Can't decide between Psych and Family Med

[Panama Red]

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I loved both rotations and I am currently stumped on which to choose. I liked both because of the patient variety, women's health, mental health care, and work schedule. It is also interesting because I have observed that a lot of patients use their FM doc for their mental health management. I also like the clinical variety in FM. I love treating URI’s, depression, performing pap smears, etc.. However, I do not believe FM's receive adequate training in psychopharm or psychotherapy. I love Psych, but I am not keen on working with severe psychopathology. I am a bit turned off by the lack of diagnostic concreteness in psychiatry, as well as the incurable nature of many psych illnesses. If I were a psychiatrist, I would want my practice to focus more on the “worried well” with a small sprinkle of severe psychopathology. Although I find severe psychopath fascinating, I want the majority of the psych issues I treat be ones that get significantly better. I know myself, and I have significant fear that I will become “disenchanted” with psychiatry because I am not seeing results with treatment. I want to help my patients. Whenever I have expressed my sentiments to psychiatrists, I have been frowned upon for not wanting to deal with severe psychopathology. One psychiatrist even said that if I don’t want to deal with severe psychopath, I should not do psych. Although it is an option, I have also received discouraging advice in regards to doing combined programs by some psychiatrists. These psych docs believe I will not realistically be able to practice both specialties. The key is that I want my specialty of choice to deal with clinical medicine as well as "treatable psych" cases. Any advice?

 

[sunlioness]

I think it's a bias (albeit a common one and I don't mean to call you biased --it's just a bias that's out there) that severe psychopathology isn't treatable. It is. And doing so is the most rewarding thing I can imagine. And consigning people to the label "untreatable" is very damaging for them. As far as combined programs go, it seems to me that just about everyone who does a combined residency ends up practicing either one specialty or the other. And if what you want to do is manage the worried well in a primary care setting and refer the more severe pathology (and while it's not what I'd pick, I can certainly respect that. We all have our strengths and passions) then I think you could probably do that in FP. And it would be good to have primary care docs out there with a good understanding of and appreciation for psychiatry, psychopathology, and psychiatric patients. Good luck making your decision!

 

[Panama Red]

Your points are well taken. After some thought, I realize that what I mean to express is that I do not want to have to consistently deal with incurable or untreatable psychopath. It does exist. To explain a bit further as to why I maybe expressing this bias- I have only worked on the psych inpatient unit and did not like the experience due to the seemingly "untreatable" nature of the psych conditions, as well as the ambiguity of diagnostic methods. I liked talking with the patients, but I REALLY didn't see improvement with the patients. I want to see progress and improvement with treatment. When I write that I want to work with the "worried well" I guess I really mean to express is that, if I were to do Psych, I want to work with more "higher functioning" patients. I want to feel I am making a difference. Furthermore, I want to have adequate patient contact. Truthfully, the psychiatrists I worked with rarely spoke with the patients. I also witnessed psych docs doing consults for medically related issues that I felt psychiatrists, as physicians foremost, should treat. There was mainly psych medication management, but, at the end of the day, I didn't think anything was really managed. Save for the fact that I love psych and find it incredibly fascinating, I have not really worked with psychiatrists that I have respected or helped me feel more validated for my interest in Psych. In addition to the other issues I have witnessed with psych, I also guess that the constant berating of Psych by other specialties has added to my indecisiveness and uncertainty.

 

[sunlioness]

I see what you mean. I think one of the drawbacks of most medical school psych rotations (and mine included) is that they are pretty much exclusively inpatient. And all you're really going to see on an inpatient psych unit these days is stabilization. The real improvement occurs on an outpatient basis and that's an exposure you don't get in medical school. Personally, I am planning to work with outpatients and do both med management and psychotherapy. I don't think I would ever be fulfilled doing exclusively inpatient or C&L.

I actually initially matched in internal medicine. I was always intellectually the most interested in psych and always did the best in my psych classes. The only class I honored in my first two years of med school. But I never seriously considered it as a career because I had that same bias --that patients never get better. And there was nothing in my 3rd year clerkship that challenged that bias. Not to mention that my clerkship occurred when our institution's residency program was in the process of absorbing a residency program across town whose hospital had closed (WPIC and St. Francis) so things were chaotic anyway. And I found out later that the attending I had on the floors left the field of psychiatry shortly thereafter to pursue a completely different career. So I didn't have the best exposure.

That changed during my intern year in which I was unhappy and not interested in a lot of things I was doing. And frustrated that my most interesting patients were the ones with mental health issues and while I wanted to manage them myself, I always had to refer them out. I got tired of that really quickly. And also during that year I had a personal encounter with the mental health field that completely caused me to revise my opinion that psychiatry never actually helps anybody. So here I am and I am very very happy with the choice and looking forward to my career. In the end, I think you just need to look inside yourself and follow your heart. And trust that even if you make what turns out to be the "wrong" decision, it's never too late to go back and fix it. 🙂

 

[RaistlinMajere]

Your points are well taken. After some thought, I realize that what I mean to express is that I do not want to have to consistently deal with incurable or untreatable psychopath. It does exist. To explain a bit further as to why I maybe expressing this bias- I have only worked on the psych inpatient unit and did not like the experience due to the seemingly "untreatable" nature of the psych conditions, as well as the ambiguity of diagnostic methods. I liked talking with the patients, but I REALLY didn't see improvement with the patients. I want to see progress and improvement with treatment. When I write that I want to work with the "worried well" I guess I really mean to express is that, if I were to do Psych, I want to work with more "higher functioning" patients. I want to feel I am making a difference. Furthermore, I want to have adequate patient contact. Truthfully, the psychiatrists I worked with rarely spoke with the patients. I also witnessed psych docs doing consults for medically related issues that I felt psychiatrists, as physicians foremost, should treat. There was mainly psych medication management, but, at the end of the day, I didn't think anything was really managed. Save for the fact that I love psych and find it incredibly fascinating, I have not really worked with psychiatrists that I have respected or helped me feel more validated for my interest in Psych. In addition to the other issues I have witnessed with psych, I also guess that the constant berating of Psych by other specialties has added to my indecisiveness and uncertainty.

You should do what you enjoy more. If it's dealing with the worried well, then I'm sure you could set up your practice to see patients with this level of severity. I'd imagine that this describes a lot of outpatient practices.

I can't speak to your inpatient experience, but in my clerkship I saw many people with severe mental illness who were psychotic receive treatments that made them psychosis free and able to be discharged relatively quickly. That's pretty rewarding when it occurs.

Also, I haven't found your last point of psych being berated by other specialties to be the case. I've found that most people who view it negatively are 1st and 2nd year med students who have not yet done their psych clerkship. Most physicians I've come across realize the importance of the field, even if it was not one they would have chosen. And every doc wants a psychiatrist around when a patient is psychotic. But also keep in mind that every specialty thinks it's the best. Don't be talked out of it by others.

Do what you enjoy the most. Only you can answer that question.