Choosing psych over FM

[SXMMD]

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Hello all,

I'm a 3rd year Carib med student applying for the 2015 Match. I'm interested in psych but also torn by the idea of turning away from FM.

I enjoy being able to walk into the hospital or clinic and being able to take care of the physical ailments people bring in, work through puzzling cases and using my hands occasionally to provide treatment. I enjoy longitudinal relationships with my patients but also get a rush out of acute cases. I enjoy working with people of all age groups, particularly kids and the elderly.

On the other hand, I hate the overbearing weight of administrative/political nonsense that hangs over primary care docs heads and realize that the type of practice I want to run will clash with the financial/legal/political realities of medicine in the U.S. On top of that, I've found in my rotations that we med students sometimes romanticize the impact medical services have on our patients. For many people getting their illness treated is like getting a burger from McD when you're hungry; you eat it and move on, life doesn't really change for the better, except you're no longer in acute pain/hunger.

This is where pysch comes in. The work is often interesting, cases can be super esoteric at times, the patients are turning out to be interesting and rewarding to work with and every pysch resident/attending I've worked with seem so happy with life in general, especially relative to their counterparts in IM/FM. On top of that, through my limited experience with psych I find that the work that psychiatrists do generally has a greater ability to improve people's experience of life, which to me is a core part of what I want to accomplish with the care that I provide to patients.

So now I'm torn between FM and Pysch, and could use some advice. Anyone feel the same way before making the leap to psych? Any "rose-tinted views" shattering information about practice after residency to share with me? And any advice about reading materials, journals etc one could look into to further explore psych as an option for residency?

Look forward to your responses!

 

[vistaril]

Hello all,

I'm a 3rd year Carib med student applying for the 2015 Match. I'm interested in psych but also torn by the idea of turning away from FM.

I enjoy being able to walk into the hospital or clinic and being able to take care of the physical ailments people bring in, work through puzzling cases and using my hands occasionally to provide treatment. I enjoy longitudinal relationships with my patients but also get a rush out of acute cases. I enjoy working with people of all age groups, particularly kids and the elderly.

On the other hand, I hate the overbearing weight of administrative/political nonsense that hangs over primary care docs heads and realize that the type of practice I want to run will clash with the financial/legal/political realities of medicine in the U.S. On top of that, I've found in my rotations that we med students sometimes romanticize the impact medical services have on our patients. For many people getting their illness treated is like getting a burger from McD when you're hungry; you eat it and move on, life doesn't really change for the better, except you're no longer in acute pain/hunger.

This is where pysch comes in. The work is often interesting, cases can be super esoteric at times, the patients are turning out to be interesting and rewarding to work with and every pysch resident/attending I've worked with seem so happy with life in general, especially relative to their counterparts in IM/FM. On top of that, through my limited experience with psych I find that the work that psychiatrists do generally has a greater ability to improve people's experience of life, which to me is a core part of what I want to accomplish with the care that I provide to patients.

So now I'm torn between FM and Pysch, and could use some advice. Anyone feel the same way before making the leap to psych? Any "rose-tinted views" shattering information about practice after residency to share with me? And any advice about reading materials, journals etc one could look into to further explore psych as an option for residency?

Look forward to your responses!

I think you should probably do FM/IM. You seem to like the mediciney aspects of medicine too much.

 

[notdeadyet]

On the other hand, I hate the overbearing weight of administrative/political nonsense that hangs over primary care docs heads and realize that the type of practice I want to run will clash with the financial/legal/political realities of medicine in the U.S. On top of that, I've found in my rotations that we med students sometimes romanticize the impact medical services have on our patients.

Nothing personal, but you may be having a grass-is-greener reaction if you don't think this applies to psychiatry as well. I think these sort of issues are universal in medicine more than specialty specific.

Psychiatrists do tend to be happy. Mostly the ones that really want to be psychiatrists. I'm not hearing a big reasoning for why you'd love practicing psychiatry itself.

 

[Shikima]

Why not do both? There are plenty of opportunities to build a med/psych clinic...
The method in building such a practice would be to take a holistic approach which is integrative, you sell yourself as such, and your notes reflect either it's a mental health visit or a physical medicine visit. You document what you want to do and in what manner you'd like to proceed. Remember, the plan for care is for yourself and colleagues, not the insurance company.

 

[SXMMD]

@vistaril: I do enjoy the mediciney aspects of medicine a whole lot but I'm becoming increasingly hesitant to put myself in the type of environment in which primary care docs have to work. It's brutal!

@notdeadyet: Truthfully, I don't have specific aspects of psych that really gets me excited in particular. I find that in a general sense enjoy the work because I still feel like I did something useful with myself when a patient's treatment is going well and psych cases can be every bit or more puzzling than medicine cases, which the detective in me finds satisfying. It seems to me thus far (and I highlight my inexperience here with the issues psychiatrists deal with on the political front) that psychiatrists tended to manage their stresses better, are happier with their work and have a greater degree of autonomy than their FM counter parts. Being happy with the work I've done and feeling like I have some degree of control over how my practice is run is important to me. As I read the responses and my own post on this thread though I do think perhaps the "grass is greener" effect may be playing a role here, so thank you for pointing that out, I'll reflect on your comment.

Do you feel that psychiatrists have (generally) the same degree of autonomy as primary care docs? More? Less?

@Shikima: That's an interesting idea, what does a patient encounter in such a practice look like? How would the billing for such a visit work?
-To be clear, $$ isn't a primary motive here but with my hefty loans... the $$ has to make sense so I can pay the bills. Can a doc running the integrative model make the avg FM or psych salary?

Thanks for your responses!

 

[vistaril]

@vistaril: I do enjoy the mediciney aspects of medicine a whole lot but I'm becoming increasingly hesitant to put myself in the type of environment in which primary care docs have to work. It's brutal!!

huh? Go over to the medicine forums and look at the offers hospitalists are getting.....doesn't sound like too bad an environment to me. They bill the same e/m outpt codes as we do but can make more because they have more passive revenue stream opportunities(very important) and more volume as they spend less time on average with patients. Oh and even though mental health care parity is supposedly a law, many states just ignore it so you have that too.

I'm doing a very low volume outpt psych practice in a few months(so this doesn't really apply to me), but if I were looking to make decent money by doing high volume(which is the only way you are going to make anything in psych or outpt primary care), there isn't any doubt in my mind that I could move through patients much faster in outpt primary care if I set things up right vs psych. And have more revenue streams.

 

[Leo Aquarius]

Dear OP,

Please listen very carefully to the points you raise. I, too, loved the idea of being able to treat all the general medical issues when I was a med student. But the working condition of FM docs can be really awful. The family medicine doctor I shadowed told me it's a war, and you have to see as many patients as possible. He spent about 10 minutes per patient, and he RAN a private practice that occupied 2 floors of a hospital. He was the big wig. I felt dizzy by the end of each day. No time for digging deep into the life of each patient.

Hospitalists get dumped on. Don't believe me? I invite you to talk to a few, or just work in any hospital. Family medicine doctors must churn thought so many patients a day its dizzying. Please go shadow a few. Vistaril... all he thinks about are revenue streams. Keep your focus on what's important to you.

I am very very happy in Psych. It's all about spending time with your patients, at a decent pace for decent pay. At the end of the day very few people can say they make a difference. We most definitely do (I know because patients tell us).

 

[Psychotic]

.

 

[Shikima]

@Shikima: That's an interesting idea, what does a patient encounter in such a practice look like? How would the billing for such a visit work?
-To be clear, $$ isn't a primary motive here but with my hefty loans... the $$ has to make sense so I can pay the bills. Can a doc running the integrative model make the avg FM or psych salary?

What I would recommend doing, and others bring up the valuable point in working like a dog for little to no reimbursement as a FM doc, is to consider doing a combined pathway which leads into geriatrics. You could then be medical director of med/psych wards, hospice, geriatric psych wards (which is a booming industry) and nursing homes/retirement facilities. Or you could go the opposite direction and work with children and adolescents.... The door will be open for you in multiple directions.

If you want to work with adults only, consider IM/Psych....

Billing would be the same, rather you won't be doing joint med/psych sessions - you'd have to pick one or the other. If you choose an employed practice model, then negotiating with your employer that you can do both in the same visit because it is very time consuming. Bottom line is, you'd have to market and sell holistic wellness.

 

[vistaril]

All I have ever heard or read about hospitalists is the burnout they experience. The "environment" that sounds so good to you is more than the compensation levels, it is what you have to do to earn that pay that matters. Otherwise we should all strive to become surgeons, for the great "environment," right?

Comparing a 7 on / 7 off inpatient hospitalist gig to a 9 to 5 outpatient psychiatry gig is apples to oranges; completely different work conditions and suitable to very different kinds of people with different goals and objectives for a medical career.

what I see(and know from experience with a couple family members who have worked such gigs part time during fellowships) is that most days you don't stay anywhere close to 7......you round, go home 2 or so and keep your pager on.....

 

[Psychotic]

.

 

[IamPsychiatrist]

And I know a guy who did a hospitalist gig for a year before starting a cards fellowship, and it was at a smallish community hospital, and he worked his butt off. He told me he was exhausted by it and could not see doing a gig like that for very long, certainly not for a long career.

N=1 (or 2...) anecdotes prove nothing. Suffice to say my point that you conveniently missed is that there is a huge difference between an inpatient, 7 on/7 off gig, and an outpatient gig with predictable hours and little in the way of overnight emergencies and home/pager call. To effectively draw no distinction between these wildly different job models and to then conclude that since the hospitalist can make more $ it is the better gig is disingenuous to say the least.

Yeah, hospitalist work is rough. I know lots who quit. It doesn't even pay that well and everyone is dumping on you. Most go do a fellowship within 10 years. It's no way to live (80 hrs during your week on, constant stress and overloaded).

Let's be honest, there are tons of gigs better than psych. I've heard of some neurosurgeons working 40 hr weeks and all elective cases earning tons of $. But one thing is for sure, general IM / hospitalist isn't one of those gigs. Keeping up with the knowledge base alone is like having another part time job.

 

[Dharma]

Let's be honest, there are tons of gigs better than psych. I've heard of some neurosurgeons working 40 hr weeks and all elective cases earning tons of $.

Did you just use "tons of gigs" and then neurosurgery to back that up? (I'm just messing with you btw 😉)

 

[gibits]

SXMMD:
Whenever I see a thread like this I am personally puzzled since I just knew I wanted to be psychiatrist the instant I entered med school. There was no ambiguity at all. In your predicament I'd say you need more exposure, and monitor which field makes you WANT to ask more questions (as opposed to being forced to). After a rotation with a FM or psychiatrist, are you reading up on the topics that were brought up or are you turning on the xbox?
This is usually a good indicator of what piques your interest more. You want to be in the field that tickles your curiosity, that makes you want to know more. Both fields can be rewarding, but they are not for everyone. IMO having a passion about the field is the most important thing, not profit or lifestyle. Those are just the tiebreakers.

 

[vistaril]

Yeah, hospitalist work is rough. I know lots who quit. It doesn't even pay that well and everyone is dumping on you. Most go do a fellowship within 10 years. It's no way to live (80 hrs during your week on, constant stress and overloaded).

Let's be honest, there are tons of gigs better than psych. I've heard of some neurosurgeons working 40 hr weeks and all elective cases earning tons of $. But one thing is for sure, general IM / hospitalist isn't one of those gigs. Keeping up with the knowledge base alone is like having another part time job.

I think if I was a 7/7 hospitalist I would look at smaller community hospitals away from large cities. Tons of those 7/7 positions have 7 on where you will work nowhere close to 80 hrs a week during your 7 on. Those guys make 275ish at the 7 on, and then another 125k during the 7 off picking shifts here and there. 400k total and they aren't working too hard.

Busier hospitals in bigger cities is probably a bit diferent.

 

[SXMMD]

@ Leo Aquarius: have your perceptions/experience with FM changed at all from your vantage point in psych?

@ Shikima: I hadn't considered those possibilities, they're far more creative than what I had in mind, thanks for broadening the horizons a little! I'll have to look into dual certs more for sure

@gibits: Thanks for your comment, you've drawn out the issue I'm having: prioritizing passion over other considerations. To clarify, in case this was lost in translation in my earlier posts, I'm not trying to push for money or lifestyle per se. I'd like to earn enough to pay off my loans in a reasonable time (about avg of fam med/psych salary is sufficient for me with the way I live). I'd like autonomy over how my practice is run, meaning I don't want $$ and politics to dictate the manner in which I run my practice and be unhappy as a result. I realize that you can't divorce these things from medicine and that these problems are also to be found in other specialties (psych included), I'm just trying to find a more level playing field and not be a slave to my debt or "to the Man/insurance companies" which leads me to the following:

I really enjoy family medicine. I enjoy psych, not as much as FM but enough that I am content with it. Enter issues of autonomy and happiness (autonomy plays a role in happiness for me)- I would like to have as much of each as possible. Where will I have greater autonomy? Is there a big enough difference between the two specialties in terms of which has more/less autonomy that I should pick the field I am less passionate about (but still enjoy, I should stress) if it gives me greater autonomy to control my practice?

Your comment: "After a rotation with a FM or psychiatrist, are you reading up on the topics that were brought up or are you turning on the xbox?" made me laugh, but it resonates with me as well. I'll sit on this one, thank you!

@ everyone: I wish I had more time to explore each field more thoroughly, but 3rd year is moving faster than I can understand the world of medicine outside academic life and your input is much appreciated! I'm following the discussion that's going on about hospitalist medicine closely too, cheers!

*edit: just to throw this out there, my rotations have all been in NY so far, so its not really clear to me how similar/different FM or psych would be outside NY. I'm not likely going to settle here, and tend to prefer rural/suburban to the city

 

[Shikima]

SXMMD,

You could use a dual training program (FP/Psych or IM/Psych) to enter into Pain management and the do an addictions fellowship. Can do procedures but also have the cognitive training for those deal with addictions and pain.

 

[Fabio001]

SXMMD,

You could use a dual training program (FP/Psych or IM/Psych) to enter into Pain management and the do an addictions fellowship. Can do procedures but also have the cognitive training for those deal with addictions and pain.

I have done a lot of looking into this and I have found no indicators that a combined psych/X fellowship will make someone any more likely to match into a pain fellowship. Though please correct me if you know something I don't!

 

[Shikima]

I have done a lot of looking into this and I have found no indicators that a combined psych/X fellowship will make someone any more likely to match into a pain fellowship. Though please correct me if you know something I don't!

Who said anything about improved chances? Nothing is guaranteed.

 

[Fabio001]

You seemed to imply that one of these combined residencies would open up doors into the field of pain management, which I'm suggesting is largely unfounded. That is all.

Edit: at least in regard to landing a spot in a pain fellowship

 

[SXMMD]

What I understood from Shikima's post was that one could use both skill sets (med and psych) to deliver care to that particular patient population, I don't think it was a comment about increasing one's competitiveness for fellowship. Correct me if I'm wrong!

 

[Shikima]

No such implication. SXMMD wanted to know what to do with med/psych combination and I presented a few different options.

 

[WolverineDoc13]

I was in a similar boat as you (psych vs. primary care) because I also liked the mediciney stuff as well. I eventually chose psych for similar reasons mentioned here, but I want to add two suggestions that may help your decision process:

1.) There's more medicine in psych than many people realize (at least more than what I had realized long ago), so it won't be completely eliminated from your future psych practice. Even in the outpatient setting, you'll be addressing medical concerns (thyroid issues, substance use, pregnancy issues, somatization, drug-drug interactions, etc.)-- even if it just involves referring patients to the appropriate specialist/PCP. Plus, you can consider a subspecialty of psych that has more intrinsic medicine involved, like geriatrics, C-L (has TONS of medicine, obviously), HIV, or eating disorders. I would suggest doing an elective in one of those fields (you mentioned NY-- I heard Cornell has a fantastic eating disorders unit, Beth Israel has a great HIV psych clinic, and I think you can shadow some psycho-onc at Sloan Kettering).

2.)While having my psych/primary care dilemma, I spoke to two mentors (1 psych and 1 IM guy). They both said similar things: Primary care (compared to psych) involves much more broad diagnostic evaluations and medical detective work. By the time a patient typically reaches a psychiatrist (in the ED or the outpatient setting), it's already clear that that person has some form of psych concern that was already screened by a PCP (or EMS). While you're still having fun figuring out the exact psych diagnosis (and r/o other etiologies), you won't see as broad a range of stuff as a PCP. So if the whole aspect of being a medical detective seems really appealing to you, you may get more of that in family practice.

Either way: good luck!

 

[vistaril]

You seemed to imply that one of these combined residencies would open up doors into the field of pain management, which I'm suggesting is largely unfounded. That is all.

Edit: at least in regard to landing a spot in a pain fellowship

the best way to land a pain fellowship is to do anesthesiology or pm&r. Neurology would come in behind these two.

If one wants to work in pain from a mental health perspective, it seems more psychologists are involved in this than psychiatrists. I suspect this is because of reimbursement issues(lots of medicare/Medicaid patients in a therapy setting isn't revenue generating).

I'm sure there are a few psychiatrists who have trained in pain medicine fellowships along with other specialties, but just because there are a few in the whole country obviously doesn't mean this is a decent option. I'm sure an IM/psych person would be in a better position to do pain medicine than a purely psych person, but even this combination would almost certainly be much less attractive than even neuro candidates by far.

The whole topic is ridiculous since someone interested in doing one of the most procedural non surgical specialties wouldn't gravitate to THE LEAST procedural specialty for a residency. If they have poor board scores or whatever they would just aim for noncompetitive pm&r programs as those aren't super hard to get into.

 

[VenusinFurs]

I was actually really interested in psych before I started clinical rotations, and I still find it absolutely fascinating, but I just could not deal with it. Medicine in general takes a lot of intestinal fortitude, but to be a psychiatrist is on a whole different level. I'd say you should only go into psych if you are REALLY INTERESTED in it.

 

[notdeadyet]

I'd say you should only go into psych if you are REALLY INTERESTED in it.

Yes, but true for any specialty, really….


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