Futility of training

[WartsnAll]

Hey everyone,
I’ve been browsing this forum for a while, and I’m someone who hopes to become a psychiatrist someday. But lately, I’ve found myself spiraling a bit. The more I dive into discussions about psychiatry, the more I run into controversy, skepticism, and criticism of the field.

I used to feel so excited and optimistic about this path, but now I’m filled with doubt and anxiety. I keep seeing posts that talk about psychiatry being in crisis, how futile many of our treatments are, and even how pointless medical school is for becoming a psychiatrist.

Even Dr. Daniel Carlat—who’s pretty respected—has written that psychologists, with the right training, are more than qualified to prescribe. He cites the Department of Defense program and the lack of adverse outcomes in states that have passed prescriptive authority laws. And I find myself wondering: if someone like him thinks that, who am I to disagree? Is that basically irrefutable evidence?

It’s left me questioning everything. Why go through the intensity of med school and residency if the training is unnecessary—or worse, even harmful? Should I just pursue a PhD instead, since that path focuses more heavily on therapy, which I care deeply about?

Honestly, I’m not even sure what I’m looking for here. Maybe just some reassurance. I wanted so badly to become a psychiatrist, and now I’m filled with dread and uncertainty.

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[lobstar]

If you care deeply about therapy it might make more sense to do a PhD, yes. I'm not sure the PhD training route is benign. You could also consider being a social worker to do more therapy. On the doc side, the therapy route is mostly in private practice for financial reasons. You can do the 30 min follow-ups with therapy add-on, but actual therapy therapy is the hour long slots that would have to be privately paid.

There are uncountable reasons to do med school and residency despite "prescribers" having similar outcomes. I assume the equivalency data is related to suicide and hospitalizations? Or a PHQ-9? There is just so much more to psychiatry than being a "prescriber". That word is awful for the profession. Perhaps an AI, or even a motivated undergrad can follow the algorithm and titrate and sequentially try antidepressants until PHQ or GAD go down. We do so much more than that. It just can't be easily captured in these chart review studies. It is true that the baseline for psychiatry work has been relatively low compared to other specialities for many years. The standard of practice is all over the place. You see all sorts of bad management and the historical quality of psychiatry trainees has been low compared to other specialties.

You'll just be better at psychiatry. Doing a suicide risk assessment, discharging BPD/ASPD from the ED or quickly from the unit, any and all things related to child psych, any and all things related to consult psych, everything forensics, investigating medical complications and etiologies. You'll be better at making the right diagnosis and removing wrong diagnoses from the chart. Conversations about antipsychotics in someone who already has tardive dyskinesia, using lithium in pregnancy and CKD, new psychosis in a geriatric patient, etc, etc.

It's like saying anyone can do family medicine--Look! We have data that outcomes from this clinic that only sees uncomplicated upper respiratory infections has the same outcomes for all precribers!! No, no, no don't look in the other rooms though, those patients have CKD, heart failure, strokes, and were just discharged 3 days ago.

 

[Crayola227]

You'll be better at making the right diagnosis and removing wrong diagnoses from the chart. Conversations about antipsychotics in someone who already has tardive dyskinesia, using lithium in pregnancy and CKD, new psychosis in a geriatric patient, etc, etc.

It's like saying anyone can do family medicine--Look! We have data that outcomes from this clinic that only sees uncomplicated upper respiratory infections has the same outcomes for all precribers!! No, no, no don't look in the other rooms though, those patients have CKD, heart failure, strokes, and were just discharged 3 days ago.

This. A lot of people feel a big lack of fulfillment by not being the ultimate expert in their chosen field they feel passionate about. Also many people appreciate these challenges, even if they aren't the bread and butter of day to day management. Eg the way EM people get through their day of 90% primary care problems is the 10% that was a real emergency. Even if it's a minority of your work people find a lot of fulfillment working at the top of their skills, and frankly doing what nobody else can.

Then you have the simple fact that psychiatry absolutely can be extremely medically complex so I call complete bull**** on the idea that psychiatrists don't do better. I've seen psychiatrists and PA psychs manage the same people and it's not even close. It doesn't matter the study, you always have to use some commonsense and what we know to determine if a finding is even medically scientifically feasible. In the summer, when ice cream sales go up, drownings increase. Does eating ice cream cause drowning? Or they did a study, jumping from an airplane without a parachute was safe and led to no injuries. (The plane was on the ground, the jump was 2 feet).

This doesn't mean psych is right for you, but it does mean the assertion psych is pointless or not needed is completely absurd in the strongest terms possible and I don't buy it or studies saying otherwise except maybe limited situations. Maybe it isn't right or necessary for all things, but many, yes.

 

[shoomer]

Even Dr. Daniel Carlat—who’s pretty respected—has written that psychologists, with the right training, are more than qualified to prescribe. He cites the Department of Defense program and the lack of adverse outcomes in states that have passed prescriptive authority laws. And I find myself wondering: if someone like him thinks that, who am I to disagree? Is that basically irrefutable evidence?

This is an appeal to authority fallacy. I would strongly disagree with his stance on this to the point that I would even question if he made this argument in good faith.

 

[lobstar]

This is an appeal to authority fallacy. I would strongly disagree with his stance on this to the point that I would even question if he made this argument in good faith.

100%. Look at the 2008 bubble and experts saying there was no problem, blockbuster not buying Netflix, Krugman and "the internet is no more important than the fax machine", the food pyramid (although that maybe was more along these lines of it wasn't even in good faith), opioids are safe as 5th vital sign, Nobel Prize for lobotomy, etc. This list is also endless.

We should give expert opinion some extra thought since they do know a lot, but they may have been bought out or can also just be plain wrong. The problem when experts are wrong is that a lot of the time the consequences are on a much larger and more severe scale than the average Joe being wrong. A la experts saying everyone is equivalent to a psychiatrist, then tons of unprepared people practice psychiatry, then bad outcomes then start coming up everywhere, and everyone asks how could this have happened we had experts on the case using research and making these policies!?!

 

[Bartelby]

The field doesn’t seem to be in crisis to me.

You will get doom and gloom about various risks in most professions. The rise of AI, competition from offshoring labor, private equity / providing cheap lowest-common-denominator services, etc. The sky has been falling for a long time, and when I chose to go into the field more than a decade ago I heard lots variations of this stuff. I don’t regret my choice at all, and the field has worked out even better than I had hoped! Also if you want to see how the grass isn’t always greener in a field laypeople might think is more solid/secure than psychiatry, check out the EM forums.

Psychologist prescribing is a small drop in the bucket currently, and under present models it seems it will remain that way. NPs are a much bigger threat in terms of flooding the market with less-skilled labor than psychologists.

As others have pointed out, the training is very valuable if you want to understand mental health from a medical perspective, including understanding how different medical conditions, medications, substances, etc. interface with mental illness. If therapy is really your passion, as already mentioned a psychology route is more direct and can be a really fulfilling path as well (though of course you can do therapy as a psychiatrist too, just expect reimbursement to be lower in most settings).

 

[Crayola227]

Question, do psychologists doing therapy make less than psychiatrists? Or is that overhead in the form of malpractice insurance and student loans make it even less profitable to be a psychiatrist doing therapy?

 

[WartsnAll]

This is an appeal to authority fallacy. I would strongly disagree with his stance on this to the point that I would even question if he made this argument in good faith.

I admit it is. I guess I'm thinking he is very experienced and knows so much about pharmacology, that his argument has a lot of merit.

 

[clausewitz2]

Question, do psychologists doing therapy make less than psychiatrists? Or is that overhead in the form of malpractice insurance and student loans make it even less profitable to be a psychiatrist doing therapy?

It's more that the appropriate codes for 53+ minutes of therapy will never, ever, ever compensate as much as 2-3 E&M codes you can stick into that same hour window, especially if you use add-on codes. Psychiatrists can definitely bill like psychologists but getting paid like psychologists doing insurance-reimbursed therapy means a big pay cut.

 

[comp1]

Given that the OP hasn't gone to medical school, I would argue they should focus on that. Medical school is indeed long and laborious. They may not want anything to do with mental health, talk therapy or otherwise, by the time they get 3/4 of the way done which is when their opinions on psychiatry both have at least minimal basis in practical reality and when it actually matters. After seeing medical practice up close, they may decide they don't actually like patient interaction that much and become a radiologist. If they really have no interest in the practice of medicine, understanding how the kidney really works, etc, then sure, they can go get an LCSW or MFT and focus on therapy. Remember, med school itself covers...almost no mental health. It's extremely important for a med school applicant to want to be a physician first and foremost. Beyond that, I would argue it's even preferential to not have a specialty firmly in mind ahead of time. This REALLY early focus on the field of psychiatry writ large or, much worse, extraordinarily inconsequential things like PsyD prescribing is putting the cart miles ahead of the horse.

 

[WartsnAll]

Given that the OP hasn't gone to medical school, I would argue they should focus on that. Medical school is indeed long and laborious. They may not want anything to do with mental health, talk therapy or otherwise, by the time they get 3/4 of the way done which is when their opinions on psychiatry both have at least minimal basis in practical reality and when it actually matters. After seeing medical practice up close, they may decide they don't actually like patient interaction that much and become a radiologist. If they really have no interest in the practice of medicine, understanding how the kidney really works, etc, then sure, they can go get an LCSW or MFT and focus on therapy. Remember, med school itself covers...almost no mental health. It's extremely important for a med school applicant to want to be a physician first and foremost. Beyond that, I would argue it's even preferential to not have a specialty firmly in mind ahead of time. This REALLY early focus on the field of psychiatry writ large or, much worse, extraordinarily inconsequential things like PsyD prescribing is putting the cart miles ahead of the horse.

actually recently got accepted. Psych is definitely my top choice, but I’m staying open to other specialties like FM or gen surgery

I’ll admit I might be overreacting a bit—it just hit a nerve. If I do end up becoming a psychiatrist, hearing someone say all that training was pointless really got to me. It’s made me second-guess some of the paths I’ve ruled out, like pursuing a Phd. But I do feel a bit silly ngl lol

 

[SmallBird]

I think this is a really important question both from the perspective of whether other professionals can choose the correct medication, and also whether we could be replaced by AI. I am by know means confident in that being impossible. But, here is what I think makes psychiatry difficult - and, it is something that neither NPs, psychologists, or AI seem interested in addressing.

It is very easy to learn that Prozac is indicated for depression. It is only slightly harder to remember the side-effects and interactions. However there is only one group of patients that I feel I can help simply by matching the symptoms to a diagnosis - ADHD. For everything else, there is just so much additional complexity to consider.

Patients in psychiatry have such diverse motivations to enter treatment. Some would like to have fewer symptoms. Some would prefer to receive a diagnosis. People may wish to identify as depressed in order to manage expectations in certain relationships. People may affiliate with groups like OCD and ASD as a permission structure to pursue a lower functional status or as a way to organize and externalize failures. Some may be comfortable in a sick role. Some are going to enter treatment with such insecurity that they will get better to avoid disappointing you. Many people develop psychiatric symptoms in the context of an important baseline neurobiological profile, greatly impacting how to make sense of their symptoms - irritability is common in people with intellectual disability; 'social anxiety' can be diagnosed in ASD if you lack the ability to formulate equivocal symptoms, many symptoms turn out to be developmental; most psychosis exacerbations in the elderly are more likely because a nursing home has been unable to maintain adequate consistency and containment and overwhelmed the patients executive and regulatory capacity.

Figuring out the role prozac plays in the context of all of this is in fact fairly complicated, and monitoring the response to treatment is even harder. There are millions of people who got switched from prozac for 'non-response' when in reality prozac did everything it was supposed to do to their brains. The fact that they continued to report symptoms after being on prozac is something with so many potential explanations, most of which have nothing to do with whether or not prozac worked. Most patients are very poorly positioned to decide this for themselves, and it takes skill to tease out the reason for the person to continue reporting symptoms (which is not even to say that they are having symptoms, they may feel better but decide to say they are not). Frequently medications are started in the context of severe psychosocial or interpersonal adversity, contexts in which it's hard to imagine a rational basis for somebody recovering, and you need to be able to distinguish between the aspects of a treatment response that are more or less likely to be sensitive to this (e.g., a patient may report some improvement in symptoms that reflect the neurocognitve underpinnings of depression like a negative attention bias or concentration difficulty, but is unlikely to say they are in a great mood if their lives remain disrupted).

I have been working in high volume clinical settings for 7 years as an attending, and I almost never need to prescribe anything other than an initial SSRI, or a switch to Wellbutrin, or an augmentation with aripiprazole for depression. But I work relentlessly to formulate and reformulate the reasons for a patients symptoms, to understand what recovery would look like, and appropriately contextualize medication within this plan.

This is not what NPs or prescribing psychologists do. People end up on bizarre combinations, fancy expensive meds, and referred for Ketamine because the person organizing their care is simply taking everything at face value. It is as if you were stalled on a highway with no gas, and you had a very nice person change your tires over and over again. They may even present themselves as smarter for being aware of very expensive tires, and think they are a better advocate for their patients by offering these. Let them do that while you learn that sometimes a stalled car needs gas, sometimes a spark plug, sometimes a tow.

Good psychiatry is very difficult. There is so much to know that can help you be a better doctor. I have ignored so many people who have tried to argue otherwise, and I continue to be very satisfied in my career, and with the reputation I have built with colleagues, trainees and to some extent patients, although I would guard against chasing reviews 🙂

 

[hamstergang]

Even Dr. Daniel Carlat—who’s pretty respected—has written that psychologists, with the right training, are more than qualified to prescribe. He cites the Department of Defense program and the lack of adverse outcomes in states that have passed prescriptive authority laws. And I find myself wondering: if someone like him thinks that, who am I to disagree? Is that basically irrefutable evidence?

It’s left me questioning everything. Why go through the intensity of med school and residency if the training is unnecessary—or worse, even harmful? Should I just pursue a PhD instead, since that path focuses more heavily on therapy, which I care deeply about?

There are many well-respected psychiatrists who disagree with Dr. Carlat, so his opinion is far from irrefutable.

I do agree that if someone wanted to practice psychiatry to the level of someone without a medical degree, they could do so easily. But that doesn't mean you are operating to an optimal level with those patients, and that probably excludes some of the more complicated patients we could see. When I was doing general child/adolescent psychiatry, I used non-psychiatric aspects of my medical training every day. Some patients have other medical conditions (that must be considered both for their impact on our medications but also due to the impact on their functioning in various settings), other medications that they take, strange/less common side effects in every organ system, or their own beliefs about how one organ system impacts their psychiatric condition (which they ask our opinion on).

If you do any C/L work, you will have very medically sick patients that require something deeper than a checklist or cookie-cutter algorithm. I currently do eating disorders work and am responsible for much of the non-psychiatric treatment as well (lots of GI complaints that I evaluate and manage, but I also need a decent understanding of the endocrine system which has a lot of influence over weight and related issues). The intensity of med school and residency are precisely why I am able to do this job well, and I couldn't imagine someone with lesser training even feeling comfortable here.

 

[comp1]

Well congrats to the OP on the med school acceptance. The advice doesn't change much, though, focus on your first two years and then, in the very distant future, have a wide open mind as you explore what you enjoy doing your third year. And my goodness put all this talk about NPs, psychologists and AI out of your mind.

 

[splik]

Honestly, I’m not even sure what I’m looking for here. Maybe just some reassurance. I wanted so badly to become a psychiatrist, and now I’m filled with dread and uncertainty.

We live in a time where there are high levels of medical mistrust and for the first time, the government is deliberately sowing the seeds of doubt and mistrust in conventional medical treatments. Interestingly, most of that distrust is not focused on psychiatry but on preventive healthcare, public health, reproductive healthcare, infectious diseases, obesity, child health, gender affirming care etc.

A lot of what you are discussing in terms of concerns of psychiatry being in crisis is from about 15-20 years ago (which was when Carlat wrote his book). Psychiatry absolutely was in crisis at the beginning of the the new millennium and was plagued by multiple scandals, including the pernicious influence of the pharmaceutical companies, the failure of genetics and neuroscience to revolutionalize our understanding of mental illness (as promised by the 90s - the so-called "decade of the brain"), fads like pediatric bipolar disorder (with children as young as 2 being so diagnosed), the failure to develop novel medications for mental illness, concerns about overdiagnosis and the psychiatrization of everyday life, a generation of psychiatrists having failed to learn psychotherapy and not knowing how to talk with patients, an over-emphasis on biology over psychosocial aspects, and influence of managed care which led to the so-called "15 minute med check".

While there is still a lot of criticize about psychiatry, I think that the field has successfully navigated a lot of these problems and is better for it. The last 11 years have really been a "golden age" for psychiatry with a dramatic increase in compensation, over 1000 more residency positions, many new residency programs opening up, increasing understanding of the importance of mental health, and significant interest from pharma, tech, venture capital, private equity etc in psychiatric care. The latter is not necessarily a good thing, but it shows that psychiatry is seen by investors as something that can be potentially lucrative which would have been unthinkable 25 years ago. That in part is because more people recognize the importance of mental health and are more willing to seek out help than ever before.

I think we've also seen psychiatry diversify a bit instead of just focusing on genetics and neuroimaging. Psychotherapies are part of the core competencies of psychiatric training and there has been considerable interest in the social determinants of mental health (something that few American psychiatrists cared about even 10 years ago). Psychiatrists have a stronger appreciation of the impact of complex developmental trauma on mental health. While the "15 minute med check" is not dead, it is no longer the norm as changes to the way psychiatrists bill make it almost as good to see patients for 25-30 minutes as for 15. While there have been no dramatic pharmaceutical developments there have been some recent interesting drugs added to therapeutic armamentarium in recent years and TMS, once considered faddish, is now an important part of practice. Psychiatrists are more likely to consider lifestyle factors such as diet, exercise, the environment, sleep, social connections and thus provide more holistic care than in the past. Put simply, many of the criticism of the field with psychiatrists being drug pushers who were too quick to diagnose and prescribe, spent too little time listening to patients, ignoring psychosocial and lifestyle factors, and ignoring the whole person in assessment and treatment are not reflective of much of contemporary practice.

Again, psychiatry, like any medical field, is imperfect. There is a lot to improve upon. You can be the sort of person who sees crisis or the person who sees opportunity. We need people of all persuasions becoming psychiatrists who see the opportunity to improve our understanding and treatment of a wide range of mental health problems.

As for prescribing psychologists, there almost 150 000 clinical psychologists in the US and only about 300 active prescribing psychologists. the DoD only trained 10 psychologists (who were very good and essentially received residency-like apprenticeship training as part of the program, something that is not available to psychologists). The DoD's reports said there was "essentially unanimous agreement that the graduates were weaker medically than psychiatrists" with their "medical knowledge variously judged as on a level between 3rd or 4th year medical students." Which is to say that even after training the most highly regarded psychologists with a level of training and supervision not available to the typical prescribing psychologist, they were considered at the medical student level knowledge wise and best at a junior psychiatry resident level in terms of functioning. None of the psychologists I know have any interest in prescribing, and usually it is the worst psychologists who've gone to unaccredited programs and are struggling or are not competent to provide effective psychotherapies who are most interested in that.