Child and Adolescent Psychiatry-least procedural specialty?

[iroquo]

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Hello everybody,
Currently at med school I am thinking of going into psychiatry and then child and adolescent psychiatry.I don't like doing procedures and would like to stay a bit away from ''real''medicine.I am a ''thinkers'' type and my strength is in devising plans and strategies and I love solving puzzles and mysteries as well.Do you think child psychiatry is my specialty? Do you think it is the least procedural medical specialty?
thank you all

 

[shan564]

I'm a lot like you (i.e. plans, strategies, puzzles, mysteries, etc.), which is why I'm also going into psych. I'm not sure if you have to subspecialize in child/adolescent psych to get away from procedures... most general psychiatrists don't really do any proecdures either.

 

[SmallBird]

Hello everybody,
Currently at med school I am thinking of going into psychiatry and then child and adolescent psychiatry.I don't like doing procedures and would like to stay a bit away from ''real''medicine.I am a ''thinkers'' type and my strength is in devising plans and strategies and I love solving puzzles and mysteries as well.Do you think child psychiatry is my specialty? Do you think it is the least procedural medical specialty?
thank you all

I would think child psychiatry and adult psychiatry are both pretty procedure-less. Regarding your other point - I have found in my experience thus far (and I admit, I am only a PGY-1) that making a diagnosis in children is significantly more challenging than in adults. The degree of discussion I have observed on ward rounds about trying to make clinically significant decisions about how to "classify" a specific patient appears to exceed what I have seen on adult psych rounds. Being a thinker will likely serve you well in this field!

 

[notdeadyet]

OP- another idea might be to ask yourself what you find off-putting about procedures. If it is the putting hands on the patient or relying on physical dexterity, EM and surgery are bad choices and you'd probably do well to avoid them. But there are a lot of medical specialties that rely more on problem solving and less on hands-on medicine. Radiology requires a lot of thinking things through to correlate the imaging with clinical presentation. Rad-onc docs play with a lot of variables but don't start a lot of IV's themselves. Psych is far from the only specialty that doesn't do many procedures and unless you have a passion for mental illness, it has heaps of its own frustrations.

Also, some folks who don't like procedures don't like them because of the responsibility and the consequences of bad outcomes. If that's your aversion, psych might be a field you'd want to really consider casually. More than most, psychiatrists find themselves making recommendations that go against what a patient says at the time and involve holds and starting medications against their wishes. It's not a big part of psychiatry and can be largely avoided after residency deciding on how you shape your career, but it's still an aspect ofa the field even if you never pick up a scalpel.

 

[vistaril]

Psych is the only specality apart from pathology(where you do procedures on dead people I guess) where one can do absolutely NO procedures ever.

In every field of medicine, you're going to at least occasionally have to do procedures in your training. Maybe occupational medicine, but that's not really a field.

 

[notdeadyet]

Psych is the only specality apart from pathology(where you do procedures on dead people I guess) where one can do absolutely NO procedures ever.

In every field of medicine, you're going to at least occasionally have to do procedures in your training. Maybe occupational medicine, but that's not really a field.

How in the world did you get through internship without doing procedures?

 

[vistaril]

How in the world did you get through internship without doing procedures?

well....internship at most places is 6 months psych to start with, so you're only going from a starting point of 6 months internship where you can do procedures. 2 months of that is neurology, and it's most common to find the off psych service psych person doing neuro consults helping out(really shadowing), which isn't going to do their own procedures usually(primary service will do lps and stuff). If you do find yourself on an inpatient neuro service, you won't be the 'main' lower level resident /intern certainly as there will be neuro people on the service of course.

So that leaves 4 months of medicine/fm/peds...whatever. Usually medicine. At some programs 1-2 months of this is outpt, and there arent likely to be a bunch of procedures there. As for your inpatient months of medicine, peds, fm, etc....there will only be from 1-4, and on a general medicine ward there generally arent a ton of procedures going down every month. Maybe a line once a week, an LP every two weeks, a paracentesis every week to 2 weeks.....given those numbers, it's very easy for the categorical(or preliminary person) to do them, as they often have to be 'signed off' on such things after a certain point. Psych interns do not have to be signed off, so even if they want to do those things(and why would they) if it's early in the year the psych person often doesn't get a chance. And if the psych intern doesnt want to do it, there is usually a med student who jumps at the chance to do it with the resident overseeing(resident doesnt care because he has to oversee it either way)


The idea that our intern year is anything like a traditional intern year is absurd. It's not a preliminary year that a neuro, anesthesia, derm, etc resident would do. And it's most definately not like a categorical med intern year.

 

[notdeadyet]

2 months of that is neurology, and it's most common to find the off psych service psych person doing neuro consults helping out(really shadowing),

Again, I think your perspective of psychiatry training might be very skewed by your program. Most residents I know, from a variety of programs (albeit, all reputable community or academic ones), don't wear a Psych hat that gets them treated like *****s. If a psych intern is shadowing during their neuro months, that's a reflection of their program. And it's in need of a tune up.

If you do find yourself on an inpatient neuro service, you won't be the 'main' lower level resident /intern certainly as there will be neuro people on the service of course.

Again, see above. At most programs I'm familiar with, interns=interns on off-service rotations, whether it's a medicine or psych intern on the neuro service. Your mileage may vary.

 

[notdeadyet]

The idea that our intern year is anything like a traditional intern year is absurd. It's not a preliminary year that a neuro, anesthesia, derm, etc resident would do. And it's most definately not like a categorical med intern year.

Uh, agreed. You're the only one arguing with you. No one is comparing a psych intern year with a different specialty's intern year.

absolutely NO procedures ever.

This is what I'm disagreeing with.

If anyone found themselves at a program where psych interns were treated as "special" and not trained/treated/exploited like every other intern, or if they found themselves dodging doing their fair share of the work under the guise of being a psych intern, well... They either went to a kinda crappy program or they were a kinda crappy intern. I don't see a 3rd explanation.

Anyway, well off topic. Good luck with your decision, iroquo. Do some navel gazing and figure out what you're going for. There are a lot of "thinker" specialties that are light on hands-on procedures. You'll find your niche. Just don't go into psych without an interest in mental illness and the mentally ill. It's not a fun job otherwise.

 

[digitlnoize]

Uh, agreed. You're the only one arguing with you. No one is comparing a psych intern year with a different specialty's intern year.

This is what I'm disagreeing with.

If anyone found themselves at a program where psych interns were treated as "special" and not trained/treated/exploited like every other intern, or if they found themselves dodging doing their fair share of the work under the guise of being a psych intern, well... They either went to a kinda crappy program or they were a kinda crappy intern. I don't see a 3rd explanation.

Anyway, well off topic. Good luck with your decision, iroquo. Do some navel gazing and figure out what you're going for. There are a lot of "thinker" specialties that are light on hands-on procedures. You'll find your niche. Just don't go into psych without an interest in mental illness and the mentally ill. It's not a fun job otherwise.

We do 1 month of EM, and 3 of IM, and so far, I've made it thorough all of EM and half of IM without any procedures...and not by slacking or special treatment. In the ED, it was simply luck of the draw. I was treated and worked just like any other intern...we get the lower acuity patients, and we have a "fast track" section that gets the sutures and the interns don't work back there. The upper levels and attendings get the traumas, so no cool stuff for me. I *could* have gotten something in theory, but I always just signed up for the next patient on the list and never got one. I did have to do pelvics and rectals though, so there's that. Our ER is a bit different though, in that we're a small-ish college town and the ER upper levels have to meet their numbers, so that's probably part of the reason the interns get a little shafted on procedures.

On medicine, the upper levels do pretty much everything. Interns will sometimes do things if they feel comfortable with it, but so far none of my patients have needed anything placed by me. Usually, if they need a central line, they're going our MICU and it's done there (not by me on gen med). So, not many procedures here either, thus far.

Psych is definitely less procedural. There are some if you're interested. Pain injections, Vagal nerve stimulation, TMS, ECT...

 

[gbv]

This is certainly program-dependent as was alluded to by notdeadyet. During my intern year I did at least two LPs while on Neurology and a couple of central lines on Medicine (it was the common 4-6 months Psych, 2 months Neuro, 4 months Medicine, 2 months elective if desired). I CERTAINLY did not go out of my way looking for procedures either, goodness knows..kinda cool to do some a few times, but certainly not missing doing them on a regular basis. But the final point remains, as a specialty, Psychiatry isn't doing much in the way of procedural activities.

 

[vistaril]

Psych is definitely less procedural. There are some if you're interested. Pain injections, Vagal nerve stimulation, TMS, ECT...

I dont consider things like tms and ect 'procedures', but oh well....

and as for 'pain injections'(whatever that means), you don't do those as a psychiatrist.

 

[digitlnoize]

Psychiatrists can do pain management fellowships and then do injections. I'm far from a pain doc, but they're typically steroid injections +\- numbing meds. Mostly for chronic back pain. Fairly common thing. Guess they don't have those at your "Top 10 residency program"

 

[notdeadyet]

Psychiatrists can do pain management fellowships and then do injections. I'm far from a pain doc, but they're typically steroid injections +\- numbing meds. Mostly for chronic back pain. Fairly common thing.

In fairness, I wouldn't consider analgesic injections part of a psychiatrists aresenal just because we can do a pain fellowship. That's like saying that psychiatrists have mad splinting skill since we can do a wilderness med fellowship.

 

[digitlnoize]

In fairness, I wouldn't consider analgesic injections part of a psychiatrists aresenal just because we can do a pain fellowship. That's like saying that psychiatrists have mad splinting skill since we can do a wilderness med fellowship.

Really? Can we do that?!? Then I'd be WAY more prepared for the Zombie Apocalypse...

 

[nancysinatra]

In fairness, I wouldn't consider analgesic injections part of a psychiatrists aresenal just because we can do a pain fellowship. That's like saying that psychiatrists have mad splinting skill since we can do a wilderness med fellowship.

Really? Is that a real subspecialty? I was under the impression you could take wilderness medicine classes and get CME credits, but I didn't know it was a fellowship.

If it is, that's what I want to do. Wilderness medicine is almost entirely procedures, btw. Unregulated emergency procedures using ballpoint pens in the middle of nowhere.

 

[billypilgrim37]

I am disappointed that no one has made a joke about CAPs performing parentectomies.

 

[digitlnoize]

I think you just did, hahaha!

 

[st2205]

Psych is the only specality apart from pathology(where you do procedures on dead people I guess) where one can do absolutely NO procedures ever.

I'm confused. So you are alluding to autopsies being a big procedure within path or you suffer from the notion that pathology = dead people?

 

[michaelrack]

I'm confused. So you are alluding to autopsies being a big procedure within path or you suffer from the notion that pathology = dead people?

I am sure Vistaril understands the field of pathology and meant that autopsies are an important part of pathology (though only a small minority of time in pathology is spent doing these/working with dead people)

 

[Fastball32]

I dont consider things like tms and ect 'procedures', but oh well....

and as for 'pain injections'(whatever that means), you don't do those as a psychiatrist.

Is this a joke? It sounds like you're serious though. ECT requires IV access, general anesthesia, an anesthesiologist, an OR, and a signed consent that it could potentially lead to death. Definitely not a lobtomy though, which at least in textbooks still exist for OCD.

 

[michaelrack]

Is this a joke? It sounds like you're serious though. ECT requires IV access, general anesthesia, an anesthesiologist, an OR, and a signed consent that it could potentially lead to death.

Outside of residency/academia, the psychiatrist pushes a button (of course there is a lot of intellectual/cognitive work involved in picking the settings etc) and the anesthesiologists does the procedural part of ECT (IV access, etc). Therefore, ECT is not a psychiatric procedure (as defined by the OP)

 

[Fastball32]

Psychiatrists place the electrodes and induce a seizure, every bit as thoughtful and invasive as an IV access "procedure".

 

[DD214_DOC]

Outside of residency/academia, the psychiatrist pushes a button (of course there is a lot of intellectual/cognitive work involved in picking the settings etc) and the anesthesiologists does the procedural part of ECT (IV access, etc). Therefore, ECT is not a psychiatric procedure (as defined by the OP)

Hey now, I put the leads on too!

I'm actually interested in interventional psychiatry and am writing a grand rounds on the topic, both its history and potential future.

It puzzles me why we make moderately/severely depressed people potentially suffer for weeks and weeks while trying different meds and therapy when there is something procedural we could do that could potentially provide relief in days. ECT is pretty low-risk and I think is very underutilized.

I am interested to see where this ketamine infusion stuff goes. Do not forget, also, that there is a university in California I believe that has a joint department between psychiatry and neurosurgery to investigate various psychosurgical procedures.

Also, there still exists a national organization advocating for the use of trepanning.

 

[notdeadyet]

Do not forget, also, that there is a university in California I believe that has a joint department between psychiatry and neurosurgery to investigate various psychosurgical procedures.

More than one. Interventional Psychiatrist job offers pop-up at a few programs out here. They typically seem to be a joint position betwen Neurosurgery and Psychiatry. DBS is big.

That said, I don't see the Interventional Psychiatrist picking up a scalpel anytime soon.

 

[DD214_DOC]

More than one. Interventional Psychiatrist job offers pop-up at a few programs out here. They typically seem to be a joint position betwen Neurosurgery and Psychiatry. DBS is big.

That said, I don't see the Interventional Psychiatrist picking up a scalpel anytime soon.

Of course they wouldn't pick up the scalpel. What, exactly, can you recall the position entailing for interventional psychiatry? I think some forms of therapy could also be considered, "interventional" as well.

Hell, CNS stimulants are better antidepressants than any antidepressant we have. We use them in the geri population. Why not utilize short courses of them in other populations as well?

 

[surftheiop]

I remember looking around awhile back and saw a couple places offer a "fellowship" that focused on things like ECT, TMS, DBS, etc. I assume it was probably intended for people hoping to do research in those fields.

 

[diagonal]

Of course they wouldn't pick up the scalpel. What, exactly, can you recall the position entailing for interventional psychiatry? I think some forms of therapy could also be considered, "interventional" as well.

Hell, CNS stimulants are better antidepressants than any antidepressant we have. We use them in the geri population. Why not utilize short courses of them in other populations as well?

I don't understand why it's not considered to use stimulants in depressed individuals, thereby giving them some motivation and energy to initiate a set of positive life habits (such as exercise), and then tapering off after several months, once those habits have been solidified and the positive consequences of said habits begin to manifest themselves to the patient.

 

[notdeadyet]

I remember looking around awhile back and saw a couple places offer a "fellowship" that focused on things like ECT, TMS, DBS, etc. I assume it was probably intended for people hoping to do research in those fields.

^^^ This.

 

[BS81]

I don't understand why it's not considered to use stimulants in depressed individuals, thereby giving them some motivation and energy to initiate a set of positive life habits (such as exercise), and then tapering off after several months, once those habits have been solidified and the positive consequences of said habits begin to manifest themselves to the patient.

That old give the depressed person enough energy to actually go through with a suicide attempt idea, eh? Isn't the whole fear of using SSRIs in adolescents that it might "activate" them enough without having the anti-depressant effect kick in yet that they are more likely to attempt suicide.

Also, it's bad enough with benzos as it is, you want to create another epidemic with an even more addictive class of drugs?

 

[BS81]

Although I have seen people use it as an adjunct. First line treatment is what i'd be more against.

Sent from my DROID RAZR using SDN Mobile

 

[diagonal]

That old give the depressed person enough energy to actually go through with a suicide attempt idea, eh? Isn't the whole fear of using SSRIs in adolescents that it might "activate" them enough without having the anti-depressant effect kick in yet that they are more likely to attempt suicide.

Also, it's bad enough with benzos as it is, you want to create another epidemic with an even more addictive class of drugs?

I'm not talking about kids. And I'm also not talking about patients with suicidal concerns. I'm talking more of the anhedonic type. The dysthymics.

Let me remind you that the standard of care in much of medicine is to give people dangerous drugs (read opiates) because it's determined necessary to get them through the therapeutic process. Are these drugs overly and misapplied? Yes. But as psychiatrists we presumably are better tuned to staving-off such problems. I'm going to go out on a limb and say that powerful drugs (and at times dangerous drugs) may have powerful effect, with powerful, and perhaps positive, consequences.

I also have similar feelings with cannabinoids.😱 I think they can help with motivation in contrast to what popular culture seems to think. Remember, my intention is to use these drugs in a transitional manner, and with obvious supervision, to include a psychotherapeutic process.

 

[BS81]

I'm not talking about kids. And I'm also not talking about patients with suicidal concerns. I'm talking more of the anhedonic type. The dysthymics.

Let me remind you that the standard of care in much of medicine is to give people dangerous drugs (read opiates) because it's determined necessary to get them through the therapeutic process. Are these drugs overly and misapplied? Yes. But as psychiatrists we presumably are better tuned to staving-off such problems. I'm going to go out on a limb and say that powerful drugs (and at times dangerous drugs) may have powerful effect, with powerful, and perhaps positive, consequences.

I also have similar feelings with cannabinoids.😱 I think they can help with motivation in contrast to what popular culture seems to think. Remember, my intention is to use these drugs in a transitional manner, and with obvious supervision, to include a psychotherapeutic process.

Cannabinoids can help with motivation...? Any links to studies or is this just personal anecdotal evidence? I've had opiate addicts also tell me they get a paradoxical burst of energy when they get high...

Also with 30% of people with MDD having a co-morbid substance use disorder there is no reason to make this a first or even second-line treatment.

 

[diagonal]

Cannabinoids can help with motivation...? Any links to studies or is this just personal anecdotal evidence? I've had opiate addicts also tell me they get a paradoxical burst of energy when they get high...

Also with 30% of people with MDD having a co-morbid substance use disorder there is no reason to make this a first or even second-line treatment.

Depressives are typically co-morbid with substance abuse because they can't find a way out, and drugs provide them with temporary relief. That very relief is what I'm talking about harnessing. I know what I'm saying isn't is your Psych First Aid, but perhaps real life is slightly more nuanced.

 

[BS81]

http://www.medscape.com/viewarticle/774462?src=nl_topic

just saw this today:

Sleep Disorder Drug May Be Useful for Bipolar Depression

SAN DIEGO, California — Armodafinil (Teva Pharmaceuticals), indicated for narcolepsy and sleep-related disorders, shows efficacy and high tolerance as an adjunctive treatment for breakthrough depressive symptoms associated with bipolar 1 disorder (BD), new research shows...