Addiction Medicine

[watermanMD]

Anyone do Addiction Med either FT or PT? Looking for some insight into the fellowship (you probably grandfathered in), day-to-day, and job/ market outlook.

---

Members don't see this ad.

 

[d2305]

Looks like NYC has an EM fellowship https://www.acaam.org/wp-content/uploads/2020/05/Fellowship-Directory-5-1-20.pdf

 

[Cinclus]

As someone who struggled with the decision of EM vs. psychiatry (I know, weird, right? - I have more of am "EM personality" and the ED folks are my people, but psych was really the only specialty that actually interested me, I love talking to patients, dislike procedures, etc.), and as someone who has had recurrent regrets about choosing EM over psych, I have also considered pursuing an addiction medicine fellowship, thinking it would give me some of what I "lost" by not pursuing psychiatry, as well as giving me an "out" from EM. I would also love to hear from anybody with more info re: the above questions. I am fortunate to be debt-free and with good passive income (even now during COVID-19), so salary differences don't bother me much (nor does a year of "lost" income), but the above questions are good.

 

[Groove]

Vanderbilt has one. I know someone who completed it and then went on to join a faculty position at an EM residency. He had told me he was making 6-700K/yr in TX working for a FSED prior to the FSED crash and subsequently applied for a fellowship. There's no way he's making that in academics. He was sick of EM though and wanted something new. He's one of these guys that constantly comes up with entrepreneurial ideas that seem somewhat sound but hasn't quite struck gold yet. I'll be curious if he does anything with addiction medicine. It doesn't sound too lucrative to me and the pt population sounds miserable.

 

[TheComebacKid]

Did an addiction medicine elective in residency. The hours were good, the docs overall seemed to like it.

But I felt more burned out, ironically, doing addiction medicine than just regular EM. It's essentially taking the most challenging patients we see in the ED with complex social situations and underlying psychiatric issues, and seeing them in the hospital for weeks on end while they get IV antibiotics for endocarditis. I followed them in the clinic as well.

It wasn't for me, but I do think it's a good option for some people, and a good way to diversify your career. Definitely has been getting more attention in health care arenas in the pre-COVID era.

 

[alphaholic06]

I"ve been thinking about addiction medicine lately too. It may be my escape hatch from EM. Fellowship doesn't seem to bad and I can still pick up some shifts to help close the income gap.

"Adversity introduces a man to himself."

 

[deleted206819]

Bumping this thread to get some thoughts.

I'm thinking about getting into addiction medicine but without going into fellowship for it. I'd like to continued practicing emergency medicine and to also practice addiction medicine on the side. Does anyone see any issues (clinical, liability, or otherwise) with this route?

 

[oldiebutgoodie1211]

Bumping this thread to get some thoughts.

I'm thinking about getting into addiction medicine but without going into fellowship for it. I'd like to continued practicing emergency medicine and to also practice addiction medicine on the side. Does anyone see any issues (clinical, liability, or otherwise) with this route?

you won’t be board certified so When you get sued it won’t look good

 

[deleted206819]

you won’t be board certified so When you get sued it won’t look good

Unless I can get the hours and get in through the practice pathway

 

[Apollyon]

Unless I can get the hours and get in through the practice pathway

Is the practice track still open? I thought I heard/read about 10 years ago that the projected close was 2019. Of course, times, they are a changin'. I didn't follow it up between then and now.

 

[deleted206819]

Is the practice track still open? I thought I heard/read about 10 years ago that the projected close was 2019. Of course, times, they are a changin'. I didn't follow it up between them and now.

Still open through 2021 and don’t know how COVID-19 will affect that timeline though.

 

[Sushirolls]

Addiction Medicine is Psychiatry.
Very rarely did I run into a patient on inpatient detox units or in out patient that didn't have a comorbid depression/anxiety/bipolar/personality disorder. The private insurance higher paying addiction facilities want Psychiatrists (+/- Addiction Psychiatry or Addiction Medicine board certification). Inpatient units typically want Psychiatrists, in part, because of the comorbidity of psych that keeps popping up. It is so hard to separate the two.

Perhaps in a large hospital health system an EM/IM/FM --> addiction medicine can lock in a gig doing the IM floor consults for alcohol detox and all the Hep C antiviral managements in the IV heroin using population on outpatient.

Simply opening up an office to do broad spectrum addiction medicine will be tough, some regional variability. But you will notice a higher skewing in patient population towards the medicaid - which doesn't exactly pay the bills. Then the other issue, is the Alcohol UD folks are bad at follow up.

I advertise my practice as Psychiatry and Addiction, but I just don't get much addiction on the front end, usually comes up as secondary issues from patient perspective. Alcohol UD have horrible follow up rates. Suboxone for OUD do follow up, but now the market it saturated with "providers" and most of the population is medicaid.

Without having the complete clinic for addiction, the PHP, the IOP, the detox unit, (maybe even the residential?) it's truly hard to capture the population. I've found that many of the clinics that do get the patients entering at their Detox/residential/PHP level, step down to the other and then follow up with the same clinic for their outpatient care. And don't venture out into the community to find a simple Addictionology practice.

In summary, good luck seeing Addiction Medicine as an out.

 

[MedScat]

For anyone who did addiction medicine....how competitive is it? Also, I have a question that i've been wondering for some time. 11 years ago, I was a heroin addict and have been drug free since Dec 21, 2010 (thanks to a very long inpatient rehab stint). I lived on the street, ended up in jail, all the things we see in our substance use disorder patients. I'm just an M4 now applying EM but, when is it an appropriate time for me to be able to share this struggle with people? I hate having to hide this crucial part of my life for so long, from everyone. I think it will make me a stronger candidate for addiction medicine and also a better doctor for my patients since I have a first hand understanding of what they are going through but, will PDs look down on this? Right now my plan is not to mention it at all until maybe my personal statement for addiction med fellowship 3 years from now but this is something I've been thinking about for a while and would love some insight.

 

[DeadCactus]

For anyone who did addiction medicine....how competitive is it? Also, I have a question that i've been wondering for some time. 11 years ago, I was a heroin addict and have been drug free since Dec 21, 2010 (thanks to a very long inpatient rehab stint). I lived on the street, ended up in jail, all the things we see in our substance use disorder patients. I'm just an M4 now applying EM but, when is it an appropriate time for me to be able to share this struggle with people? I hate having to hide this crucial part of my life for so long, from everyone. I think it will make me a stronger candidate for addiction medicine and also a better doctor for my patients since I have a first hand understanding of what they are going through but, will PDs look down on this? Right now my plan is not to mention it at all until maybe my personal statement for addiction med fellowship 3 years from now but this is something I've been thinking about for a while and would love some insight.

Academic medicine is big on talking up diversity, mental health, non-judgment, etc. Then they go behind closed doors and match white men with high board scores and no red flags. There are absolutely programs that try to practice what they preach but there is still a ton of stigma and unconscious negative bias against substance use. I generally advise people that you don't want to match somewhere that isn't going to support you but at some point you start risking matching in the tier of you should be able to or even matching at all and this may be one of those cases. I think Addiction Medicine applications is a good time to bring it up; they really should be walking the walk and you'll have several years as a practicing physician to allay any concerns about your ability to perform and handle the stress.

This is just one opinion, definitely discuss this with trusted advisors.

 

[Birdstrike]

For anyone who did addiction medicine....how competitive is it? Also, I have a question that i've been wondering for some time. 11 years ago, I was a heroin addict and have been drug free since Dec 21, 2010 (thanks to a very long inpatient rehab stint). I lived on the street, ended up in jail, all the things we see in our substance use disorder patients. I'm just an M4 now applying EM but, when is it an appropriate time for me to be able to share this struggle with people? I hate having to hide this crucial part of my life for so long, from everyone. I think it will make me a stronger candidate for addiction medicine and also a better doctor for my patients since I have a first hand understanding of what they are going through but, will PDs look down on this? Right now my plan is not to mention it at all until maybe my personal statement for addiction med fellowship 3 years from now but this is something I've been thinking about for a while and would love some insight.

If you perform well in medical school, residency and on exams, you'll get your addiction medicine fellowship. Could your background with addiction help you become a better addiction doctor? Probably. But I think the time to share you experience with addiction is probably once you're an addiction medicine attending, not on the interview trail. There are all kinds of ways you can use that experience and background to make you a better doctor and fellowship candidate, without explicitly stating the details in a confessional way.

I agree with @DeadCactus in that although sharing details of having overcome this type of experience tends to be praised and fawned over in pop culture, it's often is shunned in the medical world, regardless of what lip service is paid to non-judgementalism, on the surface.

You're experience can be used as an advantage. The place that's most likely to happen is probably not on the interview trail. That's just one person's opinion. I could be wrong.

 

[thegenius]

For anyone who did addiction medicine....how competitive is it? Also, I have a question that i've been wondering for some time. 11 years ago, I was a heroin addict and have been drug free since Dec 21, 2010 (thanks to a very long inpatient rehab stint). I lived on the street, ended up in jail, all the things we see in our substance use disorder patients. I'm just an M4 now applying EM but, when is it an appropriate time for me to be able to share this struggle with people? I hate having to hide this crucial part of my life for so long, from everyone. I think it will make me a stronger candidate for addiction medicine and also a better doctor for my patients since I have a first hand understanding of what they are going through but, will PDs look down on this? Right now my plan is not to mention it at all until maybe my personal statement for addiction med fellowship 3 years from now but this is something I've been thinking about for a while and would love some insight.

I agree with others that I would probably not bring this up in detail (or at all) until you match into EM.

If you lived on the streets doing drugs and ended up in jail...and now you are a doctor....that is one hell of a story. Did you bring any of this up when you were applying and interviewing for medical school?

 

[Lexdiamondz]

I agree with others that I would probably not bring this up in detail (or at all) until you match into EM.

If you lived on the streets doing drugs and ended up in jail...and now you are a doctor....that is one hell of a story. Did you bring any of this up when you were applying and interviewing for medical school?

I would go further and say don't bring up that detail at all until licensed and finished with residency.

People aren't open minded when it comes to addiction, and being in a profession with overall high levels of stress and where you are in close contact with narcotics, having past drug issues raises doubts.

One of my colleagues recently had the misfortune of having to intubate an EP with a drug problem. It's a much bigger problem in medicine than is talked about.

 

[Birdstrike]

People aren't open minded when it comes to addiction, and being in a profession with overall high levels of stress and where you are in close contact with narcotics, having past drug issues raises doubts.

Unfortunately, correct. First thing that pops into the mind of the interviewer: "When the stress of residency or that first post-residency community job hits, will it trigger a relapse?"

Even if unlikely, or unfair, they're going to wonder.

 

[Franzd'Epinay]

For anyone who did addiction medicine....how competitive is it? Also, I have a question that i've been wondering for some time. 11 years ago, I was a heroin addict and have been drug free since Dec 21, 2010 (thanks to a very long inpatient rehab stint). I lived on the street, ended up in jail, all the things we see in our substance use disorder patients. I'm just an M4 now applying EM but, when is it an appropriate time for me to be able to share this struggle with people? I hate having to hide this crucial part of my life for so long, from everyone. I think it will make me a stronger candidate for addiction medicine and also a better doctor for my patients since I have a first hand understanding of what they are going through but, will PDs look down on this? Right now my plan is not to mention it at all until maybe my personal statement for addiction med fellowship 3 years from now but this is something I've been thinking about for a while and would love some insight.

I think matching would be the least of your worries. Some state medical boards are downright draconian when it comes to substance use or psychiatric conditions.

Even if you share this after practicing for a while, what if some patient, coworker, or staff member with a grudge decides to make a huge deal to your state board? Maybe I'm a bit paranoid, but I would honestly never feel safe disclosing more than the minimum necessary.

 

[MedScat]

I agree with others that I would probably not bring this up in detail (or at all) until you match into EM.

If you lived on the streets doing drugs and ended up in jail...and now you are a doctor....that is one hell of a story. Did you bring any of this up when you were applying and interviewing for medical school?

Well I never brought it up thus far but its been hard in medical school with patients that I see with opiate use disorder and im like "wow i totally get you, my sister went through the same thing" when "my sister" is actually me...its been annoying but I do understand the stigma which is why I havent disclosed any of it to this point.

I think matching would be the least of your worries. Some state medical boards are downright draconian when it comes to substance use or psychiatric conditions.

Even if you share this after practicing for a while, what if some patient, coworker, or staff member with a grudge decides to make a huge deal to your state board? Maybe I'm a bit paranoid, but I would honestly never feel safe disclosing more than the minimum necessary.

Yeah...I know....I knew this was true for medical school but I was hopeful that after making it through medical school/residency it may be OK to bring up but I guess its just never OK. I have a couple of attendings at my institution that are former addicts who share this with their patients and it goes such a far way...and I'm so envious....but I guess I'll get there one day. I havent even matched EM yet but, I want to match addiction med with so many few spots in my regional limitation (NY) I feel like it would give me a leg up....but I understand yes it's probably still not as accepted as people like to make it seem. I appreciate all your input though. I guess I'll keep living under my rock of shame.

 

[MedScat]

Academic medicine is big on talking up diversity, mental health, non-judgment, etc. Then they go behind closed doors and match white men with high board scores and no red flags. There are absolutely programs that try to practice what they preach but there is still a ton of stigma and unconscious negative bias against substance use. I generally advise people that you don't want to match somewhere that isn't going to support you but at some point you start risking matching in the tier of you should be able to or even matching at all and this may be one of those cases. I think Addiction Medicine applications is a good time to bring it up; they really should be walking the walk and you'll have several years as a practicing physician to allay any concerns about your ability to perform and handle the stress.

This is just one opinion, definitely discuss this with trusted advisors.

I still have yet to find a trusted advisor to share this with...hence the SDN post

 

[Sushirolls]

This is why Addiction really is the realm of Psychiatry.

Your personal disclosures are not needed for the patient. Your journey, your experiences, are not your patients. Your job is to be a professional who makes diagnoses, establishes rapport, and offers quality evidence based treatments for patients.

It has nothing to do with being an advantage, or disadvantage or stigma or shame etc. Keep your personal life private. Draw upon it as a means for enhancing rapport or a higher threshold for screening patients but stop there. Use your experiences as a tool of hope and wellspring of positivity, knowing that the person before you may be at their worst, or near their worst, has the capacity to achieve recovery.

Recovery meetings are where shared experiences are valued to further foster sobriety days - not appointments of consults with a Physician.

The danger of your past experiences will be potential for a greater counter transference than what most folks might have. 'I took the steps for recovery, and I was in far worse shape than this person, why won't they put forth some effort?!?!?' This is where doing a psychiatry residency would be beneficial and offer further insight into the other variables impacting peoples journey into substance use. Or conversely your experiences with methadone/suboxone/vivitrol/nothing may shape your clinical impressions toward treatment recommendations for patients. Or some how your experience with recovery meetings or lack of them may shape your recommendations for patients, and when they are opposite your views? Countertransference?

Your past doesn't define you, nor should is shape your future you or professional trajectory. Choose Addiction Medicine because you are trying escape EM, or because you like it - not because you think your past experiences some how will make you better at it.

 

[Birdstrike]

I still have yet to find a trusted advisor to share this with...hence the SDN post

Here's something you might not know. There are a lot of practicing doctors, attendings, that have histories of addiction. There are many that have overcome it, are in recovery and you'd never know. There are a few who are actively abusing and need treatment. They can be more obvious, though not always.

Just be aware that there are many more out there than you think, that also have this in their past and you'd never know. Although you may not have met anyone in this situation yet (that you know of), they are out there. Ask anyone who's been in addiction medicine, on a licensing board or on a hospital credentials committee. It comes up often.

You have more company than you know. Hang in there.

 

[Apollyon]

About 10 years ago, an addiction doc told me that 17% of docs were impaired in some way - whether drugs, alcohol, psychological, or whatever. But, one out of six.

 

[MedScat]

This is why Addiction really is the realm of Psychiatry.

Your personal disclosures are not needed for the patient. Your journey, your experiences, are not your patients. Your job is to be a professional who makes diagnoses, establishes rapport, and offers quality evidence based treatments for patients.

It has nothing to do with being an advantage, or disadvantage or stigma or shame etc. Keep your personal life private. Draw upon it as a means for enhancing rapport or a higher threshold for screening patients but stop there. Use your experiences as a tool of hope and wellspring of positivity, knowing that the person before you may be at their worst, or near their worst, has the capacity to achieve recovery.

Recovery meetings are where shared experiences are valued to further foster sobriety days - not appointments of consults with a Physician.

The danger of your past experiences will be potential for a greater counter transference than what most folks might have. 'I took the steps for recovery, and I was in far worse shape than this person, why won't they put forth some effort?!?!?' This is where doing a psychiatry residency would be beneficial and offer further insight into the other variables impacting peoples journey into substance use. Or conversely your experiences with methadone/suboxone/vivitrol/nothing may shape your clinical impressions toward treatment recommendations for patients. Or some how your experience with recovery meetings or lack of them may shape your recommendations for patients, and when they are opposite your views? Countertransference?

Your past doesn't define you, nor should is shape your future you or professional trajectory. Choose Addiction Medicine because you are trying escape EM, or because you like it - not because you think your past experiences some how will make you better at it.

Oh no, I'm not choosing addiction med because I think my past experiences will make me better or worse at it, I truly want to help people who were in the same seat I was in ten years ago. I wish I had a doctor back then who could relate. I found a counselor who did though and I'm clean today very much thanks to that man. The biases you mentioned above can be present in any field for anyone....physicians are humans and go through the same experiences as their patients in many other ways other than addiction that could impact the way they practice medicine. The best thing is to just be aware of implicit biases, and keep it moving.

As I said above, I have an addiction med doc at my institution who introduces himself as "hi im dr so and so and i'm a recovering raging alcoholic, nice to meet you" and the patients really love it and connect to him, and come back to see him without feeling they disappointed him since they know what he went through. I always envisioned practicing medicine in that way, whether it was about addiction or about any other personal thing I have gone through. Maybe doctors do this to a degree that is not crossing a boundary. I guess I'm just learning where my boundaries should lie. But I can't foresee myself ever being the kind of person that does not involve at least a little of my personal stories when I talk to patients.

I appreciate everyones comments and support on this...I've been an active member of SDN for a few years and never posted about it but, I'm glad I did.

 

[Sushirolls]

But I can't foresee myself ever being the kind of person that does not involve at least a little of my personal stories when I talk to patients.

This is where I wish to insert the Captain Picard face palm meme.

 

[Rad2013]

I think you should probably find an attorney well versed in dealing with physicians, medical boards, training programs, credentialing and physician health programs to guide you through your journey. I would share no more than you are legally obligated to. Seriously. Get an attorney to guide you from now til at least your first job.

You will likely have to answer questions asking about prior substance issues multiple times. These are usually blanket statements… “Have you ever…?”

Medical licensing boards and PHPs are not your friend.

 

[MedScat]

This is where I wish to insert the Captain Picard face palm meme.

Face palm all you want, I wouldn't have gotten clean without medical professionals that shared their stories during my most vulnerable time. Sorry not sorry 🤷‍♀️🤷‍♂️

 

[Sushirolls]

I would have gotten clean without medical professionals that shared their stories during my most vulnerable time.

Exactly! That's the point. It is not needed to have professionals share their personal stories, nor recommended.

Best wishes in the future.

 

[MedScat]

Exactly! That's the point. It is not needed to have professionals share their personal stories, nor recommended.

Best wishes in the future.

lol you know i meant wouldn't** Thanks for all the advice everyone

 

[d2305]

Staying clean and sober takes considerable effort. AA is pretty standardized, but NA not so much.

 

[dl2dp2]

It's easier to get a straight addiction med job inpatient rather than outpatient. For outpatient, the job typically is Medicaid-driven. The jobs are there, but the salaries are typically not awesome (~250k). You could do this and do some EM shifts on the side, and can make a nice living. It's geographically much more flexible as a career. You'll see physicians who staff detox/rehab facilities or outpatient public addiction clinics come from a variety of specialties (peds, anesthesia, internal medicine, family medicine).

Fellowships should be relatively straightforward to match into for those who have a reasonable resume.

The real money in addiction medicine is cash practice. However, I'd say it's challenging to do a cash addiction practice without psychiatry... psychiatry actually trains you to think more in building such a practice, and because of co-morbidities, the demand for addiction psychiatrists is much higher than of other specialties in the private cash world. If you are good in this field it can be one of the best fields in medicine, and very similar to derm, etc... but it's easier to go into that angle from psychiatry than other specialties. That said, exceptions do exist.

 

[namethatsmell]

It's easier to get a straight addiction med job inpatient rather than outpatient. For outpatient, the job typically is Medicaid-driven. The jobs are there, but the salaries are typically not awesome (~250k). You could do this and do some EM shifts on the side, and can make a nice living. It's geographically much more flexible as a career. You'll see physicians who staff detox/rehab facilities or outpatient public addiction clinics come from a variety of specialties (peds, anesthesia, internal medicine, family medicine).

Fellowships should be relatively straightforward to match into for those who have a reasonable resume.

The real money in addiction medicine is cash practice. However, I'd say it's challenging to do a cash addiction practice without psychiatry... psychiatry actually trains you to think more in building such a practice, and because of co-morbidities, the demand for addiction psychiatrists is much higher than of other specialties in the private cash world. If you are good in this field it can be one of the best fields in medicine, and very similar to derm, etc... but it's easier to go into that angle from psychiatry than other specialties. That said, exceptions do exist.

Do you do cash for patients on bup products? If so, any concerns / issues with your local DEA?

 

[dl2dp2]

Do you do cash for patients on bup products? If so, any concerns / issues with your local DEA?

Patients on bup pay me cash for my expertise, and I code E&M codes. They pay the pharmacy to get the medications. I don't know why this would involve the DEA. Do you mean REMS for depot injections?

 

[namethatsmell]

Patients on bup pay me cash for my expertise, and I code E&M codes. They pay the pharmacy to get the medications. I don't know why this would involve the DEA. Do you mean REMS for depot injections?

The addiction practices I've known to get closed down have been cash-only places that prescribe bup. Thanks to a number of uscrupulous physicians in the past, the optics of opioid prescriptions for cash pts doesn't look great, even if the medical indication is completely appropriate like the use of bup for oud. Seems to be a flag that attracts extra interest from the DEA, and sometimes unfortunately their extra interest turns out to be warranted.

 

[dl2dp2]

The addiction practices I've known to get closed down have been cash-only places that prescribe bup. Thanks to a number of uscrupulous physicians in the past, the optics of opioid prescriptions for cash pts doesn't look great, even if the medical indication is completely appropriate like the use of bup for oud. Seems to be a flag that attracts extra interest from the DEA, and sometimes unfortunately their extra interest turns out to be warranted.

Right. This is why this kind of set up is best done with a psychiatrist. The hard part of this isn’t the bupe but to handle the personality disorders, transference, setting boundaries, family, comorbidity, etc. In a clinic/inpatient context you have more oversight and the role is more circumscribed, and often you have psych consult. I think it’s rare for non-psych addiction docs to bill for 90833/90836 so you end up getting paid cash for 15-min med checks for bupe, which is often not appropriate.

 

[namethatsmell]

Right. This is why this kind of set up is best done with a psychiatrist. The hard part of this isn’t the bupe but to handle the personality disorders, transference, setting boundaries, family, comorbidity, etc. In a clinic/inpatient context you have more oversight and the role is more circumscribed, and often you have psych consult. I think it’s rare for non-psych addiction docs to bill for 90833/90836 so you end up getting paid cash for 15-min med checks for bupe, which is often not appropriate.

I agree that patients with significant dual dx are best treated by psychiatrists.

I don't follow the logic that psychiatrists are somehow more protected than say an IM/addiction doc to be cash pay for oud patients.

Regardless, I wish there more a) psychiatrists and b) psychiatrists who treat sud.