Child psychiatry

[AP12]

I am a PGY-2 psych resident, and I wanted some further clarification as to whether I should do Child psychiatry fellowship or not, and specifically I am having trouble determining whether to practice in the future with adults primarily or child and adults. I have worked on my university's inpatient child unit, which was somewhat enjoyable, but it was not what I was looking for in a career. Our program has residents do a half day of clinic once a week as PGY-2s, and while I usually see adults, I was allowed to carry a few child patients in my caseload. My specific issue is, while I enjoy working with many of my adult patients, at times I encounter patients who tend to focus on their controlled substances often, or those who exhibit persistent medication non-adherence, while there are other patients who I enjoy working with greatly. In the child patients that I have, atleast in my nascent career, it feels as though they usually have less comorbidity, and at times I find them easier to interview, which helps me to enjoy the doctor-patient interaction more

My question is, what are some important pros and cons to pursuing a career in child psychiatry?

I would like to focus on cons a bit more, but certainly both would be helpful. I am concerned that I may be overlooking a career in adult psych due to some difficulties with a few patients, and I am trying to get as objective an answer as possible.

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[Stagg737]

I am a PGY-2 psych resident, and I wanted some further clarification as to whether I should do Child psychiatry fellowship or not, and specifically I am having trouble determining whether to practice in the future with adults primarily or child and adults. I have worked on my university's inpatient child unit, which was somewhat enjoyable, but it was not what I was looking for in a career. Our program has residents do a half day of clinic once a week as PGY-2s, and while I usually see adults, I was allowed to carry a few child patients in my caseload. My specific issue is, while I enjoy working with many of my adult patients, at times I encounter patients who tend to focus on their controlled substances often, or those who exhibit persistent medication non-adherence, while there are other patients who I enjoy working with greatly. In the child patients that I have, atleast in my nascent career, it feels as though they usually have less comorbidity, and at times I find them easier to interview, which helps me to enjoy the doctor-patient interaction more

My question is, what are some important pros and cons to pursuing a career in child psychiatry?

I would like to focus on cons a bit more, but certainly both would be helpful. I am concerned that I may be overlooking a career in adult psych due to some difficulties with a few patients, and I am trying to get as objective an answer as possible.

Biggest cons I've encountered (in my very limited experience) are dealing with parents who should be patients themselves and having a lot of kids who are screwed because they're in the system. The latter was my child inpatient experience where it was a revolving door of social instability and lack of support in which many of them had no chance of growing into stable, functional adults. Would be interested to hear other perspectives as well though because I'm also interested in (outpatient) child psych.

 

[TexasPhysician]

Parents can be a blessing or a curse.

Child is just 1 more year. If you are considering treating children, just do it.

 

[romanticscience]

It is very hard to do psychodynamic/transference-focused therapy with adolescents/young adults because of the difficulty in eliminating secondary gain while the patient is under the parent's care. You essentially need to set and maintain a frame with multiple people. Exhausting!

 

[MacDonaldTriad]

I am not a socialist, but if you can see yourself dealing with children and parents without the need to suppress the urge to projectile vomit, you should do a C&A fellowship. The world needs people like you. It is an extra year and it does open doors, but just being a psychiatrist has 99% of doors open anyway. If you go for it you will be the unicorn of unicorns. We just graduated a child fellow who will become the third child psychiatrist in her home state, or so she claims.

 

[Merely]

I am not a socialist, but if you can see yourself dealing with children and parents without the need to suppress the urge to projectile vomit, you should do a C&A fellowship. The world needs people like you. It is an extra year and it does open doors, but just being a psychiatrist has 99% of doors open anyway. If you go for it you will be the unicorn of unicorns. We just graduated a child fellow who will become the third child psychiatrist in her home state, or so she claims.

3rd child psych in her home state? I hope that translates into major bank? Prolly not tho..

 

[hamstergang]

We just graduated a child fellow who will become the third child psychiatrist in her home state, or so she claims.

According to AACAP, the state with the fewest child psychiatrists is South Dakota, with 3 currently there: Workforce Maps by State

 

[MacDonaldTriad]

I don't remember which state she said, but it was probably South Dakota, North Dakota or Wyoming.

 

[hamstergang]

I don't remember which state she said, but it was probably South Dakota, North Dakota or Wyoming.

Well Wyoming already has 8 child psychiatrists and North Dakota's got a whopping 16. So probably South Dakota.

To the OP, if you enjoy your child cases then I don't see cons that won't exist with adults. Some people don't like working with kids and parents, and other people do. You can do the fellowship and then see a mix of adults and kids out in the real world.

 

[Trismegistus4]

When I look at job listings, I often find myself wishing I had don a child fellowship, just because there's so much more opportunity out there if you see kids. For example, a lot of places which are desperate for a locums doc need someone who can see both kids and adults. As in so many other aspects of medicine, when you're in med school or residency, you only see a small piece of the picture, and that then forms your view of a particular field. When I was in residency, one of the most prominent C&A attendings in the department was this super-liberal, hippie-dippie, SJW woke type who was mainly focused on child development and whose mission in life seemed to be spreading the gospel of how Montessori education would bring about world peace. If I had had the impression that child psychiatry was more about treating actual mental problems in children, rather than enabling our benevolent child overlords to rise up and overthrow the evil oppressive adults so they can all live in harmony with the universe, I might have been more interested.

 

[FiveTwoFifty]

Was thinking of making this thread after browsing here, so am glad to see it posted! Can relate a lot to the OP's question.

You can do the fellowship and then see a mix of adults and kids out in the real world.

I think this is the biggest question I have, and am glad to see it was answered. I'm about to be a PGY2 as well and am going to have my primary child/adolescent rotations coming up. I've loved the (brief) interactions I've had with adolescents on psych thus far. My perspective is this: it's one extra year. Given that I enjoyed the contact I had with kids/adolescents, unless I completely hate my dedicated child psych rotations, I should go for the fellowship. It opens more doors than it closes. Is this a correct perspective to have?

Going back to the quote I've included above, how possible/likely is it to have this combination and not be pigeonholed into only seeing child cases? Especially with a model like Kaiser, for example. I'm curious how flexible employers are in the 'real world' separate from residency... and even academia.

 

[clausewitz2]

Was thinking of making this thread after browsing here, so am glad to see it posted! Can relate a lot to the OP's question.



I think this is the biggest question I have, and am glad to see it was answered. I'm about to be a PGY2 as well and am going to have my primary child/adolescent rotations coming up. I've loved the (brief) interactions I've had with adolescents on psych thus far. My perspective is this: it's one extra year. Given that I enjoyed the contact I had with kids/adolescents, unless I completely hate my dedicated child psych rotations, I should go for the fellowship. It opens more doors than it closes. Is this a correct perspective to have?

Going back to the quote I've included above, how possible/likely is it to have this combination and not be pigeonholed into only seeing child cases? Especially with a model like Kaiser, for example. I'm curious how flexible employers are in the 'real world' separate from residency... and even academia.

My favorite outpatient supervisor is child-trained and now his entire job is doing IOP work with adults with BPD at a reasonably fancy academic place. You are not going to be pigeonholed.

 

[UTsksk]

I'm about to start PGY2 and considering applying at my home program where I can enter after my PGY2 to do the 2 years of child and then come back and do 1 year adult outpatient. Only problem is I kind of don't like the child psych PD. Havent had any problems so far, but there's a fear at all times because of her history with others. My wife wants me to stay because she is worried about finding a job and we just bought a house. My friends are all telling me to apply during 3rd year to try to go back home to TX (if I can get into TX)

 

[Sushirolls]

You won't be pigeon holed into doing C&A unless you agree to it.

If you really don't like C&A and don't want it to be a big part of your future practice, don't do it. The thought process of "just another year" is the equivalent of throwing away $200K. i.e. 50K for fellow salary vs 250k for attending salary over a year.

If you are open to seeing adolescents you can easily do that as an adult psychiatrist. Most newly minted ARNP see children and adults...

So pay attention during your required C&A rotations of your residency and schedule up some electives, then add 13yo and up to the mix.

If you have a fear of a PD, don't apply to that program. A PD is god and can end your career with a snap of the finger. Don't voluntarily go to a program where you will play russian roulette with your career.

 

[TexasPhysician]

The thought process of "just another year" is the equivalent of throwing away $200K. i.e. 50K for fellow salary vs 250k for attending salary over a year.

While this statement could be correct, it isn’t always. Months of my program were easier than being faculty, so I did plenty of moonlighting. In the end, I earned more than my faculty. They asked me to stay on after fellowship and in my head I was thinking - “and take a paycut?”

 

[Merovinge]

I like Sushi, but really disagree with this thought that somehow adult training covers 13-17 year olds. My adult training was really amazing but outside of my 2 months on child had zero exposure to 17-under which I think is pretty typical for adult training programs. The teenage years are not an easy time and I consistently see adult psychiatrists misdiagnose and mismanage teenagers who are clearly just seeing a handful every so often to improve access (CAP is generally understaffed almost everywhere but the biggest cities).

If you like seeing kids, do right by your future patients and do a CAP fellowship. You can take on gero, addictions, forensic, and C&L work as well off of adult but if you really like those sub-populations, you will generally do better with a fellowship in them. No you do not have to, but $200k is not making or breaking your life's comfort. Psychiatry as a whole is kind of anti-fellowship but I find the whole thinking that extra training does not help make someone better a very slippery slope (see PA/NP, Rx psychology). Of any of the fellowships, CAP is the most marketable and gives you access to jobs you would not otherwise have.

 

[FiveTwoFifty]

Yes, I've definitely heard the "you'll lose out on an attending's salary for a year" comment before. And it's valid for some people, to be sure! What I'm looking at, I suppose, is the opportunity to save a year (as opposed to going back later for two years) and to have the extra training. Anecdotally, I have heard from my attendings who see adult patients primarily that the developmental training can be helpful in working with them. For example, exposure to autism and really being able to distinguish that in the adult population rather than classifying the symptoms as something else.

I think that point really stuck with me. The idea of having an additional, more thorough perspective seems like it would benefit everyone.

 

[Sushirolls]

I like Sushi, but really disagree with this thought that somehow adult training covers 13-17 year olds. My adult training was really amazing but outside of my 2 months on child had zero exposure to 17-under which I think is pretty typical for adult training programs. The teenage years are not an easy time and I consistently see adult psychiatrists misdiagnose and mismanage teenagers who are clearly just seeing a handful every so often to improve access (CAP is generally understaffed almost everywhere but the biggest cities).

If you like seeing kids, do right by your future patients and do a CAP fellowship. You can take on gero, addictions, forensic, and C&L work as well off of adult but if you really like those sub-populations, you will generally do better with a fellowship in them. No you do not have to, but $200k is not making or breaking your life's comfort. Psychiatry as a whole is kind of anti-fellowship but I find the whole thinking that extra training does not help make someone better a very slippery slope (see PA/NP, Rx psychology). Of any of the fellowships, CAP is the most marketable and gives you access to jobs you would not otherwise have.

Some residency programs have more in depth months, and rotations, each program is different. But overall you are right, and I personally don't see anyone under 18, except the times in the past they showed up in the ED and I was it for who had to do the consultations. Its a mix of simply just not wanting to work with the population but also knowing there is a reason why C&A is a 2 year fellowship.

I made my post not in view point of medicine striving to raise and elevate standards of care, but recognition in the reality that there are too few psychiatrists and the market gap is being filled by nurse practitioners, who after their 400hrs of clinical training are minting themselves as full spectrum psychiatric providers - just take a look at websites in your local area. As a parent, should I ever need to seek the services of a C&A I would want the fellowship trained first, but before I ever consider an ARNP I would establish with a general adult psychiatrist who does some C&A.

I get calls all the time to my office, because some of my insurance panels don't have option of listing restrictions like 18+ on their directories. I talk with the parents and tell them who is in the community, and my response above is in part fueled by review of local resources I do with those parents.

As an observation, the floor is dropping in the medical establishment - we are returning to era pre-flexner report. With the expansion of midlevels; training, certifications, experience are all meaning less and less. Just peek over a the CRNA issue in anesthesiology forum where CRNA have asserted themselves as superior, and the best solution. Recently I have even had ND clinicians prescribing psychotropics, or hormones for transgender patients.

 

[Merovinge]

Yes, I've definitely heard the "you'll lose out on an attending's salary for a year" comment before. And it's valid for some people, to be sure! What I'm looking at, I suppose, is the opportunity to save a year (as opposed to going back later for two years) and to have the extra training. Anecdotally, I have heard from my attendings who see adult patients primarily that the developmental training can be helpful in working with them. For example, exposure to autism and really being able to distinguish that in the adult population rather than classifying the symptoms as something else.

I think that point really stuck with me. The idea of having an additional, more thorough perspective seems like it would benefit everyone.

Look, I've heard this "it makes you a better adult psychiatrist" thing from so many of my collegues who I really do admire, and there is some truth to this. If you take care of a lot of ID/ASD pts in the adult psych world, CAP is helpful, although I'd argue a good neuropsychiatry fellowship is even more so for that specific population. But lets be honest, spending 2 years in CAP if you really don't plan on seeing many kids to have a "lifespan perspective" is ridiculous.
There are great people in CAP to learn from, but no more or less than there are in the adult world.

There's no reason to make this complicated, if you think you want to see a significant portion of kids, do CAP, if you don't want to, do any of the fields in adult.