FM vs Psychiatry (need to choose!)

[Osteosaur]

Its getting to the point where I need to plan fourth year soon and I’m really stuck on the specialty I want to do. I’ll need to set up my fourth year and pick a third year elective very soon. I’ve had most of my cores by this point and I really liked FM and psychiatry the most. For psychiatry I was at an adolescent inpatient site. I’m really just stuck on which specialty to go into, or how to best winnow it down quick.

I can see myself potentially doing both “forever” but I have some concerns. I know some may be unfounded, but these are just gut feelings where I feel I need some clarity.

Psychiatry Pros
- I felt comfortable doing it and find the material interesting. At least from a student perspective I felt like I was doing good on rotation and knew my stuff.
-I have a lot of research in neuroscience from before that might be useful for matching.
-There is a shortage of psychiatrists and the life-style seems good. In the face of major healthcare restructuring it seems like a good place to be?

Psychiatry Cons
-I’ve met a lot of psychiatrists who seem burnt out. Life satisfaction is rated very low.
-I have not yet done adult psychiatry.
-I do like medicine and think I would miss the variety.

FM Pros
-I like building long-term relationships with patients, and keeping them out of the hospital.
-I like the variety of cases. At least from what I could see you get a little bit of everything.
-I understand FM docs may do some procedures, and I like being handy.
-The hours and life-style seem okay.

FM Cons
-I worry about midlevels encroachment, and falling compensation if there is major healthcare reform. It seems like FM may really take the brunt of this.
-After getting a 230, which while not great, it seems like it’s a waste of my efforts to do ‘just FM’. I know that might sound a little disrespectful but it sits in the back of my mind. While I very much enjoyed the FM attendings I worked with, the residents all seemed to barely hide it was a backup decision. It bummed me out.

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[fldoctorgirl]

Most of your reasons for liking psych seem like you just enjoyed having a better grasp on the material, which doesn't seem like a super valid reason to me. You don't talk about actually liking the rotation, just that you felt like you were doing good. I would maybe dig in a bit more and think about what you actually like about psych as a specialty...your reasons for FM sound a lot more convincing.

"-After getting a 230, which while not great, it seems like it’s a waste of my efforts to do ‘just FM’" I mean....alright, but it's your life. Do you want to do a specialty you don't love just so people don't think you "just did FM?". I got a 250+ and I'm doing IM, it's your life and who cares what other people think. I would push this thought out of your mind.

I think both are great specialities, good luck!

 

[Cranjis McBasketball]

Its getting to the point where I need to plan fourth year soon and I’m really stuck on the specialty I want to do. I’ll need to set up my fourth year and pick a third year elective very soon. I’ve had most of my cores by this point and I really liked FM and psychiatry the most. For psychiatry I was at an adolescent inpatient site. I’m really just stuck on which specialty to go into, or how to best winnow it down quick.

I can see myself potentially doing both “forever” but I have some concerns. I know some may be unfounded, but these are just gut feelings where I feel I need some clarity.

Psychiatry Pros
- I felt comfortable doing it and find the material interesting. At least from a student perspective I felt like I was doing good on rotation and knew my stuff.
-I have a lot of research in neuroscience from before that might be useful for matching.
-There is a shortage of psychiatrists and the life-style seems good. In the face of major healthcare restructuring it seems like a good place to be?

Psychiatry Cons
-I’ve met a lot of psychiatrists who seem burnt out. Life satisfaction is rated very low.
-I have not yet done adult psychiatry.
-I do like medicine and think I would miss the variety.

FM Pros
-I like building long-term relationships with patients, and keeping them out of the hospital.
-I like the variety of cases. At least from what I could see you get a little bit of everything.
-I understand FM docs may do some procedures, and I like being handy.
-The hours and life-style seem okay.

FM Cons
-I worry about midlevels encroachment, and falling compensation if there is major healthcare reform. It seems like FM may really take the brunt of this.
-After getting a 230, which while not great, it seems like it’s a waste of my efforts to do ‘just FM’. I know that might sound a little disrespectful but it sits in the back of my mind. While I very much enjoyed the FM attendings I worked with, the residents all seemed to barely hide it was a backup decision. It bummed me out.

You'll find burnt out physicians in both psych and FM. One of the psychiatrists i rotated with is in his 60s and could practice another 20 years he loves it so much. One of the FM docs i rotated with was in his early 40's and cant wait to get out.

For FM cons, no one can predict fallouts from reform. Some people think FM will benefit because preventative medicine will become even more important in order to save money for the government. Others think FM will be phased out. No one can accurately predict. Your 2nd con for FM seems silly. Do you not feel like your efforts would be wasted in psych? Im not saying they should be, I'm just making sure you only feel that way about FM and not psych.

In the end, it sounds cliche, but you just gotta go with what you'd rather do for 30+ years, instead of overcomplicating it.

 

[slowthai]

FM Cons
-After getting a 230, which while not great, it seems like it’s a waste of my efforts to do ‘just FM’. I know that might sound a little disrespectful but it sits in the back of my mind. While I very much enjoyed the FM attendings I worked with, the residents all seemed to barely hide it was a backup decision. It bummed me out.

There is no such thing as "just FM". Those people "just" didn't work hard enough or do whatever they needed to do to get into their original field of choice. I would hate to end up in North Dakota just much as anyone else, but I completely reject the notion of devaluing any specialty. That's how NPs/PAs are able to feel so brazen as to declare primary care as "so easy", and it pisses me off.

At the end of the day, you have to do what you truly enjoy, regardless of how anyone else feels about it.

 

[Drrrrrr. Celty]

Depends entirely on what you want in terms of your training. If you do Psychiatry, you're going to learn how to manage the expanse of psychiatric illness with a significantly robust inpatient psychiatry and consultation psychiatry exposure. You will only treat psychiatric illnesses and possibly some minor metabolic consequences of psychiatric medications.
If you choose FM you'll pretty much have a much more informal psychiatric training with a lot more learning on the job, but can do electives that will allow you more inpatient exposure and training in it. I'm personally IM but in clinic I manage plenty of depression, anxiety, and some addiction disorders. I don't manage bipolar patients or schizophrenics and I wouldn't prescribe many medicines like lithium because I have no training in it.
I think Psychiatry can be pretty neat. I think a lot of people like their psych rotation, because it's usually easier and the hours are more manageable. I would recommend seeing how you enjoy working with adult psychiatric patients and dealing with severe illnesses like schizophrenia and mania. If you cannot see yourself comfortable with severely ill patients then it might not be a good fit.

 

[LunaOri]

Both fields are fairly flexible and would allow you to find a practice niche you enjoy. CJCregg described FM perfectly, so I won't add to that. In psychiatry, you can do primarily med management, adult or child inpatient care, or outpatient therapy for any demographic you choose. If you prefer psychotherapy, you would need to choose your residency program carefully (or perhaps do a fellowship) because most psychiatry training focuses on medications and inpatient treatment, and provides minimal education in how to do good psychotherapy.

 

[Neopolymath]

Do psych and do not look back. If medicine goes to **** then you have a cash only way out that's very easy to set up unlike a true clinic. FM is a great field for the right personality but it will always be constrained on the business side more than psych (but still less than other specialties). With consolidation and corporatization of healthcare, I would be picking the more flexible job. Others will disagree but I think as flexibile as FM is that psych is even more flexible and relatively unencumbered by dumb **** that happens in primary care.

 

[NonTrad16]

Was considering psych until my adult inpatient (which was NOT for me, but I had no chance to see outpatient psych which was realistically where I’d be regardless of specialty).Also wanted to keep seeing patients with other diagnoses, and acting in more of a full spectrum capacity (which is dramatically different than psych).

FM has lots of psych (identification, minor management, referrals, etc) so I anticipate getting more than my fair share in clinic.

Re scores: the average step 1 for FM is ~228? FM may accept lower scores, but there’s plenty of students who got at and above mean med student Step 1 score. Also, applying with marginally above specialty average stats was somewhat comforting for me...

You have time to do more rotations. Psych experience and interest is appreciated in FM, but try to show interest in both or else you may come across as using FM as a backup. FM appreciates fit. You’d probably still get interviews even if FM was your backup, but better to have strong demonstrated interest if you plan to apply to up your chances.

**edited for clarity/removal of sarcastic text

 

[Taddy Mason]

Was considering psych until my adult inpatient (which was NOT for me, but had no chance to see the “real” psych).

....the “real” psych...?????

 

[NonTrad16]

....the “real” psych...?????

Haha sorry I meant the real psych that I wanted... ie outpatient. But I’m also not an inpatient person (for medicine either).

 

[VA Hopeful Dr]

Do psych and do not look back. If medicine goes to **** then you have a cash only way out that's very easy to set up unlike a true clinic. FM is a great field for the right personality but it will always been constrained on the business side more than psych (but still less than other specialties). With consolidation and corporatization of healthcare, I would be picking the more flexible job. Others will disagree but I think as flexibile as FM is that psych is even more flexible and relatively unencumbered by dumb **** that happens in primary care.

DPC would like a word with you

 

[Neopolymath]

DPC would like a word with you

My own physician is DPC! I still think *relatively* that it is easier to rent a single office with one computer and some chairs for a psych office than hang a shingle as a PCP even DPC.

edited

 

[longhaul3]

There is no such thing as "just FM". Those people "just" didn't work hard enough or do whatever they needed to do to get into their original field of choice. I would hate to end up in North Dakota just much as anyone else, but I completely reject the notion of devaluing any specialty. That's how NPs/PAs are able to feel so brazen as to declare primary care as "so easy", and it pisses me off.

At the end of the day, you have to do what you truly enjoy, regardless of how anyone else feels about it.

This will last about 5 days into your residency. Then you will join in the great resident pastime of calling every other service "clowns" and "jokers" and never look back.

 

[Cranjis McBasketball]

My own physician is DPC! I still think *relatively* that it is easier to rent a single office with one computer and some chairs for a psych office than hang a shingle as a PCP even DPC.

edited

True but if you dont have the right personality, psych is so emotionally draining. I was zapped every weekend from seeing all the schizophrenics and bipolar disorders. Seems like a tough patient population that requires a certain personality. I could be wrong though

 

[FrontierPsychiatry]

I struggled between these 2 specialties as well. As my name implies I chose psych. I have to be honest, I am on my medicine rotation right now and I have no idea why I was ever considering anything other than psych. And its not just the hours, there would be days where I would have to get out of bed just as early as I do now when i was on psych, and it wouldn't feel like a burden. 2 of the 4 pros you list for FM also apply to psych(the first one and last one). Also I was hesitant because I thought I wanted variety. It sounds good in theory, and while there is certainly a decent amount of psych in FM, even after only 6 months of Psych, I can see the difference in management when I come across a patient who had been managed by a PCP until being admitted to the hospital(even for seemingly simple things like depression and anxiety). And don't take that as me bad mouthing FM, they have to know everything, so obviously none of it is going to be at the depth of a specialist. And I think that is what this question really comes down to. Specialist vs. generalist. And not what sounds cooler, but what you would actually be happiest doing. I liked the idea of being a generalist, but I realize now that I would have been miserable. And if the answer is specialist, the follow up question is if the most interesting field of medicine to you is psychiatry. Also I'm not going to lie, the culture of psychiatry can't be beat imo.

 

[slowthai]

Also I'm not going to lie, the culture of psychiatry can't be beat imo.

Can you go into more detail about this, please?

 

[Osteosaur]

From an FM resident:

Agree that it sounds like you have more interest in the actual work that comes with being an FM doctor vs being a psych doctor, at least from what you've written here. Your psych reasons are that you think you'd be good at it/able to match, and that it's a good lifestyle. Nothing about the job itself. For FM the pros you've identified are the reasons many people choose to go into the field.

For the cons...I really don't think FM is any more susceptible to midlevel encroachment than any other non-surgical field. Plenty of psych NPs out there these days too. The job market remains incredibly accessible for FM, I was getting hit up by recruiters as an intern and not one of our soon-to-graduate residents are having issues finding jobs they're happy with. Also worth noting that FM Is one of the most flexible specialties out there. You can do primary care and lots of procedures for all ages, urgent care, nursing home, not to mention OB/prenatal care, hospitalist work, ER, addiction medicine if you go to a program that prepares you well for that. You can focus on different areas and build a niche practice around psych, lifestyle medicine, sports medicine, LGBT care, geriatrics, women's health, or whatever based on your interests.

As for reimbursement- Lately in the insurance/healthcare industry there is increasing focus on preventive care and value-based care. Payers are starting to realize good primary care saves money, and are more and more willing to reimburse well for it. Any significant healthcare reform will almost certainly trend in that direction as well, and I think we have already started to see some of those changes (e.g. the recent changes to billing for outpatient E&M services were hugely beneficial to PCPs).

As for "just FM"...sounds like you were at a program where for most people, FM was not their first choice. That is not the case at most programs. I would encourage you to do an away rotation at a more competitive residency program and talk to some other family medicine attendings and residents. Everybody at my program picked FM as our first choice because we enjoy the variety and the opportunity to make a real difference for patients. If you are a US grad with a 230 and no major red flags, you'll have no problem getting into a program like that. Also worth noting that contrary to popular belief, FM is really, really hard to do well. Primary care is one of the few specialties where you have a completely undifferentiated patient walk into your office. FM is one of the only ones where you could go from a newborn visit to an elderly patient with numerous comorbidities to a fracture or lac repair to an IUD placement to a prenatal care visit in the same day. A good family doctor can be a huge asset to a healthcare system and to patients. And I agree with what someone else said above...are you really willing to do a specialty you don't even enjoy just because of how it looks?

Really appreciate hearing your perspective! Needed to hear from a resident more passionate about the field. I got a little bummed about my choice from the residents on service.

Is there a difference in terms of job opportunities based upon region? I should have mentioned but I'm mostly interested in the northeast/mid-Atlantic.

I guess where I am stuck now too is trying to get broader exposure to psychiatry - or using my elective to demonstrate more interest in FM. I don't know if I need to have such a track record behind me before fourth year. I do very much like treating behavioral and mental health issues, and it has to me a lot of the same appeal as FM in terms of longitudinally improving patients lives. Its just hard for me to grasp if helping some kid with bipolar or depression (over a week) is going to feel the same to me as bipolar in an adult over years.

There is no such thing as "just FM". Those people "just" didn't work hard enough or do whatever they needed to do to get into their original field of choice. I would hate to end up in North Dakota just much as anyone else, but I completely reject the notion of devaluing any specialty. That's how NPs/PAs are able to feel so brazen as to declare primary care as "so easy", and it pisses me off.

At the end of the day, you have to do what you truly enjoy, regardless of how anyone else feels about it.

I didn't mean to sound disparaging. I like the specialty. Three residents who said they soaped into it just made me a little sad about it.

Depends entirely on what you want in terms of your training. If you do Psychiatry, you're going to learn how to manage the expanse of psychiatric illness with a significantly robust inpatient psychiatry and consultation psychiatry exposure. You will only treat psychiatric illnesses and possibly some minor metabolic consequences of psychiatric medications.
If you choose FM you'll pretty much have a much more informal psychiatric training with a lot more learning on the job, but can do electives that will allow you more inpatient exposure and training in it. I'm personally IM but in clinic I manage plenty of depression, anxiety, and some addiction disorders. I don't manage bipolar patients or schizophrenics and I wouldn't prescribe many medicines like lithium because I have no training in it.
I think Psychiatry can be pretty neat. I think a lot of people like their psych rotation, because it's usually easier and the hours are more manageable. I would recommend seeing how you enjoy working with adult psychiatric patients and dealing with severe illnesses like schizophrenia and mania. If you cannot see yourself comfortable with severely ill patients then it might not be a good fit.

That's why I'm sort of hesitant to say I fully like it. It certainly felt rewarding to me when a few days later a little kid with bipolar was ready to go home, with the potential of radically changing that family's life. It felt like such a small niche of psychiatry I wonder how representative adolescent inpatient would be of psychiatry in general.

You have time to do more rotations. Psych experience and interest is appreciated in FM, but try to show interest in both or else you may come across as using FM as a backup. FM appreciates fit. You’d probably still get interviews even if FM was your backup, but better to have strong demonstrated interest if you plan to apply to up your chances.

How do you make it not look like a back-up? The amount of electives I've done in FM? letters? Or sort of service activities like flu shot clinics etc.?

 

[LunaOri]

Maybe you should use your elective this year to further explore psych, and do sub-I's (or more electives) in both specialties next year.

 

[Drrrrrr. Celty]

Really appreciate hearing your perspective! Needed to hear from a resident more passionate about the field. I got a little bummed about my choice from the residents on service.

Is there a difference in terms of job opportunities based upon region? I should have mentioned but I'm mostly interested in the northeast/mid-Atlantic.

I guess where I am stuck now too is trying to get broader exposure to psychiatry - or using my elective to demonstrate more interest in FM. I don't know if I need to have such a track record behind me before fourth year. I do very much like treating behavioral and mental health issues, and it has to me a lot of the same appeal as FM in terms of longitudinally improving patients lives. Its just hard for me to grasp if helping some kid with bipolar or depression (over a week) is going to feel the same to me as bipolar in an adult over years.


I didn't mean to sound disparaging. I like the specialty. Three residents who said they soaped into it just made me a little sad about it.


That's why I'm sort of hesitant to say I fully like it. It certainly felt rewarding to me when a few days later a little kid with bipolar was ready to go home, with the potential of radically changing that family's life. It felt like such a small niche of psychiatry I wonder how representative adolescent inpatient would be of psychiatry in general.



How do you make it not look like a back-up? The amount of electives I've done in FM? letters? Or sort of service activities like flu shot clinics etc.?

Personally I spent a lot of my 4th year interested in Psychiatry. I even applied to Psych and didn't get in ( Though in truth I sort of did that to myself). But I honestly ended up being a very late decision to reformat my goals into medicine and for me it was after doing a lot more psychiatry at bigger university programs.

I now personally believe I'm much more happy doing medicine. The only thing I truly miss is the opportunity to work less during residency.

Both specialities you'll be able to find a job in. In the DMV area there's an oversaturation of specialists in cities, so if you go into the more suburban or rural areas you'll find significantly better pay and a very easy time getting a job. In terms of earning, FM and Psychiatry generally fit into the not surgeons or rich subspecialists zone of the pay scale.

I think you already know you like FM. As long as you have a letter from your department head or a physician involved in your training then you're done. Most FM programs are going to be interested in who you are as a person. Psychiatry is more competitive and picky.

Longitudinal care is family medicine.

Specialty competitiveness shouldn't impact your decision making. It's problem on SDN where we rag on FM as this circle of hell where you're supposed to be ashamed of doing it. Yes, it's not going to earn as much as something more competitive, but you alternatively will have a stable work-life balance. What FM doctor looks like they're overworked and stressed out to meet company quotas? Not that many. Look at cardiologists, and a lot of them are going to look it.

I think there's satisfaction in fixing anyone. It's seeing what you're interested in the long run. If you want to deal with more sick psychiatric patients who are going to need more specific management then Psychiatry is undoubtedly your best option. If you want to deal with more stable patients who are coming to you for more maintenance, screenings, and more general complaints ( Most Psychiatric illness prevalence-wise in the population is going to be mild to moderate depression, GAD, insomnia) and you're happy to talk to them for a bit and give them a trial of a few first line meds +/- augmenting before referral then it'll be a good fit.

 

[Prehealth1011]

My own physician is DPC! I still think *relatively* that it is easier to rent a single office with one computer and some chairs for a psych office than hang a shingle as a PCP even DPC.

edited

+ DPC typically requires lots of call. Yeah it might be non urgent and you might be able to text the patient, but the very fact that you’re on call that much in a primary care job is a no for many people

 

[Neopolymath]

+ DPC typically requires lots of call. Yeah it might be non urgent and you might be able to text the patient, but the very fact that you’re on call that much in a primary care job is a no for many people

It's possible but you will find that many DPC people say they don't get called much at all. The vast majority of people do NOT want to talk to their doctor all the time.

 

[VA Hopeful Dr]

It's possible but you will find that many DPC people say they don't get called much at all. The vast majority of people do NOT want to talk to their doctor all the time.

Lots of DPC doesn't do after hours stuff. I knew several that were 8-5 M-F only. You build up your practice more slowly that way, but its very doable.

 

[Mad Jack]

My own physician is DPC! I still think *relatively* that it is easier to rent a single office with one computer and some chairs for a psych office than hang a shingle as a PCP even DPC.

edited

I could run a psych practice with a notebook, a pen, a prescription pad, a stethoscope, a blood pressure cuff, two folding chairs, and a card table

 

[Mad Jack]

Can you go into more detail about this, please?

Psych docs are much more chill and pleasant to work with than those in most other specialties from what I've seen. The only intolerable psychiatrist I've ever met was some guy that came out of MGH with a God complex that had dangerous prescribing habits and telling him as much just resulted in him yelling "you just don't understand my methods!" Abrasive egos are a rarity and your colleagues will generally be supportive, friendly people. Medicine, I feel like there is more ego being thrown around, be it by generalists or specialists, and people that are miserable to work with for one reason or another seem to be far more common. Most doctors in any speciality, however, will be good people, it's just that psych seems to have a smaller cluster of bad apples than other specialties.

 

[Oedipa Maas]

I was torn between IM (hospitalist) and psych during the tail end of my third year (psych was my last rotation) and ended up choosing psych. My psych rotation was split between child inpatient and adult psych consults and psych EM. My psych sub-I was in child psych - outpatient, consults, and EM. I applied to psych without any adult inpatient experience. I do intend to complete a child fellowship and primarily treat children when I finish residency.

Regarding variety - one of the things I like about psych is that even if the pathology is the same, you get to really engage with the whole person who is always different. On medicine while obviously everyone is different, I often found that I didn't really get to spend time with "the whole person" because we were so busy. Looking back, during third year I realized that I loved inpatient IM because of my role as the medical student getting to go back and hang out and walk with patients, not because I loved managing CHF and COPD exacerbations.

Regarding adult inpatient vs. adolescent inpatient. There are no guarantees that you will like adult inpatient work. However, I will say that if you enjoy working with families, psychiatry has a lot more of that than other fields regardless of patient age because you are always trying to get collateral and engage the patient's natural support system. Additionally, inpatient bipolar/psychosis/mania treatment is amazing no matter what the patient's age if they respond well to medication. I just had a patient in their 30s who was admitted during a manic episode. They were grandiose, aggressive, and calling me a Russian spy the first day we met and once they were stabilized on meds they were reading me poems they had written and I was tearing up during their last family meeting seeing how their family responded to their progress.

I hope that you get the opportunity to explore both fields further and assess where you see yourself ending up! While you are in it, it is stressful trying to make the choice, but remind yourself that having two viable options that you could see yourself happy in is a great thing. It likely means that you will be happy doing either, regardless of what you choose. Better to have multiple options than none!

 

[RangerBob]

Psych docs are much more chill and pleasant to work with than those in most other specialties from what I've seen. The only intolerable psychiatrist I've ever met was some guy that came out of MGH with a God complex that had dangerous prescribing habits and telling him as much just resulted in him yelling "you just don't understand my methods!" Abrasive egos are a rarity and your colleagues will generally be supportive, friendly people. Medicine, I feel like there is more ego being thrown around, be it by generalists or specialists, and people that are miserable to work with for one reason or another seem to be far more common. Most doctors in any speciality, however, will be good people, it's just that psych seems to have a smaller cluster of bad apples than other specialties.

All I can think of to say is you’re right-psychiatrists do seem to have a smaller cluster of bad apples than other specialties. But they have a larger cluster of weirder apples! (Part of why I originally thought I fit in well. I still think I’d love the field-I just found something I liked more).

Definitely better than having a large cluster of cluster B apples as seen in some other specialties...

 

[Mad Jack]

All I can think of to say is you’re right-psychiatrists do seem to have a smaller cluster of bad apples than other specialties. But they have a larger cluster of weirder apples! (Part of why I originally thought I fit in well. I still think I’d love the field-I just found something I liked more).

Definitely better than having a large cluster of cluster B apples as seen in some other specialties...

Yeah, psych really gives you a pass if you let your freak flag fly. I'm pretty damn weird and I fit right in.

 

[sloop]

Yeah, psych really gives you a pass if you let your freak flag fly. I'm pretty damn weird and I fit right in.

I don’t even know if it’s so much that shrinks are weird, per se, as it is that they’re just not really boring and one-dimensional like people in medicine generally tend to be.

I don’t really think that my colleagues are really all that extreme compared to the general population. It just seems that people in this field more strongly value authenticity, both personally and professionally. Nobody is spontaneously engaging in Dadaist performance art on the units, but they are generally more comfortable with the idea that they will stand out for something uniquely positive and that it is okay to have a professional style based on your temperament.

My colleagues have a lot of varied interests aside from medicine. To me this is just the hallmark of people with active curious minds. In some other fields, though, it might be perceived as a lack of focus and discipline.

 

[Drrrrrr. Celty]

I was torn between IM (hospitalist) and psych during the tail end of my third year (psych was my last rotation) and ended up choosing psych. My psych rotation was split between child inpatient and adult psych consults and psych EM. My psych sub-I was in child psych - outpatient, consults, and EM. I applied to psych without any adult inpatient experience. I do intend to complete a child fellowship and primarily treat children when I finish residency.

Regarding variety - one of the things I like about psych is that even if the pathology is the same, you get to really engage with the whole person who is always different. On medicine while obviously everyone is different, I often found that I didn't really get to spend time with "the whole person" because we were so busy. Looking back, during third year I realized that I loved inpatient IM because of my role as the medical student getting to go back and hang out and walk with patients, not because I loved managing CHF and COPD exacerbations.

Regarding adult inpatient vs. adolescent inpatient. There are no guarantees that you will like adult inpatient work. However, I will say that if you enjoy working with families, psychiatry has a lot more of that than other fields regardless of patient age because you are always trying to get collateral and engage the patient's natural support system. Additionally, inpatient bipolar/psychosis/mania treatment is amazing no matter what the patient's age if they respond well to medication. I just had a patient in their 30s who was admitted during a manic episode. They were grandiose, aggressive, and calling me a Russian spy the first day we met and once they were stabilized on meds they were reading me poems they had written and I was tearing up during their last family meeting seeing how their family responded to their progress.

I hope that you get the opportunity to explore both fields further and assess where you see yourself ending up! While you are in it, it is stressful trying to make the choice, but remind yourself that having two viable options that you could see yourself happy in is a great thing. It likely means that you will be happy doing either, regardless of what you choose. Better to have multiple options than none!

I don't really think we get to know the whole person during inpatient management of anything tbh, nor is that probably a good use of your energy. You draw the line between what is important for managing their medical condition, their discharge needs, and direct barriers to good outcomes. I can sit down and talk to the pt about why a person with a bili of 2 and an inr of 1.7 with alcoholic hepatitis needs to quit drinking, but they already get it probably, and aside from maybe a 10 minute talk what's going to keep them off the booze is outpatient management. Which mind you can be what you manage as a PCP.

I know I enjoy talking to my patients and their families a lot to be honest. I think a decent amount of medicine folks do. But I think a lot of people in medicine are drawn to it because they like medicine. I'm very excited when I diagnose something extremely weird and new. I enjoy managing chronic illnesses and optimizing people to stay out of the hospital. That is my way of dealing with "the whole person".

 

[Drrrrrr. Celty]

I don’t even know if it’s so much that shrinks are weird, per se, as it is that they’re just not really boring and one-dimensional like people in medicine generally tend to be.

I don’t really think that my colleagues are really all that extreme compared to the general population. It just seems that people in this field more strongly value authenticity, both personally and professionally. Nobody is spontaneously engaging in Dadaist performance art on the units, but they are generally more comfortable with the idea that they will stand out for something uniquely positive and that it is okay to have a professional style based on your temperament.

My colleagues have a lot of varied interests aside from medicine. To me this is just the hallmark of people with active curious minds. In some other fields, though, it might be perceived as a lack of focus and discipline.

Most of my co-residents are significantly more interesting outside of the hospital than they are in the hospital. We all have our own varied interests and things we enjoy. Most are just not going to sit down and actively have a discussion when they've just spend 6 hours rounding lol.

 

[Mad Jack]

Most of my co-residents are significantly more interesting outside of the hospital than they are in the hospital. We all have our own varied interests and things we enjoy. Most are just not going to sit down and actively have a discussion when they've just spend 6 hours rounding lol.

Yeah but like, they're usually normal people interesting. Psych people are weird-ass interesting

 

[sloop]

Most of my co-residents are significantly more interesting outside of the hospital than they are in the hospital. We all have our own varied interests and things we enjoy. Most are just not going to sit down and actively have a discussion when they've just spend 6 hours rounding lol.

I think the difference is that in psychiatry it’s often not only appropriate but beneficial to express these interests at work. It’s not even just that these interests come out after rounds, they often come out during rounds themselves. Boundaries are so important in our field and we spend a ton of time thinking about them, but I think that gives us a certain comfort level with using our personalities and calculated self-disclosure for the benefit of our patients.

Like you’re interested in philosophy and want to use that to pose the right questions to help your patient navigate their existential concerns? Great. You’re a history nerd and want to use some well-times quotes or historical analogies to motivate your patient in a therapeutic direction? Also great. You love cars and you want to spend most of the time during rounds talking to the depressed car guy about what his next project car is going to be and why? Sounds great.

These are all things I have either done or witnessed done.

Like I said, I think psych is very accepting of the idea that appropriately expressing an authentic personality simply contributes to a style and can be very beneficial for patients. This isn’t to say my patients know everything about me but I just think that we’re more likely to appear interesting because we’re not in the habit of being super buttoned up all the time at work. I think this can be seen as weird by people in other fields where the standard is more to project an air of unflappable confidence and stoicism.

 

[Drrrrrr. Celty]

I think the difference is that in psychiatry it’s often not only appropriate but beneficial to express these interests at work. It’s not even just that these interests come out after rounds, they often come out during rounds themselves. Boundaries are so important in our field and we spend a ton of time thinking about them, but I think that gives us a certain comfort level with using our personalities and calculated self-disclosure for the benefit of our patients.

Like you’re interested in philosophy and want to use that to pose the right questions to help your patient navigate their existential concerns? Great. You’re a history nerd and want to use some well-times quotes or historical analogies to motivate your patient in a therapeutic direction? Also great. You love cars and you want to spend most of the time during rounds talking to the depressed car guy about what his next project car is going to be and why? Sounds great.

These are all things I have either done or witnessed done.

Like I said, I think psych is very accepting of the idea that appropriately expressing an authentic personality simply contributes to a style and can be very beneficial for patients. This isn’t to say my patients know everything about me but I just think that we’re more likely to appear interesting because we’re not in the habit of being super buttoned up all the time at work. I think this can be seen as weird by people in other fields where the standard is more to project an air of unflappable confidence and stoicism.

I've often had very philosophical discussions with my intubated patients. I share those thoughts on occasion with my ICU attendings who then proceed to after their own long analysis through their stethoscope remark that the patient has gravely disagrees with my position and then tell me that they're right main stemed too!

I don't disagree that you're going to talk to your patients about a lot of things with a lot more emphasis on it. Your patients are going through conditions that need perspective. I don't think offering a philosophical discussion to many of my patients is going to change their disease. I certainly do offer perspective and my own style of care where it is needed or frankly wanted. And in the end a significant portion of my rounds are dedicated towards teaching and treating our patients, not trying to figure out

That being said and I apologize for saying this but I think your head is pretty firmly up your ass. I and the rest of my collogues bring in our own persons to work here. We all have our own styles of care, our own interests, our own ways of approaching a patient. I can assure you that some of my interns will approach rural patients in ways that I cannot and I suspect you wouldn't even know where to begin with. We guide therapeutic discussions, establish rapport with the sick and the dying. We break bad news and we discuss the conditions of life and living. And all of that is part of our teaching experience as well as mentorship and we are all free to do so in our own style and expression.

I think it's not about projecting an air unflappable confidence. It's accepting that we know the science and the theory and that despite that we can still lose someone horrifically. I take my job seriously because if I don't people die.

 

[sloop]

I've often had very philosophical discussions with my intubated patients. I share those thoughts on occasion with my ICU attendings who then proceed to after their own long analysis through their stethoscope remark that the patient has gravely disagrees with my position and then tell me that they're right main stemed too!

I don't disagree that you're going to talk to your patients about a lot of things with a lot more emphasis on it. Your patients are going through conditions that need perspective. I don't think offering a philosophical discussion to many of my patients is going to change their disease. I certainly do offer perspective and my own style of care where it is needed or frankly wanted. And in the end a significant portion of my rounds are dedicated towards teaching and treating our patients, not trying to figure out

That being said and I apologize for saying this but I think your head is pretty firmly up your ass. I and the rest of my collogues bring in our own persons to work here. We all have our own styles of care, our own interests, our own ways of approaching a patient. I can assure you that some of my interns will approach rural patients in ways that I cannot and I suspect you wouldn't even know where to begin with. We guide therapeutic discussions, establish rapport with the sick and the dying. We break bad news and we discuss the conditions of life and living. And all of that is part of our teaching experience as well as mentorship and we are all free to do so in our own style and expression.

I think it's not about projecting an air unflappable confidence. It's accepting that we know the science and the theory and that despite that we can still lose someone horrifically. I take my job seriously because if I don't people die.

You’re too sensitive about this. I never made an accusation about you personally. I never said that people in other specialties can’t offer unique perspectives. I was making a comment about a general difference in culture.

The thing about psych residency is that I’ve actually worked in a non-psychiatric capacity. I spent a year working on medicine wards and in ICUs, taking care of the same intubated patients you speak of. I’m not making these cultural differences up. They exist.

People die if I don’t do my job correctly, too. The last part of your post seems to imply that I don’t take my job seriously, which is a completely unfair accusation. You’re being very petty in this insecure tirade. Don’t believe for a moment that’s lost on anyone.

 

[Drrrrrr. Celty]

You’re too sensitive about this. I never made an accusation about you personally. I never said that people in other specialties can’t offer unique perspectives. I was making a comment about a general difference in culture.

The thing about psych residency is that I’ve actually worked in a non-psychiatric capacity. I spent a year working on medicine wards and in ICUs, taking care of the same intubated patients you speak of. I’m not making these cultural differences up. They exist.

People die if I don’t do my job correctly, too. The last part of your post seems to imply that I don’t take my job seriously, which is a completely unfair accusation. You’re being very petty in this insecure tirade. Don’t believe for a moment that’s lost on anyone.

Bud you're going around calling folks one dimensional and talking about how great it is to talk to you. I'm not going to derail this thread anymore, but my comment stands.

 

[LunaOri]

If you really think that physicians in other departments are less interesting and more “one dimensional “ then you haven’t spent enough time with physicians in other departments. I once had a psychiatrist tell a group of us (med students) that he and his colleagues didn’t waste time talking with other physicians (at lunch) because what the other docs talked about was “so trivial”. I disagree, but to each his own!

 

[VA Hopeful Dr]

Yeah but like, they're usually normal people interesting. Psych people are weird-ass interesting

That's what the rest of us have been saying for decades

 

[sloop]

If you really think that physicians in other departments are less interesting and more “one dimensional “ then you haven’t spent enough time with physicians in other departments. I once had a psychiatrist tell a group of us (med students) that he and his colleagues didn’t waste time talking with other physicians (at lunch) because what the other docs talked about was “so trivial”. I disagree, but to each his own!

You’re getting hung up on a general criticism of people who go into medicine compared to the cohort that enter psychiatry as if I individually prejudge every doctor from another department. I don’t.

I’ll try to make this a little more clear. I think the best temperamental marker for being an interesting person with varied interests is openness to experience. This dimension really serves to characterize interest in ideas, interest in aesthetics, novelty-seeking, and broad creativity. While this is a great thing if you want to have an engaging conversation, it’s not the best thing in all fields. For instance, nobody wants a high openness accountant. Your creative accountant will get you thrown in prison.

It’s pretty clear that psychiatry has the highest average trait openness of any medical specialty. First, there are some studies empirically showing this to be the case. Second, it lines up with first hand accounts of the specialty. Third, compared to other specialties, psychiatrists are high on other characteristics that you would expect to covary with trait openness, such as political liberalism. This is not an attempt at a political argument (I’m not even particularly liberal myself). It is just to say that there is a moderate correlation between openness and political liberalism, so, on a population level, you would expect a group higher on trait openness to skew more liberal than a group of lower openness. This is exactly what one sees in psychiatry relative to other specialties and serves as confirmatory evidence that psychiatrists are higher on openness than other specialties.

I think that this difference is partly due to the fact that openness is more beneficial to—or at least not as problematic for—the practice of psychiatry. It is also probably partly due to the fact that the field is somewhat stigmatized so it is a more “rebellious” choice than other specialties, leading to a higher proportion of non-conformist type people.

Regardless, there is a variety of evidence that psychiatry is higher in openness than any other specialty. If you have actual evidence that contradicts mine, I’m happy to consider it. As it stands, the objection seems to be that people have had their feelings hurt by my assertion. Unfortunately, such objections don’t do anything to establish that I’m actually wrong.

 

[Mad Jack]

I've often had very philosophical discussions with my intubated patients. I share those thoughts on occasion with my ICU attendings who then proceed to after their own long analysis through their stethoscope remark that the patient has gravely disagrees with my position and then tell me that they're right main stemed too!

I don't disagree that you're going to talk to your patients about a lot of things with a lot more emphasis on it. Your patients are going through conditions that need perspective. I don't think offering a philosophical discussion to many of my patients is going to change their disease. I certainly do offer perspective and my own style of care where it is needed or frankly wanted. And in the end a significant portion of my rounds are dedicated towards teaching and treating our patients, not trying to figure out

That being said and I apologize for saying this but I think your head is pretty firmly up your ass. I and the rest of my collogues bring in our own persons to work here. We all have our own styles of care, our own interests, our own ways of approaching a patient. I can assure you that some of my interns will approach rural patients in ways that I cannot and I suspect you wouldn't even know where to begin with. We guide therapeutic discussions, establish rapport with the sick and the dying. We break bad news and we discuss the conditions of life and living. And all of that is part of our teaching experience as well as mentorship and we are all free to do so in our own style and expression.

I think it's not about projecting an air unflappable confidence. It's accepting that we know the science and the theory and that despite that we can still lose someone horrifically. I take my job seriously because if I don't people die.

Gotta agree. Plenty of my colleagues in other fields are fun and interesting people. Psych just has more... Eclectic people, on average. Not smarter, not more interesting, just more weird.

 

[Damson]

Just here to cheer for FM

Quick question for y'all, can a family doc do psych consultation for his/her patient?

 

[Matthew9Thirtyfive]

Psych docs are much more chill and pleasant to work with than those in most other specialties from what I've seen. The only intolerable psychiatrist I've ever met was some guy that came out of MGH with a God complex that had dangerous prescribing habits and telling him as much just resulted in him yelling "you just don't understand my methods!" Abrasive egos are a rarity and your colleagues will generally be supportive, friendly people. Medicine, I feel like there is more ego being thrown around, be it by generalists or specialists, and people that are miserable to work with for one reason or another seem to be far more common. Most doctors in any speciality, however, will be good people, it's just that psych seems to have a smaller cluster of bad apples than other specialties.

I just got to help write a textbook chapter for a psych book. The psychiatrists I worked with were the most supportive and awesome people I’ve ever done anything with. I want to be them lol.

 

[Matthew9Thirtyfive]

I take my job seriously because if I don't people die.

And my nephew is dead because his psychiatrist didn’t do his job. Psychiatrists are keeping people alive too. Just in a different way.

 

[Frazier]

I'd lean toward psych from your breakdown, OP. FM can also be very rewarding.

I remember as a med student there were times I was very interested in both too! Ultimately, I did neither, pursued a different field, and now practice another subspecialty entirely.

Curvis via.

 

[Splenda88]

People who go into psych these days are all about lifestyle + money... Most specialties don't pay people 300k/yr to work 32-34 hrs/wk Mon-Thurs. Kind of envy these people.

 

[Candidate2017]

It’s pretty clear that psychiatry has the highest average trait openness of any medical specialty. First, there are some studies empirically showing this to be the case. Second, it lines up with first hand accounts of the specialty. Third, compared to other specialties, psychiatrists are high on other characteristics that you would expect to covary with trait openness, such as political liberalism.

This is very true. With telepsych visits from home during COVID, I have seen "interesting" things in residents' homes. Things that likely would get an IM resident a stern talking.

 

[Candidate2017]

And my nephew is dead because his psychiatrist didn’t do his job. Psychiatrists are keeping people alive too. Just in a different way.

Patients and families often ask me to "fix" them. I politely decline because I don't have the power to do so.

Other than locking people up who need to be locked up, psychiatrists do not have much power to keep people alive. Unlike surgery, anesthesiology etc, we're not a specialty where patients' lives rest in our hands.

We are more similar to FM. We provide education on the disease process and potential outcomes, offer meds and non-medication options, monitor/address side effects of meds. FM cannot force their DM/HTN/CHF patients to take their meds, stop smoking, eat right, exercise, undergo physical therapy. They make suggestions, which the patient is free to follow or not. Same with psychiatric patients.

 

[Successful BM]

If you really can't decide, look into FM-psych combined programs.