Give an MS4 reasons to pick psychiatry over neurology (or vice versa) . . .

[Cinnameg]

Hello! I'm a newly minted 4th year medical student who has only three months to decide between the following exciting career paths: Psychiatry followed by neuropsychiatry fellowship, Neurology followed by behavioral neurology fellowship, or a combined Neurology/Psychiatry residency program. In theory, I could apply to all three residency types (psych, neuro, neuro/psych combo), but I would rather not, it seems like a good way to confuse my recommendation letter writers and interviewers alike. I am fascinated by the brain in all its aspects, neurological and psychiatric diseases alike. I've had a little more experience in psychiatry prior to medical school, and therefore am currently more knowledgeable in psych than neuro, but I'm not convinced that one would be much easier for me than the other. Any advice from someone who has made a similar choice, or someone who is in one of these specialties? Thank you!

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[peppy]

Do you prefer depressed and psychotic patients or strokes and seizures? Do you like talking to patients or physical exams/imaging? I'd go with whatever field you prefer the bread and butter general work in, since a lot of people who start off intending to do a fellowship end up deciding "I'm tired of being a resident" and decide not to go through with it.
In either field, an interest in the other one will be useful. There is a lot of crossover.

 

[strangeglove]

Depends on whether you are going to spend most of your time doing clinical work or doing research (you are an MD-PhD, right?). If you are interested in research, then what excites you more: questions about how the mind works and goes awry in disease, or questions about how neurons die? The former is the province of psychiatry, while the latter is the province of neurology.

 

[psychattending]

Hello! I'm a newly minted 4th year medical student who has only three months to decide between the following exciting career paths: Psychiatry followed by neuropsychiatry fellowship, Neurology followed by behavioral neurology fellowship, or a combined Neurology/Psychiatry residency program. In theory, I could apply to all three residency types (psych, neuro, neuro/psych combo), but I would rather not, it seems like a good way to confuse my recommendation letter writers and interviewers alike. I am fascinated by the brain in all its aspects, neurological and psychiatric diseases alike. I've had a little more experience in psychiatry prior to medical school, and therefore am currently more knowledgeable in psych than neuro, but I'm not convinced that one would be much easier for me than the other. Any advice from someone who has made a similar choice, or someone who is in one of these specialties? Thank you!

I would encourage you to think about what type of problems/illnesses you most enjoy treating. Do you prefer patients with behavioral/cognitive problems or do you prefer sensory/motor problems? The former tend to be psychiatrists, the latter neurologists.

 

[rgerwin]

Don't forget, though, about neuropsych fellowships, where you can get a little bit of everything.

 

[Mattchiavelli]

have you done clerkships in both? if not, bend space and time to get into the one you didn't have before deciding- the day to day of both are very different, psych is kind of it's own entity and neurologists operate a lot like internists. You will probably not be in any patient drum circles on neuro but I was when I did my psych clerkship. My decision to go neuro was because I like anatomy and procedures so much and when you do psych you kiss that goodbye in a way. Psych you will also be doing a LOT more work with social services and will be in court to testify that your patient needs to be committed against their will (forget the term for it, had to go to one of these and watch a patient totally crazy out on the stand, very interesting).

 

[Cinnameg]

have you done clerkships in both? if not, bend space and time to get into the one you didn't have before deciding- the day to day of both are very different, psych is kind of it's own entity and neurologists operate a lot like internists. You will probably not be in any patient drum circles on neuro but I was when I did my psych clerkship. My decision to go neuro was because I like anatomy and procedures so much and when you do psych you kiss that goodbye in a way. Psych you will also be doing a LOT more work with social services and will be in court to testify that your patient needs to be committed against their will (forget the term for it, had to go to one of these and watch a patient totally crazy out on the stand, very interesting).

Yes, I've done clerkships in both . . . and had a great time in both, met happy residents in both . . . I, too, thought I would figure this out after both clerkships, but it just made me more ambivalent, unfortunately. What do you mean by a patient drum circle? You mean that literally? As far as the legal aspect, I like that stuff, forensic psychiatry looks like one of the more interesting areas of psych.

 

[Faebinder]

Go to neurology, we dont need more competition in psych. 😀

 

[Cinnameg]

Go to neurology, we dont need more competition in psych. 😀

I know you're being funny . . . But actually, how is the job outlook in psych?

 

[Manicsleep]

You may want to break it down to what you liked most about each specialty and that may allow you (and us) to give you a better idea.

Both specialties have the ability to crossover.
For example in psychiatry: neuropsychiatry, consulation liaison psychiatry, sleep etc.

You can do a dual residency. There are some that are only 5 years

 

[Cinnameg]

You may want to break it down to what you liked most about each specialty and that may allow you (and us) to give you a better idea.

Both specialties have the ability to crossover.
For example in psychiatry: neuropsychiatry, consulation liaison psychiatry, sleep etc.

You can do a dual residency. There are some that are only 5 years

Hi Manicsleep -- Here's the breakdown as I see it so far:

Cool stuff in psychiatry:
- The patients (fascinating! and very fun to spend time with)
- The diseases
- The enigma, the "gray area" of uncertainty
- Getting to spend a lot of time with patients
- The coworkers: psychiatrists seem a great group in general
- Getting to help people who are marginalized
- The social and legal issues

Disadvantages of psychiatry:
- No neuro exam
- Fewer management tools than neurology has to offer
- No looking at brains
- Diagnosis is pretty easy

Cool stuff in neurology:
- The diagnosis: solving the mystery of with a variety of tools
- Getting to look at brains (MRI's and brain pathology)
- The neuro physical exam (fun!)
- All the exam tricks for differentiating between a neurologic vs a psychiatric disorder

Disadvantages of neurology:
- Not enough time with patients
- Neuromuscular & peripheral nerve disorders aren't very interesting
- If your exam tricks reveal the patient to have a psychiatric diagnosis, you send him/her elsewhere
- Post-diagnosis management isn't as fun/interesting as in psychiatry



A note on dual psych-neuro residencies: I've done some research on this, and a dual residency does not appear to be a very good option. There are less than 10 programs, and all except one are seven years long (one year medicine, three years psych, three years neuro). Each program only takes one person a year. Frankly, even if I desperately wanted a psych-neuro combined residency, I am an average applicant and I don't think I could get a slot. I DO have to choose between psych and neuro, which is why I'm asking for help . . . and I really appreciate all the responses so far in this thread, THANK YOU!!!

 

[cyneuron]

Disadvantages of psychiatry:
- No neuro exam
- Fewer management tools than neurology has to offer
- No looking at brains
- Diagnosis is pretty easy

Really ? Neuro-imaging (Not just MRI, you get to play with PET, DTI and fMRI increasingly) is currently and going to be a big component of psychiatry research and clinical management as well.

 

[Cinnameg]

Really ? Neuro-imaging (Not just MRI, you get to play with PET, DTI and fMRI increasingly) is currently and going to be a big component of psychiatry research and clinical management as well.

That's great! I was just listing impressions I'd gotten from my rotations, not facts . . . I know psych research has a lot of neuroimaging (actually I worked in a neuroimaging lab for a year as an undergraduate, in the psychiatry department) but didn't know we were anywhere near clinical application. Do you look at scans in your clinical work currently?

 

[cyneuron]

That's great! I was just listing impressions I'd gotten from my rotations, not facts . . . I know psych research has a lot of neuroimaging (actually I worked in a neuroimaging lab for a year as an undergraduate, in the psychiatry department) but didn't know we were anywhere near clinical application. Do you look at scans in your clinical work currently?

Well it depends on the clinician to clinician (and hospital policies). More and more literature is coming up supporting use of various Neuro-imaging techniques in various disorders. I have seen psychiatrist employing at least PET studies in quite few cases but they were mostly on clinical research protocols. I don't see why won't psychiatrist be using these studies in routine clinical use in very near future. Also, insurance coverage for ordering study affects the frequency with which clinician will order the test even if there is strong evidence available.

Current Attendings and Fellows will be able to better answer this.

 

[michaelrack]

If you like the neuro exam, go for a neurology residency. In private prac, neurologists do tend to spend a lot of time with patients (more than IM).

If you change your mind about specialties, you can switch from neuro to psych after the first year without losing any time.


When I was at WVU, the combine neuro/psych residency was 6 years.

 

[Faebinder]

I know you're being funny . . . But actually, how is the job outlook in psych?

To sum it up: About the same.

They work harder with worse hours for practically same pay. They are slightly more rare than us but we are WAY more in demand cause more people need to see a psychiatrist rather than a neurologist (I said need, not want). You are more likely to be under managed care control in psychiatry. Both have a large potential to have weak job satisfaction. Both can easily rely on outpatient if they get screwed by hospitals. Neurology doesn't have scientologists thinking it's bogus and doesn't have as many psychologists or nurse practitioner who think they can practice it without residency (yet). In psychiatry you usually are more able to keep on working till very late age compared to neurology. Both fields are growing at a fast rate in terms of what we know and what we can do about it. The standard of care will probably be different every 10 years for psych more than for neuro.

 

[mathilda25]

there are programs in psych that offer neuroimaging exposure - both research and clinical. I have received some lectures on PET, fMRI and their uses in forensic psychiatry as an intern
we often order brain scans on patients - especially with first breaks and sometimes you find abnormalities and work with neuro consult together

I am required to do a thorough neuro exam on every patient I admit to psych - even if they have no complaints

 

[surftheiop]

Both have a large potential to have weak job satisfaction. .

Could you elaborate on this a little (lot?) more?

 

[RugbyJC]

I was in your shoes a few years ago surftheieop. All I can say is good luck. Just something to think about are other fellowship opportunities. Forensics is mentioned below, as is neuropsych vs behavioral neuroscience, but there are a lot more than that in both specialties and the line of work you do for psych can be quite different depending on if you sub-specialize.

I decided to stick with psych and here was my reasoning:

In neuro I found that I saw a lot of psych, but it was not the type of psych I wanted to work with. For instance, I saw a lot of psych patient's presenting as neurological/internal medicine patients--fibromyalgia, chronic pain, conversion disorders, somatization, factitious disorders, etc.

From an academic perspecitve I found the "real" pathology more interesting in neurology than with psychiatry--MS, strokes, ALS, seizures, etc., but I found more often than not we were diagnosing debilitating diseases that we could do little about. Yes, tPA when it works and can be used is pretty cool, and assisting the MS patient with high dose steroids is awesome when effective, but the outcomes often came with poor prognosis...and headaches turn into headaches after a while.

In psych, the process can also be slow but for some reason I found it more hopeful. Disease course was less predictable and helping patient's go from completely debilitated to successfully reintegrated in society was more the norm than the exception. Although there are diseases that are refractory to treatment and some patients can never be "cured" or reach remission (and then there's always the patient's that will go on to commit suicide...or the alcoholic who continues to drink despite your advice, and they lie to you often), for some reason this didn't bother me as much as with neurology.

I also hate to say this, but psych was sometimes relatively amusing. Very often after an interview my first thought would be "he did not just say that, did he?!?" To a point of amusement vs. disbelief.

From a research perspective, both have a lot of opportunities--all of medicine does. For neuro you are more doing an IM subspecialty. If you like that, psych consult is not too far off. Some programs offer more interaction with imaging studies or the biological vs psychological approach for psych.

Lifestyle is comparable once you are done with residency and often varies on the program or where you go.

I had looked at psych/neuro programs, but for me knew they were not an option (long story). The rumor I heard about these is that it is very difficult to master both fields and stay up to date enough in both to practice both; however, from a research end if might serve a benefit if you are interested in a specific area of neuropsych, but this is all hearesay.

Sorry for the ramble, but hopefully you found some of it useful. Keep in mind also that if you do change your mind, you are not completely screwed. Both are not the most competative and if you do quit residency in one you can often find a position in the other, but may or may not have to repeat the internship or part of it depending on the program.

 

[surftheiop]

I was in your shoes a few years ago surftheieop.

Just to clarify (not that it really matters), but I'm not the OP, you would have been in my shoes a lot longer ago 🙂

 

[Scorcher31]

Keep in mind sometimes there is no right answer. From what you said and provided you've had multiple experiences in different settings with both fields, I would say that you'd probably be happy whether you end up doing neuro or psych. Sometimes you just have to pick. Chances are that no matter what you choose years down the road you will look back and say wow I made the right choice.

 

[Faebinder]

Could you elaborate on this a little (lot?) more?

It depends on how you obtain job satisfaction. Is it your feedback from patients when you "cure" them?

Inpatient psychiatrists job involves doing things against the patient's wishes to make him better... so feedback is dead there. Inpatient neurologists dont improve strokes (that's more of the PMR field when they go to rehab) and encephalopathies (treated by IM usually) so hardly any patient cares about their work to give them feedback in house.

Outpatient is not that much better. More good feedback for both but if you really depend on the patient's liking you, then you might start leaning on giving people things they shouldnt have like benzos anxiety and opiates for chronic pain. That would turn you into a "feel good" psychiatrist/neurologist.


Note I said potential... i didn't say that's the end result.. the end result will depend on you seeing the glass half full.

 

[OldPsychDoc]

It depends on how you obtain job satisfaction. Is it your feedback from patients when you "cure" them?

Inpatient psychiatrists job involves doing things against the patient's wishes to make him better... so feedback is dead there. Inpatient neurologists dont improve strokes (that's more of the PMR field when they go to rehab) and encephalopathies (treated by IM usually) so hardly any patient cares about their work to give them feedback in house.

Outpatient is not that much better. More good feedback for both but if you really depend on the patient's liking you, then you might start leaning on giving people things they shouldnt have like benzos anxiety and opiates for chronic pain. That would turn you into a "feel good" psychiatrist/neurologist.


Note I said potential... i didn't say that's the end result.. the end result will depend on you seeing the glass half full.

Unnecessarily bleak. Inpatient (where I am anyhow) is less than 20% involuntary commitments. We have a LOT of people admitted because they want help. Almost all of them leave the hospital in better shape than they came in. Often, they will even thank you for it. Every now and then, they'll even profusely let you know that you saved their life. 😍 (And maybe once every other month, one of them even sends a box of candy to us! 😀)

Outpatient, done right, is about partnering with the patient to help them achieve their goals. Sometimes you have to start by telling them your goals, sometimes you have to set limits, etc... If you're so worried about them liking you that you are prescribing against your principles, then maybe you shouldn't be prescribing at all. I see far more inappropriate opiate prescribing from our PCPs than our psychiatrists. (Personally, my policy is to not prescribe opiates--except buprenorphine--from my outpatient clinic, since I don't examine and evaluate pain, order x-rays, manage those conditions, etc. Saves me a lot of hassle! )

 

[Mattchiavelli]

What do you mean by a patient drum circle? You mean that literally?

Yep, literally, like patients with percussive instruments in hand being led by a music therapist and one of the earthier floor nurses in a group session. This was on my 3rd year clerkship on a locked inpatient unit. The best groups however were the ones that involved wii.

 

[Faebinder]

Unnecessarily bleak.

Agreed and that's why I said potential.