Cold feet

[m3ds]

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I have a strong application for psychiatry that I have been working on to my maximum capabilities including specialized volunteering, lots of psychiatry research, strong connections in the field. I absolutely love research and know my career needs to include a substantial research component for me to be happy, and I feel that I have the best shot at breaking into an academic circle in Psychiatry given my existing strong research background and connections. In retrospect I should've gone MD-PhD, but I was worried I was too old. I took a ton of gap years mostly because I was scared to make the financial commitment associated with medical school; I fell into a very high paying corporate job that felt impossible to walk away from. However, I also am an inherently cautious/indecisive/anxious person as I think will become overtly clear.

Approaching residency apps, I'm scared because my clinical exposure in Psychiatry is so limited as a medical student and I don't know if I will actually like being a Psychiatrist. I loved my Psychiatry rotation. I felt that I really got along with the residents and attendings - it was so beyond fulfilling after years of working in a dry corporate environment to be around smart people who share my niche interests. I can talk about Psychiatry endlessly and it feels really exciting to dedicate my life to doing so.

However, I can't look past the fact that I saw a total of (maybe) 30 patients total during my rotation and it just doesn't feel like enough data to base the rest of my life on, particularly when Psychiatry feels so distinct from the rest of medicine. I really liked CL and inpatient and am doing more intensive electives in these areas in the coming months. I hated outpatient psychiatry, which feels like a huge red flag and is probably my biggest concern at this point, since the "lifestyle" aspect of psychiatry centers on people's perceptions of outpatient psych as an easy fallback job. In the past, when I've worked from home, I have very quickly become very depressed. However, I really like the flexibility of being my own boss one day and not being tethered to a hospital system. On the other hand, I often worry about midlevel encroachment in Psychiatry.

I have had lots of conversations with attendings in different specialties about this. One told me, point blank, I am "too smart" to be a Psychiatrist. Some of them have told me, in softer language, that I seem to like Medicine too much to be a Psychiatrist. I am constantly facing the frustrating assumption that I don't want to be involved in procedures or learn things because I'm "doing Psych". I wish I could know myself and trust myself enough to disregard these opinions, but there is a kernel of truth there. I feel really apprehensive about giving up the rest of medicine. I genuinely really enjoy the mental exercise of IM rounds (just maybe not when my back and feet hurt after 5 hours).

I can't talk to any of my Psychiatry mentors about this because I don't want them to know I'm not all-in. I tried going to a therapist and it was just so exhausting to explain this whole process to them we got nowhere. I have a similar experience with friends and family, although my SO is quick to remind me how happy I seemed during Psych rotation and really wants me to pick Psych "for the lifestyle". The consensus on the internet seems to be that people who are between Psych and anything else should pick Psych. I have tried asking around in my networks about combined IM-Psych programs, and everyone tells me not to do it and that it's a complete waste of effort/time. My other concern is that none of the combined IM-Psych programs are anywhere near my/my SO's family and I am going to be in my 30s when I start residency; if we want children during residency we will realistically need to be near family and the combined programs make that impossible.

Really appreciate any insight from those who may have gone through similar concerns, thank you.

 

[TexasPhysician]

I’m going to ignore the psychiatry aspect and focus on specialties in general.

Everyone will need to follow their own thought process on what specialty is right for them. The mindset is different person to person.

A classmate of mine disliked every rotation but hated Derm clinic the least. She is now a dermatologist that is pleased with her decision, but she isn’t passionate about her field. She proves that liking your field isn’t a necessity to be happy, but I’ll argue that it certainly helps.

Every field is also a bit of a compromise. Family medicine gets all ages, but many say an expert at nothing. Ortho see bone, fix bone and nothing more. Many fields have no long-term patient relationships, but not everyone wants that. Plastic surgery is often criticized as focusing on aesthetics which doesn’t actually treat a real medical diagnosis. All fields have merit, but none are without criticism or judgement.

There is no choice that impresses everyone or is objectively the right answer.

On top of this, you won’t get adequate exposure to all fields. I’ve been practicing a decade, and I’ve never seen a PM&R specialist at work.

My tips:
1. Ignore everyone else. You have to do the job weekly for the next 15+ years, not them.
2. Ignore finances. Every field averages more than $150k and realistically every field has access to $200k+ options.

 

[clausewitz2]

It is also worth noting that a) this board should prove to you there are plenty of psychiatrists happily working in the field who have no interest in outpatient work and b) the outpatient rotations you are likely to have had access to in residency often means residency clinics. Residency outpatient psychiatry clinics are where people who don't really have any other options seek care, for the most part. The population is very unrepresentative of what you encounter in most outpatient psychiatry settings. It's perfectly possible to be a psychiatrist who loves working outpatient who would not take a job in the clinic you rotated in in a million years.

 

[thelastpsych]

It is also worth noting that a) this board should prove to you there are plenty of psychiatrists happily working in the field who have no interest in outpatient work and b) the outpatient rotations you are likely to have had access to in residency often means residency clinics. Residency outpatient psychiatry clinics are where people who don't really have any other options seek care, for the most part. The population is very unrepresentative of what you encounter in most outpatient psychiatry settings. It's perfectly possible to be a psychiatrist who loves working outpatient who would not take a job in the clinic you rotated in in a million years.

I'll second that - one of the reasons that I decided against Psych in med schoolwas that the clinic that we rotated on had some of the most unresponsive, chronically ill patients I've ever seen, so I had this impression that pysch didn't help anyone. A lot more exposure to different environments changed that decision, fortunately. I still can't tolerate inpatient pysch, even though that was where most of my first and second years in residency happened, and I would NEVER work in a residency clinic.

 

[FatherPsychiatry]

However, I also am an inherently cautious/indecisive/anxious person as I think will become overtly clear.

One of the best aspects of psychiatry for someone who is indecisive - it has more flexibility than most (if not all) of the other specialties. You can work as much or as little as you want (while still getting paid a very decent amount), sit in a chair all day at home or on your feet all day interacting with other medical staff, treat smelly people smearing feces on a wall or good looking people whose handbag cost more than you made in two months during residency. As you learn more about yourself as you age, your family grows, and the people close to you grow, you can shift your life accordingly and more easily as a psychiatrist than any other specialty IMO.

Do not underrate your spouse saying that you appeared so happy when rotating in psychiatry. Weigh your spouse's opinion appropriately when comparing it to individuals (who you will likely never interact with ever again) that you're too smart for this field.

Best of luck to you.

 

[Bartelby]

I agree with TexasPhysician that you have to pick something you will like doing. The people saying you are "too smart" for psychiatry aren't going to be there each day with you, so pick what you enjoy and not what is perceived as more prestigious. And while there are some physicians who still look down on psychiatry that way, most recognize the value of psychiatrists (especially when they need our input!).

Others have pointed out that resident clinics are different than real-world outpatient clinics, which is true. I would also add that outpatient as a medical student is, I think, a lot less fulfilling than inpatient or CL. On inpatient and CL you see extreme presentations and situations that are inherently fascinating when you encounter them for the first time. On outpatient, you see people who are generally basically stable and who you will never see again. Presentations in outpatient lack that "wow" factor but when you are actually responsible for their management the challenge and engagement increases significantly. You often work with these patients for years, develop real relationships, and make decisions that can move them toward gradual recovery or a slow-moving trainwreck. It's not for everyone, but being an outpatient psychiatrists heading up your own clinic is much different than being a medical student who can, if you choose, passively float through the rotation with no real negative consequences.

 

[comp1]

Oh so much to unpack!! I definitely disagree with idea of ignoring everyone else. You don't know what it's like to be a practicing internist or psychiatrist, the only way to figure that out is by talking to a lot of people. I can't imagine that any of your mentors would be turned off by your cold feet. Quite the opposite, I'm guessing they would be just as eager to reassure you as the people on this board. Definitely agree that the flexibility of psychiatry makes it really great for people who are indecisive. You can make it whatever you want. I also hate outpatient! And I've seen more than just resident clinics, it sucks, but fortunately after residency, you don't have to do it! Yes, yes you can manage your own private practice and do whatever the heck you want, I know. Outpatient is still very much not for me and it might not be for the OP either. Or, it might be. They'll figure it out in residency. Hating outpatient is in no way a red flag though, I hated it from the moment I first saw it in MS3 and still do to this day while I adore inpatient (and CL to a much lesser extent) almost every day.

I don't quite relate to the ambivalence personally because I hated just everything other than psych so much, but some other advice I would give is to think about the people involved. The OP's comments above focus a bit on the patients, but I would focus a little more on the people who work in the field. Do you get along with psychiatrists? I was advised to "find my tribe" as an MS3 and it was definitely amongst psychiatrists. The amount of stress surgeons and internists seemed to be under was massive and quite honestly, barely tolerable for the couple of months I had to handle it. the comment about being too smart for psychiatry was kinda funny as I definitely got that from internists as well. This is why the OP needs to share their concerns with psychiatrists. You can make any field as cerebral or as checklist as you want, even ortho.

 

[Merovinge]

I have had lots of conversations with attendings in different specialties about this. One told me, point blank, I am "too smart" to be a Psychiatrist. Some of them have told me, in softer language, that I seem to like Medicine too much to be a Psychiatrist. I am constantly facing the frustrating assumption that I don't want to be involved in procedures or learn things because I'm "doing Psych". I wish I could know myself and trust myself enough to disregard these opinions, but there is a kernel of truth there. I feel really apprehensive about giving up the rest of medicine. I genuinely really enjoy the mental exercise of IM rounds (just maybe not when my back and feet hurt after 5 hours).

Have you seen this board? I would take vacation just to watch @splik run a consult service (I know they don't this job anymore, but if they did). I could grab a drink and listen to @clausewitz2 talk for 5 hours. Look at @mistafab's posts and this person is just out of training...

This is such outdated BS I can hardly dignify it with a response. Yes psychiatry went through a phase of being very non-competitive and it did attract people who scored poorly on the STEP exams. But holy cow, spend some time with good psychiatrists and anyone ought to be blown away. The combination of understanding neuroscience, probabilities, pattern recognition, empathy, persuasion, and wisdom is just unparalleled. Psychiatry attracts one of the higher percentages of MD/PhD's for a reason and unlike neurologists the "soft" skills are often much more refined in addition to the raw intellectual horsepower.

Do you know what they call psychiatrists who understand IM? Psychiatrist. You definitely need a good medical background to provide optimal care for patients, there is a reason we go to medical school and not pharmacy school before training.

So at the risk of being wildly overdefensive, please to not pay any mind to doctors denigrating the intellect of psychiatrists or thinking you won't fit in due to your cognitive abilities. You even have first hand experience on your rotation of what it's like to spend time with psychiatrists.

 

[FlowRate]

We need smart people with a passion for research in the field. The state of the science in psychiatry--despite how many smart and hard working researchers are in the field--remains far below pretty much any other specialty. If you could find a way to make a true impact on bridging the syndrome-disease divide, for example, that would be immensely impactful. (Reasonable discussion to be had as to how feasible that will ever be.)

A result of the syndrome problem is that, in comparison to most other specialties, you don't get to feel as certain that you're definitively putting the probabilistic puzzle pieces together in a way that's objectively helpful to the patient. I think that is also part of the "you're too smart for psychiatry" thinking of people outside of the field; the relative effects of being "smart" vs "unsmart" are far more immediately visible in other fields.

 

[m3ds]

This is such outdated BS I can hardly dignify it with a response. Yes psychiatry went through a phase of being very non-competitive and it did attract people who scored poorly on the STEP exams. But holy cow, spend some time with good psychiatrists and anyone ought to be blown away. The combination of understanding neuroscience, probabilities, pattern recognition, empathy, persuasion, and wisdom is just unparalleled. Psychiatry attracts one of the higher percentages of MD/PhD's for a reason and unlike neurologists the "soft" skills are often much more refined in addition to the raw intellectual horsepower.

I don't agree with it either! This reasoning is just something I routinely encounter on other rotations; revealing a genuine interest in Psychiatry feels like coming out of a closet. I am often met with open revulsion/distaste. One attending stopped a PROCEDURE and said "What could possibly make someone interested in PSYCHIATRY? The LIFESTYLE?"

It's already grating on me and I wonder if I'm going to spend the rest of my life with a chip on my shoulder or if I will develop the ability to just not care. For example let's say I achieve at a high level and become an amazing CL Psychiatrist at an academic medical center; are other physicians going to talk down to me forever? At what point will I not care?

 

[TexasPhysician]

It's already grating on me and I wonder if I'm going to spend the rest of my life with a chip on my shoulder or if I will develop the ability to just not care. For example let's say I achieve at a high level and become an amazing CL Psychiatrist at an academic medical center; are other physicians going to talk down to me forever? At what point will I not care?

You need to look at this differently. You are the impressionable medical student. You are surrounded by faculty that took a 6 figure pay cut to teach and influence the next generation on how amazing their field is. You are honestly telling them that you would prefer another field to their personal favorite.

If you are stuck talking to me about how I love Harry Potter and dedicate 40 hours per week to Harry Potter, how do you think it will go when someone says Star Wars is their favorite? I’ll be more than happy to explain how Star Wars is inferior to Harry Potter in every way. It doesn’t mean that I can’t get along with the Star Wars crew or even that I don’t respect their passion for their chosen movie series. If I need a lightsaber, Im happy to give them a call.

 

[tr]

I don't agree with it either! This reasoning is just something I routinely encounter on other rotations; revealing a genuine interest in Psychiatry feels like coming out of a closet. I am often met with open revulsion/distaste. One attending stopped a PROCEDURE and said "What could possibly make someone interested in PSYCHIATRY? The LIFESTYLE?"

The years of hoop-jumping required for medical school admission tend to select for people who are dogged rule-followers. They are often very socially conservative and have low openness to experience. The few who don't fit this profile mostly seem to gravitate to psychiatry.

This person's inability to recognize that others have different interests than they do is a reflection on them, and has nothing to do with you. We are all certainly better off if they stick to removing people's gallbladders or whatever it is that interests them.

It's already grating on me and I wonder if I'm going to spend the rest of my life with a chip on my shoulder or if I will develop the ability to just not care. For example let's say I achieve at a high level and become an amazing CL Psychiatrist at an academic medical center; are other physicians going to talk down to me forever? At what point will I not care?

I treat a lot of physicians and they are uniformly extremely grateful for my services. I love my job and I certainly do not feel condescended to regarding my choice of specialty. Again, if anyone were to make such a bizarre statement I would consider it a reflection on them, nothing to do with me or my career choice.

 

[J ROD]

I was also told by "mentors" in medical school that I was too smart to go into psych and I was "wasting my talent". I even went to the point of doing both acting internships in psych and internal med my 4th year. I had to literally defend my decision to only apply psych when time came to our clerkship director. End of the day you have to make the decision with as much information as you can. I am very happy with doing psych and could not see myself doing general medicine.

 

[shoomer]

In medicine, people trash other specialties all the time. The more different/less understood you are, the worse it gets. Psychiatry is so unique and still fascinates me regularly even as day to day work becomes mundane no matter what you do.

I dealt with huge cultural stigma against psychiatry in my family/community and second guessed myself a lot during the application process. I thought I would miss the aspects of medicine and neurology that I loved, and I thought I would struggle with seeing the issues that are bread and butter in psych. Sticking with my gut and going psychiatry was the best decision I ever made.

The flexibility we have in psych is unparalleled. I make meaningful medical decisions frequently while avoiding what I consider the boring aspects of medicine. I hear about the most interesting cases that my friends in other specialties bring up and they honestly don't come close to my most interesting cases.

I know plenty of psychiatrists who hate one of inpatient/consults/outpatient and love one of them. I don't really like outpatient either but I could see a practice where I work with more niche interests actually being interesting to me. "Lifestyle" is a broad, nebulous term but it's not like inpatient and consults jobs can't give you that. A ~40-hr work week with minimal after hours responsibility is definitely possible in any setting if you look around enough.

 

[LeJoker]

I have a strong application for psychiatry that I have been working on to my maximum capabilities including specialized volunteering, lots of psychiatry research, strong connections in the field. I absolutely love research and know my career needs to include a substantial research component for me to be happy, and I feel that I have the best shot at breaking into an academic circle in Psychiatry given my existing strong research background and connections. In retrospect I should've gone MD-PhD, but I was worried I was too old. I took a ton of gap years mostly because I was scared to make the financial commitment associated with medical school; I fell into a very high paying corporate job that felt impossible to walk away from. However, I also am an inherently cautious/indecisive/anxious person as I think will become overtly clear.

Approaching residency apps, I'm scared because my clinical exposure in Psychiatry is so limited as a medical student and I don't know if I will actually like being a Psychiatrist. I loved my Psychiatry rotation. I felt that I really got along with the residents and attendings - it was so beyond fulfilling after years of working in a dry corporate environment to be around smart people who share my niche interests. I can talk about Psychiatry endlessly and it feels really exciting to dedicate my life to doing so.

However, I can't look past the fact that I saw a total of (maybe) 30 patients total during my rotation and it just doesn't feel like enough data to base the rest of my life on, particularly when Psychiatry feels so distinct from the rest of medicine. I really liked CL and inpatient and am doing more intensive electives in these areas in the coming months. I hated outpatient psychiatry, which feels like a huge red flag and is probably my biggest concern at this point, since the "lifestyle" aspect of psychiatry centers on people's perceptions of outpatient psych as an easy fallback job. In the past, when I've worked from home, I have very quickly become very depressed. However, I really like the flexibility of being my own boss one day and not being tethered to a hospital system. On the other hand, I often worry about midlevel encroachment in Psychiatry.

I have had lots of conversations with attendings in different specialties about this. One told me, point blank, I am "too smart" to be a Psychiatrist. Some of them have told me, in softer language, that I seem to like Medicine too much to be a Psychiatrist. I am constantly facing the frustrating assumption that I don't want to be involved in procedures or learn things because I'm "doing Psych". I wish I could know myself and trust myself enough to disregard these opinions, but there is a kernel of truth there. I feel really apprehensive about giving up the rest of medicine. I genuinely really enjoy the mental exercise of IM rounds (just maybe not when my back and feet hurt after 5 hours).

I can't talk to any of my Psychiatry mentors about this because I don't want them to know I'm not all-in. I tried going to a therapist and it was just so exhausting to explain this whole process to them we got nowhere. I have a similar experience with friends and family, although my SO is quick to remind me how happy I seemed during Psych rotation and really wants me to pick Psych "for the lifestyle". The consensus on the internet seems to be that people who are between Psych and anything else should pick Psych. I have tried asking around in my networks about combined IM-Psych programs, and everyone tells me not to do it and that it's a complete waste of effort/time. My other concern is that none of the combined IM-Psych programs are anywhere near my/my SO's family and I am going to be in my 30s when I start residency; if we want children during residency we will realistically need to be near family and the combined programs make that impossible.

Really appreciate any insight from those who may have gone through similar concerns, thank you.

After reading yoru second paragraph, my reaction is "seems like this person likes psych!"

What's conspicuously absent from your reflection here is any particular passion towards any other specialty. When I was deciding on my specialty, I was (somewhat) torn between psych and surgery or psych and anesthesia because I liked, and still like, using my hands and enacting immediate change. But my love for the holistic, philosophical elements of psych won out and I'm verily happily boarded in psych now. In your case, you're more torn between what sounds like intrinsic affinity for psychiatry and fears about the negative stereotypes associated with psychiatry. The fact that you haven't even named another specialty here you feel passionate about says something, imho. Doing a head to head comparison here, how much did you love your IM rotation, not just the mental exercise in isolation but the whole experience?

To your concerns, there is a historical pattern of psychiatry attracting lower test scorers from Step-1 etc. I don't know all the reasons for this. I do know that I've felt no difference at all in the intellectual richness of conversations with my peers compared with conversations with cardiologists, orthopods or other more competitive specialties. I don't think I've ever experienced being treated as less-than by other specialties. You do earn, on average somewhat below average income, less that EM and most surgeons, more than Family and Peds, for whatever that's worth. If you don't like outpatient psychiatry, there are many different routes to do the things you did like (evidently CL and inpatient).

Good luck with this!

PS - I also had the experience of someone telling me I was "too smart for psychiatry". Some chief/chair professor of a specialty I won't name when I impressed him on rounds. I think some specialties might need to resort to this kind of thing to attract recruits 😉

 

[Crayola227]

Fwiw I loved IM, but one thing I tell students, is don't just pick what you enjoy. Pick what you are good at. Longterm it's hard to enjoy something that doesn't suit your talents, and what's more, you may not be super fascinated by what you are good at, or good at what super fascinates you. Work is about more than what is fascinating. Work is... work. I'm the first to talk about medicine as a calling, but that's in the more general sense. When you do the grind day in day out, it's work.

If you find something both interesting and you are good at it, and your family appreciates what things are like in your off time...

Fwiw I didn't go into psych, and I think to some extent I was guided by feeling like I was leaving too much of "medicine" behind. But I also didn't feel like the specialty I picked was my "tribe." I think I regret not picking psych, even as I wonder if I would have felt bored.

For the learner in med school, everything is novelty. And you fear leaving the novelty behind as well. While we always learn and if we picked well, will always be interested, at some point there's a lot of doing the same old thing. So keep that in mind as well. No field holds the same fascination that you might have felt in med school long term, as there is more and more familar and less new. Even EM loses the excitement over much of it. Research and academia is one way to combat that I think.

Ultimately, I think in medicine, HF is HF... stitches are stitches. The main problems of every field are the same. I think the presentations and what you get into as far as psych, it's your job to appreciate how varied the humans are under your care... it is the presentation. And the details of a human life, the diversity, is the greatest there is.

So it is worth hearing feedback from mentors on what you are good at. Take it as a compliment anyone suggesting they think you could do what they are doing. Consider what it says about your skills more than just what specialty to pick.

I would take it more seriously if you are interested in a field and getting negative feedback about your skills.

Also I too found psych outpt insanely boring. Watching someone else do psychiatry this way I think can just be boring. Lots of IM folks despise outpt. We see IM as an inpt specialty and that has been the trend, but there's still a lot of outpt post residency. I have never heard from any physician anything other than, residency outpt clinic is never a true to post-residency life experience.

Since it all becomes old hat to some extent, the other factor is your life.

People forget, that a lot of the things you no longer get from your occupation (novelty, working with your hands, whatever), you can get in the rest of your life, especially if you have work life balance. A lot of physicians experience burn out because they are consumed by work, and no one job can be everything.

 

[whateverforever]

It's already grating on me and I wonder if I'm going to spend the rest of my life with a chip on my shoulder or if I will develop the ability to just not care. For example let's say I achieve at a high level and become an amazing CL Psychiatrist at an academic medical center; are other physicians going to talk down to me forever? At what point will I not care?

Come hang out with some veterinarians 🙂 "why go to veterinary school when you could be a DOCTOR?" you get used to it. Most of the world realizes, eventually, that job/status doesn't make you happy, working the hardest isn't a flex, and your title does not always represent your capabilities or intelligence. I wonder how many lives a surgeon saves each day compared to a psychiatrist? Best of luck to you friend!

 

[dl2dp2]

Lots walls of texts here:
I am:
1. Mdphd
2. Similar thoughts as u did when applying
3. Doing very well in a sub specialty (addiction)

My thoughts:
1. Likely you won’t be doing majority research but this is okay. Research career is a bit oversold. You need to write too many grants. Mdphd is useful but not essential.
2. This field >> neurology and > most of internal medicine. Hindsight very thankful didn’t go down those paths.
3. Prestige is improving, some procedures (TMS, etc). Fairly technical field, sick people, lots of esoteric new meds, depots, etc
4. Aim to match as well as u can. Top program grads in this field have more options (PP, academic, pharma, leadership, gov).
5. Start to learn a bit about biz of medicine. Private practice work in this field is unique and lucrative, some of the best gigs in medicine.
6. Being “too smart” is a concern for many, and the right cope is to further sub specialize. Research also enhances niche reputation ==> money and prestige. 10 years in this is not a concern. At a cocktail party oncologist vs forensic psychiatrist prestige and pay level broadly similar…

Don’t want to oversell this field but I’m having a lot of fun and my colleagues are all burnt out. I think it says a lot.