Combining psych/FM: a good idea?

[235750]

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I know there's a forum for the combined programs, but hear me out! I have two quick questions to all the psychiatrists or PGY4s out there.

I am seriously considering a combined psych/FM program. I had figured that such a program would be quite long, but it is only 5 years: the same time for a combined child fellowship. That's an extra year for another specialty which to me seems insane. My questions are:

(1)How much, if any, of the PGY3/4 years is superfluous? I've talked to two psychiatrists (who trained in the military if that matters) who said that a good part of their last two years could have been eliminated without effecting their competency as psychiatrists. Thoughts?

I'm just trying to understand how they could trim two years off of training that is, I am told, already challenging.

(2) Do you think it's possible to be an expert in two different fields of medicine? Yes, there is some overlap between psych & FM, but they are distinct specialties to be sure. Is it possible for someone to digest that much information and actually be good at what they do? Where do you draw the line at: combining 3, 4, maybe 5 different specialties?

I plan on practicing someplace very rural after graduation, so I thought it might be handy to have versatile job skills.

Thank you for your responses.

 

[nitemagi]

1) They cut training down to the minimum ACGME requirements for each program. With that comes less depth in training in each. I have great respect for my colleagues and friends in our combined program. But man, they look tired.

2) Competent, yes. Expert, no. Not within the 5 years. I think it takes longer at this point. Psychiatry alone is a complex discipline. Ask anyone finishing residency if they feel they're an expert in psychotherapy AND psychopharm. Maybe in one, not the other, more often the pharm.

 

[peppy]

(2) Do you think it's possible to be an expert in two different fields of medicine? Yes, there is some overlap between psych & FM, but they are distinct specialties to be sure. Is it possible for someone to digest that much information and actually be good at what they do? Where do you draw the line at: combining 3, 4, maybe 5 different specialties?

Sure it's possible, but I've heard many people express the view that it is not very practical to actively practice two different specialties because of billing issues and other logistics. Those two specialties are both needed enough that you will be able to fill a practice with just FM or just Psych patients even in a rural area. I'd just try really hard to figure out which one you like the most and focus on it, while trying to educate yourself on the crossover areas between FM and psych along the way.
Clearly there are areas of crossover. You will deal with plenty of psych issues in a family medicine clinic (especially when you consider the chronic pain population) and it would not be a bad thing to be a FM doc who enjoys dealing with stuff like ADHD, depression, and anxiety. On the other hand, in some settings (particularly inpatient) psychiatrists are expected to manage minor medical issues that come up and only consult for complicated issues. There are certainly cases where medical problems lead to psychiatric symptoms and it is good to remember your general medical knowledge well enough to recognize those cases. It's not a bad thing to be a psychiatrist who is comfortable managing simple cases of hypertension or diabetes, or who recognizes when the patient wasn't adequately "medically cleared" by the ED.
Personally, though, I feel that doing a combined residency is not worth the trouble for the vast majority of folks.

 

[235750]

They cut training down to the minimum ACGME requirements for each program.

I do not understand. Are you saying that all 4 year psychiatry programs are adding 1 or 2 years of optional non-ACGME required content? I know there are electives, for example, in PGY3/4, but I assume they were like electives in med school. That is to say, you can take what you want, but completing them is not optional. Would you mind elaborating?

Does this mean there are some psych sites where one could graduate in less than 4 years and still be BE/BC? Did an equivalent to the psychologist's psychopharm program finally make it over to physicians? 🙂

Competent, yes. Expert, no. Not within the 5 years.

That was my gut reaction as well. Just like the suspiciously cheap shrimp cocktail at my local grocer, it all just seems too good to be true.

So why do a combined residency at all? The 'rural' card seems to be the only good reason why you'd consider them at all

 

[235750]

Those two specialties are both needed enough that you will be able to fill a practice with just FM or just Psych patients even in a rural area.

I'm talking really rural though. I understand what you'd saying about this not being right for the "vast majority". I also know there's a demand for psychiatrists, but what if I go to one of American's more isolated communities? What if I can't get 40 hrs a week in? It seems like being a well-rounded doc might be handy.

I am completely ignorant to the billing issues you talk about, and I'm sure you're right on that account. But just considering the area that I wish to serve, do you think a combined residency might be good in my specific case?

 

[Manicsleep]

First, its important to be clear that you are not really cutting 2 years but 1. IF you were to do FP then start a psychiatry residency you would start as a PGY2. That one year can be accounted for with electives over the 5 years.

Most of your electives are going to be in the other specialty because that is likely what your practice focus is going to be. You still have extra electives left over even after that to allow you to develop some interests but its not as much as the 'regular' psychiatry residents.

 

[notdeadyet]

iloveDrStill: You just started second year, right? I think one thing you'll find is that combined residencies are a lot more attractive in the pre-clinical years.

Particularly for FP/IM-Psych, a lot of folks start out that way, and then after doing third year clerkships, they see the advantage of doing one specialty well rather than doing the bare minimum of two. You definitely may be the exception (the psychiatrist-scared-of-hanging-up-the-stethoscope is more the norm), but you may very well find your plans changing.

There's a reason there are only 13 positions nationwide for Psych-Family Medicine.

If you do a search for the term "combined" in the title and limit it to the Psych forum, you'll find lots of good discussion about exactly this topic. You'll find it very informative. And in the meantime, preparing for a Psych-FP program is pretty much the same as preparing for a Psych program: study well during second year (this will make the Step 1 a lot easier), work hard and with an open mind throughout third year (it's your first real introduction to whether or not you'll actually like any field, and all clerkships contribute to Psych and FP), and see where your interests fall at the end.

 

[235750]

You definitely may be the exception (the psychiatrist-scared-of-hanging-up-the-stethoscope is more the norm), but you may very well find your plans changing.

Hi notyetdead,

Thank you for replying. You are correct, I am in the first couple weeks of my second year. As you point out, it is entirely possible that the time spent in my clinical years may change my mind regarding what specialty I choose. That said, I am an older student with a decent amount of work experience in healthcare, and I know what I like. I can say with almost complete certainty that I will go into psychiatry.

What I'm debating is a adding a year (what's one year at this point?) to be a more well-rounded physician who can better serve a specific undereserved population. My concern is, will this make me a crappy psychiatrist vs. a great one had I done a psych only residency?

I did search the forum before posting to find this and other answers, and I didn't find any thread that explained the combined programs to my satisfcation. I did see some people who were afraid to lose some of their medical skills as you pointed out, but that's not a concern I have. I saw no thread that addressed the possibility of becoming a true expert in 2 fields, nor the usefulness of such training in the rural setting. But, I am no SDN guru so perhaps I missed it

Manicsleep: I see what you are saying about the intern year counting for both specialties. Still, I find it difficult to comprehend that an additional specialty may be learned sufficiently by just using a few electives. Also, it seems that other aspects of psychiatry would have to be skimmed or outright skipped. I'm still interested to know what the consensus is re: psychiatry residency, and if people think that parts could be skipped and still produce outstanding psychiatrists.

I will take notyetdead's advice and try to keep an open mind. Thank you again for everyone's responses

Cheers

 

[billypilgrim37]

Wanting to practice in the middle of nowhere is a perfectly good reason to pursue FM/psych.

 

[Manicsleep]

The idea of losing out on both specialties is a fallacy if you go to a good program. I didn't do a combined program but I did do extra rotations in medicine, neurology and sleep. I also did a sleep fellowship which strengthened my psychiatry skills significantly.

Having seen the combined program I can say that those residents actually became better in both fields as opposed to weaker in each. When you are on your psych rotation, you don't just stop being an FP resident and vice versa. A good way to look at it is doing a 5 year psychiatric residency that is heavy on the FP AND as a 5 year FP residency with a lot of psychiatry/neurology. You do both all the time even if it isn't actively.

 

[235750]

The idea of losing out on both specialties is a fallacy if you go to a good program...Having seen the combined program I can say that those residents actually became better in both fields as opposed to weaker in each.

That's an interesting perspective, and I appreciate that taking some extra rotations would help broaden one's skills, no matter the specialty. And certainly with your experience in sleep medicine, where there is a lot of overlap with psych, I can see the undeniable advantage there.

However, the more I research, the more it seems that FM and psych mgiht be too different to work like that. Looking at the curriculum of a couple of 'good' combined programs (I use quotations because I have no experience with ranking residencies), it does seem heavy on FM. But, if you're going to be an expert in FM or any other field, it seems you need to do more than have a heavy elective focus. It should be your main focus.

I mean no offense to anyone in a combined program. I am probably speaking of my own limitations as I'm sure it's possible to be brilliant and good at many things simultaneously.

 

[Manicsleep]

You should do what you believe is best for you.

You are correct in that a lot of your time will come out of your psychiatry electives. Primary care electives are pretty stringent and so will only have about 6 months that can be devoted to psychiatry or psychiatric specialties out of FP.

If you want a very eclectic psychiatric training, you probably wont get it (in a combined program). Then again, depending where you go for training, they may have you doing 16 months of inpatient psychiatry, 6-8 months of consults etc. How varied and diverse you get really depends on your desire as well as your program's flexibility.

 

[nitemagi]

I do not understand. Are you saying that all 4 year psychiatry programs are adding 1 or 2 years of optional non-ACGME required content? I know there are electives, for example, in PGY3/4, but I assume they were like electives in med school. That is to say, you can take what you want, but completing them is not optional. Would you mind elaborating?

Does this mean there are some psych sites where one could graduate in less than 4 years and still be BE/BC? Did an equivalent to the psychologist's psychopharm program finally make it over to physicians? 🙂



That was my gut reaction as well. Just like the suspiciously cheap shrimp cocktail at my local grocer, it all just seems too good to be true.

So why do a combined residency at all? The 'rural' card seems to be the only good reason why you'd consider them at all

ACGME requirements are a lot less than you'd think. 2 months neuro, 4 months medicine, 2 months c/l, 2 months child, 1 month addiction. 6-16 months inpatient psych. 1 year outpatient psych.

So roughly that could be done in 2 years, 3 months. But I know of no programs that are shorter than 4 years. Supposedly they shortened training to 3 years many years ago, and reportedly the graduates were considered quite undertrained. Or so I've heard.

 

[hippiedoc13]

The idea of losing out on both specialties is a fallacy if you go to a good program. I didn't do a combined program but I did do extra rotations in medicine, neurology and sleep. I also did a sleep fellowship which strengthened my psychiatry skills significantly.

Having seen the combined program I can say that those residents actually became better in both fields as opposed to weaker in each. When you are on your psych rotation, you don't just stop being an FP resident and vice versa. A good way to look at it is doing a 5 year psychiatric residency that is heavy on the FP AND as a 5 year FP residency with a lot of psychiatry/neurology. You do both all the time even if it isn't actively.

Excellent post and I 100% agree. I am a combined FM/psych resident. People frequently ask questions like, "don't you feel you're missing out on the full training experience?" or "isn't it hard to switch back and forth between two specialties?", both of which reflect a superficial and incomplete understanding what combined training (in any two fields, not just FM/psych) entails.

To address the latter question, I do not "switch" between being one or the other. I am spending 5 years building a single cohesive skill set (though admittedly a broad one) and each rotation gives me the opportunity to focus on honing a specific facet of that skill set. Approaching your training from this perspective, no matter your specialty, is very helpful because it helps you frame your own learning objectives in a meaningful way.

And to address the former question, which Manicsleep already alludes to in his post: we aren't half-psych and half-FM. We are BOTH psych and FM all the time. We spend 5 years in residency, and graduate with a level of clinical maturity that really reflects the time spent.

Another way to consider it is that there is a core set of intellectual skills involved in "being a doctor" and becoming a mature clinician, which is common to all specialties: synthesizing information, framing appropriate clinical & management questions (& figuring out how to answer them), leading a team, weighing risks/benefits in a meaningful way, becoming increasingly responsible for your own outcomes and making decisions independently, etc. Those core skills apply whether you are doing psychotherapy or vascular surgery, and THAT is the core change that occurs between the first day of internship and being an attending. The specific content and procedural skill-set of each specialty is different, but the core skills and clinical maturity required for independent practice is actually fairly universal. Viewed from that perspective, the logic of combined program length actually makes a lot of sense. 3 + 4 does not equal 7, in this case. Because a lot of what a categorical FM resident is doing in 3 years, and a categorical psych resident is doing in 4 years, is not just learning content, but developing "clinical maturity." We combined residents are developing "clinical maturity" at the same rate as our categorical colleagues. We need more time to get exposure/experience in all the content areas for each specialty, but we learn the universal skill of "how to be a doctor" in the same way and at the same rate as our categorical colleagues.

As I have said on these boards many times, overall I am very happy with my decision to pursue combined training. It takes a particular type of person to thrive in such training, and it's not for the faint of heart. We work HARD...as nitemagi said above, "man, those guys look tired..." To get the most out of this training, you have to be a very self-directed learner and more intellectually and personally flexible than most.