Career Advice: Pediatrics vs Psychiatry

[Ice Lotus]

Hello! I am a medical student nearing the end of my clinical years. I am interested in pediatric mental health and neurodevelopmental conditions but am struggling to decide between:

• Pediatrics > Developmental-Behavioural Pediatrics
• Pediatrics > Adolescent Medicine
• Psychiatry > Child and Adolescent Psychiatry
• Triple Board

I have enjoyed my clerkships in both pediatrics and psychiatry and currently think I prefer outpatient settings of both. I can’t see myself practicing adult medicine long-term but equally think I would not enjoy clinical practice as much without mental health components.

I know it’s possible to dual apply of course but was hoping to get some perspectives and advice! Thank you in advance 😊


p.s. I’ve posted this to both the pediatrics and psychiatry forums to get perspectives from both sides; it’s my first time posting so please let me know if I should delete one!

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[HemeOncHopeful19]

I’m an adult Oncologist but have close friends/family in both fields.

Psych all day every day.

Also, the number of people currently alive that have triple boarded and actually use all three boards is probably a single digit number… maybe low double digits.

 

[SurfingDoctor]

Don't listen to the terrible advice above from an adult oncologist who spoke to people on Facebook. Triple board... its only 2 years more. Brown actually has a very good pathway for specifically this. There's probably others, but that's the one I'm most familiar with.

Then you can decide after all is said and done. I've known many who picked that path. More than a dozen. They've had all sorts of longterm paths.

As far as behavioral health... well, that's mostly left to psychologists these days. For instance, in the pediatric wards/ICU, we can't get a psychiatrist to see behavioral patients beyond prescribing Seroquel. And frankly, how can you treat a problem when there is no insight as to its cause? Not that pediatric psychiatric disorders have a ton of insight... but your chance of making an impact is greater if you can reason with the person you are treating. Fundamentally, I think development and genetics are a better combination that development and psychology. At least that is the more modern approach.

Also... pediatric psych is actually very high in demand these days. The wait lists are crazy long... so more power to you.

Anyway... triple board.

 

[Ice Lotus]

Thanks for the comment @HemeOncHopeful19 - any insights for psych>peds?

That's a very good perspective @SurfingDoctor - of those you know who did triple board, do they tend to regret doing triple board, or did they find that having training in both pediatrics and CAP was helpful to their practice? CAP fast-tracking is also 5 years and Peds subspecialties are only a year more than triple board. I guess I'm trying to know if they were able to add something to their practice that makes up for the lesser time in a single specialty.

Thanks again for the answers 😊

 

[SurfingDoctor]

Thanks for the comment @HemeOncHopeful19 - any insights for psych>peds?

That's a very good perspective @SurfingDoctor - of those you know who did triple board, do they tend to regret doing triple board, or did they find that having training in both pediatrics and CAP was helpful to their practice? CAP fast-tracking is also 5 years and Peds subspecialties are only a year more than triple board. I guess I'm trying to know if they were able to add something to their practice that makes up for the lesser time in a single specialty.

Thanks again for the answers 😊

Well, that I can’t quite answer for you as I myself did not triple board and my experience was mostly limited to them when we were residents together. I did Google about the half a dozen that I remembered off the top of my head and they have a broad practice experience. Some are directors and chief medical officers for inpatient programs, one is the PD of triple boarding at Duke, one runs their own psychiatry private practice (adult and children) and one works in a private practice pediatric group but also does child psychiatry.

Since they are tripled boarded, I think you are going to find that the outcomes are broad. And child psych being a subspecialty pathway, the training is going to be extended no matter the path. Does an extra year lead to regret when you are practicing in your 40s and 50s? I highly doubt it. Even though I didn’t do psych, I did 7 years post-graduate training and don’t regret it.

 

[HemeOncHopeful19]

Thanks for the comment @HemeOncHopeful19 - any insights for psych>peds?

That's a very good perspective @SurfingDoctor - of those you know who did triple board, do they tend to regret doing triple board, or did they find that having training in both pediatrics and CAP was helpful to their practice? CAP fast-tracking is also 5 years and Peds subspecialties are only a year more than triple board. I guess I'm trying to know if they were able to add something to their practice that makes up for the lesser time in a single specialty.

Thanks again for the answers 😊

So to start I obviously don't know you and could be misreading your post(s) but it seems to me that you like both Child Psych and DB/Adolescent Peds, and could potentially be happy doing either? I don't really subscribe to the idea that there is one specific field that a person needs to find their passion for, I enjoy the field I am in but ultimately this is a career/job and I would probably enjoy a few other fields as well had I ended up in them. If instead you know exactly what you want and you're trying to ask how to develop a career path that involves seeing BOTH child psych and DB-Peds patients, then definitely ignore my advice as it isn't as relevant to that situation.

IMO, in 2024, if someone were to be deciding between DB Peds or Child Psych and honestly thinks they would be happy doing either one... I would advise them to choose child psych every time. Pediatrics is in a weird place currently where their Academic leadership is clueless and not very supportive. This leads to things like mandatory 3 year fellowships (so 6 years for DB or Adolescent Peds vs ?I think 5 years for child psych) and ridiculous board pass rates (literally 1 in 5 Peds residents fail their boards yet it's ok to have online school NPs running around everywhere?) that never get addressed. Meanwhile child psych has better pay, similar hours, you can find a job in basically any city in the country on top of shorter training length... it's just a better deal currently.

I guess I was misinformed and triple boarding may be the same length as doing Psych + Child Psych? Other people kept referring to it as "an extra 2 years"

 

[calvinhobbes]

Peds in theory is a wonderful speciality. What can be more rewarding than treating kids? But practically and financially, these days, it’s not (see above). If you like psych, do Psych and then Child Psych. You’ll be able to see kids, adults, young adults, and spend more time with them. You will have freedom. You will be a specialist. You’re in demand and can really collaborate more with pediatricians and PCPs if you want, or not. You can also look into triple board programs but there aren’t many, and it’s 5 years which condenses training in all 3 specialities. Post Pediatric Portal Programs are actually better than Triple Board programs, because you graduate from a fully 3 year peds residency, than you do another 3 total years in combined gen psych and child psych (and the training in psych or child psych is not shortened, as you’re just not doing any of the adult EM and adult IM rotations a gen psych would do [b/c you did 3 years of medical peds!], nor the admin/teaching rotations a fourth year gen psych resident would be doing; you’re focusing only on adult psych and child psych rotations, plus electives). Also keep in mind, if you do triple board or Post Pediatric Portal Program, you don’t have to, nor are your forced, to take the peds boards. The goal is to become a child psychiatrist, so you can take the adult psych boards and child psych board exams, but don’t need to take or pass the peds boards. So in some ways, just do the traditional Psych and Child Psych residency / fellowship route, and skip peds.

 

[Ice Lotus]

Thank you for all the great advice! This is a lot to think about and was really helpful.

I definitely see the benefits of both paths and think I will speak with my mentors more as well. I think the option to involve both pediatric and psych aspects in my training would be valuable, and I think there is value to it beyond just delaying a decision between psych vs peds. The portal option is certainly a good shout; it's just a pity that there are so few (of both the portal and the triple board).

I think what I'll end up doing is applying mostly psych + triple board, as I don't think I can justify applying only peds when there are so few portal/dbp programs and the state of pediatrics at the moment. That said, I'll still keep an open mind and may still apply to a few pediatric programs.

I'll try to update the thread with what I end up doing in case anyone's curious! Happy to leave the thread open in case anyone else is in a similar position and wants to ask any related questions. Also thought I'd note that it's interesting to see the commonalities and differences in perspectives between the responses in this questions' threads on the pediatrics and psychiatry boards. Really helpful advice on both ends, just from different points of view.

Thanks again

 

[calvnandhobbs68]

As far as behavioral health... well, that's mostly left to psychologists these days. For instance, in the pediatric wards/ICU, we can't get a psychiatrist to see behavioral patients beyond prescribing Seroquel. And frankly, how can you treat a problem when there is no insight as to its cause? Not that pediatric psychiatric disorders have a ton of insight... but your chance of making an impact is greater if you can reason with the person you are treating. Fundamentally, I think development and genetics are a better combination that development and psychology. At least that is the more modern approach.

This is just an awful take…yes the ICU and inpatient medical units are not optimal places to work to start working on managing long term psychiatric conditions. What you guys want is someone to sit around and wave a magic psych wand to make a noncompliant ICU patient compliant or stop causing the nurses problems. Yeah your consults are often for delirium or agitation (that you could probably manage yourself anyway), that’s why you end up seeing seroquel…

So no, behavioral health is not “mostly left to psychologists”. You just don’t see it on the inpatient units…it’d be like extrapolating out only your interactions with any consult service inpatient to the whole field. There’s often also a division of labor on inpatient consults in bigger children’s hospitals where there can be a psychologist who is willing to see a handful of patients inpatient for weekly psychotherapy if they’re there long term. Thats not a viable situation for your typical consult person whose either having to deal with all the psych consults in some huge hospital or also covering the ER or inpatient psych unit. Outpatient, partial, residential, even inpatient child units can be and are totally different. But extrapolating your pure inpatient experience consulting psych as “behavioral health is mostly left to psychologists these days” is frankly insulting.

This is why I hated consults lol consulting teams barely have any idea about any other setting besides “psych wouldn’t come talk to my anxious patient in the ICU for an hour every day” or “this patient is being difficult must be a psych problem!”.

I’ll just say this is coming from someone who is very familiar with both sides of this situation.

 

[CopaceticOne]

Also, the number of people currently alive that have triple boarded and actually use all three boards is probably a single digit number… maybe low double digits.

Tell that to the all the PICU Peds anesthesiologists, that's technically 4 boards - Pediatrics, Pediatric Critical Care, Anesthesiology, Pediatric Anesthesiology. Pretty sure they "use" all of them.

 

[SurfingDoctor]

This is just an awful take…yes the ICU and inpatient medical units are not optimal places to work to start working on managing long term psychiatric conditions. What you guys want is someone to sit around and wave a magic psych wand to make a noncompliant ICU patient compliant or stop causing the nurses problems. Yeah your consults are often for delirium or agitation (that you could probably manage yourself anyway), that’s why you end up seeing seroquel…

So no, behavioral health is not “mostly left to psychologists”. You just don’t see it on the inpatient units…it’d be like extrapolating out only your interactions with any consult service inpatient to the whole field. There’s often also a division of labor on inpatient consults in bigger children’s hospitals where there can be a psychologist who is willing to see a handful of patients inpatient for weekly psychotherapy if they’re there long term. Thats not a viable situation for your typical consult person whose either having to deal with all the psych consults in some huge hospital or also covering the ER or inpatient psych unit. Outpatient, partial, residential, even inpatient child units can be and are totally different. But extrapolating your pure inpatient experience consulting psych as “behavioral health is mostly left to psychologists these days” is frankly insulting.

This is why I hated consults lol consulting teams barely have any idea about any other setting besides “psych wouldn’t come talk to my anxious patient in the ICU for an hour every day” or “this patient is being difficult must be a psych problem!”.

I’ll just say this is coming from someone who is very familiar with both sides of this situation.

Nearly everyone one my current system who does developmental and behavior health is a PhD psychologist… including the division directors. Now, those divisions are housed within the department of pediatrics. There are more psychiatrists in the division of pediatric psychiatry in the department of psychiatry, but still a good number of psychologists mixed with NPs. When we tried to get our own child into behavioral health, we saw psychologists. They couldn’t prescribe medications though, so our PCP prescribed them.

My state is more rural and poor though, so maybe that’s a reflection of that, because in the really rural areas, I suspect there is no one but the PCP. But that’s just a guess on my part.

If that’s different in your system or you are personally offended by the system I’m in, I don’t know what to tell you.

 

[SurfingDoctor]

Tell that to the all the PICU Peds anesthesiologists, that's technically 4 boards - Pediatrics, Pediatric Critical Care, Anesthesiology, Pediatric Anesthesiology. Pretty sure they "use" all of them.

Also true for Pediatric, Critical Care, Cardiology.

 

[HemeOncHopeful19]

Tell that to the all the PICU Peds anesthesiologists, that's technically 4 boards - Pediatrics, Pediatric Critical Care, Anesthesiology, Pediatric Anesthesiology. Pretty sure they "use" all of them.

Ok well if OP comes back and tells us they have decided to pivot from their interest in outpatient pediatric mental/behavioral health to... PICU Anesthesiologist... I would be more in favor of them having 3+ boards, I guess.

 

[SurfingDoctor]

This is just an awful take…yes the ICU and inpatient medical units are not optimal places to work to start working on managing long term psychiatric conditions. What you guys want is someone to sit around and wave a magic psych wand to make a noncompliant ICU patient compliant or stop causing the nurses problems. Yeah your consults are often for delirium or agitation (that you could probably manage yourself anyway), that’s why you end up seeing seroquel…

Since I didn't address this the first time, I will say I agree with this. I frankly don't think psychiatrists have any role in the ICU care of patients. I don't actually consult for seroquel, I just give it. And when I’m feeling extra spicy… just give the good ol’ “Vitamin H”. The only time I consult psychiatry is when a kid tried to kill themselves and survived to ICU discharge for disposition. ICU delirium isn’t even a real diagnosis anyway, so I can’t understand why people would consult for it. I mean, I guess I understand because intensivists aren’t generally the sharpest tools in the shed… but anyway.

So I agree that I think it is a waste of your time and every other psychiatrists to see ICU patients and I would be frustrated too.

 

[CopaceticOne]

Ok well if OP comes back and tells us they have decided to pivot from their interest in outpatient pediatric mental/behavioral health to... PICU Anesthesiologist... I would be more in favor of them having 3+ boards, I guess.

Honest respect to you. I was just pointing out you, and many other folks, probably know more people than you think.

 

[wysdoc]

@Ice Lotus SDN posted a great interview featuring two physicians who took different paths to developmental/behavioral pediatrics but it took me a while to find it. They talk about their paths to the specialty and what their work balance of patients is like.

Developmental-Behavioral Pediatrics

 

[Just D.O. it]

Triple board... its only 2 years more.

This is even worse advice. With the current job market in psych/child psych that’s $800k of opportunity cost. Not a single child psychiatrist I know has any reason to use/maintain gen peds board certification. They are different jobs and there is enough psych/child psych volume to fill your panel at least 3x over in most places. The adult oncologist is right. Generally dual residencies just end up being a several hundred thousand dollar mistake. If you want child psych, do the accelerated pathway (5 years) instead of extra time being academia’s b*tch.

 

[Ice Lotus]

@Ice Lotus SDN posted a great interview featuring two physicians who took different paths to developmental/behavioral pediatrics but it took me a while to find it. They talk about their paths to the specialty and what their work balance of patients is like.

Developmental-Behavioral Pediatrics

Thank you for hunting this down! Really looking forward to watching it

 

[SurfingDoctor]

This is even worse advice. With the current job market in psych/child psych that’s $800k of opportunity cost. Not a single child psychiatrist I know has any reason to use/maintain gen peds board certification. They are different jobs and there is enough psych/child psych volume to fill your panel at least 3x over in most places. The adult oncologist is right. Generally dual residencies just end up being a several hundred thousand dollar mistake. If you want child psych, do the accelerated pathway (5 years) instead of extra time being academia’s b*tch.

I mean, I personally know several, but okay.

 

[Just D.O. it]

I mean, I personally know several, but okay.

I’m sorry, the tone of my post may have been antagonistic. I didn’t mean for that. I legitimately am echoing what I have heard from practicing child psychs. But I am curious. Outside of teaching Peds residents (or other very academic practice setting type things), I can’t even imagine a reason. It’s not like billing well child checks is a particularly lucrative endeavor. Do you have any insight on why they maintain gen peds boards?

 

[SurfingDoctor]

I’m sorry, the tone of my post may have been antagonistic. I didn’t mean for that. I legitimately am echoing what I have heard from practicing child psychs. But I am legitimately curious. Outside of teaching Peds residents (or other very academic practice setting type things), I can’t even imagine a reason. It’s not like billing well child checks is a particularly lucrative endeavor. Do you have any insight on why they maintain gen peds boards?

Many are in academic administrative roles. I only know about a dozen or so and only one of them is in private practice as a pediatrician.

I mean, I will say, if one's goal is just to see kids and bill, then triple board probably isn't a necessary path. If one's goal is to be in programmatic leadership, hospital leadership, academics, etc., then that path creates those opportunities. Again, this is my observation of the people I know, nothing more since I am not in pediatric psychiatry. Also, just to clarify, triple board is 5 years total. If there are shorter pathways, then okay, again, not my area of expertise.

Anyway, I think the OP got the advice he/she wanted so all is well.

 

[calvinhobbes]

More info for you here

Gen Peds vs. Psych/Child and Adolescent Psych....indecision and angst!

This is a novel, sorry. I have been trying to choose between Peds and Psych since...December or January? Now I'm 38 weeks pregnant and tired and emotional and I really need to choose soon to get those letters of reference and my personal statement and everything going for the Match!! Currently...

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