Addiction Psychiatry

[Chops20]

I am a PGY 2 interested in Addictions but am relatively older in age and have student loans. Is an Addictions fellowship valuable in the future job market? Is it potentially lucrative in private practice settings over and above the standard training?

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[reca]

I don't know if any psychiatry fellowship is lucrative. Any fellowship is potentially lucrative if it helps you break into a niche but certainly nothing like IM fellowships where doing the fellowship is guaranteeing you a massive change in income potential. The plus side with psychiatry fellowships is that with the option to moonlight, it's not as big of a financial hit to delay becoming an attending for a year.

 

[psyguru]

I don't know if any psychiatry fellowship is lucrative. Any fellowship is potentially lucrative if it helps you break into a niche but certainly nothing like IM fellowships where doing the fellowship is guaranteeing you a massive change in income potential. The plus side with psychiatry fellowships is that with the option to moonlight, it's not as big of a financial hit to delay becoming an attending for a year.

Forensic psychiatry fellowship can be lucrative if you focus on building an expert witness practice. Sometimes other board certifications (with or without a fellowship) can help develop a niche.

 

[thepoopologist]

I think child psych and forensic psych are the only two that make a difference. Everything else can be done with general boards.

 

[Bartelby]

I imagine that it could be useful for something like residential rehab units catering to the wealthy, or working on an addiction service at an academic medical center. Otherwise, I don't imagine it will be a big deal because your general training should cover addiction management well and finding a position dealing primarily with addiction as a general psychiatrist should be no problem.

 

[psyguru]

As an expert witness, additional board-certifications could be helpful after forensics...particularly in fields well-suited to litigation. I plan on getting board-certified in Addiction Medicine via the practice pathway. Addictions is well suited for litigation (such as BIM and child). I don't know if c/l or community psychiatry is (although I believe I am qualified to sit for the community boards via the practice pathway). Of course, it helps to have a solid marketing plan for your expert witness practice. FYI I have seen some board-certified addiction specialists (non-forensic psychiatrists) do defense work for big tobacco. Each case could net 40-50k and they may do several a year (grossing about a million over a decade). I believe there probably is litigation related to opioids and vaping as well.

 

[Chops20]

As the practice pathway to Addiction medicine board certification will be ending in 2021, does anyone foresee an addiction psychiatry fellowship becoming a requirement in order to work at an Addictions job as a psychiatrist in the next 20 years?

 

[dl2dp2]

As the practice pathway to Addiction medicine board certification will be ending in 2021, does anyone foresee an addiction psychiatry fellowship becoming a requirement in order to work at an Addictions job as a psychiatrist in the next 20 years?

I don’t think this is a concern. Addiction jobs are extremely plentiful and at the moment beggars can’t be choosers. Having suboxone waiver and some experience with vivitrol and methadone in and of itself will make you very valuable. In particular, govt jobs or private suboxone programs are willing to retrain FM/IM for their MD roles even though they clearly prefer psych as they often still need to hire an additional psych (often an under qualified NP) for all the comorbid psych issues.

Fellowships do give you more negotiating power in salary, especially if you are dually boarded, as often large institutions tie salary scale to it. in private practice, I do think there is “halo effect“ if you went to a fellowship at a reputable program. You won’t lose money doing a fellowship and if you are really interested in going in a bit more depth in this field it’s useful in terms of practical knowledge in dealing with more complex cases. I have not heard anyone who did a fellowship and regretted it, and generally addiction trained psych do focus a large portion of their work in addiction. This ironically is unlike for child, where several current attendings I know do zero child work and told me point blank that if they knew better they’d never do the child fellowship. This is not related to demand, as demand for child work is equally high if not higher but rather to the overall nature/ lifestyle of the work. Addiction is often logistically “cleaner” (believe it or not) as a specialty.

I don’t know many forensic attendings but to the extent that I know it’s actually not easy to carve out a niche witness practice. There’s less average “value-add” in terms of income IMO. The ceiling is definitely higher for forensic.

This is a good niche field: definitely decent development in newer interventions and IMO less risk for NP encroachment, and demand is not diminishing. Career rise/leadership development is often fast with a fellowship as often large systems have very few fellowship trained addictionologists, as demand for services and reimbursement environment overall is improving, so it’s becoming more of a revenue generator than a cost center. (This was an unexpected pleasant surprise for me going into the field about 5-10 years ago, where most public/Medicaid taking facilities are running deficits on block grants )

 

[Chops20]

I don’t think this is a concern. Addiction jobs are extremely plentiful and at the moment beggars can’t be choosers. Having suboxone waiver and some experience with vivitrol and methadone in and of itself will make you very valuable. In particular, govt jobs or private suboxone programs are willing to retrain FM/IM for their MD roles even though they clearly prefer psych as they often still need to hire an additional psych (often an under qualified NP) for all the comorbid psych issues.

Fellowships do give you more negotiating power in salary, especially if you are dually boarded, as often large institutions tie salary scale to it. in private practice, I do think there is “halo effect“ if you went to a fellowship at a reputable program. You won’t lose money doing a fellowship and if you are really interested in going in a bit more depth in this field it’s useful in terms of practical knowledge in dealing with more complex cases. I have not heard anyone who did a fellowship and regretted it, and generally addiction trained psych do focus a large portion of their work in addiction. This ironically is unlike for child, where several current attendings I know do zero child work and told me point blank that if they knew better they’d never do the child fellowship. This is not related to demand, as demand for child work is equally high if not higher but rather to the overall nature/ lifestyle of the work. Addiction is often logistically “cleaner” (believe it or not) as a specialty.

I don’t know many forensic attendings but to the extent that I know it’s actually not easy to carve out a niche witness practice. There’s less average “value-add” in terms of income IMO. The ceiling is definitely higher for forensic.

This is a good niche field: definitely decent development in newer interventions and IMO less risk for NP encroachment, and demand is not diminishing. Career rise/leadership development is often fast with a fellowship as often large systems have very few fellowship trained addictionologists, as demand for services and reimbursement environment overall is improving, so it’s becoming more of a revenue generator than a cost center. (This was an unexpected pleasant surprise for me going into the field about 5-10 years ago, where most public/Medicaid taking facilities are running deficits on block grants )

Thank you for this detailed and informative reply. Do you think the fellowship still makes sense if I am >350k in debt from student loans?

 

[dl2dp2]

Thank you for this detailed and informative reply. Do you think the fellowship still makes sense if I am >350k in debt from student loans?

This doesn’t change things much. Fellowship will expect to enhance your salary about 30k a year so you make the money back in about 5 years. If you do PSLF that year would count against the time. If you work hard in private and live a very frugal lifestyle you can probably kill 350k debt in about 3 years.

 

[littlefred]

This doesn’t change things much. Fellowship will expect to enhance your salary about 30k a year so you make the money back in about 5 years. If you do PSLF that year would count against the time. If you work hard in private and live a very frugal lifestyle you can probably kill 350k debt in about 3 years.

Hey sluox, you seem to be well versed in the world of addiction. Mind if I ask you a couple of questions through PM (mostly salary-wise)?
I couldn't PM you because your profile is private.

 

[Mass Effect]

@futuredo32 is trying to get certified via the practice pathway as we speak. She may have some insight for you.

 

[Chops20]

This doesn’t change things much. Fellowship will expect to enhance your salary about 30k a year so you make the money back in about 5 years. If you do PSLF that year would count against the time. If you work hard in private and live a very frugal lifestyle you can probably kill 350k debt in about 3 years.

Great. Do you think the fellowship is worth it if I don't want to exclusively focus on treating Addictions patients as the bread and butter for my career?

 

[Sushirolls]

No. If you don't plan on doing 50% or more of your time doing addictions, don't do it. If you don't find yourself thinking, "(wo)man... I'd rather be knee deep in chemical dependency patients today instead of depression, anxiety, schizophrenia" at times, than don't waste your time.

 

[TexasPhysician]

Great. Do you think the fellowship is worth it if I don't want to exclusively focus on treating Addictions patients as the bread and butter for my career?

Before answering this, what do you imagine doing the fellowship for?

 

[Chops20]

Before answering this, what do you imagine doing the fellowship for?

Hmm. Principally to be better trained at treating addicted patients. I imagine having the fellowship will improve my CV for the job market?

Honestly, I worry that I might be "missing out" in some way due to not having a fellowship. I wonder if these are more my own sentiments rather than the reality of things.

I am concerned about my loans. The idea of becoming an attending so I can launch my career and start aggressively paying down my loans is also appealing to me.

I suppose if I choose more addictions electives in the PGY-4 year and later take an attending job at a facility with a fair number of addictions patients, I could hone my skills with those patients rather quickly while forgoing the fellowship?

 

[dl2dp2]

Hmm. Principally to be better trained at treating addicted patients. I imagine having the fellowship will improve my CV for the job market?

Honestly, I worry that I might be "missing out" in some way due to not having a fellowship. I wonder if these are more my own sentiments rather than the reality of things.

I am concerned about my loans. The idea of becoming an attending so I can launch my career and start aggressively paying down my loans is also appealing to me.

I suppose if I choose more addictions electives in the PGY-4 year and later take an attending job at a facility with a fair number of addictions patients, I could hone my skills with those patients rather quickly while forgoing the fellowship?

I agree with the two above posters. I personally think if you get a fellowship it will define your career--you'll declare yourself as an addiction psychiatrist, and the better pay/more marketability come out of jobs that'll be > 50% addiction. If you don't want to make a commitment to treat >50% addiction patients it'll be not worth it.

 

[TexasPhysician]

Hmm. Principally to be better trained at treating addicted patients. I imagine having the fellowship will improve my CV for the job market?

Honestly, I worry that I might be "missing out" in some way due to not having a fellowship. I wonder if these are more my own sentiments rather than the reality of things.

I am concerned about my loans. The idea of becoming an attending so I can launch my career and start aggressively paying down my loans is also appealing to me.

I suppose if I choose more addictions electives in the PGY-4 year and later take an attending job at a facility with a fair number of addictions patients, I could hone my skills with those patients rather quickly while forgoing the fellowship?

I worked PT at an addiction center while building my pp. It was a fairly cush gig. The addictions background can help you land such roles at addiction centers. If you want such a role at an inpatient center, the fellowship will really help.

If you just want to work general outpatient with basic addiction stuff, I’d skip it.

 

[vistaril]

I think you must first define what 'addiction psychiatry' even is. Working at an addiction/rehab center can mean different things? Do you want to be the medical director there? Do you want to be the psychiatrist there? Do you want to be heading the detox part of things there?

In general.....a fellowship probably helps if you want to do things like maybe one day head up a physician health program or something. Or other admin type jobs. But the truth is these jobs pay less than that of general psychiatrists.....

If you just want to give people suboxone....then hell, you don't need a fellowship for that.

 

[psyguru]

I don't know if any psychiatry fellowship is lucrative. Any fellowship is potentially lucrative if it helps you break into a niche but certainly nothing like IM fellowships where doing the fellowship is guaranteeing you a massive change in income potential. The plus side with psychiatry fellowships is that with the option to moonlight, it's not as big of a financial hit to delay becoming an attending for a year.

Forensic fellowship can potentially cause a very decent change in income. It is not guaranteed. It requires good marketing via multiple niches (civil, crim, WC, DBA, PI, Occ. IME, Testamentary Capacity, military, intoxication-related, capital, etc) . If you can invoice 600 hours a year (little over 10 hours a week) and do a part-time 10 hour a week $200/hr clinical job (total 20 hours a week), you could earn as much as a gastroenterologist at around 400k. Of course this won't be true if the gastroenterologist does expert witness work as well. Also, if you do a forensic fellowship and work full-time in a jail or state hospital, this won't apply as well.

Going back to the addictions, I have heard of some non-forensic addiction psychiatrists doing big tobacco expert witness cases. They do about a 2 a year at 60k each. Perhaps they do other addiction-related IMEs (impaired professionals, FAA, etc). If you are interested in this, maybe get ABIME training or there is another informal Forensic medicine certification with training. Basically, you could any type of psychiatric IME or case with the exception of criminal.

I am looking into getting the addiction medicine certification via the practice pathway. The MRO helps as well.

 

[CowsRule]

Forensic fellowship can potentially cause a very decent change in income. It is not guaranteed. It requires good marketing via multiple niches (civil, crim, WC, DBA, PI, Occ. IME, Testamentary Capacity, military, intoxication-related, capital, etc) . If you can invoice 600 hours a year (little over 10 hours a week) and do a part-time 10 hour a week $200/hr clinical job (total 20 hours a week), you could earn as much as a gastroenterologist at around 400k. Of course this won't be true if the gastroenterologist does expert witness work as well. Also, if you do a forensic fellowship and work full-time in a jail or state hospital, this won't apply as well.

Going back to the addictions, I have heard of some non-forensic addiction psychiatrists doing big tobacco expert witness cases. They do about a 2 a year at 60k each. Perhaps they do other addiction-related IMEs (impaired professionals, FAA, etc). If you are interested in this, maybe get ABIME training or there is another informal Forensic medicine certification with training. Basically, you could any type of psychiatric IME or case with the exception of criminal.

I am looking into getting the addiction medicine certification via the practice pathway. The MRO helps as well.

I'm confused, are you saying to not do the fellowship and instead pick up part time work in forensic/addiction? And just do a certification for forensic or addiction through getting hours?? Asking because I was interested in the forensic and addictions fellowships but idk if it's worth it for the pay difference or a better route. I looked online however and found this

*The Addiction Medicine Practice Pathway will expire in 2021. Beginning in 2022, all applicants for certification in Addiction Medicine must successfully complete an ACGME-accredited Addiction Medicine fellowship program. This subspecialty certifying exam will be given annually throughout this period.

 

[OldPsychDoc]

Do addiction because you want to help patients achieve and maintain sobriety.
There's no other good reason for it.

 

[psyguru]

I'm confused, are you saying to not do the fellowship and instead pick up part time work in forensic/addiction? And just do a certification for forensic or addiction through getting hours?? Asking because I was interested in the forensic and addictions fellowships but idk if it's worth it for the pay difference or a better route. I looked online however and found this

*The Addiction Medicine Practice Pathway will expire in 2021. Beginning in 2022, all applicants for certification in Addiction Medicine must successfully complete an ACGME-accredited Addiction Medicine fellowship program. This subspecialty certifying exam will be given annually throughout this period.

For forensic board-certification, a fellowship is required for over a decade. For addiction medicine board certification, it will be required around 2021. For addiction psychiatry it is required currently. However, I talked to someone in the know who said they may postpone the date for addiction medicine due to the opioid crisis (and wanting more board-certified docs).



If you are interested in expert witness work generating 50% or more of your income or over 300k a year, doing a high variety of cases, high-profile cases, interested in criminal cases, academics, or a leadership position at the prison or state hospital then I would recommend the forensic fellowship. Without the fellowship, I would consider maybe SEAK conference, ABIME, that informal forensic medicine certification and/or a mentor (we are starting a mentorship program at Orbit...PM me). Perhaps develop a niche focus in either case.

Forensic board certification can pay off as evidenced by the number of cases and the hourly rate the market will support (i.e. higher for forensic board certification). Of course their maybe non-forensic psychiatrists with some well-developed niche (i.e. a well-published psychopharmacologist in drug mass-tort cases). Even if you get one capital mitigation case (which I would not do without the forensics certification) along with a much smaller $30k case or two, that in itself will pay the difference for the fellowship. That being said, many board-certified forensic psychiatrists will dabble around and do several cases a year as a small side gig and have a regular paying job at the prison or state hospital. I interact with non-psychiatrists that do many more cases and they don't have to compete with any forensically trained colleagues (i.e. forensic psychiatry, forensic pathology, forensic dentistry or maybe even occupational medicine).

While it's available, you could get the addictions certification via the practice pathway. There is a fellowship-lite option (almost like a remote fellowship where you can keep your current job) in NJ at Executive Fellowship in Addiction Medicine .