Gen Peds vs. Psych/Child and Adolescent Psych....indecision and angst!

[NavyBlueRabbit]

This is a novel, sorry.

I have been trying to choose between Peds and Psych since...December or January? Now I'm 38 weeks pregnant and tired and emotional and I really need to choose soon to get those letters of reference and my personal statement and everything going for the Match!! Currently finishing up a peds psych rotation and I don't have time to rotate in more specialties prior to August/September bc this baby is coming in 2 weeks. Step 1 254, Step 2 268. Fairly competitive. I did a Peds SubI.

To answer some of the main "specialty-narrowing" questions:

Inpatient or Outpatient? Outpatient

Surgical or Non-Surgical? Non-surgical

Sick or Healthy Patients? Mostly Healthy

Specialized or Generalized? Generalized

I loved learning about all body systems and aspects of medicine in pre-clinicals (huge nerd), but when I started clinicals it turned out I really really don't like adult IM so anything similar to it got ruled out. I also have little to no aptitude for surgery. I loved OB/Gyn in theory but everything I hear about the lifestyle is terrible and I refuse to do that to my husband and future children.

So let's get down to what I have narrowed it to:

Peds: wide variety of pathologies. I am one of the few people in my class who actually really likes well child checks and doesn't find them boring at all. I don't mind sniffles and coughs, the kids are still cute. I still don't love inpatient (I just don't like rounding and having to worry about the patient ALL THE TIME) but in outpatient...I was happy during the day. Seeing kids of all ages, exams felt way less awkward than adults...promoting wellness...people were happy. And I sort of get my OB kick when I see newborns and talk to the moms. Despite it being mostly WCC and URI, there was enough other stuff that would pop in too. And if I get bored I can always do a fellowship.

Possible cons: Low(er) pay..I don't really care tbh but it's still a con. I still see nothing when I try to look in an ear. The residency seems grueling. What honestly happened is my school offered this "Coffee with a Resident" thing and I got coffee with a peds resident. She looked SO TIRED and never gets a full weekend off, seemed like she barely had any time for anything....and then mentioned her friend in a psych residency who gets weekends and goes home at 4:30 every day...now I am not a lazy person, but I do want my family to be a big part of my life and I just honestly worry about having my own small children during residency and how stressful and sleepless it could all be.

Psych: I honestly didn't start thinking about Psych until I started hearing all this stuff about the lifestyle. And then I retroactively remembered that I enjoyed learning the pathology in pre-clinicals. My clinical experience in the first clinical year was shadowing rounds at a state mental health hospital for one morning every 2 weeks. It was interesting but I never once thought..."I want to do this." I always had more fun delivering babies or stitching in the ER or seeing a 6-month old.

Then I started doing a lot of reading online. All these psych residents that LOVE their jobs. Child psych being in huge demand! The higher salaries, the better hours, the flexibility. My husband and I want to travel more...the thought of doing appointments from a laptop really appeals to me. Peds or psych, a job becomes a job in the end, and having more time outside of work and more flexibility can be huge for you and your family...

Cons: I've been on a couple child psych rotations now with the thought that yes, this is what I am going to do..and I haven't exactly felt fantastic about it. All I learned in medical school before clinicals feels...gone and far away. I don't even really see psych pathologies coming to life in these children, mostly just bad home situations. I feel like I became a social worker with an Rx pad...
The kids are sweet but their stories and their med lists blur together for me. I feel...understimulated. On the one hand maybe I'm just tired and crabby in these last few weeks of pregnancy. But something doesn't feel right....I don't know if adult psych would have a wider spectrum of pathology and interest me enough...but historically I haven't enjoyed it all that much either.

A lot to read and consider but in conclusion..I am just.. torn. I don't want to pick peds and then be in the depths of residency and think mannnnn why did I not go that psych route and have a better lifestyle. Why am I missing out on my own kids growing up because I am taking care of other kids?

But I don't want to pick psych/child psych and miss medicine and get bored. Even if hours are less and pay is eventually better, if I feel bleh or meh about what I am doing , who is that helping???

Any insight or things I am overlooking? I really thought I had decided on peds psych, I even wrote a psych personal statement! And it's just these last few weeks that I'm feeling weird about it.

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[mrbreakfast]

So let me try to over-simply summarize what you wrote, and see if you agree with it:

-You'd be happy as an outpatient general pediatrician, but are worried about the salary.
-You don't actually like psychiatry or child psych, but have been convinced it's a "smart choice" because of the lifestyle/pay.
-You're concerned peds residency (three years) will impact your overall quality of life more than child psych residency (five years? I don't remember) enough to base your 30+ year career decision on it.

If you want a random internet stranger's opinion based solely on the above, you should pick peds.

 

[bGMx]

Think about the bread and butter here: you will likely get consulted to solve problems no one else wants to deal with (labile patient), and if you don't want to deal with it because you're daydreaming about the end of your shift, you're going to have a bad time.

 

[Tenk]

For what it’s worth: one of my good friends and former co-resident’s wife is a pediatric psychiatrist. They are so sought after that she works only as much as she wants and has a cash only practice. I’m sure this is area dependent but I’ve practiced in several states and getting a good peds psych is like finding a unicorn that’s also a zebra. Good luck.

 

[kuzy]

My understanding is that you can do a child psych fellowship after a pediatrics residency, so you could learn all the medicine/pathology that has drawn you to peds but do a child psych fellowship if you are still interested

 

[NavyBlueRabbit]

So let me try to over-simply summarize what you wrote, and see if you agree with it:

-You'd be happy as an outpatient general pediatrician, but are worried about the salary.
-You don't actually like psychiatry or child psych, but have been convinced it's a "smart choice" because of the lifestyle/pay.
-You're concerned peds residency (three years) will impact your overall quality of life more than child psych residency (five years? I don't remember) enough to base your 30+ year career decision on it.

If you want a random internet stranger's opinion based solely on the above, you should pick peds

Yes, that mostly sums it up. I actually don't mind too much about the salary, I am more worried about hours I suppose. And yes I know it's 3 years vs. 5 but I'm told the hours are different? A good point though...I would come out into the attending lifestyle 2 years earlier. It sounds like I'm lazy but really I'm mostly just worried about being a present, good mother. My mother was extremely present in my childhood and that was huge for me. Apparently not enough to stop me from going to med school lol, but still a consideration for specialty choice.

 

[NavyBlueRabbit]

For what it’s worth: one of my good friends and former co-resident’s wife is a pediatric psychiatrist. They are so sought after that she works only as much as she wants and has a cash only practice. I’m sure this is area dependent but I’ve practiced in several states and getting a good peds psych is like finding a unicorn that’s also a zebra. Good luck.

I knowwwwww. But if in the end I don't like it enough, no matter how cool that is, I might just be a garden variety gen peds horse

 

[Candidate2017]

I don't even really see psych pathologies coming to life in these children, mostly just bad home situations. I feel like I became a social worker with an Rx pad...
The kids are sweet but their stories and their med lists blur together for me. I feel...understimulated.

100%. Most psychiatrists dislike child psychiatry, hence a shortage. My child psych rotations in residency were soul sucking.

From the lower SES/Medicaid side, the system (hospitals, facilities, courts/juvenile, parents) expects you to medicate children, when these kids need to be prescribed new parents or new living situation. A teen who is anxious because mom's boyfriend raped her and released from jail, or a kid acting out because they've been removed and returned a dozen times to their abusive parents... these kids need a real change other than bumping their SSRIs and/or antipsychotics.

From the higher SES/insurance and cash side, it's titrating ADHD stimulants and a smattering of autism. Then there are the teens whose parents expect you to medicate and magically therapize them into giving up weed and stop being snotty to their parents, as well as divorced parents trying to pull you into family drama and weaponize you against the ex and child.

Then there's the huge of amount of time you will spend reviewing records, filling out paperwork, making reports to CPS, and coordinating with school/courts/peds.

 

[WildWing]

SDN just hosted a webinar with two Developmental-Behavioral Pediatricians about their job, which might hit the sweet spot in your interests. The income is not as high but the hours sound great. EDIT: Though it is a sub-specialty and you did say you weren't interested in specialization.

Here's a link:

 

[sloop]

My understanding is that you can do a child psych fellowship after a pediatrics residency, so you could learn all the medicine/pathology that has drawn you to peds but do a child psych fellowship if you are still interested

This is entirely incorrect. You can only do a CAP fellowship after general psych residency. Your first year of fellowship can count as your first of the two-year fellowship (fast tracking), but the residency has to be a psychiatry residency. There are good reasons for this, too. You simply can’t teach a pediatrician to be a psychiatrist (let alone a child psychiatrist) in two years.

OP, overall I think you just need to decide if you like psychiatry. You not only need to figure out if you like the bread and butter of child psych but also whether you like psychiatry generally. Even if you decide you like child psych, there is always the chance that you might decide you hate it when you’re actually doing that work as a resident. In such a situation, you need to actually like psychiatry generally so that you’re not totally screwed with no options that you actually enjoy.

In my opinion, psychiatry is not like IM or some other fields, where some of the fellowships lead to subspecialties that are so different from the general speciality on a day-to-day basis where someone might love the subspecialty and really dislike the general specialty such that it’s worth going through a residency you don’t like just to get to the fellowship. All of the subspecialties of psychiatry lead to jobs that are pretty similar to general psychiatry in terms of lifestyle, job structure, etc. My field (forensics) is the one that is probably the most different from general psychiatry, but even then most forensic psychiatrists don’t purely do non-clinical forensic work, meaning that they’re generally still spending a good deal of their time being either a general psychiatrist or a treating psychiatrist in a correctional or state hospital setting. For these reasons, I really think you need to like psychiatry to pursue any of its subspecialties.

 

[wanderer534]

You can do triple board (i.e. 5 year training in peds/psych/child psych).

You can do peds residency first and then at the end if you still want to do psych, you can do a post peds portal program and do child psych after.

You can find out more information here: https://tripleboard-postpediatricportal.com/

 

[TempuraOreos]

I have a similar decision to make as a rising M4. Pretty settled on Child Psych though. Like others have said you have various pathways in both psych and peds to a more "balanced lifestyle" if that's what you're looking for. There's also Child Psych Consult Liaison if you decide child psych that will give you continued exposure to the medical side of pediatrics if you miss that. On peds side, Adolescent medicine is a good mix of bread and butter peds (with teens and young adults) but also you spend a lot of time on the psych side of things since a lot of mental health issues can start in adolescence.

 

[Taddy Mason]

I would strongly recommend against triple board for OP. Corners are cut on both the peds and psych side and the schedule is generally more stressful and less flexible due to having to fit what is essentially 7 years of residency plus 2 years of fellowship into 5 years. The vast majority of triple boarders also don’t use their full scope of training and end up just doing straight peds or CAP (more so the latter). I’m going to echo what others have said that peds seems like a much better fit. From a time/schedule standpoint peds training is shorter, the difference in hours worked in residency is negligible, and post training schedule is equally flexible in both. CAP likely offers better income as an attending, but if you don’t like the work….

The things that bother you now with CAP are only going to become more pronounced with training. If you don’t enjoy psych (as much as peds anyway), get to CAP fellowship and are miserable then what? There’s a reason it’s not terribly uncommon for people to leave CAP fellowship, not practice CAP after fellowship, or do a mix of adult and CAP after fellowship v. straight CAP. Also, keep in mind that for psych you’ll still have to do 6mo of adult medicine and neuro. Some programs may allow you to substitute a month or two of peds but not all.

Edit - In re-reading your posts, I just want to emphasize you have a skewed perception of the work/life balance/hours worked per week between psych and peds. While it’s going to vary depending on the program (both for peds and psych) and, yes, peds will likely skew higher, the difference (as per above) is largely negligible (like on the scale of about 5hrs per week). I say this as someone who has seen several years worth of GME data for resident reported hours worked logs for the programs where I am currently, is close friends with multiple peds residents at my current program, and have stayed in touch with several classmates from med school who went into peds elsewhere.

 

[butidontwantto]

Hey op, career changer here. Just wanted to say that spending less time on something you don't enjoy is not better than spending more time on something you actually like. 8 hours a day is still a large amount of time in your day. Might help to look at the marginal cost of the peds programs you're interested in. Is the difference 5 hours a week? 10? Did a quick random check of some general peds programs on freida and their average PGY1 hours didn't look all that different from psych (obviously going to be super program and rotation dependant). Also important to not base your decision on a sample size of 1. It could be the person you had coffee with was on a super rough rotation at a particularly malignant program. Could be she had something else going on she didn't want to mention. At the end of the day, 3 years of a little less time to be with your family vs. an entire career (40+ years) doing something you don't actually enjoy seems like easy math to me. Your family will understand, and they'll get to see their mom accomplish something that's awesome.

 

[calvinhobbes]

This is entirely incorrect. You can only do a CAP fellowship after general psych residency. Your first year of fellowship can count as your first of the two-year fellowship (fast tracking), but the residency has to be a psychiatry residency. There are good reasons for this, too. You simply can’t teach a pediatrician to be a psychiatrist (let alone a child psychiatrist) in two years.

OP, overall I think you just need to decide if you like psychiatry. You not only need to figure out if you like the bread and butter of child psych but also whether you like psychiatry generally. Even if you decide you like child psych, there is always the chance that you might decide you hate it when you’re actually doing that work as a resident. In such a situation, you need to actually like psychiatry generally so that you’re not totally screwed with no options that you actually enjoy.

In my opinion, psychiatry is not like IM or some other fields, where some of the fellowships lead to subspecialties that are so different from the general speciality on a day-to-day basis where someone might love the subspecialty and really dislike the general specialty such that it’s worth going through a residency you don’t like just to get to the fellowship. All of the subspecialties of psychiatry lead to jobs that are pretty similar to general psychiatry in terms of lifestyle, job structure, etc. My field (forensics) is the one that is probably the most different from general psychiatry, but even then most forensic psychiatrists don’t purely do non-clinical forensic work, meaning that they’re generally still spending a good deal of their time being either a general psychiatrist or a treating psychiatrist in a correctional or state hospital setting. For these reasons, I really think you need to like psychiatry to pursue any of its subspecialties.

You’re actually incorrect ☺️.
You can do a CAP fellowship after Peds. You can teach a pediatrician to be a psychiatrist — it’s called a psych peds portal fellowship, completed after doing 3 years of peds residency (it’s even better than triple board programs). I know several pediatricians that have done this and they are now all excellent psychiatrists, for example running the CL service, doing addiction med, ECT, inpatient, etc. It’s a combined adult
residency / child fellowship, formally approved by the ABPN, and here is more information to educate yourself:

Post Pediatric Portal Programs

www.aacap.org

OP, I would encourage you to apply to psych but if you end up doing peds, just know that you can always become an officially trained adult and child psychiatrist through this fellowship program. Good luck!

 

[Rapsidy]

Career changer here as well, but I went into medical school with the intention of going into psychiatry as I was a social worker before medical school.

Do not go into child psych if you don’t love it. I wouldn’t touch child psych with a ten foot pole mostly because I can’t stand the parents. It’s also soul sucking to work with these kids and watch them go back into the same dysfunctional home and everything you did was completely moot.

I’ve had parents try to call the national guard on me, try to storm down hospitals doors, attack our staff, throw themselves on the floor screaming about the doctors taking medical protective custody etc.

Even in outpatient, you’ll be dealing with a lot of Give my kid something I can’t stand their behavior! They must have ADHD fix them!

Give me inpatient adults with schizophrenia or on the middle of a severe manic episode any day, but all the money in the world couldn’t get me to want to specialize in child psych.

Just my two cents. Good luck to you!

 

[sloop]

You are actually very wrong.
You can do a CAP fellowship after Peds. You can teach a pediatrician to be a psychiatrist — it’s called a psych peds portal fellowship, completed after doing 3 years of peds residency (it’s even better than triple board programs). I know several pediatricians that have done this and they are now all excellent psychiatrists, for example running the CL service, doing addiction med, ECT, inpatient, etc. It’s a combined adult
residency / child fellowship, formally approved by the ABPN, and here is more information to educate yourself:

Post Pediatric Portal Programs

www.aacap.org

OP, I would encourage you to apply to psych but if you end up doing peds, just know that you can always become an officially trained adult and child psychiatrist through this fellowship program. Good luck!

I will say that I was not aware of this pathway, but I’m also not wrong. What you described is not a CAP fellowship. It is a specific 3-year combined general and child psychiatry program offered by a total of four institutions. You cannot go through peds residency and then expect to apply to a CAP fellowship and be able to practice CAP, which was mostly my point.

 

[calvinhobbes]

I will say that I was not aware of this pathway, but I’m also not wrong. What you described is not a CAP fellowship. It is a specific 3-year combined general and child psychiatry program offered by a total of four institutions. You cannot go through peds residency and then expect to apply to a CAP fellowship and be able to practice CAP, which was mostly my point.

Yes you can! 🤩 The combined integrated program/pathway (or portal program as it’s called) is for pediatricians who then enter the program as a PGY-4 and start rotations alongside gen psych residents and CAP fellows. You do the same rotations they do, lots of inpatient, ED, outpatient, forensics, addiction, consults, ECT, etc just like any gen psych or CAP fellowship program would require, because you’re completing two ACGME programs at the same time, without the added free fluff time in fourth year (admin/elective time) found in a traditional gen psych program; you are a true psych resident and child fellow at the same time, in the respective gen psych and CAP programs, working alongside the other residents and fellows, with the same expectations. All rotations are strictly supervised and approved by the ABPN, because you are literally completing the same exact ACGME program requirements that a gen psych resident and CAP fellow would be training in, except it’s a combined integrated program. You work the same hours, see the same patients, etc. You’re an additional psych resident to the gen psych program and an additional CAP fellow in the child program. Take the same calls, shifts, present the same cases at didactics, etc. You obviously don’t do the 6 mos of inpatient adult medicine (as it’s not needed since you’re a pediatrician), but still do adult Neuro, some IM electives, etc.

This program been around for over ten years: its a fact that pediatricians can apply to CAP, and do practice CAP, as they are eligible because this program gives pediatricians the gen psych and CAP board certification opportunity, as all the graduates of this program can attest to; the ABPN created this program so it’s legit (here is more information in case you are still not convinced:

Combined Training Programs - ABPN )

Don’t forget, many gen psych residents fast-track and start their CAP fellowships in their third years, and finish their entire program in five years. (See below):

Child and Adolescent Psychiatry Training

www.aacap.org

Thus, doing a portal program is not all that different (see chart).

Also an interesting recent article on future of CAP:

Making More Child and Adolescent Psychiatrists: Responding to the National Emergency in Mental Health in Children and Adolescents - Academic Psychiatry

link.springer.com

OP, feel free to message me if you have any questions as I can ask the people doing these programs! Of course, if your end goal is CAP, it would be easier to match into a psych residency, but know that CAP fellowships do exist for peds trained folks, and these are real CAP programs that thus take pediatricians as their fellows. Best of luck to you!! 😀