Confused about specialty

[CrypticRomantic]

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[IMGASMD]

I have done more than enough years in residency to say that your assessment is just wrong. If you think IM is stress and anesthesia is less stressful.

Seems like you’re worried about stress. If that’s your primary driving force, psych would probably be the best choice out of three.

If you don’t like inpatient medicine, I don’t think you’d be a good fit for anesthesia. 90% of your training would be in a hospital. IM little less, psych I cannot comment.

 

[Cawolf]

I think your lack of exposure shows in your pros and cons list, as I was surprised by some of your assessments. It sounds like you are leaning towards psychiatry, which will help you there as you have no inpatient experience. Can you also get an anesthesia rotation to help you get more information?

 

[CrypticRomantic]

I have done more than enough years in residency to say that your assessment is just wrong. If you think IM is stress and anesthesia is less stressful.

Seems like you’re worried about stress. If that’s your primary driving force, psych would probably be the best choice out of three.

If you don’t like inpatient medicine, I don’t think you’d be a good fit for anesthesia. 90% of your training would be in a hospital. IM little less, psych I cannot comment.

Yeah, I understand my assessments may be wrong since I have limited exposure. Thanks for your input!
Do you think it is possible to get into admin type roles of a hospital (i.e. medical director, CMO) even with a psychiatry background or is IM more favorable?

 

[CrypticRomantic]

I think your lack of exposure shows in your pros and cons list, as I was surprised by some of your assessments. It sounds like you are leaning towards psychiatry, which will help you there as you have no inpatient experience. Can you also get an anesthesia rotation to help you get more information?

What were you surprised by? Not currently due to COVID, and the application cycle is coming up so timing is an issue there.

 

[IMGASMD]

If that’s where you want to end up, probably IM and anesthesia. Because you actually deal with “hospital” itself more than psychiatry. A lot of places, psychiatry even though in the same building, is considered a total separate entity.

 

[jurassicpark]

Yeah, I understand my assessments may be wrong since I have limited exposure. Thanks for your input!
Do you think it is possible to get into admin type roles of a hospital (i.e. medical director, CMO) even with a psychiatry background or is IM more favorable?

If you're looking for hospital admin role, IM or FP. Those are generally the work horses for the hospital with exposure to almost all the departments, and all the CMOs or MD-Admin I know come from those backgrounds. But those are not something most people just jump in to either. They take years if not a decade or so post-residency to break into and by that time your lifestyle, needs, etc may have looong changed.

 

[Cawolf]

What were you surprised by? Not currently due to COVID, and the application cycle is coming up so timing is an issue there.

Sorry you won't get to explore the specialities you are interested in, what a mess. My thoughts below based on your comments in the OP.

IM - You can go inpatient or outpatient without specializing easily - both hospitalist and PCP positions exist. If you specialize you can likely do both inpatient and outpatient work as well. I also think that as a residency, it is less stressful than others, only 3 years, and has lower risk than something like anesthesia.

Anesthesia - I think this can be more stressful (rather than less), as you have the most vulnerable patients on the table in front of you with serious risk if you act incorrectly. Lifestyle is dependent on your work, but you could be on call a lot depending on the position.

 

[CrypticRomantic]

Sorry you won't get to explore the specialities you are interested in, what a mess. My thoughts below based on your comments in the OP.

IM - You can go inpatient or outpatient without specializing easily - both hospitalist and PCP positions exist. If you specialize you can likely do both inpatient and outpatient work as well. I also think that as a residency, it is less stressful than others, only 3 years, and has lower risk than something like anesthesia.

Anesthesia - I think this can be more stressful (rather than less), as you have the most vulnerable patients on the table in front of you with serious risk if you act incorrectly. Lifestyle is dependent on your work, but you could be on call a lot depending on the position.

Thanks, that is helpful. I think I crossed anesthesia off my list. What are your thoughts on psychiatry?

 

[jurassicpark]

Anesthesia - I think this can be more stressful (rather than less), as you have the most vulnerable patients on the table in front of you with serious risk if you act incorrectly. Lifestyle is dependent on your work, but you could be on call a lot depending on the position.

To be fair, same thing with IM especially inpatient. Responding to ABCs, code blues, stabilizing patients all the day long, pages coming in every couple of minutes from stool softners to, "they maaaay not be breathing."

 

[jurassicpark]

Thanks, that is helpful. I think I crossed anesthesia off my list. What are your thoughts on psychiatry?

I remember when I was in my rotations as a wee little third year, I was doing inpatient at a State-facility. One of my Attendings actually was a former anestheiologist converted pscyh. He would try to convince us psych, especially what he was doing was the greatest gig ever. They came in around 9am. Made their rounds, adjusted meds. Usually left after lunch to their private clinics, home by 4-5 and pulling in $$$. Wish I listened to him :-D

 

[Brules_Rules]

I had a great experience on my inpatient psychiatry rotation and was even strongly considering pursuing the specialty afterwards. However, there were a couple key factors that I realized I really couldn't reconcile with my personal desires, despite the excellent hours and decent pay of the specialty (if I'm not mistaken psych salaries have increased pretty substantially over the past 10 years).

First, the lack of application of the majority of medical knowledge I had spent the past several years accumulating was a bit frustrating for me. I totally get that when you pick a specialty you end up giving up a certain amount of medical knowledge, but psychiatry in particular felt like it would use my basic foundation of medical knowledge the least. No stethoscopes, minimal physical examination, minimal lab work, etc. was hard for me to accept, given how much time and effort I had sunk into learning these things. It almost felt like psychiatry should have had a separate track outside of traditional medical education given how different it felt to me than any of the other rotations I had done (not a bad thing, just an observation as a student).

Second, at least where I was rotating, it felt like psych nurse practitioners did pretty much the same job as the psychiatrists, and had fairly similar patient outcomes. This is a major concern I have about many specialties (although is something I haven't heard many psychiatrists speak on personally), but in general if there is a medical field with good lifestyle and decent pay, you can almost guarantee that mid level providers will want to take a piece of the pie. In some specialties this is certainly less reasonable given how much that field may rely on accumulated traditional medical training to achieve expertise (something that NPs and PAs can't really make up for). However, given how little of the day to day of psychiatry practice seemed to be built upon the content and material I learned during the first couple years of medical school and through previous clinical rotations, it does seem like a field in which NPs could make major headway in the near future, eating into employment opportunities and wages.

I will say that it does seem like demand for psychiatry has sky rocketed, and at least anecdotally currently seems to provide some of the best jobs in some of the best locations with great pay. For example, my psych attending had just recently finished up 6 months of locums work in Hawaii where he was paid a crazy amount to work 5 days a week (9 to 5), and had housing and transportation provided for him. Prior to this he had done locums with similar benefits in major Pacific NW cities, with similar hours and pay. If you compare this to a field like EM or anesthesia where the locums opportunities are most often (but not always) in some of the least desirable locations I suppose it says a lot about the current environment for psychiatry employment.

 

[IMGASMD]

It requires you be completely honest with yourself. That very thing that can change with time, age and experiences.

Do you want to go after prestige, money, lifestyle. All those play a part. Do you want to live in the sticks? Do you want to be a big fish in a small pond? Vice versa? How are your scores?

All those things play a part of your decision.

At end of the day, it’s something you will be doing daily at least for the next 5-10 years. If you just hate the field, you will be miserable for ~15% of your life, is that worth it?

Good luck op.

 

[Cawolf]

To be fair, same thing with IM especially inpatient. Responding to ABCs, code blues, stabilizing patients all the day long, pages coming in every couple of minutes from stool softners to, "they maaaay not be breathing."

Sure, definitely true in residency. But afterwards you could settle down into outpatient work or do a fellowship in A/I and not worry about those things either. But I am only doing a medicine internship so my knowledge is biased and limited.

Thanks, that is helpful. I think I crossed anesthesia off my list. What are your thoughts on psychiatry?

Just my opinions. I can't really give you an opinion on psychiatry, I didn't ever seriously consider it - I am doing ophthalmology and looked into more surgical/procedural fields. But the people I know who matched into it seem to think it's awesome.

 

[OrangePaint]

What about radiology? Low stress, good hours. You can still work for a hospital without having the stress that other inpatient specialities have. At my training hospital, radiology was involved in a lot of the administration. There lifestyle also allowed them to easily step away for committee meetings and such which I imagine is important to climb up the administrative ladder. They also seem a very practical straight-shooting type.

You may also want to pursue and MBA or something along those lines if administration is truly your goal.

 

[Candidate2017]

Second, at least where I was rotating, it felt like psych nurse practitioners did pretty much the same job as the psychiatrists, and had fairly similar patient outcomes. This is a major concern I have about many specialties (although is something I haven't heard many psychiatrists speak on personally), but in general if there is a medical field with good lifestyle and decent pay, you can almost guarantee that mid level providers will want to take a piece of the pie. In some specialties this is certainly less reasonable given how much that field may rely on accumulated traditional medical training to achieve expertise (something that NPs and PAs can't really make up for). However, given how little of the day to day of psychiatry practice seemed to be built upon the content and material I learned during the first couple years of medical school and through previous clinical rotations, it does seem like a field in which NPs could make major headway in the near future, eating into employment opportunities and wages.

I'm going to say that any med student who studies reasonably hard for their psych and medicine shelfs should see that the polypharmacy and psychotropics chosen by NPs are generally bad medicine. Bad medication choices by inpatient NPs lead to terrible side effects and non-compliance, which creates plenty of work for outpatient psychiatrists when these inpatients are discharged.

Inpatient is sort of a glorified triage because the standard of care in my opinion is woefully low due to lack of funding at the institutional level and marginalization of severe mental illness. Stabilize and street is what you see. Outcomes appear the same on the surface because you see the very short term outcomes: resolution of active SI or improvement in psychosis or mania. Actively suicidal people removed from their environment and fed, sheltered, with daily visits from nurses, SWs, med students, doctors will lose active SI relatively quick, independent of medication choices or even placebo. For the psychotic or manic, antipsychotics and mood stabilizers are very effective, even if they are not chosen for the correct side effect profiles. So, it is easy for NPs to "practice" psychiatry and then DC the patients to PCP or a psychiatrist to clean up.

In any event, psychiatry is largely an outpatient specialty. Most psychiatrists don't want to do inpatient and NPs do the jobs psychiatrists don't want to do.

 

[Candidate2017]

Currently, have one sub-i coming up in psych at a university program.

Psych:
Pros- good hours, interesting, enjoyed my rotation, I believe I would be good at it, lower risk
Cons- potentially dangerous (physically), more difficult patients (such as drug addicts), stepping away from medicine

IM:
Pros- broad scope so it never gets boring, can go into admin roles, generally good option if you don't know what to specialize in
Cons- prefer outpatient vs inpatient, difficult residency, long hours, stressful, higher risk/liability

Anesthesia:
Pros- good lifestyle, $$, usually less stressful, docs seem happy
Cons- can get boring, higher risk/liability, no experience yet!

Any advice would be appreciated.

Risk/liability shouldn't be a concern. Everyone will get sued some time for whatever. Practicing good medicine is all you can do.

IM: residency has lots of inpatient but it's mostly outpatient afterwards. Don't let residency hours deter you if you want to do IM. I enjoyed my IM months during intern year. Wasn't a cakewalk but the days/nights went fast. It seems the first 1.5 years are hardest since the learning curve is steep. By the latter half of pgy2, things get easier due to less hours and broader knowledge. Bonus: subspecialties.

Gas: yes they're a happy bunch because it attracts those who are calm under pressure. Chill people who make serious work look chill. Gas patients go south very quick. Nights and weekends need to be covered too since it's mostly a hospital based specialty.

Psych: if you engage psychotic patients (or anyone) as if you're in a life or death SDN debate, then yes you will get punched. Common sense and you should be ok. You'll be doing a minimum of 6 months on the psych ward, but likely 12 months, because you need to know really sick to understand to how treat the merely sick (just like IM training). Difficult patients and substance users abound in most specialties. However psych training prepares you well, as addictions is part of psych training. I used to dread substance seekers but its not a big deal any more with experience and firm boundaries. Bonus: in private practice you can tailor your panel to a population you enjoy or even have a no controlled substance policy.