To become a Psychologist, or a Psychiatrist?

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jim harbaugh

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Hello all,

I'm a recent graduate of a prestigious school (liberal arts major) and I'm thinking about either going for a PhD and becoming a psychologist, or going for an MD and becoming a psychiatrist.

Now, according to the 2009 BLS report, a Psychiartist's median annual salary ($160,230) is more than twice as much as a Psychologist's median annual salary ($64,140); and the difference in length of education is only two years (for me at least, see below)...so it seems like Psychiatrist would be the obvious choice.

But, I'm not at all interested in conducting 15 minute medication management appointments, and I read in this 1998 WebMD article(http://www.webmd.com/mental-health/features/psychology-vs-psychiatry-which-is-better?page=2) that most health insurance plans won't even cover psychotherapy treatments from psychiatrists? Is that still true today? Is it going to be true post-health care reform?

I also read in the same WebMD article that psychiatrists only charge $5-$16 more for psychotherapy sessions (45-50 minutes) than psychologists. Is that still true today? Is it going to be true post-health care reform?

Thank you very much in advance for any help!

Best,

Jim



*Personal Education Paths:

Psychologist: masters (1-2 yrs), phd (6 yrs), licensing (1-2 yrs); total 8-10 yrs.

Psychiatrist: post-bacc (1-2 yrs), md (4 yrs), residency (4 yrs), fellowship (1-2 yrs); total 10-12 yrs.
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Since many things may be in a state of flux with respect to reimbursement and payment issues, etc between now and the completion of your training, I'd suggest that the question your really need to answer is whether you want to be a doctor--e.g. completing rotations in pediatric runny noses, ob/gyn, general surgery and the like. If that kind of well-rounded physician training appeals to you, then by all means, follow the -iatry path.
 
jim harbaugh said:
specialization (1-2 yrs)
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Just a note about your time calculations: residency is where one specializes and becomes a psychiatrist. You didn't mention fellowships in your quote about pay, so perhaps you misunderstood and can subtract those years

But yeah, listen to OPD. The focus of your MA/PhD from day one would be psychology, vs. a post-bacc/MD which has about 2 months of psychiatry in 6 years. Be sure you're interested in medicine before you make the leap

Good luck
 
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Money really shouldn't be a factor for someone who was an NFL quarterback and now coaches the Cardinal.

Don't beat around the BUSH, you know you can't LEAVE us. STICK with the TREE Harbaugh. Go Cardinal!
 
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1) OldPsychDoc/iloveDrStill, you bring up excellent points. Am I interested in "completing rotations in pediatric runny noses, ob/gyn, general surgery and the like"? Absolutely not. I'm really just interested in being the best paid psychotherapist that I can be. I'm a hard worker, and I can push through med school courses that I'm not really interested in to reach my end goal. The question for me really is just, will it be worth it?

...At the completion of my education, will psychiatrists even be able to partake in psychotherapy?

...Will the difference in psychotherapy rates EVER make up for the 100 grand I spend on medical school?



less important responses (lol):

2) Sorry iloveDrStill, I was just casually (and incorrectly, I see) using the term 'specialization' to represent fellowships. I'll change that in the OP. (I'd probably do a child/adolescent specialization, fyi)

3) Sorry Manicsleep, but Ann Arbor, Michigan is where I belong. (more than 30,000 of you should've shown up to convince me otherwise in my last home game)
 
If you're wanting to gointo psychiatry to make more as a psychotherapist it's important you understand why psychiatrists are making nearly twice that of psychologists, as you state. The average psychiatrist doing psychotherapy only will not be making what the average psychiatrist in general will be making. If you just want to do psychotherapy then you're better off as a psychologist and I wouldn't get caught up in the disparity between average salaries because that is not the kind of psychiatrist who is highly represented by that average. Also consider that many PhD programs pay tuition and give a stipend.
 
st2205 said:
If you're wanting to gointo psychiatry to make more as a psychotherapist it's important you understand why psychiatrists are making nearly twice that of psychologists, as you state. The average psychiatrist doing psychotherapy only will not be making what the average psychiatrist in general will be making. QUOTE]

That depends on your level of expertise and your market. There are therapists that make $3-400/hr in top paid markets, cash based.

I went to medical school for many reasons, one of which is I wanted to be able to potentially help everyone, not just the subset that are treatable via psychotherapy.
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nitemagi said:
st2205 said:
If you're wanting to gointo psychiatry to make more as a psychotherapist it's important you understand why psychiatrists are making nearly twice that of psychologists, as you state. The average psychiatrist doing psychotherapy only will not be making what the average psychiatrist in general will be making. QUOTE]

That depends on your level of expertise and your market. There are therapists that make $3-400/hr in top paid markets, cash based.
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This is why I left room for exceptions, which that is. The question must also be asked if that is exclusive to being a psychiatrist. Perhaps doing cash-only to a high-end patient base would bias toward them selecting a therapist that can also do their meds, but how common is that? If the OP isn't interested in medicine then all of the other factors and minimal benefits of being a psychiatrist in these circumstances are going to get negated fast.
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jim harbaugh said:
Am I interested in "completing rotations in pediatric runny noses, ob/gyn, general surgery and the like"? Absolutely not.
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Well then, that's your answer. Life is too short to be miserable

jim harbaugh said:
...Will the difference in psychotherapy rates EVER make up for the 100 grand I spend on medical school?
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If you spent only 100k on medical school, you either went to Canada or you got some incredible scholarship. My partner goes to a state medical school, and I go to a public one. Total COA: state $50k/yr, private $53k/yr.

So, let's recap: you have zero interest in general medicine, and you're looking at ~$200k debt plus interest.

Good luck in your psychology program :thumbup:
 
well

...if psychologists and psychiatrists doing psychotherapy really make more or less the same amount

...and one route comes with 200k+ more in debt

...and one route might only be able to do 'high-end/cash-only' psychotherapy in the future

i guess my decision is simple.

thank you very much everyone, I really appreciate hearing the opinions (and I'd still like to hear more!)
 
The real question to me is, do you want to treat the entire spectrum of psych illness, or just those portions best managed by therapy? Also, do you want to be the final word, or are you comfortable having to call a doc for help when you need a med? Finally, do you want to understand how other medical conditions play a role in a patient's psych health?

The cost is high, but easily paid off at doc salaries. If you're playing the averages, the extra 100k of doc cash would pay off your loans in 2 years, and leave ~20+ years of 100k extra per year...minus the difference in training time...docs still come out ahead, usually.
 
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Hi Jim,

You raise in your original post a few things: the length of time you need to spend to become (an entry-level) psychologist/psychiatrist (who wants to do psychotherapy), the issue of money, and the issue of reimbursement.

I am a psychiatrist with a very strong interest in individual psychotherapy, and I also graduated from a psychoanalytic institute. So, you will need to look at what I say through this filter (and my limited experience).

"the difference in length of education is only two years (for me at least, see below)...so it seems like Psychiatrist would be the obvious choice." Well, the training as a psychotherapist (the excellent one you imply you want to become) is a little longer than what you mention. Especially if you want to obtain a formal psychoanalytic training and if you want to do psychoanalytically-oriented psychotherapy (not psychoanalysis). Traditionally, after you get your PhD or Psy.D., you go through an advanced psychotherapy training program (that lasts usually 2 years); after that, you might become eligible to become a Candidate of the Institute (which, in general, adds at least 6-7 years to your training). This is not to mention that you will have to go into your own therapy and, then, analysis. It is true that, while you're still a Candidate, you can practice, but you will not be making the kind of money you implied you would like to make

Regarding the money, if you're really excellent in what you do, you will make a lot of money, whether you're a psychopharmacologist or a psychotherapist. Comparing the medians of salaries of what psychologists and psychiatrists would make does not help much in that case since you will be talking about the high-end salaries.

As far as the health care reform and reimbursements are concerned, nobody knows for sure what will happen. Many people are concerned about the downward trend of doctors' salaries and they have reasons to be concerned. Doctors, by and large (with quite a few exceptions, of course), don't make the kind of money they used to make back in the 70s. In the current managed care system we've been working under for the past few decades, it is very difficult (on the verge of impossible) for an attending to do 45minute-long psychotherapy sessions in, let's say, a hospital/clinic setting. You are not only being paid by the time you spend working, but also by the number of pts you see. And this paradigm of health care has, as you pointed out, a lot of flaws.
And partly because of this managed care system, many (excellent) psychotherapists do not accept insurances. It is also true that quite a few excellent psychotherapists offer sliding scales and fees based on the pt's income. And if they choose to do so, it is not because they lack pts or because they are poor managers.

If you have any questions, feel free to ask me! Good luck in your career!
 
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digitlnoize said:
The real question to me is, do you want to treat the entire spectrum of psych illness, or just those portions best managed by therapy? Also, do you want to be the final word, or are you comfortable having to call a doc for help when you need a med? Finally, do you want to understand how other medical conditions play a role in a patient's psych health?

The cost is high, but easily paid off at doc salaries. If you're playing the averages, the extra 100k of doc cash would pay off your loans in 2 years, and leave ~20+ years of 100k extra per year...minus the difference in training time...docs still come out ahead, usually.
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Yes, and no...

In the contemporary mental health service milieu, it is rare that one provider treats the whole spectrum of mental illness - even in private practice. In most cases, split care is the typical model of service delivery - for better or worse. In these cases, the psychiatrist (or other prescriber) manages the meds and the psychologist (or other therapist) provides therapy. So even though, in theory, the psychiatrist can treat the whole spectrum, this rarely is the case. Also, unless you seek out one of the rare residencies that provide adequate training in psychotherapy, this will not be a focus of psychiatry training.

The only place (really) to practice psychotherapy as a psychiatrist is in private practice. The income numbers reflected above are for employee or contract positions, and those are almost exclusively med management positions. For example, a local community agency in my city has now pushed med management appointments to 10 minutes and 5 - 6 patients/hour are scheduled for 7 hours/day with 1 hour allowed for lunch, paperwork, phone calls, etc. which is nowhere near enough time to do all the extra stuff necessary (med bridges, PA's, charting, etc.). If you said you wanted to do therapy in these settings as a psychiatrist (or NP), admin would laugh and then show you the door.

Even if you're a private practice psychiatrist providing one-stop-shopping (therapy and meds), you're not likely to make that much more than a psychologist in private practice - unless you focus on med management which greatly limits the amount of therapy you can provide. And, BTW, all the psychologists I know in private practice make well into 6 figures.

Follow your interest.
 
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medium rare said:
Yes, and no...

In the contemporary mental health service milieu, it is rare that one provider treats the whole spectrum of mental illness - even in private practice. In most cases, split care is the typical model of service delivery - for better or worse. In these cases, the psychiatrist (or other prescriber) manages the meds and the psychologist (or other therapist) provides therapy. So even though, in theory, the psychiatrist can treat the whole spectrum, this rarely is the case. Also, unless you seek out one of the rare residencies that provide adequate training in psychotherapy, this will not be a focus of psychiatry training.

The only place (really) to practice psychotherapy as a psychiatrist is in private practice. The income numbers reflected above are for employee or contract positions, and those are almost exclusively med management positions. For example, a local community agency in my city has now pushed med management appointments to 10 minutes and 5 - 6 patients/hour are scheduled for 7 hours/day with 1 hour allowed for lunch, paperwork, phone calls, etc. which is nowhere near enough time to do all the extra stuff necessary (med bridges, PA's, charting, etc.). If you said you wanted to do therapy in these settings as a psychiatrist (or NP), admin would laugh and then show you the door.

Even if you're a private practice psychiatrist providing one-stop-shopping (therapy and meds), you're not likely to make that much more than a psychologist in private practice - unless you focus on med management which greatly limits the amount of therapy you can provide. And, BTW, all the psychologists I know in private practice make well into 6 figures.

Follow your interest.
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Sorry, I should have been more clear. Psychiatrists are still ABLE to provide medical treatment AND therapy, even if they choose not to. Many choose to do both. Others do not. That choice is up to the physician. Does the OP want that choice available them? Also, the current model is not likely to stay this way, although no one knows the future, I would at least predict a sight increase in doc performed therapy, either because the govt decides to reimburse it better, or because people go cash pay.
 
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digitlnoize said:
I would at least predict a sight increase in doc performed therapy, either because the govt decides to reimburse it better..
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Unlikely. If you are a government trying to figure out how to make your money go further, paying a physician to do a job that someone else is willing to do for much less money is the last thing on your agenda. The health management and policy types simply do not buy our arguments for combined treatment and they never will. I'm not endorsing this, but I had enough arguments with the folks at the public health school to be pretty thoroughly defeated on this matter.
 
Lets also remember a few other things.

1) The definition of therapy is not restricted to the therapeutic hour.

2) Private insurance, self pay, consults, inpatients etc may continue to get their therapy from psychiatrists.

3) You don't need to have ology or iatry to do therapy.

Psychiatry is really clinical understanding of the 'therapy' with everything that it takes to be a physician. What percentage of that is used on a regular basis varies but I suspect the physician part is going to increase.
 
digitlnoize said:
Sorry, I should have been more clear. Psychiatrists are still ABLE to provide medical treatment AND therapy, even if they choose not to. Many choose to do both. Others do not. That choice is up to the physician. Does the OP want that choice available them? Also, the current model is not likely to stay this way, although no one knows the future, I would at least predict a sight increase in doc performed therapy, either because the govt decides to reimburse it better, or because people go cash pay.
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Just because one chooses to does not mean they are competent. What worries me the most are those from any field who think they can do everything. You will have limitations as a psychiatrist and you will have limitations as a psychologist. This is why we often refer to one another, or is at least why we should IMO.

Even though I am formally trained in therapy, with over 1,000 hours of direct treatment, I've spent most of my doctoral training in neuropsych assessment and wouldnt dream of being able to treat many patients who I refer out for therapy. Also, I simply do not have the time, and enjoy doing other things.

Money is a powerful but misleading reinforcer of behavior, and does not make one a good doctor. Clinical curiosity, however, will keep you energized and will benefit you and your patients, no matter what kind of doc you decide to be. Keep that in mind as you make your decision and down the road.
 
IT514 said:
Just because one chooses to does not mean they are competent.

Money is a powerful but misleading reinforcer of behavior, and does not make one a good doctor. Clinical curiosity, however, will keep you energized and will benefit you and your patients, no matter what kind of doc you decide to be. Keep that in mind as you make your decision and down the road.
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Not sure its the point you were trying to make but quite salient nonetheless. Competency in making medical decisions is very difficult even when someone thinks they can prescribe drugs after a few online courses.
It is not the same as psychotherapy which is most effective based on rapport and time spent. Unfortunately, time is a luxury for most psychiatrists, not to mention the patients, in todays healthcare system.
 
Manicsleep said:
Not sure its the point you were trying to make but quite salient nonetheless. Competency in making medical decisions is very difficult even when someone thinks they can prescribe drugs after a few online courses.
It is not the same as psychotherapy which is most effective based on rapport and time spent. Unfortunately, time is a luxury for most psychiatrists, not to mention the patients, in todays healthcare system.
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Sure, it goes both ways, I think I was pretty clear about that.

However, rapport and time spent wont help a lot of the kids I've seen in a school setting. Definitely doesnt work for PTSD, autism, severe behavior problems, dyslexia, clueless parenting etc, etc...
 
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Time spent and rapport is crucial in all those problems and no good data indicates that they aren't the best indicators of success in therapy. I am not saying they are the only thing thats necessary. No one (that I know) is implying that dogs, even though they can play a excellent role in therapy, can replace therapists.
 
to the OP,

I think the first question you need to ask yourself is do you want to be a doctor? The psychiatrist, while being able to do *some* psychotherapy, is and will always be a doctor first. Hence you will need at least a cursory understanding of OBGYN, SURGERY and all that jazz, because when your 35 year old psychotherapy patient complains to you about him being sick with a "flu" for 3 weeks, you may want to order him the HIV test (that turns positive, true story) and send him to your friend who's an ID doctor. You'll be calling OBGYN consults for your perinatally depressed who has a high blood pressure (and thus possibly progress to preeclampsia) taken at YOUR free clinic . The daily content of practice of a psychiatrist is very different from that of a psychologist. For some populations, such as the elderly and the chronic persistent mentally ill, psychiatrists are often also, at least temporarily, the primary care doctors.

It's not really possible to do only therapy as a psychiatrist except in very limited circumstances. And if you do any pharmacology, one'd hope that you know your stuff well, because if you don't check that Lithium level and the patient dies on you, that's malpractice. Or if you don't call the hematologist when someone gets the rare pancytopenia. Or if you miss the MS patient who presents as a borderline (and may comorbid as a borderline), and forget to order the MRI or do a neurologic exam.

Psychologists are not really trained or are effective in terms of communicating medical issues with other physicians.

So I think if you have 0 interest in being a doctor, then psychiatrist isn't the right thing for you because you'll be grinding over too much of what you don't care about. I'm not sure if you are interested in dealing with the liabilities associated with practicing medicine.
 
MS patients, neurological exam, lithium toxicity...I mean c'mon, what do you believe we actually do in our 7 years of training? To be fair, training in clinical psych is not consistent across all programs. OP take note...

To the OP, going to a clinical psych program doesnt mean you wont learn anything about the medical world. I work mostly with neurology and I do just fine with "communicating medical issues." In fact I've seen multiple cases referred by psychiatry for depression, when the real issue was subcortical/vascular dementia. Good thing they referred out...

And if you do decide on psychiatry, please admit when you dont know stuff. For example, the "wait and see" approach just doesnt work when it comes to autism assessments. Just admit you dont know and refer out. Thats my personal pet peeve.
 
IT514 said:
MS patients, neurological exam, lithium toxicity...I mean c'mon, what do you believe we actually do in our 7 years of training? To be fair, training in clinical psych is not consistent across all programs. OP take note...
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This is exactly the problem. While a handful of very specialized psychology PhD programs might train in some limited neurology or psychopharmacology, certainly the vast vast majority of program will not. However, if you are a board certified psychiatrist, you will be EXPECTED to handle any of the above things. The same cannot be expected of a clinical psychologist, none of whom I have EVER seen done a neurological exam on anyone...and I have interacted with quite a few of them. This is not to say that psychologists are not good at what they do, but psychologists are not expected to do medicine.

How many clinical psychologists are comfortable with acute lithium toxicity? Really?? What about NMS? What about alcohol withdrawal? Are you really comfortable handling consults on inpatients from the ID service and get bitched on when you can't pronounce the names of 10 antibiotics and 5 antiretrovirals the patient is on? Correct me if I'm wrong here, perhaps I'm only seeing East Coast and California, but nobody inside the hospital or in the clinic system expect psychologists to behave like medical doctors precisely because medical doctors communicate with each other differently than they communicate with lay public.

As for the dementia issue, in case you aren't aware, there's no treatment. At least treating the superimposing depression can sometimes be useful. It's not that the psychiatrist doesn't know what dementia is, it's that it's often just a hail Mary. I'm not even sure how to respond to the autism comment.

Without having you becoming too defensive, I'm simply point out to the OP the fact that psychologists are not medical doctors. If you want to be a medical doctor, go to medical school. If you don't, don't. The other points are simply illustrative.
 
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sluox said:
Psychologists are not really trained or are effective in terms of communicating medical issues with other physicians.
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Really? Have you worked on a multi-disciplinary team with a psychologist or more specifically a neuropsychologist? Being able to communicate effectively with other healthcare professionals about medical issues is a large part of what a neuropsychologist does on a multi-disciplinary team. Earlier this week I had a case where the dx was in question: Was it FTD, ALZ, DLB...etc? I regularly get consults for differential diagnosis, often having to tease out possible organic origins. Not all psychologists deal with feelings and talk therapy...I sure as heck don't! :laugh:

sluox said:
This is exactly the problem. While a handful of very specialized psychology PhD programs might train in some limited neurology or psychopharmacology, certainly the vast vast majority of program will not.
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Fellowship trained neuropsychologists and rehabilitation psychologists have the associated training, though it is less common with the touchy-feely and/or non-fellowship trained folks.

In regard to which is the more appropriate course for the OP...it all depends what they want their daily work to entail. Money can be made in either setting, though it is probably more easily made in psychiatry.
 
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Manicsleep said:
Time spent and rapport is crucial in all those problems and no good data indicates that they aren't the best indicators of success in therapy. I am not saying they are the only thing thats necessary. No one (that I know) is implying that dogs, even though they can play a excellent role in therapy, can replace therapists.
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I appreciate the sentiment and the clarification. I'm not trying to be a pain here, but for the sake of the OP, there is definitely good research out there showing that time spent and rapport may have an initial effect but that the change does not persist over time, which I think you are suggesting in saying that they are not the only thing thats necessary. I can post an abstract if you want it.
 
sluox,

I'm glad you've posted what you have, and I think that your comments have provided some good info to the OP on what the day to day of a psychiatrist looks like.

I was simply clarifying that the training and competencies of a (neuro)psychologist might be different than what you have experienced, which is also good for the OP to know. Afterall, the neuropsychological evaluation is seen by the ABPN, and all neurologists I've worked with, as an extension of the neurological exam, which is why we take med school level neuroanatomy and neuropathology...we just focus on different aspects of it. And no, I'm not comfortable with handling acute lithium toxicity, and some of the other stuff you mentioned because I'm not a physician. This is not to say that I'm clueless that those are factors to consider in my care of a patient. Meds and medical issues are not limitations to my practice, I work with them and with the physicians responsible for that aspect of patient care.

Now to the dementia comment. Dementia is a progressive condition regardless of treatment, yes, but it helps to catch it at a time when meds can help (which the MMSE usually is not able to do, but is possible with someone who understands the neuropsychometrics of cortical/subcortical function). After that piont, behavioral mods and family therapy is helpful from my experience. This is, at least, how its been done at the VA dementia clinic and neurology clinic's that I've been a part of.
 
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sluox said:
to the OP,

I think the first question you need to ask yourself is do you want to be a doctor? The psychiatrist, while being able to do *some* psychotherapy, is and will always be a doctor first. Hence you will need at least a cursory understanding of OBGYN, SURGERY and all that jazz, because when your 35 year old psychotherapy patient complains to you about him being sick with a "flu" for 3 weeks, you may want to order him the HIV test (that turns positive, true story) and send him to your friend who's an ID doctor. You'll be calling OBGYN consults for your perinatally depressed who has a high blood pressure (and thus possibly progress to preeclampsia) taken at YOUR free clinic . The daily content of practice of a psychiatrist is very different from that of a psychologist. For some populations, such as the elderly and the chronic persistent mentally ill, psychiatrists are often also, at least temporarily, the primary care doctors.

It's not really possible to do only therapy as a psychiatrist except in very limited circumstances. And if you do any pharmacology, one'd hope that you know your stuff well, because if you don't check that Lithium level and the patient dies on you, that's malpractice. Or if you don't call the hematologist when someone gets the rare pancytopenia. Or if you miss the MS patient who presents as a borderline (and may comorbid as a borderline), and forget to order the MRI or do a neurologic exam.

Psychologists are not really trained or are effective in terms of communicating medical issues with other physicians.

So I think if you have 0 interest in being a doctor, then psychiatrist isn't the right thing for you because you'll be grinding over too much of what you don't care about. I'm not sure if you are interested in dealing with the liabilities associated with practicing medicine.
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Agreed.

Therapist4Chnge said:
Really? Have you worked on a multi-disciplinary team with a psychologist or more specifically a neuropsychologist? Being able to communicate effectively with other healthcare professionals about medical issues is a large part of what a neuropsychologist does on a multi-disciplinary team. Earlier this week I had a case where the dx was in question: Was it FTD, ALZ, DLB...etc? I regularly get consults for differential diagnosis, often having to tease out possible organic origins. Not all psychologists deal with feelings and talk therapy...I sure as heck don't! :laugh:

Fellowship trained neuropsychologists and rehabilitation psychologists have the associated training, though it is less common with the touchy-feely and/or non-fellowship trained folks.

In regard to which is the more appropriate course for the OP...it all depends what they want their daily work to entail. Money can be made in either setting, though it is probably more easily made in psychiatry.
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Comparing fellowship trained neuropsychologists to clinical psychologists is the only thing that is laughable. Please read the the post to which you are responding. These people are usually the creme de la creme of the psychology profression, at least at academic centers and even then have a very specialized knowledge base that pales compared to the medical knowledge of any physician.

If you mean to imply that multidisciplinary teams have clinical psychologists where they can address medical issues effectively to non mental health providers about non mental health issues, you are mistaken. I have been at many academic and VA centers, worked on many such teams and I have not seen effective communication of which you speak. I have seen attempts and grandiose beliefs, but never actual knowledge of medical issues or effective communication regarding those issues.
 
I think this is potentially getting into the old turf battle. Which is often not productive. I think psychiatry has more flexibility in what you choose to do, and it's easier to get into any niche that you would like. There's a whole lot more psychologists than there are psychiatrists, which means more competition for everything. Some people theorize that's what has led to much of the pharm turf battles, simply an oversupply and need to find new markets.

For the OP, I'd think about a more practical evaluation -- try shadowing a couple of psychiatrists and psychologists in different environments. See what excites you, and imagine what you'd like to do for the next 40+ years.

Really weigh the pro's/con's of each. Money and time in cost and income is a piece of it. Other factors like lifestyle, respect, job satisfaction, impact on the world, and career flexibility should also be factored in. IMHO.
 
As someone who will be starting med school next year, but considered other careers as well -

In general the consensus I got from practicing physicians is that you shouldn't go to med school unless you could picture yourself being happy in several fields. (I know there are several posters here who only ever wanted to do psych, but I would suspect even they could at least pretend to be happy in a different specialty)



Also if one of your primary medical interests is psych, be prepared for some amusing medical school interviews. I'm a bio-engineer, so a lot of my interviews opened with talking about engineering, bio-materials, mechanics, etc. As a transition one of my interviewers then asked, "So if you could solve a problem as your career's accomplishment, what would it be?"

Me: "Find a universally effective treatment for depression"

Him: :wow:

Later on he ended the interview with
"Well I personally think the world will be missing out if your don't become a surgeon, but good luck curing depression" (I got accepted, fwiw)
 
digitlnoize said:
The real question to me is, do you want to treat the entire spectrum of psych illness, or just those portions best managed by therapy? Also, do you want to be the final word, or are you comfortable having to call a doc for help when you need a med? Finally, do you want to understand how other medical conditions play a role in a patient's psych health?

The cost is high, but easily paid off at doc salaries. If you're playing the averages, the extra 100k of doc cash would pay off your loans in 2 years, and leave ~20+ years of 100k extra per year...minus the difference in training time...docs still come out ahead, usually.
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WOW!!! Thank you all so much for all the help. I actually sort of came to a conculsion after the first series of responses and stopped checking for new ones until today. Some of this stuff is sort of over my head, but I'm going to try and respond to what I can...

digitlnoize:

1) I'd rather just treat the portions best managed by therapy. 2) I am comfortable calling a doc for med advice. 3) I'd certainly like to understand other medical conditions - I think it'd make me a better therapist - but I really just want to be the best therapist that I can be. 4) I realize that I'd probably make more money as a psychiatrist, but I really just want to be excited about going to work when I get up in the morning above all else.

Thank you for the input!
 
slope said:
Hi Jim,

You raise in your original post a few things: the length of time you need to spend to become (an entry-level) psychologist/psychiatrist (who wants to do psychotherapy), the issue of money, and the issue of reimbursement.

I am a psychiatrist with a very strong interest in individual psychotherapy, and I also graduated from a psychoanalytic institute. So, you will need to look at what I say through this filter (and my limited experience).

"the difference in length of education is only two years (for me at least, see below)...so it seems like Psychiatrist would be the obvious choice." Well, the training as a psychotherapist (the excellent one you imply you want to become) is a little longer than what you mention. Especially if you want to obtain a formal psychoanalytic training and if you want to do psychoanalytically-oriented psychotherapy (not psychoanalysis). Traditionally, after you get your PhD or Psy.D., you go through an advanced psychotherapy training program (that lasts usually 2 years); after that, you might become eligible to become a Candidate of the Institute (which, in general, adds at least 6-7 years to your training). This is not to mention that you will have to go into your own therapy and, then, analysis. It is true that, while you're still a Candidate, you can practice, but you will not be making the kind of money you implied you would like to make

Regarding the money, if you're really excellent in what you do, you will make a lot of money, whether you're a psychopharmacologist or a psychotherapist. Comparing the medians of salaries of what psychologists and psychiatrists would make does not help much in that case since you will be talking about the high-end salaries.

As far as the health care reform and reimbursements are concerned, nobody knows for sure what will happen. Many people are concerned about the downward trend of doctors' salaries and they have reasons to be concerned. Doctors, by and large (with quite a few exceptions, of course), don't make the kind of money they used to make back in the 70s. In the current managed care system we've been working under for the past few decades, it is very difficult (on the verge of impossible) for an attending to do 45minute-long psychotherapy sessions in, let's say, a hospital/clinic setting. You are not only being paid by the time you spend working, but also by the number of pts you see. And this paradigm of health care has, as you pointed out, a lot of flaws.
And partly because of this managed care system, many (excellent) psychotherapists do not accept insurances. It is also true that quite a few excellent psychotherapists offer sliding scales and fees based on the pt's income. And if they choose to do so, it is not because they lack pts or because they are poor managers.

If you have any questions, feel free to ask me! Good luck in your career!
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Slope:

1) Wow, I didn't realize (a good) psychologist's training could last so long. That's definitely a detracting factor. 2) That is very reassuring. Exactly how high can the high end salaries for a great psychologist be? 3) The more I think about it, and research it, I just can't see the health care system of the future backing the paying of psychiatrists for therapy. Thoughts?

Thanks a ton for the input man!
 
medium rare said:
Yes, and no...

In the contemporary mental health service milieu, it is rare that one provider treats the whole spectrum of mental illness - even in private practice. In most cases, split care is the typical model of service delivery - for better or worse. In these cases, the psychiatrist (or other prescriber) manages the meds and the psychologist (or other therapist) provides therapy. So even though, in theory, the psychiatrist can treat the whole spectrum, this rarely is the case. Also, unless you seek out one of the rare residencies that provide adequate training in psychotherapy, this will not be a focus of psychiatry training.

The only place (really) to practice psychotherapy as a psychiatrist is in private practice. The income numbers reflected above are for employee or contract positions, and those are almost exclusively med management positions. For example, a local community agency in my city has now pushed med management appointments to 10 minutes and 5 - 6 patients/hour are scheduled for 7 hours/day with 1 hour allowed for lunch, paperwork, phone calls, etc. which is nowhere near enough time to do all the extra stuff necessary (med bridges, PA's, charting, etc.). If you said you wanted to do therapy in these settings as a psychiatrist (or NP), admin would laugh and then show you the door.

Even if you're a private practice psychiatrist providing one-stop-shopping (therapy and meds), you're not likely to make that much more than a psychologist in private practice - unless you focus on med management which greatly limits the amount of therapy you can provide. And, BTW, all the psychologists I know in private practice make well into 6 figures.

Follow your interest.
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mediumrare:

Thank you very much for the input. Really just kind of backs the direction I'm leaning towards in all regards (Psychologist)
 
digitlnoize said:
Sorry, I should have been more clear. Psychiatrists are still ABLE to provide medical treatment AND therapy, even if they choose not to. Many choose to do both. Others do not. That choice is up to the physician. Does the OP want that choice available them? Also, the current model is not likely to stay this way, although no one knows the future, I would at least predict a sight increase in doc performed therapy, either because the govt decides to reimburse it better, or because people go cash pay.
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digitlnoize:

Sure, I'd like to have both choices available to me - but it sounds like, in the end, I'm going to have to chose to do one or the other. My real goal is to just become the best THERAPIST that I can become.

...also...I don't really follow your reasoning for Doc's doing MORE therapy in the future?
 
digitlnoize said:
Sorry, I should have been more clear. Psychiatrists are still ABLE to provide medical treatment AND therapy, even if they choose not to. Many choose to do both. Others do not. That choice is up to the physician. Does the OP want that choice available them? Also, the current model is not likely to stay this way, although no one knows the future, I would at least predict a sight increase in doc performed therapy, either because the govt decides to reimburse it better, or because people go cash pay.
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billypilgrim37 said:
Unlikely. If you are a government trying to figure out how to make your money go further, paying a physician to do a job that someone else is willing to do for much less money is the last thing on your agenda. The health management and policy types simply do not buy our arguments for combined treatment and they never will. I'm not endorsing this, but I had enough arguments with the folks at the public health school to be pretty thoroughly defeated on this matter.
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makes sense to me too.
 
jim harbaugh said:
digitlnoize:

Sure, I'd like to have both choices available to me - but it sounds like, in the end, I'm going to have to chose to do one or the other. My real goal is to just become the best THERAPIST that I can become.

...also...I don't really follow your reasoning for Doc's doing MORE therapy in the future?
Click to expand...

Therapy works, and is the treatment of choice for many conditions. More docs would do it if it were reimbursed at rates equal to med management. That will only happen if the govt and insurance decides mental health is an important investment in our future, which could happen, and in the wake of the school shootings, recent bullying deaths, etc, is being discussed more and more in political circles. We'll have to see what happens. Just my guess.
 
digitlnoize said:
Therapy works, and is the treatment of choice for many conditions. More docs would do it if it were reimbursed at rates equal to med management. That will only happen if the govt and insurance decides mental health is an important investment in our future, which could happen, and in the wake of the school shootings, recent bullying deaths, etc, is being discussed more and more in political circles. We'll have to see what happens. Just my guess.
Click to expand...

I tremble with fear even bringing this up, but if "govt and insurance decides mental health is an important investment in our future", don't you think they might also be asking the question whether there is evidence of any sort that MD-delivered therapy is more cost-effective, or produces any better outcome, than that delivered by a psychologist, social worker, or even school counselor?

I'm just saying, my hour might be better spent managing three or four medication patients, thus allowing someone whose time is less pricey to work on the cognitive reframing, or emotional regulation, or examination of primitive defenses...
 
OldPsychDoc said:
I tremble with fear even bringing this up, but if "govt and insurance decides mental health is an important investment in our future", don't you think they might also be asking the question whether there is evidence of any sort that MD-delivered therapy is more cost-effective, or produces any better outcome, than that delivered by a psychologist, social worker, or even school counselor?

I'm just saying, my hour might be better spent managing three or four medication patients, thus allowing someone whose time is less pricey to work on the cognitive reframing, or emotional regulation, or examination of primitive defenses...
Click to expand...

I know I'm neglecting that possibility. Although I think (but don't want to start any flame wars), that its possible that an unbiased study might show well trained docs are better...maybe. Maybe not. Hmmm, I should probably go look this up, when I'm not suffering through OBGYN.

I'm also neglecting the fact that therapy seems to be, um, neglected in many psychatrists' training these days, from what I hear...so maybe we wouldn't do it anyways.

Regardless, I think the question for the OP remains the same: do they want to do medicine? If so, the go MD/DO. If not, then PhD FTW.
 
OldPsychDoc said:
I tremble with fear even bringing this up, but if "govt and insurance decides mental health is an important investment in our future", don't you think they might also be asking the question whether there is evidence of any sort that MD-delivered therapy is more cost-effective, or produces any better outcome, than that delivered by a psychologist, social worker, or even school counselor?

I'm just saying, my hour might be better spent managing three or four medication patients, thus allowing someone whose time is less pricey to work on the cognitive reframing, or emotional regulation, or examination of primitive defenses...
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I tremble with fear to take this a step further and ask the question why would we pay for a PhD psychologist to deliver therapy when a well trained clinical SW can do it? :oops:
 
Chimed said:
I tremble with fear to take this a step further and ask the question why would we pay for a PhD psychologist to deliver therapy when a well trained clinical SW can do it? :oops:
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I think a lot of people see a MSW as being one of the primary "therapy delivery" degrees for the future. My fiance was considering PhD programs for awhile, but after deciding she wasn't really interested in the academic rat race anymore (she had done 4 years of neuroscience research throughout college), she started to look at other options.

After talking to several of her professors with clinical psych degrees and talking to psychiatrists and MSW's in the community, it sounds like MSW's are providing a quickly expanding percent of the total therapy/counseling provided. Seems like MSW is going to nearly replace the master's level counseling psychology degree and probably will be knocking on the PsyD's door pretty soon.
 
surftheiop said:
I think a lot of people see a MSW as being one of the primary "therapy delivery" degrees for the future. My fiance was considering PhD programs for awhile, but after deciding she wasn't really interested in the academic rat race anymore (she had done 4 years of neuroscience research throughout college), she started to look at other options.

After talking to several of her professors with clinical psych degrees and talking to psychiatrists and MSW's in the community, it sounds like MSW's are providing a quickly expanding percent of the total therapy/counseling provided. Seems like MSW is going to nearly replace the master's level counseling psychology degree and probably will be knocking on the PsyD's door pretty soon.
Click to expand...

ugh.
 
surftheiop said:
Seems like MSW is going to nearly replace the master's level counseling psychology degree and probably will be knocking on the PsyD's door pretty soon.
Click to expand...

Master's level counselors (LPC/LMHC) with MAs in counseling psychology have been expanding their ranks in relation to social workers in several areas of the country and often outnumber them (e.g., Colorado, Texas).

Additionally, to my knowledge, there have been no studies conducted that demonstrate that any mental health profession provides better therapeutic outcomes than any other. Master's level folks have already moved well into the territory of psychologists and have been the primary providers of therapy for some time. This fact, and the overabundance of new graduates from diploma-mill PsyD institutions (Alliant, Argosy, and the like), have been driving down the income (and prestige) of psychologists quite significantly.

With little to distinguish themselves beyond testing and assessment, many are forced into longer and longer postdocs to carve out a more significant specialization (neuro, etc.)... and then there's the push for RxP, which as it stands is a pathetic and frantic attempt to remain viable and clearly reflects their weakened position.
 
jdawgg said:
Additionally, to my knowledge, there have been no studies conducted that demonstrate that any mental health profession provides better therapeutic outcomes than any other.
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Yes, but with the caveat that they all receive adequate training in evidence-based therapy, which I don't believe to be the case, even among programs at the same level (e.g., doctoral, etc.). I think that if master's level folks were all receiving adequate training in EFFECTIVE therapy, that this is a good thing for patients (and I say this as someone who is 6 months away form a Ph.D. in Clinical Psyc). It improves access to evidence-based care, especially for those that can't pay $100+/hour with a doctoral-level therapist in private practice or can't travel long distances to see ensure they're seeing someone with appropriate training.
 
Agree with points made by jdawgg and FuturePhd2--where I am there is a real glut of MA/MSW level "therapists" who are wonderful at nodding their heads sympathetically, yet to find someone capable and competent to do real CBT for an bad OCDer or agoraphobe is a near impossibility...
 
OldPsychDoc said:
Agree with points made by jdawgg and FuturePhd2--where I am there is a real glut of MA/MSW level "therapists" who are wonderful at nodding their heads sympathetically, yet to find someone capable and competent to do real CBT for an bad OCDer or agoraphobe is a near impossibility...
Click to expand...

I'm likely biased from where I'm training, but some of our best therapists in evidenced-based therapies are MSWs. It certainly can be done. The role for our PhDs is more in education and training.
 
jdawgg said:
Master's level counselors (LPC/LMHC) with MAs in counseling psychology have been expanding their ranks in relation to social workers in several areas of the country and often outnumber them (e.g., Colorado, Texas).
Click to expand...

Yeah, I almost certainly over generalized. I'm sure everything varies greatly with geography.

I think MSW is getting really popular in my state b/c an MSW can qualify you to get the same counseling jobs as an LPC (or whatever the title is) that the counseling psych people get. But then addition you can also do all the social work jobs that wouldn't be open to a MA in counseling psychology.

So a MSW is kind of like a "buy one, get one free" degree in some (many?) states.

(I have no idea of the clinical effectiveness of the different degrees, but just looking at it from a career flexibility standpoint. For example in my fiance's case, she is really scientifically minded, so whatever degree she got she would be keeping up with the latest research/journals/continuing education. So for her its really just a concern of getting a degree that allows her to get licensed to legally do the most things)
 
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surftheiop said:
I think MSW is getting really popular in my state b/c an MSW can qualify you to get the same LPC (or whatever the title is) that the counseling psych people get. But then addition you can also do all the social work jobs that wouldn't be open to a MA in counseling psychology.

So a MSW is kind of like a "buy one, get one free" degree in some (many?) states.
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I would be very wary about generalizing this- if that's true where you are, it's an exception to the rule. Most state licensing boards delineate the degrees/degree fields that can apply for a LPC/LCPC or equivalent license. My state requires the degree a masters or equivalent in counseling, clinical psychology, counseling psychology, counseling and guidance, or school psychology. I did a quick check of 4 nearby states and all were similar.

I also have no sense of why a LCSW would want to get both licenses. It's a PiTA enough to deal with one licensing board and the neverending tests and fees. Who'd want to deal with that twice when it wouldn't confer any additional marketability or other benefits?! But that's a discussion for a different thread and a different forum.
 
pingouin said:
I would be very wary about generalizing this- if that's true where you are, it's an exception to the rule. Most state licensing boards delineate the degrees/degree fields that can apply for a LPC/LCPC or equivalent license. My state requires the degree a masters or equivalent in counseling, clinical psychology, counseling psychology, counseling and guidance, or school psychology. I did a quick check of 4 nearby states and all were similar.

I also have no sense of why a LCSW would want to get both licenses. It's a PiTA enough to deal with one licensing board and the neverending tests and fees. Who'd want to deal with that twice when it wouldn't confer any additional marketability or other benefits?! But that's a discussion for a different thread and a different forum.
Click to expand...

I'll delete the part of my post that was ambiguous so as to not confuse anyone, what I meant to say was that most of the counseling job listings in my state treat a LPC or LCSW as equivalent.
 
OldPsychDoc said:
Agree with points made by jdawgg and FuturePhd2--where I am there is a real glut of MA/MSW level "therapists" who are wonderful at nodding their heads sympathetically, yet to find someone capable and competent to do real CBT for an bad OCDer or agoraphobe is a near impossibility...
Click to expand...

Absolutely.

I have seen this for DBT and treating people with borderline personality disorder (and motivational interviewing with non-compliant pts). Many people seem to practice CBT-lite and DBT-lite....which is to say they are applying basic concepts from a particular model, but they are not fully implementing the approaches. Failure to practice within the parameters an approach was developed is like implementing your own dosing and med management plan....almost always a bad idea.
 
Comparing fellowship trained neuropsychologists to clinical psychologists is the only thing that is laughable. Please read the the post to which you are responding. These people are usually the creme de la creme of the psychology profression, at least at academic centers and even then have a very specialized knowledge base that pales compared to the medical knowledge of any physician.
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You do know all neuropsychologists are clinical psychologists by training, right? :confused:
 
futureapppsy2 said:
You do know all neuropsychologists are clinical psychologists by training, right? :confused:
Click to expand...

I believe what was trying to be conveyed was that the example of neuropsychologists being used in a comparison when clinical psychologists (i.e. Clinical psychologists who are not neuropsychologists) was not a relevant comparison and not that neuropsychologists weren't clinical psychologists.
 
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