Applying for Fellowships

[splik]

the current stickied thread is so out of date that it's no longer useful so I thought I would start a new thread on fellowships as I've recently put this together for my residents.

Why apply for fellowship?
- spend additional year honing craft
- chance to get comprehensive training in what you really love
- opportunity to get added qualification board certification (depending on job can increase salary by 5% per board certification, up to a max of 2)
- may be necessary if you want an academic job in a particular field (for example head of C/L service at academic medical center will be essential in future to be boarded in psychosomatic medicine)
- you want to relocate and make connections
- could be stepping stone to faculty position at particular institution
- may be the standard qualification in the specialty (really only applies to child and adolescent psychiatry)
- may allow you to cultivate a niche or increase your marketability
- correct deficiencies in your residency training
- allow you to “move up” to a more prestigious training program (as fellowships are woefully uncompetitive)
- not ready to grow up and want an additional year to figure it out

Why not apply for fellowship?
- Another year of indentured servitude
- Essentially a loss of income of >150K
- Not necessary to practice addiction, psychosomatics, geriatrics, nor forensic work
- Itching to get out into practice
- Unlikely to significantly increase your income
- Feel your residency training in subspecialty was adequate
- Feels like a waste of time
- Possible to hone craft with a “real job” plus mentorship and reading and make a wage
- Partner/spouse will kill you if you don’t get a real job already
- Disgruntled by the ABMS-ACGME shakedown
- Not sure if you are interested enough in any subspecialty
- Hard to find full time job in subspecialty anyway

How to be competitive for fellowships?
- Most important to perform well in residency and have strong letters of recommendation speaking to your professionalism, interpersonal skills, ability to work as part of a multidisciplinary team, clinical skills, and clinical knowledge
- Most fellowships are not competitive at all
- USMLEs irrelevant
- Some programs/subspecialties will ask for –ITE scores, but rare
- Evidence of commitment to subspecialty (publications, presentations, educational projects, awards) can be helpful
- Residents have found winning awards such as APA Fellowships (SAMHSA/Minority, Public Psychiatry, Child psychiatry, Diversity Leadership) looked upon favorably

The Good News
- There are many great fellowship programs for psychiatric subspecialties
- Psychiatric subspecialties with ACGME accredited fellowships: child and adolescent, geriatric, forensic, addiction psychiatry, psychosomatic medicine, hospice and palliative medicine, pain medicine, clinical neurophysiology, brain injury medicine
- Non-psychiatric subspecialties with ACGME accredited fellowships: preventive medicine, occupational and environmental medicine, medical genetics
- Non-ACGME accredited fellowships: integrated care, public psychiatry, behavioral neurology/neuropsychiatry, addiction medicine (soon to be ACGME accredited), headache medicine, psychoanalytic psychotherapy, emergency psychiatry, clinical informatics, women’s mental health
- Research Fellowships: (T32 Fellowships from NIMH such as primary care psychiatry fellowship; VA-based MIRECC fellowships, RWJ Health and Society Scholar, National Clinician Scholars Program, and others)
- You could be awful and get into a top fellowship program (depending on subspecialty)

The Bad News
- pain medicine is highly competitive, and especially so for psychiatry
- some fellowships will require you to develop interest early:
o residents interested in pain medicine should show an interest by PGY-2 – try to attend national pain meetings, hospital pain conferences, do pain elective, and pain research and present posters or get publications in press; they may also want to see your PRITE scores o)
o residents interested in hospice and palliative medicine should do an elective in the PGY-3 year
o residents interested in forensics on the west coast should apply by April of the PGY-3 year, and June for the east coast

- some fellowships will allow psychiatry residents but you might not be able to find employment outside of an academic center (if you can get a job at all):
o sleep medicine (jobs preferred to pulm/cc, IM, neuro)
o headache medicine (neurologists preferred for jobs)
o clinical neurophysiology (neurologists only pretty much unless doing research)
o brain injury medicine (physiatrists mainly)

- some are through the match (but all CAN offer pre-matches):
o child and adolescent psychiatry
o psychosomatic medicine
o sleep medicine
o pain medicine
o hospice and palliative medicine

- some are free-for-all (no match, offered job on the spot):
o geriatrics
o forensics
o addiction psychiatry
o behavioral/neuropsychiatry

- cycle for fellowship apps does not follow that for jobs so you might forego a job to go through the match for fellowship (and not even get what you want )

Child and Adolescent Psychiatry Fellowships
- good programs should include training in family therapy, CBT, psychodynamic therapy, and play therapy, schools consultation, corrections/juvenile court consultation
- most highly regarded programs include: MGH/McLean, Stanford, NYU, Cambridge Health Alliance
- Apply July of PGY3 (if you want to fast-track) or PGY4 year, ROL due December, Match Day Jan
- More info:
o http://www.aacap.org/AACAP/Medical_Students_and_Residents/Residents_and_Fellows/Home.aspx
o https://apps.acgme.org/ads/Public/R...&SpecialtyId=88&IncludePreAccreditation=false

Geriatric Psychiatry Fellowship
- Good programs should include memory disorders (including rarer disorders like CBD, PCA, FTD, PSP), ECT, nursing home, palliative care, inpatient, outpatient and consultation
- Most highly regarded programs include: Cornell, Hopkins, UCLA
- More info:
o http://www.aagponline.org/clientuploads/Geri Psych fellow weblinks.pdf (may be out of date)
o https://apps.acgme.org/ads/Public/R...&SpecialtyId=90&IncludePreAccreditation=false

Psychosomatic Medicine Fellowship
- Good programs should include exposure to weird and wonderful, outpatient consultation, and subspecialties: neuropsychiatry, transplantation, psycho-oncology, HIV psychiatry
- Most highly regarded programs include: MGH, Brigham and Women’s, Columbia, Inova Fairfax, UW, Stanford
- More info:
o http://www.apm.org/cl-pgms/
o https://apps.acgme.org/ads/Public/R...SpecialtyId=139&IncludePreAccreditation=false

Addiction Psychiatry Fellowship
- Good programs should include public and private sector training, training in CBT relapse prevetion, motivational interviewing, inpatient and outpatient detox, behavioral addictions
- Most highly regarded programs include: Yale, NYU, UCSF, MUSC
- More info:
o http://www.aaap.org/education-training/addiction-psychiatry-subspecialty-programs/
o https://apps.acgme.org/ads/Public/R...&SpecialtyId=87&IncludePreAccreditation=false

Forensic Psychiatry Fellowship
- Good programs include training in corrections, state hospital, occupational psychiatry, malpractice, criminal evaluations, sex offenders, psychological testing
- Most highly regarded programs: Case Western (Phil Resnick), UC Davis (Charles Scott), Yale (Howard Zonana), Columbia-Cornell (Ken Hoge)
- Apply early!
- You will need to submit an anonymized forensic report (mock will do) or forensic-related admission note, consult note, or discharge summary
- For more competitive programs consider doing away rotation in PGY-3 year
- More info:
o http://www.aapl.org/fellow.php
o https://apps.acgme.org/ads/Public/R...&SpecialtyId=89&IncludePreAccreditation=false

Sleep Medicine
- good fellowships will be multidisciplinary including exposure to parasomnias, dyssomnias, CBT-i, sleep lab technology, reading PSGs, MSLTs, actigraphy, MWT, nasal endoscopy, and work with adults and children
- psychiatry friendly programs: Dartmouth, Pittsburgh, Thomas Jefferson, Stanford, BIDMC
- become very uncompetitive now due to cut reimbursements, mostly IMGs
- limited jobs for psychiatrists L
- More info:
o https://apps.acgme.org/ads/Public/R...SpecialtyId=145&IncludePreAccreditation=false
o http://www.nrmp.org/fellowships/sleep-medicine-match/

Pain Medicine Fellowship
- good fellowships offer comprehensive multidisciplinary pain management including exposure to MBSR, CBT, biofeedback, acupuncture, and multiple procedures (nerve blocks, epidurals, regional anesthesia, annuloplasty, nucleoplasty, joint injections)
- More info:
o http://www.painrounds.com/index.php?option=com_content&task=view&id=11&Itemid=0
o https://apps.acgme.org/ads/Public/R...SpecialtyId=152&IncludePreAccreditation=false

Hospice and Palliative Medicine Fellowship
- good fellowships should be multidisciplinary
- most highly regarded programs include: Harvard, UCSF
- More info:
o https://apps.acgme.org/ads/Public/R...SpecialtyId=153&IncludePreAccreditation=false
o http://aahpm.org/career/clinical-training

Brain Injury Medicine Fellowships
- good programs will provide training in acute trauma, inpatient, subacute, outpatient, spasticity
- most highly regarded programs: JFK medical center, Harvard/Spaulding
- prefer physiatrists but can consider psychiatrists
- more info:
o http://www.physiatry.org/blogpost/1205353/219380/FELLOWSHIP-OPPORTUNITIES-BRAIN-INJURY-MEDICINE https://apps.acgme.org/ads/Public/R...SpecialtyId=373&IncludePreAccreditation=false

Addiction Medicine Fellowship
- Different to addiction psychiatry, open to all specialties (multidisciplinary) – often physician in recovery
- More info:
o http://www.abamfoundation.org/wp-co...MF-Accredited-Fellowships-2016-17-3-31-16.pdf
o https://apps.acgme.org/ads/Public/R...SpecialtyId=152&IncludePreAccreditation=false

Public Psychiatry Fellowship
- may be able to fast-track as a PGY-4
- most highly regarded program: Columbia
- UCSF allows psychiatrists to audit the didactic component
o More info: http://www.communitypsychiatry.org/pages.aspx?PageName=Public_and_Community_Psychiatry_Fellowships
o http://ppf.hs.columbia.edu/

Behavioral Neurology/Neuropsychiatry Fellowship
- accredited through UCNS, not ACGME or ABMS
- some only open to neurologists (e.g. UCLA)
- most highly regarded: Brigham and Women’s, MGH, UCSF, Hopkins, UIC, Baylor
- often need to apply halfway through PGY-3 year
- many are two years
- more info:
o http://www.anpaonline.org/ucns-fellowships
o http://www.ucns.org/go/subspecialty/behavioral/accreditation

Headache Medicine Fellowship
- accredited through UCNS, not ACGME or ABMS
- only some open to psychiatrists – you will have to inquire within
- more info:
o https://www.ucns.org/go/subspecialty/headache
o http://www.americanheadachesociety.org/residents_fellows_students/fellowship_opportunities/
o http://www.nrmp.org/fellowships/headache-medicine/

Clinical Neurophysiology/Epilepsy Fellowship
- technically open to psychiatrists but only a few will actually accept
- more likely for researchers
- more info:
o https://www.aan.com/uploadedFiles/Website_Library_Assets/Documents/4.CME_and_Training/2.Training/3.Fellowship_Resources/3.How_to_Apply_for_a_Fellowship/Clinical Neurophysiology Fellowship FAQ.pdf
o https://apps.acgme.org/ads/Public/R...&SpecialtyId=38&IncludePreAccreditation=false
o https://apps.acgme.org/ads/Public/R...SpecialtyId=365&IncludePreAccreditation=false

Preventive Medicine Residency/Fellowship
- most highly regarded: Harvard, Emory, Hopkins, UCSF (?now defunct)
- More info:
o https://apps.acgme.org/ads/Public/R...&SpecialtyId=84&IncludePreAccreditation=false
o http://www.acpm.org/?GME_MedStudents

Occupational and Environmental Medicine Fellowship
- psychiatric disorders are now the biggest cause of occupational related disability
- most highly regarded: Harvard, Hopkins, UCSF
- More info:
o http://www.aoec.org/training.htm
o https://www.acoem.org/uploadedFiles/What_is_OEM/ACOEM Residency Program Showcase.pdf

Medical Genetics Residency/Fellowship
- open to all specialties
- more info:
o http://www.abmgg.org/pages/training_accredprog.shtml
o https://apps.acgme.org/ads/Public/R...&SpecialtyId=17&IncludePreAccreditation=false

Other Clinical Fellowships
- Women’s mental health
o NYU: http://www.med.nyu.edu/psych/education/fellowship-training/womens-mental-health-fellowship
o Brown: https://www.brown.edu/academics/med...dphb/womens-mental-health-fellowship-overview
o Brigham and Women’s Hospital: http://www.brighamandwomens.org/dep.../fellowship/womensmentalhealthfellowship.aspx
o Keck/USC: http://keck.usc.edu/Education/Acade...Training/Womens_Mental_Health_Fellowship.aspx
o UIC: http://www.psych.uic.edu/education/women-s-mental-health-training

- Neuromodulation/Brain Stimulation
o MUSC: http://academicdepartments.musc.edu/psychiatry/education/res_fell/brain/brain
o University of Florida: http://psychiatry.ufl.edu/training/fellowships/neuromodulation-fellowship/

- Eating Disorders Fellowship
o Rosewood Ranch: http://www.rosewoodranch.com/eating-disorder-and-obesity-medicine-fellowship/
o Sheppard Pratt: http://eatingdisorder.org/employment-opportunities

- Psychoanalytic Psychotherapy Fellowship
o Cambridge Health Alliance: http://www.challiance.org/Academics/PsychotherapyTrainingOverview.aspx
o Austen Riggs: http://www.austenriggs.org/fellowship

- UW Integrated Care Fellowship: https://sharepoint.washington.edu/uwpsychiatry/Education/Pages/IntegratedCareFellowship.aspx

- Emergency Psychiatry Fellowship (not really sure what the point is):
o Kaiser: http://residency-ncal.kaiserpermane...sychiatry-fellowship/#application-information
o Columbia: http://columbiapsychiatry.org/fellowships/Emergency-Psychiatry

Clinical Informatics Fellowships
- Stanford: http://systemsmedicine.stanford.edu/education/CI-Fellowship.html
- UCLA: https://www.uclahealth.org/Pages/Clinical-Informatics-Fellowship.aspx
- VA: http://www.va.gov/oaa/specialfellows/programs/sf_medicalinformatics.asp
- BIDMC: http://www.bidmc.org/MedicalEducation/Departments/Medicine/Divisions/ClinicalInformatics.aspx
- OHSU: http://www.ohsu.edu/xd/education/sc...nal-programs/clinical-informatics-fellows.cfm
- Mayo Clinic: http://www.mayo.edu/msgme/residenci...ogy/clinical-informatics-fellowship-minnesota

Transgender Psychiatry Fellowship
- Mount Sinai: www.icahn.mssm.edu/education/residencies-fellowships/list/transgender-psychiatry-fellowship

Research Fellowships (not exhaustive)
- VA MIRECC fellowships: http://www.mirecc.va.gov/mirecc_fellowship.asp
- RWJ Health and Society Scholarship: http://www.healthandsocietyscholars.org/
- National Clinician Scholar Program: http://www.nationalcsp.org/
- Columbia Global Mental Health Fellowship: http://www.cugmhp.org/education-training/gmh-t32-research-fellowship/
- MGH Global Psychiatry Research Fellowship: http://www.massgeneral.org/psychiatry/education/fellowship.aspx?id=189
- UW Primary Care Psychiatry Fellowship: https://sharepoint.washington.edu/u...es/Psychiatry-in-Primary-Care-Fellowship.aspx
- UW Geriatric Mental Health Service Research Fellowship: https://sharepoint.washington.edu/u...ntal-Health-Services-Research-Fellowship.aspx
- UNC Eating Disorders Fellowship: http://www.med.unc.edu/psych/eatingdisorders/research eating disorders
- Johns Hopkins Clinical Research Fellowship in Eating Disorders:
http://www.hopkinsmedicine.org/psychiatry/specialty_areas/eating_disorders/fellowship.html
- Pharmaceutical Psychiatry Fellowship: http://www.advancedclinical.com/position/436858

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[wolfvgang22]

Super nice write up!

 

[MacDonaldTriad]

"not ready to grow up and want an additional year to figure it out"

This is why 99% of fellows do a fellowship.

 

[freudianslipp]

Great Post. I had a question about logistics of forensics applications...

Since the forensic fellowships are not match based, I'm wondering how many programs I should actually apply to and how to gauge how competitive you will be for programs. What's the general advice on how many programs you should apply to and how to know if you need to apply to more if you're not getting interviewed, etc. I'm assuming that it would be a bad idea to apply to very many just in order to cast a wide net, but by the same token if I were dead set on doing a forensics fellowship and wasn't getting love from the top programs, I would consider expanding my interest in other programs or in locations that were not most desirable.

 

[splik]

it looks like you're still a med student. so you shouldn't even be thinking about this for another 2-3 years. as someone has already pointed out, this thread is already out of date and i've just posted it. too far away to give you any sense. forensic fellowships tend to be quite unstable and are very personality-dependent too so it's not clear which will be around and who will be running them. Resnick has said that he'll retire next year (but he's been saying that for years) and Zonana is getting on a bit too so who knows how long he will be around for.

 

[HarryMTieboutMD]

One comment about addiction fellowships- most AAAP fellowships ("addiction psychiatry") are run through VAs, whereas ABAM fellowships ("addiction medicine") are not. And addiction treatment in the VA is different (for a lot of reasons) than in the general population.

Truthfully, I find doing a clinical addiction psychiatry fellowship after residency very difficult to rationalize. What other major skills is one going to learn that can't be taught in a psychiatry residency? Detoxing, dosing buprenorphine, motivational interviewing, cbt etc are all basics of psychiatry. Methadone is much more dangerous and complicated to use, but one can gain experience by doing an elective month at an MTD clinic during residency. Some ABAM fellowships might have more training on how to do icu type detoxing (running Ativan ggts, precedex dosing, etc) and exposure to the end stage medical sequelae of substance disorders (endocarditis, de compensated hepatorenal, etc), but again, one could do an elective MICU month. And ABAM fellowships should offer formal training on how to use the ASAM criteria when doing an evaluation for treatment, but this can be learned through reading or taking one of David Mee Lee's seminars (he might have videos too).

And if you want an academic career, you are much better off doing a research post doc with a big name mentor.

 

[Blitz2006]

This is amazing post. Why is this not stickied?

I'm pretty sure this post has given me more info on fellowships than what I'll receive from my program over the 4 years.

Thanks!

 

[notdeadyet]

This is amazing post. Why is this not stickied?!

Because it's about 48 hours old?

I'm pretty sure this post has given me more info on fellowships than what I'll receive from my program over the 4 years.

Splik is like that.


Sent from my iPhone using Tapatalk

 

[JamesPhilly]

wow this is really helpful, thank you

"- allow you to “move up” to a more prestigious training program"

I don't doubt this is a reason some people do fellowships, but this seems like the silliest reason to pursue more training. Like, "Geri could be my ticket to MGH!" All the psychiatrists I've talked to have said that no-one cares where you did residency, and that the lay public tends to focus on where you went to medical school, if anything.

 

[clausewitz2]

wow this is really helpful, thank you

"- allow you to “move up” to a more prestigious training program"

I don't doubt this is a reason some people do fellowships, but this seems like the silliest reason to pursue more training. Like, "Geri could be my ticket to MGH!" All the psychiatrists I've talked to have said that no-one cares where you did residency, and that the lay public tends to focus on where you went to medical school, if anything.

Unless of course you want an academic career, in which case name-dropping is a bloodsport.

 

[notdeadyet]

All the psychiatrists I've talked to have said that no-one cares where you did residency, and that the lay public tends to focus on where you went to medical school, if anything.

What's important is your last position.

Undergrad can be important when you're applying to grad schools. After that, no one cares. Medical school can be important when you're applying to residency. After that, no one cares. And so on.

After you get your first job, your last job trumps everything else. If you went to Columbia for undergrad, Yale for medical school, MGH for residency, then worked as NYU faculty for three years, then worked for Kaiser for three years, when you start work at your new place, you're "the guy/gal from Kaiser." The only exception to this is if you're the person who namedrops ("when I was at Harvard"). Then you become "the guy/gal who always tells everybody s/he went to Harvard." Don't be that guy/gal.

As for the lay public, they tend to focus on what you tell them. And namedroppers will inevitably drop the biggest name. You will hear people say "I went to medical school at Columbia," if they went to Acme County Mental Health for residency, even though Acme County has 20X the impact on the type of psychiatrist/physician you've become. If the namedropper went to University of Backwater Falls for medical school and Hopkins for residency, get ready to hear "I trained at Johns Hopkins" a lot.

 

[freudianslipp]

it looks like you're still a med student. so you shouldn't even be thinking about this for another 2-3 years. as someone has already pointed out, this thread is already out of date and i've just posted it. too far away to give you any sense. forensic fellowships tend to be quite unstable and are very personality-dependent too so it's not clear which will be around and who will be running them. Resnick has said that he'll retire next year (but he's been saying that for years) and Zonana is getting on a bit too so who knows how long he will be around for.

Fair enough splik, I was just trying to get a sense of how people go about applying for the fellowships and how many they tend to apply to. How many did you apply to for instance? Since the forensics fellowship is not through the match, once you apply for the fellowships, and they interview you and give you an offer, do you have to reply very quickly with an answer, or can you wait to see all the fellowships you've been accepted to and then choose?

If you have to answer quickly, it seems you would ONLY want to apply to programs that you really want to go to and in locations that are ideal. Then perhaps if you don't get into those, you can widen your applications to other programs that you might not have considered initially.

 

[splik]

Fair enough splik, I was just trying to get a sense of how people go about applying for the fellowships and how many they tend to apply to. How many did you apply to for instance? Since the forensics fellowship is not through the match, once you apply for the fellowships, and they interview you and give you an offer, do you have to reply very quickly with an answer, or can you wait to see all the fellowships you've been accepted to and then choose?

If you have to answer quickly, it seems you would ONLY want to apply to programs that you really want to go to and in locations that are ideal. Then perhaps if you don't get into those, you can widen your applications to other programs that you might not have considered initially.

technically you have until 30th october - according to the ADFPF guidelines. however if you wait too long you might find someone else takes it. overall fellowships in psych including forensics are not competitive. even now almost 50% of forensic fellowships have openings for july! (assuming the AAPL website is correct). if you just want to do a forensics fellowship anywhere becsause you just want to do the training and become a better psychiatrist (and there are some pretty decent ones like colorado, NYU, AECOM, Emory that didn't fill) you're all good. if you actually want to become a major player in the field and have a successful forensics practice then you will want to train with one of the forensic psychiatry leaders. in my experience most of the people who wanted to go a specific program only interviewed at that program, sometimes doing an away rotation there as a PGY-3. some people who were less sure maybe interviewed at 3-5 programs. I'm sure there are people who do more than that. Basically if you apply you would probably receive an interview (assuming they dont take all internal candidates). Phil Resnick said "we review the applications and any one who can speak english we invite for interview". obviously depending on your competitiveness and factors outside of your control (like internal applicants), you may want to apply to more programs.

 

[Blitz2006]

With with regards to interviews/vacation time.

I know it depends on the fellowship, but roughly how many interviews should I go for? Is this like residency where I am aiming for 8-10 interviews?

I'm an IMG, and am planning on applying to Pain and/or Sleep. How many interviews should I 'gun' for to assure matching? I understand this is subjective, but generally?

I'm wondering because my program isn't giving me that many days for interview days, so I might have to set aside some vacation time....

thanks,

 

[splik]

that sucks - hopefully you will warn all applicants that they won't be able to get time off for interviews if they come to your program. hell even the plastic surgery residents at my institution are allowed unlimited days for interviewing for jobs/fellowship... will they let you use your sick leave? or take unpaid time off (which is pretty sucky)? presumably how many interviews you go on depends on how many interviews you are offered? and how many programs you apply to. you might be better off posting on the pain or sleep forums. sleep is not competitive its almost entirely IMGs now (and being an IMG is largely irrelevant at the fellowship level), but you probably want to be applying to a ton of programs for pain in undesirable locations away from the coast unless you have a ton of pain publications

 

[scudiera]

Great thread! Thank you so much for putting this together

 

[moedog45]

This posting is absolutely fantastic. I do have one question: how important are medical school grades for attaining a psychiatry fellowship? I was surprised to learn that many psychosomatic fellowship programs require your dean's letter for the application and while my grades aren't terrible (no failures, Honors in psych, neuro and related psych-neuro electives), they're not particularly great either. Any thoughts on how significantly this could impact one's competitiveness?

 

[Bartelby]

This posting is absolutely fantastic. I do have one question: how important are medical school grades for attaining a psychiatry fellowship? I was surprised to learn that many psychosomatic fellowship programs require your dean's letter for the application and while my grades aren't terrible (no failures, Honors in psych, neuro and related psych-neuro electives), they're not particularly great either. Any thoughts on how significantly this could impact one's competitiveness?

I think it would have very little impact. If there was a large red flag (like repeating a year) then maybe, but 'meh' med school grades probably will not factor into the decision at all. They really care about how you did in residency.

 

[Mapplicant]

Great information. Stumbled upon this while poking around for neuromodulation fellowships. Looks like northwestern also has a neuromodulation fellowship as well.

My current attending is pushing me to do a fellowship. I was thinking of not doing any and so PGY3 just cruised through the outpt, and not really did much elective or prepare much. Not interested much in CAP at all. So deciding between geri vs forensic vs neuropsych/neuromodulation

Any general career advice on fellowship path? Most of the stuff can be done without fellowship, especially addiction/geri/some child/etc. But in the next 20-30 years could psych go down the track of what path is today (where every resident essentially needs fellowship to get a job) and segmentation of the subspecialities call for fellowship training?

I see geri being a growing population (obviously), forensic would mostly be just cognitively interesting, neuromodulation may be the future of psych as all the current interventionalist methods translate into widespread clinical use (fMRI, MRS, PET, EEG, ECT, TMS, DBS, tDCS, etc.)

 

[splik]

Great information. Stumbled upon this while poking around for neuromodulation fellowships. Looks like northwestern also has a neuromodulation fellowship as well.

My current attending is pushing me to do a fellowship. I was thinking of not doing any and so PGY3 just cruised through the outpt, and not really did much elective or prepare much. Not interested much in CAP at all. So deciding between geri vs forensic vs neuropsych/neuromodulation

Any general career advice on fellowship path? Most of the stuff can be done without fellowship, especially addiction/geri/some child/etc. But in the next 20-30 years could psych go down the track of what path is today (where every resident essentially needs fellowship to get a job) and segmentation of the subspecialities call for fellowship training?

I see geri being a growing population (obviously), forensic would mostly be just cognitively interesting, neuromodulation may be the future of psych as all the current interventionalist methods translate into widespread clinical use (fMRI, MRS, PET, EEG, ECT, TMS, DBS, tDCS, etc.)

fMRI, MRS, PET are imaging modalities not interventions and EEG is a neurophysiological technique not an intervention. ECT is in terminal decline and I dont think we are going to see much in the way of a resurgence. It has a bad reputation (whether fair or not) and a lot of vocal people who were harmed by it, as well as mental patient liberation groups, scientologists, and antipsychiatry groups have kept the controversy alive. The other aspect is that it doesn't pay. The main way a hospital makes money off ECT is by keeping their inpatient unit full of patients (which gives a perverse incentive to do ECT inappropriately on patients as insurance companies do not fight longer hospitalizations if you do ECT). However medicaid is pretty sucky and even medicare and private insurances do not reimburse very well of it (the anesthesiologists do alright off it, not so much the psychiatrists). Similarly the largest DBS study for depression was stopped by St Jude medical early because it was clear it didn't work and is a money loser. It is a superspecialist treatment, and I had high hopes for it, but the results for affective disorders have been pretty disappointing (and it's expensive and cognitive disorders and structural brain disease are exclusions). tDCS has been around for a little while now and likely the current is just too low to be of any meaningful use in the treatment of mental disorders. It may have other uses outside of psychiatry, but I would not bet any money on it influencing psychiatric practice.

rTMS has the most promise out of the ones you mentioned, but not because of efficacy, but because there is a new device that is much cheaper to use and more insurance companies (including the federal employees plan and medicare in some parts of the country, but not others) are paying for it. Even the VA will fee-service out for it. The price of treatment has been freefalling the past few years (though the patient base has expanded so this might be an overall net positive). So I think we will see it being used more often, particularly in private practice. Academic medical centers for the most part have been too stupid to make any money off it (it's not really cost-effective for the psychiatrist to do the TMS when doing evals pays more money, they only need to calculate the RMT and make adjustments as needed).

Psychiatrists are not going to have to do fellowships in order to get jobs. The dearth of psychiatrists is only getting greater. If we could actually convince more psychiatrists to see mentally ill people then we might get somewhere but a generalist who is confortable with a large age range, working in diverse settings, and treating comorbid substance use disorders is really best equipped to survive in the world.

Also it is not right to conflate neuromodulation/brain stimulation with neuropsychiatry. as a neuropsychiatrist i objection to the co-option of the term by the brain stimulation people to lend some credibility to the field or to try and rebrand psychiatric disorders as brain disorders. Some neuropsychiatry fellowships will include training in TMS and ECT but may will not. Neuropsychiatrists treat psychiatric manifestations of neurological disease, as well as neurological manifestations of psychological disturbance. ECT is certainly an important part of the therapeutic armamentarium of the neuropsychiatrist, though I think it would be hard to argue that some of these other new fangled treatments are.

You shouldn't do a fellowship because people are pushing you to do it, or because you think that you have to (that is almost certainly not the case), but because you really want to and are willing to further delay gratification and lose 150-200k+ in doing so

 

[Mapplicant]

Thanks for those thoughts. Interesting that you do not like neuropsychiatry to be lumped into the "interventional" psychiatrists. My dept chair is VERY adamant in that ALL psych disorders are brain disorders and that biologically-based imaging and interventions will be the future of the field...where psychiatrists will come in, order the approrpiate tests (EEG, fMRI, MRS, etc.) and then apply the intervention (ECT, TMS, etc.) and then go home after seeing a days worth of patients and drive in a Maserati to the country club for golfing.

 

[splik]

Thanks for those thoughts. Interesting that you do not like neuropsychiatry to be lumped into the "interventional" psychiatrists. My dept chair is VERY adamant in that ALL psych disorders are brain disorders and that biologically-based imaging and interventions will be the future of the field...where psychiatrists will come in, order the approrpiate tests (EEG, fMRI, MRS, etc.) and then apply the intervention (ECT, TMS, etc.) and then go home after seeing a days worth of patients and drive in a Maserati to the country club for golfing.

sounds like your chair needs some ECT and clozapine himself and maybe and FDG-PET scan and MRI to r/o bvFTD!

 

[SeniorWrangler]

Just a note: addiction medicine just became a multispecialty boarded subject through the board of Preventive Medicine, sometime in 2017 they will announce criteria for a practice pathway so you can grandfather in to addiction medicine boards without doing a fellowship for five years after that.