programs proposed as of right now are not even adequate to duplicate for general adult psychiatry, let alone child psychiatry, and really it's not about providing better care, it's about providing "adequate" care with less cost. The quality of training for psychologists is too heterogeneous for this kind of thing to work well. Let's not sidetrack our discussion here though.
Yes. These kids need help. If they are not able to find the help, the families can only put up with so much before they are shuffled off to group homes. If they are very unstable in group homes, and going from one home to another, eventually no one is going to want to take them and they end up in state facilities where they are heavily medicated and zombied out.
The pattern can be prevented with early, appropriate treatment. Yes antipsychotics have long term side effects, but not using them can have worse effects on the patient's life.
The pattern can be prevented with early, appropriate treatment. Yes antipsychotics have long term side effects, but not using them can have worse effects on the patient's life.
I felt doing only an adult psychiatry residency was inadequate, and felt I needed a child psych fellowship to get complete training. I love working with adults and I love working with kids. The fellowship will increase my ability to care for adults, give me flexibility in career, and make me a more competent psychiatrist.
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Seriously, don't you ever stop? You're qualified to talk about psychiatry....how? I count at least 10 recent posts by you lamenting horrible Psychiatrists and PCPs (according to you) as a reason to allow psychologists to prescribe/practice medicine. In another post you suggested increased reimbursement for psychologists "so we [psychologists] wouldn't be so eager to take a piece of your pie!" (What pie? go to medical school if you want to do it, otherwise open up a subway if you just want more money)
That last bit of trying to seem un-self-serving is inspired btw. Anyone that has read your posts on children and psych eventually sees a disingenuous version of Helen Lovejoy's "Won't somebody please think of the children?" I've been meaning to call you out on this for a while because it is truly annoying.
Added: BTW, Sorry for being a little rude but why the hell are you constantly commenting on threads about medications, medical residencies, medical fellowships, etc? You've made some useful contributions from the psychology side, maybe stick to that.
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Social psychology literature consistently finds that the phenomenon knows as "groupthink" is most likely to occur when___________?
I look forward to your response.
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For those in Child Psychiatry, do you feel like you're making real impacts in lives by helping patients when they are young, more so than if these same patients were 20 or 30 years older? Any examples?
Well there are different degrees of being outside the trenches. Sometimes there is a happy medium for criticism whereby one has a superficial level of familiarity and experience with something, but not too much such that they are blinded by their own passion/bias.
Like I said I'm sure there are some child psychs out there who do more good than harm.
He's qualified to talk about it because he works with these kids and adults and has seen the crap treatment many of them get...one doesn't need to be an adult or child psych to know that there is an awful lot of terrible practice with meds out there
There is almost always one study out there which becomes the study pro-med people want to look at....the problem with garbage like this is if you throw together enough different inputs into the pot, something is bound to sorta stick.....doesn't mean it is real. That's why I go with Cochrane generally above anything....
But going back to the original question.....do I throw risperdal at these pts? Sure....everyone does. And then some throw a bunch of other stuff at them too. Certainly doesn't mean I am impressed with the evidence base behind it
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I think you are seeing an agenda that isn't there. The main reason that I have posted about child psychiatry is not because I am an expert on child psychiatry. It is mainly because for the last 5 years of my career in three different states, the only way I could get a kid to a psychiatrist was by hospitalizing them. I don't want mid-levels to take over but I am afraid that they will and I think that if psychiatry and psychology fight each other, then that just helps open the door for more encroachment. The only reason I post on psychiatry board is because I have enjoyed the collaboration I find here that I can't find in my own community because we have no psychiatrists.
BTW the nurse practitioner who is independently operating at the clinic where I work didn't go to med school either and the board of the hospital has decreed that they no longer need psychiatrists and the nurse practitioner can handle ages 13 and up.
For the record, I think it is a huge strength of this board that there are several psychologists who post regularly, all of whom seem passionate about and dedicated to their important work. I have appreciated their perspectives on this board all the more for the fact that I have had no opportunity to collaborate with psychologists "in real life" thus far in my training.
