First job out of res/fellowship training: what was important to you?

[fiatslug]

I'm *finally* going to be done with training (finishing my child psychiatry fellowship in June) and just starting to dip a toe into the job market. I'd love to do an inpatient/outpatient hybrid, but inpt jobs where I want to be are hard to come by in child, so the main options seem to be:

1. Take a faculty/academic position (I never thought I'd end up in academic medicine!) where I'm training. I love my program, love the hospital where I work, love the faculty who would be my colleagues. Salary is distinctly not great for child... starting is 140K, with some kind of way to bump that up with one's own clinical practice, but I'm not clear just how much you could bump that up. The university has a huge budget crisis and faculty recently had to take salary cuts. There would be consult responsibilities, which can mean later hours and can cut into your private patients. Plus call coverage (going in to staff floor consults, advising fellow over the phone for ED consults). Faculty positions are partially funded by community mental health contract work, which you do ~half time. The contract work could be done with #2, which might be the best of both worlds.

2. Take a position with a developmental pediatrics large, multidisciplinary practice, where I'm currently doing an elective in infant-toddler mental health. I love this place, love the work they're doing, love that there's in house OT/SLP services, love the devotion among the docs there to attachment issues and behavioral issues in young children. I'd see 6 hrs of pts/day, with the rest of the day for the unending hell of collateral that is child psychiatry. They're very into lifelong learning, and bring in major researchers in attachment theory (Allan Schore!) to educate the staff. We haven't talked numbers yet--no idea if it would be more or less than the faculty position. I hope not less!

3. Take an outpt position at Kaiser. Starting is ~180K, Kaiser benefits are second to none, a friend who accepted a job there recently got a 25K signing bonus. Downside: primarily med mgmt, potentially huge caseloads over which you don't have a ton of control. Upsides (aside from salary/benefits, which are a combined awesome): no billing issues, no dealing with insurance companies ever, malpractice is covered.

4. Go into private practice. I know several graduates of this program who have done that and are doing *really* well, like >$250K well. I worry that it would be isolating. I worry that it would be lonely. I like the idea of total autonomy, and good income potential, and having total control over who you do and do not treat. Billing, setting oneself up as a business, etc all seems like a huge hassle, but it's probably worst at the beginning, and once you settle on a system that works for you, it's probably pretty decent, I'd imagine.

5. Various community mental health options (residential, substance abuse, community treatment) while setting up a part time private practice.

What was your decision making process like for your first job out of fellowship or residency? Did you have a long term career trajectory you were following, or just looking at the most attractive offer at the moment? How much did salary factor into your decision? The combo of 1 & 2 sounds most appealing to me, but I worry about shorting myself anywhere from $40-90K--I have loans, I'm the sole breadwinner, I have 2 toddlers, and we'd like to buy a house soon (but have nothing saved yet, just scraping by as we have been for the past 10 yrs!).

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[OldPsychDoc]

It looks like you have some good options.

I went through residency thinking I was going academic, but I really saw I didn't have the dedication to put up with the downsides (salary, politics, granting & publishing) to have the upside (teaching, "prestige", being on the "cutting edge")--especially when I factored in, as you are, the need to provide for and be present for a growing family.

I ultimately chose something between 2 & 3--a large multi-specialty practice, that also happens to be affiliated with a major teaching hospital, giving me the bonus benefit of having med students and residents to teach. Bottom line is, I wanted to be a full-time clinician, and I am NOT an entrepreneur--it was great to show up on day 1 and be told "OPD, here's your keys, here's your patients, here's your paycheck". All the pesky administrative stuff is covered, and the size of our group ensures reliable vacation coverage, q 3 MONTHS call responsibility, and plenty of peer support. Being in a large organization isn't for everyone, we still have our politics and adminstrative BS to tolerate, but this turned out to be ideal for me.

 

[whopper]

I chose the first job straight out of residency to a forensic site because I was accepted to U. of Cincinnati's forensic fellowship program one year after I wanted to start.

They said I could work at the forensic facility which is where the fellows work, and take up several of the learning opportunities of the fellows.

The job had several highs and lows. It was a great learning experience, but it was also a tough job. I think what made it very tough was I was literally put on one of 2 units known to be the hardest units in the facility. (One is the unit for the chronically violent, and remember this is a forensic facility--so literally this unit had the most violent psychiatric offenders in the state, the other which was my unit was an all female forensic unit where all the hard to deal with females in the facility were grouped together--borderline/antisocial/histrionic and violent to the 10th power--the worst in the state).

The pros I got out of it were I now feel I can handle some of the worst psychotic patients that can be thrown at me. I've had patients who were even clozaril resistant and chronically violent. I feel my understanding of treating psychosis has progressed farther than most of the attendings I had in residency. My understanding of Borderline has progressed to the point where I can actually see a realistic postive outcome for several borderline patients if they are given the appropriate treatment which is not something I learned in residency.

I've also learned to incorporate the use of an occupational therapist report, several scales for predicting future violence such as the HCR-20, utilizing a psychologist for psychometric testing in several areas (Halstead Reitan, Luria Nebraska, M-FAST, SIRS, TOMMS, etc) and testified in court over 50 times so far.

I'm in a similar position as you are. While I did spend one year as an attending, I'm still trying to figure out for myself what I will do after fellowship ends.

One factor I'm putting into this in addition to the pay and the money is what I can learn out of the experience, and will the job keep me sharp as a psychiatrist. I've noticed that if you just work in one scenario--you tend to forget the aspects of psychiatry and medicine not used in that scenario. I hope to do a mixture of inpatient, outpatient and forensic practice in the future.

 

[Psych2014]

I've appreciated reading the thinking and experience here. It's helpful to be thinking forward and learning from other's experiences.

All the best with your choice.