FORENSICS vs ADDICTIONS vs BOTH?

[JMC_MarineCorps]

PGY-3 fast approaching PGY-4 status and fellowship apps/career decisions need to be made.

Planning on attending both conferneces this year to help decide, but would be interested in your thoughts comments, especially from the forum/field elders.

Thanks in advance,

JMC

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[whopper]

I mentioned this before with you over the phone but I'll elaborate it here in a bit more detail.

Forensic psychiatry and other branches often go hand-in-hand. E.g. if you have a child fellowship and a forensic fellowship under your belt, you're an ideal candidate to do child evaluations for the court and you will be able to command a lot of customers across the country so long as you are good because of the rarity of the two fellowships in one psychiatrist.

Addiction and forensic psychiatry are a similar situation. As we all know, several criminals have drug abuse histories. Several people attempt to get a not guilty by reason of insanity (NGRI) defense based upon a drug-induced psychosis and that is not something the Court allows for an NGRI defense. Someone with training in both fields would be on better standing than a typical forensic psychiatrist.

If you do both, however, you will have to carve out the niche and specialization more so than just take a job at a place. That is true of pretty much all of forensic psychiatry. I know a lot of forensic fellowship graduates that just picked up a general psychiatry job and never did anything more because doing so was outside their comfort zone. That is not a criticism of them, but a warning to you that the comfort zone effect is big and it may temper your desire to do 2 fellowships. After all, who can deny that a regular paycheck, schedule, colleagues, a pension, and benefits would not have an appeal?

If you're desire is strong to do both and you don't see yourself cutting off your big dreams (and I don't mean sarcasm there--after all big dreams need to be there for people to achieve big things), consider doing both.

I know a psychiatrist with a child and forensic fellowship. He is currently faculty at the forensic psychiatry fellowship where I graduated from, and he carved out the niche including writing several published articles, a research award, and actively working on private forensic child cases. Doing such a track will certainly not be conventional, there could be some uncertainty. You will also have to look for fellowships that'll tap your combined training because some will not offer you increased opportunities with your wider training.

 

[zac16125]

In general, do psychiatrists with fellowships (apart from child which I know pays more) make more money than general psychiatrists? I know life's not all about money, I was just wondering if there were financial rewards to being fellowship trained in, say, addiction psych.

 

[JMC_MarineCorps]

Whopper,

Thanks, really appreciate your comments and feedback, especially by phone as well - was hoping to chat longer, but have been managing a housing crisis among other things. Look forward to chatting again in the near future.

Any chance I may bump into you at the ACOFP Symposium in San Diego this March?

 

[JMC_MarineCorps]

In general, do psychiatrists with fellowships (apart from child which I know pays more) make more money than general psychiatrists? I know life's not all about money, I was just wondering if there were financial rewards to being fellowship trained in, say, addiction psych.

I'm pretty sure you need to have a vision of sorts (I have a schema I suppose), getting hired somewhere and being an employee with your fellowship training may or may not be worth your while.

I think its one of those fork in the road type questions you need to figure out for yourself - kind of like surgical field vs non-surgical field, except employee vs consultant comes to mind - although there's probably a significant advantage to having a little of both in your life like a balanced portfolio (or so I hear).

Others may feel free to correct me if I'm wrong.

 

[digitlnoize]

In general, do psychiatrists with fellowships (apart from child which I know pays more) make more money than general psychiatrists? I know life's not all about money, I was just wondering if there were financial rewards to being fellowship trained in, say, addiction psych.

There was a discussion about this on here a while back, should be a few pages in, but I'm too lazy/busy/tired to go digging for it. I think the general consensus was that "it depends".

Forensics CAN be lucrative, but it isn't guaranteed.

I haven't heard much about addiction being where the money's at. It's kinda like selling musical instruments. You're targeting a segment of the population that, by definition, doesn't have money (usually).

Sleep is currently pretty lucrative.

Geriatrics is not.

C/L can be.

I think that's the gist, real docs correct me if you have other things to add...where's that old thread...

 

[JMC_MarineCorps]

Who on this forum is doing or has already done addictions fellowship...how about current PGY3s contemplating addictions, what are your thoughts, plans, goals?

 

[whopper]

So far, I've had a few defendants that were found NGRI but when under my care, my opinion was it was truly drug-induced psychosis. Again, that does not afford legal defense. The court's opinion, and this went all the way up to the Supreme Court, was that if you're under the influence of substances (e.g. you got drunk and shot up someone's house), too bad. You shouldn't have gotten drunk, you damn well knew you could've done something stupid while drunk but let yourself do it, and you will suffer the consequences.

The only exception to this is if the person was intoxicated because someone forced them to be (Ever see North by Northwest ?), or if the person's intoxication was the result of a medication where the person was not given sufficient warning that they could have done something dangerous as a result of the medication. (e.g. the person is put on Ultram, gets a seizure from the Ultram, and during the seizure ends up kicking someone, and yes I've actually seen that happen for real.)

I've seen the doctor's report where they reported the person was psychotic or manic and never once ever touched upon the possibility that the episode was drug induced.

There's also plenty of people who, while drunk or high, do dangerous things, and are now in a forensic setting. When doing a risk for future violence, the conclusion is the person will be fine, only so long as they remain sober, but then what is the chances that'll happen?

These are just a few cases where the combined fellowship could be a major factor, and if it's a big big case, you could be the first guy the lawyers want to hire as an expert witness.

I'll likely not be at San Diego. The wife's due for a child and I ought to be home with her!

 

[whopper]

In general, do psychiatrists with fellowships (apart from child which I know pays more) make more money than general psychiatrists?

Child psychiatrists do make more, and I mentioned this in another thread, but IMHO, based on the figures I've seen, its not significantly much more to the point where I'd use it as a factor to go into the field only for that reason (and trust me, you should not do it for that reason). Remember, doing child fellowship is two years. (Of course you could start it right after PGY III that in effect will keep you from being an attending by only one extra year). That's two years of making a lot less money. If your pay went up as a child psychiatrist by $30K a year, but you spent two years earning $120K less per year becuase you were a fellow (and remember, most fellowships are not an easy experience compared with being an attending), you'd have to work about 8 years to make up that difference. Is it worth it? IMHO no, especially if you put in money into paying off loans or investments the first year out as an attending.

The money factor, of course is important. Trust me, I'm about making money too. Don't be shy to ask us on the board about making money, but just don't lose sight that this isn't the end all be all. Many ways to make money by making short-cuts that lead to poor patient care are just financially dangerous as they will invite the risk of lawsuits that will drive up your insurance premiums, and get you a bad rep that will be followed up by decreased job opportunities.

 

[JMC_MarineCorps]

I'll likely not be at San Diego. The wife's due for a child and I ought to be home with her!

I somehow imagined the swinging bachelor type by way of 'The Hoff' (whom I've actually seen in person waiting for the elevator at Cedars Sinai during my psych elective there) avatar -- congrats!

 

[OldPsychDoc]

I did an addiction fellowship and passed that board. It's "officially" 20% of my job, but as you know, in reality it's more like 75% of what I see clinically. No particular advantage in job seeking or income, but I enjoy being a "go-to" guy for substance abuse issues in our group and am in charge of that piece of our residents' education.

 

[whopper]

Child, forensics, even general psychiatry are all fields where if you think outside the box you could make a lot more money vs. the typical person in the field. Someone could argue that my additional $30K/year example might not hold for all child psychiatrists. Of course that is true. I'm just basing that on stats I've seen online for the average child psychiatrist.

But the same is true for even general psychiatry. Someone could make $400K a year as a general psychiatrist given the right conditions and it's not to the degree where it's one in a million possibility. It's about setting up in the right place (e.g. an underserved area), offering the right services, and doing quality practice.

 

[JMC_MarineCorps]

I did an addiction fellowship and passed that board. It's "officially" 20% of my job, but as you know, in reality it's more like 75% of what I see clinically. No particular advantage in job seeking or income, but I enjoy being a "go-to" guy for substance abuse issues in our group and am in charge of that piece of our residents' education.

Cool, I didn't realize you had done addictions as well...I'm finding it hard to believe that there is 'no particular advantage' when it comes to job seeking or income, but perhaps you're absolutely right. I guess I would imagine it as a ticket for more opportunities in the community to pick up consultant work/expert testimony, etc. I know some would argue that one certainly doesn't need to be fellowship trained to get this type of piece-meal work.

So besides the personal satisfaction of being an expert, you're saying the return on your investment of an additional year of training and a PGY5's salary fell a little short of being a good business move for you? What about the possibility that your additional training was partially the reason you were hired (in addition to your charm and wit, of course) instead of the other guy.

 

[OldPsychDoc]

So besides the personal satisfaction of being an expert, you're saying the return on your investment of an additional year of training and a PGY5's salary fell a little short of being a good business move for you? What about the possibility that your additional training was partially the reason you were hired (in addition to your charm and wit, of course) instead of the other guy.

There were personal reasons that made taking the extra year of clinical work somewhat sensible as well--but I'm pretty sure I would have gotten a job with this group even without the fellowship, though it did somewhat alter my "niche" within the group.

 

[whopper]

So far the forensic fellowship I did has not made me anymore money than I would have gotten just doing general psychiatry. It certainly has opened several career opporutunities, but those opportunities I'm interested in not because of the money but because of the academic and wow factor with the type of work.

But I had questions and interests I wanted to pursue in psychiatry that would've been left unanswered possibly indefinitely had I not done fellowship. I never got good training on how to deal with issues such as malingering had I not done fellowship. I just went through attending after attending in residency that I felt did not give me what I felt was adequate information on that issue. The best attending that gave me instruction in that area in general residency knew more than most but still didn't quite fill the gap. I didn't have that gap and several others filled until fellowship.

Those curiosities were to the degree were literally, everyday I worked, I kept thinking, "there's got to be a better way to do this, why aren't we doing it?" to the point where it was a regular frustration. Those frustrations only went away during and after fellowship.

 

[Fermata]

There were personal reasons that made taking the extra year of clinical work somewhat sensible as well--but I'm pretty sure I would have gotten a job with this group even without the fellowship, though it did somewhat alter my "niche" within the group.

Do you find that completing the fellowship has had any negative consequences? No being dumped on by colleagues? It seems like a really interesting fellowship but I'm not sure it's something I'd want to do 100% of the time.

 

[OldPsychDoc]

Do you find that completing the fellowship has had any negative consequences? No being dumped on by colleagues? It seems like a really interesting fellowship but I'm not sure it's something I'd want to do 100% of the time.

That's why I don't do it 100% of the time...
(see my earlier post in the thread)

 

[JMC_MarineCorps]

It certainly has opened several career opporutunities.

But I had questions and interests I wanted to pursue in psychiatry that would've been left unanswered possibly indefinitely had I not done fellowship. I didn't have that gap and several others filled until fellowship. Those frustrations only went away during and after fellowship.

Yup. Thank you.

 

[toothless rufus]

So it appears that with psych, there are no guaranteed big money-makers in terms of fellowship and a fellowship does not even guarantee any more money than general psych. That's a super bummer.

 

[billypilgrim37]

So it appears that with psych, there are no guaranteed big money-makers in terms of fellowship and a fellowship does not even guarantee any more money than general psych. That's a super bummer.

Nah, it's wonderful. It means that the most annoying people leave after four years while you go on to do fellowships with other people who are theoretically there because they're interested in what they're doing.

 

[toothless rufus]

Nah, it's wonderful. It means that the most annoying people leave after four years while you go on to do fellowships with other people who are theoretically there because they're interested in what they're doing.

Haha! Hey I'm all about real interest for sure! And the stuff is all fascinating. You shouldnt go into medicine unless theres a real compassion and interest. But It would be awesome if fellowships reflected the same guaranteed salary boost as in other fields.

 

[whopper]

Nah, it's wonderful. It means that the most annoying people leave after four years while you go on to do fellowships with other people who are theoretically there because they're interested in what they're doing.

People go into fellowship for differing reasons. Several will go in because of the $$ factor only, then discover it's not quite as simple as that after graduation.

Child psychiatry does make more money on average. Some people go into it for that reason without computing the advice I mentioned above (E.g. it could take almost 10 years to be ahead if you're the average earning child psychiatrist).