Big Decision

[RamblinMan]

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I'm having a hard time working this out.... I'm going to be a psychiatrist, no doubt about that... the question is how to decide if I should do a combined psyc/FM residency (5 years) or a pure psyc residency. My feeling is that I would prefer to do psyc on a day to day basis in the future but it would be nice to have the option of integrating FM, having the option of doing more FM if I get burned out at some point, and having an enormous amount of practice options when I complete residency.

I wonder if I could hear some thoughts on any of these concerns:
- What do you see as the role of the dual psyc/FM boarded doc?
- Do any of you ever wish that you could practice general/FM years out of residency?
- Do you know anyone that is dual boarded and what has their experience been?
- Do you think that there will be holes in my psychiatric skill set if I choose a combined program?
- I also have dreams of doing global health work at some point.... do you think I would be giving this up if I don't include a medicine component?

Thanks for any thoughts, I'm doubtful that this decision will become easier but maybe some more insight will help, I got a couple weeks before match list deadlines.

 

[cookymonster]

You're probably going to get a biased perspective on this forum. My take is that if you're even agonizing over this decision, you should just do a categorical psych residency. The combined programs IMO aren't a good fit unless you equally love both fields. If you really prefer to do psych on a day-to-day basis, chances are, you're going to hate slaving away in the ICU and on L&D if you're uncertain that you're learning much that's applicable to your practice.

You'll have to learn an enormous amount of adult medicine, pediatrics, obstetrics, and psychiatry over five years. I think you're far more likely to burn out attempting that than get burned out on psychiatry alone (especially if that's where your strongest interest resides).

I'm not the best person to answer your questions on how dual-boarded physicians craft their careers, but as someone who strongly considered a combined residency, that's what ultimately made me decide against it. It's a huge decision, so choose wisely.

 

[dca_55]

I'll agree with cookymonster on this one....that you are going to get a biased perspective. I was in a similar position this time of year as a 3rd year and felt on the fence between FM and Psych, but through my first few rotations in 4th year I realized that my love for psych was stronger than FM. I had mental images of myself in a combined program of dreading some of my non-psych rotations and just wanting to do psych more, so that was the rational for just applying to psych. There's not a lot of dually boarded FM/Psych people that I could find to talk to, so it was difficult to get advice and truly know what people do with the combined certification. One of my advisors used to help run a IM/Psych program, and he told me that the graduates ended up doing one or the other as opposed to truly integrating both. I think that's a major issue for the combined field, but if you have a somewhat clear vision of how you want to integrate the two, doing a combined program can be a great opportunity and a unique experience. I think doing the combined program so you have backup training in FM in case you get burned out in Psych might not be the best reason. In my mind if you practiced Psych for 10+ years and then all of a sudden get burned out, are you going to feel comfortable enough to switch to FM considering you did your training in it so long ago? (Granted you may use and practice varying amounts of medicine being a psychiatrist, but i think it's still pretty different) Plus, I think every so often you have to take board exams for certification (at least I think for FM it's every 7 or 10 years), so if you end up not truly using both, you may end up having a hard time maintaining certification in the field youre not practicing in (again, this is an assumption I'm making as a med student).

You should probably think about maybe contacting some of the programs to learn more about what dually boarded FM/Psych doctors do? From what I remember I think the UCSD program does a 4th year elective that might be a good idea to check out.

 

[whopper]

Those I've seen who've done more than one area tell me they felt they would have mastered multiple fields, but in reality haven't been able to master one. It may have been an indvidiual thing with that person, or with the specific program. Unfortunately it's not as if I've talked to dozens in this situation, just a handful.

- What do you see as the role of the dual psyc/FM boarded doc?

I would see it (at least if I were one) as being able to be a PCP that could also very well provide for the psychiatric needs of my patients to a degree that a FM doctor could not--e.g. treating severe depression that is treatment resistant. Yet at the same time being able to also treat the patient's physical health. I would attempt to exploit the mind-body interactions.

- Do any of you ever wish that you could practice general/FM years out of residency?

No. I do actually do some pseudo PCP if you can call it that. Several times my patients, even with a PCP, have a medical issue that's not being addressed by their PCP. I notice it, and I have to leave a phone call to the PCP so I can write in the patient's chart that I at least attempted to deal with the issue within my boundaries.

E.g. cholesterol is over 250, and the PCP, for several years never started an statin; patient is on birth control but also smokes, and the PCP still gives out the birth control.

I've been in the uncomfortable position where my patient's medical needs were not being met by their PCP, and I knew it, but could only tell them to consider a second opinion from another PCP.

- Do you know anyone that is dual boarded and what has their experience been?

As I mentioned above, I sometimes hear a colleague say they feel they have not mastered a field to the degree they would have if they just picked one field.

- Do you think that there will be holes in my psychiatric skill set if I choose a combined program?

I think it would depend on the program and your own skills. If possible, I think asking a number of dual boarded psychiatrists (with the additional board in FM or IM or Peds) this question.

- I also have dreams of doing global health work at some point.... do you think I would be giving this up if I don't include a medicine component?

Unfortunately I can see this as a possibility. In many areas outside the U.S., especially in non first world countries, physical needs always trump the psychiatric. I don't know exactly what you plan on doing with global health, but if its for third world countries, I would expect them to want someone with more medicine training than the traditional psychiatrist. I don't have much experience in this field, but I do know a few people who do practice outside the U.S. to 3rd world countries including some psychiatrists, and those psychiatrists are for the most part used for their non-psychiatric medical skills.

 

[michaelrack]

there are several old threads in this forum and the combined residency forum talking about fm/psych or med/psych- often both in one thread:

http://forums.studentdoctor.net/showthread.php?t=472064

 

[Red Beard]

- I also have dreams of doing global health work at some point.... do you think I would be giving this up if I don't include a medicine component?

This is the one sticking point for me too, and I am having a REALLY hard time choosing between IM and psychiatry because of it---meanwhile, rank list is due in less than 2 weeks 😕

The practice of psychiatry in most locations in the country is very appealing to me, but I wouldn't be able to practice comfortably in the isolated town that we may want to live in down the road, and would not have useful skills to offer if I wanted to volunteer internationally. I am also much more attracted to the culture and colleagues I would have in psychiatry.

IM on the other hand looks 'ok' to me, but being a hospitalist or outpatient doc as exists in this country could be a real slog...I love the medicine and working in the room with the patients but HHHHAAAAAAAAAAATTTTTTTTTTTTTTTTEEEEEEEEEE being in the center of coordinating care/navigating the bureaucracy of our medical system. Would love being a clinician in that isolated town down the road and the ability to go anywhere in the world and offer my skills.

So I guess I am not helping you out, but certainly empathizing with part of your dilemma.

 

[RamblinMan]

Thanks for the responses, I definitely appreciate the insights. I sometimes envy those who are solidly behind one specialty. This process of deciding what to practice has not been easy for me... so many things to take into consideration.

Sounds like Red Beard and I are in the same boat.... I like what I can do with the medical skills, the applications, but I'm wondering just how easy or realistic it is to integrate both skill sets into practice... I have heard that insurance companies usually force you to choose one or the other... If I had to choose, it would more likely be psyc

I'm also concerned, as was mentioned above, that if I had to choose one or the other after completing residency, I would lose within a few years the skills I had acquired in the other specialty.

Appreciate the responses, just writing about this dilemma is helping me to organize my thoughts and work it out.

 

[nancysinatra]

No. I do actually do some pseudo PCP if you can call it that. Several times my patients, even with a PCP, have a medical issue that's not being addressed by their PCP. I notice it, and I have to leave a phone call to the PCP so I can write in the patient's chart that I at least attempted to deal with the issue within my boundaries.

E.g. cholesterol is over 250, and the PCP, for several years never started an statin; patient is on birth control but also smokes, and the PCP still gives out the birth control.

I've been in the uncomfortable position where my patient's medical needs were not being met by their PCP, and I knew it, but could only tell them to consider a second opinion from another PCP.

Do you think that a neurologist would feel the same "boundaries" about not prescribing cholesterol medications or OCPs for their patients as you do as a psychiatrist? I kind of think they wouldn't, but they don't rotate for THAT much more time than we do on internal medicine. Several months more, but that's about it, if I'm correct.

I am just curious about this. Do family practice or IM residents rotate through psychiatry at all? They are the ones prescribing most of the SSRIs in this country, and they're known to continue mood stabilizers too, but a psychiatrist can't prescribe an antihypertensive or a cholesterol lowering drug without it being a "boundary violation?" How does all this stuff get monitored, by the way? A surgical problem wouldn't default to IM or FM... but psych stuff does? So then why shouldn't some of their stuff default to us? We train for half of our intern year in their programs.

 

[235750]

Plus, I think every so often you have to take board exams for certification (at least I think for FM it's every 7 or 10 years

It's every 7 years, and that alone would make me reconsider being double boarded. That seems like a lot of extra work/money/time for an option that you think you might take advantage of.

I do understand your hesitance to do just psych. I've followed psychiatrists who have forgotten a lot of basic medicine, and it scares me. I don't think the answer is to complete another residency. Instead, just consider taking some really good CMEs and make an effort to keep your knowledge up. If you don't use it, you lose it

I also have dreams of doing global health work at some point.... do you think I would be giving this up if I don't include a medicine component?

I'm with Whopper on this one. I used to recruit MDs/RNs for a charity that did medical missions in less economically developed counties, a bit like doctors without borders. These were the doctors we wanted, listed from most helpful to least. Psych was not considered to be eligible

OBGYN >>>>>>>>> ID (tropical med/HIV,etc) >>>> general surgery > EM/FM/peds/IM

 

[nancysinatra]

I used to recruit MDs/RNs for a charity that did medical missions in less economically developed counties, a bit like doctors without borders. These were the doctors we wanted, listed from most helpful to least. Psych was not considered to be eligible

OBGYN >>>>>>>>> ID (tropical med/HIV,etc) >>>> general surgery > EM/FM/peds/IM

Whenever I have looked into international medical positions, the most sought after physicians are surgeons and anesthesiologists, so I'm a bit surprised by your ranking. ID might be intellectually useful, but I don't know that you actually would need to have that fellowship level expertise to go abroad unless you're investigating an unusual outbreak or new disease. For garden variety infectious disease I would think IM or peds would be fine. Yeah I could be wrong but this is what I've seen posted when I've looked...

There is also the World Health Organization and other similar institutions. Depression, bipolar disorder and substance abuse are among the most disabling and common conditions in the world and in the past I have noticed public health type postings for mental health professionals overseas.

 

[235750]

Whenever I have looked into international medical positions, the most sought after physicians are surgeons and anesthesiologists, so I'm a bit surprised by your ranking

If you look at positions on doctors w/o borders, they pretty much mirror my list. As that page shows, ID docs are like gold, we certainly never had enough of them.

Surgeons and anesthesiologists are great, but if you look at what people are dying of in third world countries, the main concerns are due to with infectious disease and child birth. Our goal, shared by most other medical charities, is to have the greatest impact per provider, and that means TB pros and as many OBs as we could get.

We used CRNAs for the most part, as I think most organizations do. NPs were big too

I should have specified when I posted that list: the demand for different physicians will depend on the organization. Operation smile has a very clear agenda, for example.

 

[notdeadyet]

RamblinMan-

I'm currently considering doing FP/Psych, though more set on just Psych.

FP/Psych is a small field, without that many folks going into it, so keep in mind that you won't find many folks who did it. A place like SDN's psych forum is bound to have more folks who ruled out FP/Psych than opted for it.

I'd strongly suggest contacting some of the FP/Psych programs and asking the folks if you could get in touch with some of their residents. I did this and found it valuable. Talking to the faculty was helpful too.

- What do you see as the role of the dual psyc/FM boarded doc?

Frankly, the most compelling roles I've heard are from people who want to do the true primary care or academic medicine.

The scope of practice for an FP/P isn't any different from an FP, just with more training in psych (to answer nancysinatra's question, some FP programs you can get through without any significant psych training).

For the option of academic medicine, I'm a little less convinced, as most seem to work both primary care and psych clinics. Some academic spots have specific psych/med clinics, where you folks who have significant physical/mental health issues are referred. But on the inpatient side, I haven't been as impressed, as they often seem to get pretty good care by the internal medicine team with C/L psychiatry taking care of the mental health issues.

- Do any of you ever wish that you could practice general/FM years out of residency?

If your intent is to just be a psychiatrist and keep FP in your pocket in case you get burned out, you'd probably be better off taking a year to do a fellowship in something you're passionate about or just carefully construct your career to avoid burnout.

If you're not planning on working on both the Psych and FP side throughout your career, a joint residency just doesn't seem worth it.

- Do you know anyone that is dual boarded and what has their experience been?

Mostly happy, from the folks I've talked to. Again, I'd contact the residency programs you're interested in.

- Do you think that there will be holes in my psychiatric skill set if I choose a combined program?

Some. This is my concern. You have a lot less elective time in a combined program, by definition. This is one worry of mine. Several Psych/PF folks I've talked to were concerned that they didn't have as much psychotherapy training as their Psych counterparts

Thanks for any thoughts, I'm doubtful that this decision will become easier but maybe some more insight will help, I got a couple weeks before match list deadlines.

If you actually interviewed at these places, did you ask these same questions? If not, I'd contact the programs you're thinking of ranking and ask to speak to some of the residents.

Another big thing to try to get a handle on is find out if there's an "orphan effect." Some of the Psych/FP programs have a problem with the residents being sort of shared entities but not really belonging to either, which can results in them getting the short end of the stick. You want to be sure that the program has strong leadership dedicated to Psych/FP that will be making sure you're represented.

 

[notdeadyet]

Do family practice or IM residents rotate through psychiatry at all?

Most FP programs I looked at, psych is an elective, but not a requirement. Most FP residents and attendings I spoke to strongly recommended FP residents take psych electives because psych issues (though often not as the CC) are a big part of most practices. You'd think it would be required, wouldn't you?

A surgical problem wouldn't default to IM or FM... but psych stuff does?

Most FP's I know limit their psych scope to depression and refer anything other than that. And the FP's I've chatted to about the subject have said they'd be comfortable referring out the depression, but there's a shortage of psychiatrists in most places. Good for us, not so good for the patients.

 

[psychotrope]

I'm having a hard time working this out.... I'm going to be a psychiatrist, no doubt about that... the question is how to decide if I should do a combined psyc/FM residency (5 years) or a pure psyc residency.

if you do a 5 year combined program, do psych-IM.....I've had people tell me that psych-IM is great if you eventually want to work CL or you want to work an inpatient unit with some geri pts.

Of course, the best answer is just to do psych.

 

[billypilgrim37]

I have five friends at 3 different programs doing combined fp-psych, and the ones that seem happiest are the ones who wanted to do family from the beginning, realized that they really liked psychiatry, and thought that having substantial psychiatric training would allow them to do the sort of family medicine work they wanted to do.

I think if you're starting at psych, and thinking of expanding into fp/psych, then you are setting yourself up for frustration and redundancy.

 

[masterofmonkeys]

I struggled with this decision too quite a bit because I'm very general medically minded.

But then I realized that all sorts of non primary care docs handle general medical issues all the time. Surgeons, at least where I went to medical school, did no go screaming at the first sign of medical complexity to get a medicine consult for managing HTN, nonsurgical infxns, whatever.

Why do we have to?

There are certainly some practical issues there (medical malpractice insurance for one), no denying that.

But in the end, an MD really should mean something, like basic competence in medical issues. I decided I didn't need another couple of years of residency for that. Just a conscious effort to stay on top of my general medical knowledge and ability. Don't forget, we get more training in medicine than they do in psych lol. Yet 30% of what they do is psych (in the PCP environment).

 

[whopper]

Do you think that a neurologist would feel the same "boundaries" about not prescribing cholesterol medications or OCPs for their patients as you do as a psychiatrist?

I'm not so sure. The reason why I will not touch a non-psychiatric medical issue is because my insurance tells me not to do so. I use the APA recommended insurance. I imagine that most insurance companies will tell psychiatrists the same. I don't know if the same applies to neurologists.

It's frustrating. A woman over 30 is not supposed to be on birth control if she smokes, yet the PCP keeps giving it out. I've already seen a patient die from their PCP not realizing this. I left him a message, told the staff at the group home to please remind him, wrote it in the chart so he could see it in writing, told her that it could kill her and offered her medications to help her to stop smoking, yet she still continues to smoke and the PCP (who is 89 years old and several claim not all his marbles are in his head) keeps giving out the birth control.

While that is probably the worst one I got, about 5-10% of my cases have a medical issue where the PCP is not dealing with the issue to my satisfaction and I'm confident I could fix the issue on my own.

I still give out ranitidine because there are some articles claiming it reduces the weight gain associated with psychotropic medication. So it's analogous to giving out cogentin with an antipsychotic. It's not that I prefer to do this, but most of my patients were already started on it by their previous doctor, and they are in an unfortunate situation where if they go off of it--now they have GERD that was not there before.

Insurance aside, if it were up to me, I would practice primary care medicine with my patients that did not have a PCP, or where I felt the PCP was not dealing with an important issue to the standard of care. I do not have this option, nor do most psychiatrists.

 

[psychotrope]

Most FP programs I looked at, psych is an elective, but not a requirement. Most FP residents and attendings I spoke to strongly recommended FP residents take psych electives because psych issues (though often not as the CC) are a big part of most practices. You'd think it would be required, wouldn't you?

Most FP's I know limit their psych scope to depression and refer anything other than that. And the FP's I've chatted to about the subject have said they'd be comfortable referring out the depression, but there's a shortage of psychiatrists in most places. Good for us, not so good for the patients.

I think for severe and/or refractory MDD psych should be consulted.

For dysthymic and adjustment disorders.....well....I think we have to consider the big overall picture in terms of cost. When a family medicine physician gives a pt celexa because they've been feeling a little down lately because they had their hours cut by 30% at work, he's also probably treating their dyslipidemia, htn, and that twisted angle a few days ago as well. So by him treating the psych issue, except the medication cost, there isn't any more $$ going into the system is there?(unless it somehow become a more complex billing office visit?). With a separate psych referral, that is more $$ going into the system......

there is only so much money after all.

 

[RamblinMan]

So if I come out of residency dual boarded FM/psyc and I'm looking around for salaried psyc jobs, I wonder how marketable I am compared to someone who is single boarded psyc? Does this make me a better or worse candidate, or does it even make a difference? I am of course focusing solely on my training and skills, not taking into account all the other myriad factors that come into play when hiring someone.

If I wanted to do primarily FM, my guess is this would make me a more desirable candidate, but I'm not sure about psyc.

I wonder how I would negotiate a salary at a place where I have the opportunity to use both skill sets.

 

[notdeadyet]

Does this make me a better or worse candidate, or does it even make a difference?

I share your concern.

Doing a combined residency means fewer electives in your chosen specialty, which means less training.

 

[Saluki]

I thought for a while about doing the triple boards programs where you train in peds, child psych and psych, but finally decided against.

Almost no one actually practices in both primary care and psychiatry. So, the main utility is if you're interested in positions that combine both aspects like being the director of an eating disorders program or consult liason program. I'm interested in both, but I was told by multiple people that you don't actually need the training to do both. Also, although intuitively it sounds good to have one person who can manage both the medical and psychiatric sides of an eating disorder patient, I think in reality it's better for the patients and the physicians to have a team working together on the issues.

Also, if you do a combined program, you have to do rotations that may have very little application to what you want to do at all- in my case, the NICU; in yours, I'm assuming surgery, labor and delivery, etc..

And I don't think it even works well as a backup. If you're mainly practicing psychiatry for 20 years and then get burned out, the transition to family practice is going to be really difficult.

The global medicine thing is a bit harder... If you worked as an academic psychiatrist, it's possible you could take lectureships, etc. to teach physicians in poorer countries about your area within psychiatry. Some organizations also need psychiatrists to provide care to their members who are overseas for long periods of time. Also, you can choose to simply work more hours in the US and help support the costs of sending OB/Gyns, ID specialists overseas. None of those are perfect solutions, though...