Going crazy

[Apollyon]

And a psychotherapist can legally perform vascular surgery. Equally bad idea.

I thought psychotherapists were PhD/PsyD (I mean, a psychiatrist can do it, but they would call themselves a psychiatrist). No surgery for them!

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[gutonc]

I thought psychotherapists were PhD/PsyD. No surgery for them!

A lot of psychiatrists do psychotherapy.

 

[Apollyon]

A lot of psychiatrists do psychotherapy.

Yeah, you quoted before my edit. They do it, but they don't call themselves psychotherapists. It was like when I worked on the ambulance - Sisters Hospital in Buffalo, NY absolutely, abjectly refused to put on our nametags anything but "ambulance driver". As was said, many times, by EMTs and paramedics, "That is part of our job, but only a minor one".

 

[NotAProgDirector]

You're reading much more into my post than I meant. The point is that once you have a medical license as an MD/DO/MBBS/etc, you can actually do "anything" with it. But realistically, you can / should only do what you were trained to do.

 

[Can'tdecide111]

You're reading much more into my post than I meant. The point is that once you have a medical license as an MD/DO/MBBS/etc, you can actually do "anything" with it. But realistically, you can / should only do what you were trained to do.

As a PCP, I'm under the impression that you can see all comers and also have an interest in patients with specific disorders such as Autism. Couldn't I do counseling for all their medical issues and perhaps lifestyle issues as well?

My understanding is that autistic patients need interdisciplinary care, so I CAN be involved as a doctor that handles their medical issues if I seek out the right institution. And I can additionally treat obesity, HTN and DM.

I have an idea that I want to have a practice connected to a gym almost. Like be a lifestyle coach as well as a doctor if that makes sense.

 

[hallowmann]

Definitely suburban. I want to be close to the city, but not far.

IM practice is easier and I've been working on it for while. My parents and friends are well established in IM world, but I do have connections to psych. Autism practice, I would have to look for patients that want to be treated by me and I would probably have to compete with other well established specialists in that field.

I know. I might just do IM and then apply to Psych after I finish residency. >_>

Crazy I know.

To the first question, it wouldn't be bad for me to treat Schizophrenia or Bipolar. I love patient interaction and would love to be of service to patients of this population as they are victimized a lot.

To the second question, yes. Completely. I would love to be of service to patients suffering from pain disorders or cancer or patients recovering from surgery. IM is interesting because it's an endless ocean and learning about new things in general is fun for me.

Why didn't you apply Med-psych exactly? There's like 13 IM-Psych programs, I think they at least take 2 each. It honestly looks exactly like what you're interested in, and I'd imagine you would use both aspects of training doing what you want to do (regardless of what people say about only using one after combined training). Med-psych is 5 yrs, meaning only 1 yr longer than a Psych residency, and you'd get all the training in medicine that you want. That makes a whole lot more sense than doing sequential training for 6-7 yrs.

I know a few people doing sequential training, but its a tougher road.

"Jones, a family physician, spends a full hour with each person. This allows him to uncover medical issues that people with autism may not readily communicate. He has learned, for example, that constipation is common in adults with autism, particularly those who take antipsychotic drugs. Severe constipation often manifests as behavioral problems, he has found."

THIS! This is why I wanna train both in IM and Psych, because Autism also has a lot of medical problems that need to be addressed in a population like this as well. I would love to have both medical and psychiatric training in helping this population!

So I know a few people that treat autism, CP, ID, and more patients with disabilities. They are primarily trained in either IM, IM/peds, or physiatry, and had a particular interest. The best of them was an IM/peds trained physician I did a rotation with that works as the medical director of a huge "facility" that covers acres of land, includes dorms, a school, a clinic, a farm, and other things. He is uniquely able to serve in that capacity due to both his training and his interest in serving that population, and honestly he seems to do an amazing job.

Another doc I know did 1 year of IM, and then transferred to a Psych residency. Does primarily mood work, but also is heavily involved in a Diet and Weight loss center for obese patients with medical complications. A lot of his patients have major psych comorbidities (i.e. schizophrenia, bipolar 1, as well as MDD, GAD, etc.). Part of that is related to the side effects of many psych meds.

A lot of medicine is guided by our interests, and the additional training we're willing to complete. I'm sure you could do a lot after either IM, Psych, combined, or through fellowships (accredited and not), training sessions, workshops, etc. after residency. My advice is to rank the programs in the order you felt that you would succeed most in, whether that's IM or Psych programs. If you're still up for it by the end of one residency, I think you could certainly get more training in the area you want, it'll just be a matter of how willing you are to move or take a pay cut.

 

[Can'tdecide111]

Why didn't you apply Med-psych exactly? There's like 13 IM-Psych programs, I think they at least take 2 each. It honestly looks exactly like what you're interested in, and I'd imagine you would use both aspects of training doing what you want to do (regardless of what people say about only using one after combined training). Med-psych is 5 yrs, meaning only 1 yr longer than a Psych residency, and you'd get all the training in medicine that you want. That makes a whole lot more sense than doing sequential training for 6-7 yrs.

I know a few people doing sequential training, but its a tougher road.



So I know a few people that treat autism, CP, ID, and more patients with disabilities. They are primarily trained in either IM, IM/peds, or physiatry, and had a particular interest. The best of them was an IM/peds trained physician I did a rotation with that works as the medical director of a huge "facility" that covers acres of land, includes dorms, a school, a clinic, a farm, and other things. He is uniquely able to serve in that capacity due to both his training and his interest in serving that population, and honestly he seems to do an amazing job.

Another doc I know did 1 year of IM, and then transferred to a Psych residency. Does primarily mood work, but also is heavily involved in a Diet and Weight loss center for obese patients with medical complications. A lot of his patients have major psych comorbidities (i.e. schizophrenia, bipolar 1, as well as MDD, GAD, etc.).

A lot of medicine is guided by our interests, and the additional training we're willing to complete. I'm sure you could do a lot after either IM, Psych, combined, or through fellowships (accredited and not), training sessions, workshops, etc. after residency. My advice is to rank the programs in the order you felt that you would succeed most in, whether that's IM or Psych programs. If you're still up for it by the end of one residency, I think you could certainly get more training in the area you want, it'll just be a matter of how willing you are to move or take a pay cut.

I think initially I wanted to choose Psych, but then I thought about how much I would miss IM and so applied at my friend's urging. And it just never crossed my mind to apply to combined programs as I thought I would just choose one or the other. In any case, I can't think about what I should have done. I have to think about what I can do now.

I feel like the IM route seems pretty good and if I wanted to do Psych later I can. Money is nice, but I'm motivated by making a difference more so than money. I wouldn't be bothered by prolonged training. And it sounds to me I can accomplish all I want to do as a IM doctor or PCP.

Autism, in general, involves interdisciplinary care and I can have patients that do have Autism. I can handle their medical problems and also counsel them on appropriate lifestyle interventions. And then I don't have to abandon treating HTN, DM and obesity and I get to see more of the different pathologies. Sure, I'll miss out on learning psychotherapy and managing schizophrenia or bipolar, but I think I can live with that. I would rather be involved with getting my patients fit and motivating them to be fit.

 

[Crayola227]

I think initially I wanted to choose Psych, but then I thought about how much I would miss IM and so applied at my friend's urging. And it just never crossed my mind to apply to combined programs as I thought I would just choose one or the other. In any case, I can't think about what I should have done. I have to think about what I can do now.

I feel like the IM route seems pretty good and if I wanted to do Psych later I can. Money is nice, but I'm motivated by making a difference more so than money. I wouldn't be bothered by prolonged training. And it sounds to me I can accomplish all I want to do as a IM doctor or PCP.

Autism, in general, involves interdisciplinary care and I can have patients that do have Autism. I can handle their medical problems and also counsel them on appropriate lifestyle interventions. And then I don't have to abandon treating HTN, DM and obesity and I get to see more of the different pathologies. Sure, I'll miss out on learning psychotherapy and managing schizophrenia or bipolar, but I think I can live with that. I would rather be involved with getting my patients fit and motivating them to be fit.

this makes sense to me given your stated goals and I think realistic enough, but I'm no expert on these things

 

[michaelrack]

Insurance would reimburse you, no different than any other provider that submits a bill. The issue would be credentialing and recruitment of patients, not legality or billing.

not necessarily. Unless a doctor registers with an insurer as a psychiatrist, psychotherapy add-on codes will likely not be reimbursed. Standard E and M codes still should be reimbursed.

 

[Oso]

As a PCP, I'm under the impression that you can see all comers and also have an interest in patients with specific disorders such as Autism. Couldn't I do counseling for all their medical issues and perhaps lifestyle issues as well?

My understanding is that autistic patients need interdisciplinary care, so I CAN be involved as a doctor that handles their medical issues if I seek out the right institution. And I can additionally treat obesity, HTN and DM.

I have an idea that I want to have a practice connected to a gym almost. Like be a lifestyle coach as well as a doctor if that makes sense.

I know this is not helpful now, but I wish you had applied to FM -- you would have been able to treat both medical and (straight forward) psych issues in both adults AND kids.

I agree though that the best route for you sounds like it's IM -> outpatient doc/PCP so you can manage medical issues but also be on the front-line for psych issues (though I'd expect would mostly be depression and anxiety, and much less autism). Over time I do think you could carve out a niche by building up a panel of patients who have both medical and psych issues. A lot of internists do NOT like working with patients with psych issues, so you would be providing a much needed service.

Of note, I do know of at least 2 internists who focus exclusively on patients with obesity and all its complications -- things like DM, HTN, and yes, psych issues -- so they work with an interdisciplinary team that includes people like nutritionists and psychologists. I feel like they are as close to a 'life coach' as you can get.

 

[Can'tdecide111]

I know this is not helpful now, but I wish you had applied to FM -- you would have been able to treat both medical and (straight forward) psych issues in both adults AND kids.

I agree though that the best route for you sounds like it's IM -> outpatient doc/PCP so you can manage medical issues but also be on the front-line for psych issues (though I'd expect would mostly be depression and anxiety, and much less autism). Over time I do think you could carve out a niche by building up a panel of patients who have both medical and psych issues. A lot of internists do NOT like working with patients with psych issues, so you would be providing a much needed service.

Of note, I do know of at least 2 internists who focus exclusively on patients with obesity and all its complications -- things like DM, HTN, and yes, psych issues -- so they work with an interdisciplinary team that includes people like nutritionists and psychologists. I feel like they are as close to a 'life coach' as you can get.

To be honest, I didn't know too much about FM and therefore didn't apply. I think what turned me off was that I couldn't work as a hospitalist (which I later learned to be false. You can do so in FM), fact that I'm shut off from doing Cardiology, Pulm or Allergy if I so desire (which is true, I am shut off from those fields) and also that I would have to learn Ob/gyn which is a huge turn off (which I now realize doesn't matter if I stack my practice with the patients I so desire).

However, I don't think I'm that unhappy about going into IM. I went to medical school to become a chessmaster and in IM, that's the closest you'll be to being a chessmaster (or at least strive to be for however long you practice).

 

[Can'tdecide111]

I've been having a bit of cold feet about my decision and I guess I need to ask something. In IM, burnout and workload is rampant. Not to say I want to take it easy, but I eventually do want to have a family and have some work/life balance. The thing is with IM that people have heart attacks, COPD exacerbations all the time and you need to be at your phone ready to respond and go to work.

While psychiatry might have the emergencies where suicide was threatened or someone is manic, it's appears that psych has less burnout and more of a lifestyle friendly balance.

So what do you guys think about this? I'm partially asking so that someone can come here and just destroy this line of reasoning and therefore I can stop being not so confident in my decision to go IM.

 

[hamstergang]

The thing is with IM that people have heart attacks, COPD exacerbations all the time and you need to be at your phone ready to respond and go to work.

While psychiatry might have the emergencies where suicide was threatened or someone is manic, it's appears that psych has less burnout and more of a lifestyle friendly balance.

Psych lifestyle does tend to be good. But, what on call looks like for an outpatient office depends on the set up of the office, not the specialty. All specialties have emergencies, or at least patients that feel they're having emergencies. Some people in both Psych and IM will be on call always for their patients (typically providing guidance over the phone, not going into the office -- if someone is having a heart attack you tell them to go to the ED). Others will work in a group that rotates the call. Some work for a hospital system that has some sort of call/back-up system.

 

[neoexile]

I'm actually interested to see what the Psychiatrists have to say about this guy's predicament.

@splik @OldPsychDoc

 

[splik]

Yeah, you quoted before my edit. They do it, but they don't call themselves psychotherapists.

I call myself a "psychiatrist and psychotherapist" when advertising my practice because nowadays a lot of people don't realize that psychiatrists do provide psychotherapy and im not really interested in treating patients who don't want psychotherapy.

 

[neoexile]

I call myself a "psychiatrist and psychotherapist" when advertising my practice because nowadays a lot of people don't realize that psychiatrists do provide psychotherapy and im not really interested in treating patients who don't want psychotherapy.

Just wanted to ask: In your opinion, could the OP treat Autistic patients as IM doctor and let Psychiatrists like you handle the psychiatric/mental health side while he deals with their medical issues?

 

[splik]

I am interested in why you want to treat autistic people. are you autistic? do you have any family members who are autistic? seems like a very specific interest at this point in time. I started out in IM and then switched to psychiatry. I received zero training in the treatment of adults with autism in my residency training. I did co-facilitate a social skills group for kids with autism but that is about it. I would say that my experience is typical for the vast majority of psychiatrists. I wish I had learned more about this. the director of our adult autism clinic was incidentally a neurologist, not a psychiatrist. Even if treating adults, autism is a neurodevelopmental disorder so training in pediatrics, child psychiatry or neuodevelopment is a must.

dentists can specialize in treating autistic patients, so i don't see why you couldn't be an internist who specializes in autism. you could certainly with additional training and experience manage psychotropic medications in this population as an internist. you would have a lot of grateful parents i am sure. one thing you want to bear in mind is if you are working with more impaired autistic patients who can't work, then they will likely have medicaid, especially if they're over 26 and can;t be on their parents' insurance, so your reimbursement would be poor. Unless you were catering to wealthy families with an autistic child etc.

 

[Can'tdecide111]

I am interested in why you want to treat autistic people. are you autistic? do you have any family members who are autistic? seems like a very specific interest at this point in time. I started out in IM and then switched to psychiatry. I received zero training in the treatment of adults with autism in my residency training. I did co-facilitate a social skills group for kids with autism but that is about it. I would say that my experience is typical for the vast majority of psychiatrists. I wish I had learned more about this. the director of our adult autism clinic was incidentally a neurologist, not a psychiatrist. Even if treating adults, autism is a neurodevelopmental disorder so training in pediatrics, child psychiatry or neuodevelopment is a must.

dentists can specialize in treating autistic patients, so i don't see why you couldn't be an internist who specializes in autism. you could certainly with additional training and experience manage psychotropic medications in this population as an internist. you would have a lot of grateful parents i am sure.

I had a buddy of mine who was Autistic (Asperger's) and I kinda started learning more about it. Soon I was on online forums with other autistics talking to them and how they call others NTs. And I kinda learned how alienated that community was so perhaps I just wanted to do what I can to help. Because people who suffer from the disorder (although a lot of them will say that people make them suffer, not the disorder) are interesting to talk to.

It feels bad because my buddy had a lot of problems in his life, but he's doing pretty well now. There is a whole population of these guys that need help and I wanna do what I can.

 

[hamstergang]

Just wanted to ask: In your opinion, could the OP treat Autistic patients as IM doctor and let Psychiatrists like you handle the psychiatric/mental health side while he deals with their medical issues?

Yes, it's definitely possible. Where I work now there is a center that does exactly this. It's grant-funded, and they see adults with any developmental disability not just autism.

 

[smq123]

Mm, in some states don't need credentials beside the MD and a license. As I understood it, some insurances can balk at bills submitted by those who aren't BC/BE. I guess I assumed that would be related to the type of thing they were billing for, but perhaps as long as you are boarded in SOMETHING they don't care that a vascular surgeon submits a bill for psychotherapy?

You're confusing credentials and credentialing.

Technically speaking, if you're a self-employed physician, then you can do whatever you want. But most of us AREN'T self employed; we are employed by hospitals, health systems, clinics, etc. And all of those larger entities require a credentialing process, where you request credentials for types of procedures that are typical for someone with your type of training. For example, as an FM physician in a multi-specialty group, my employer has credentialed me to do pap smears, IUD removals (NOT insertion), joint injections, EKG interpretation, etc. I could request to be credentialed in the same things that the OBs in our group are, but I would have to prove that I am equally experienced/competent as they are in those procedures (which isn't going to happen).

This credentialing process is not just for billing health insurances companies. If anything, it is mainly for your malpractice insurance. So yes, perhaps the health insurance companies won't balk if a BC/BE vascular surgeon bills for psychotherapy, but if something goes wrong, your malpractice insurance absolutely will care.

I've been having a bit of cold feet about my decision and I guess I need to ask something. In IM, burnout and workload is rampant. Not to say I want to take it easy, but I eventually do want to have a family and have some work/life balance. The thing is with IM that people have heart attacks, COPD exacerbations all the time and you need to be at your phone ready to respond and go to work.

While psychiatry might have the emergencies where suicide was threatened or someone is manic, it's appears that psych has less burnout and more of a lifestyle friendly balance.

So what do you guys think about this? I'm partially asking so that someone can come here and just destroy this line of reasoning and therefore I can stop being not so confident in my decision to go IM.

If you are in an exclusively outpatient practice, then you'll be seeing patients from 9-5. Anything that happens after hours will get sent to the ER, and be handled by the Emergency Physician/Hospitalist. Few practices nowadays are "full spectrum."

 

[calvnandhobbs68]

If you want to treat primarily autism, you will need to do a peds and/or child psych residency.
There are not large concentrated populations of adult with autism waiting for you to treat, they are scattered around here and there. There are some adults with severe autism and comorbid MR in institutions for the ******ed, so I guess if you were interested in ******ation also you could do IM or adult psych.

You'll get a LOT more exposure to autism in pediatrics than in internal medicine if that's one of your big interests (and it's awesome that it's an interest for you!). I don't even know how you would get exposed to autism in a general IM residency...maybe if you have a big institution that has an adult developmental disabilities clinic? But even then that would likely be part of the psychiatry/neurology/developmental department. Peds gets tons of exposure to autism screening, autism evals, management, behavioral management, etc. If you go to a big institution, the developmental and behavioral peds department will see a LOT of older teenagers and adults with autism, since there aren't many places for them to be seen. Big institutions often also have an autism diagnostic/management center although this is also usually within the peds/neuro/psych departments (not IM).

If you don't want to just do kids and get some adult training too, I would definitely choose med/peds over IM. You'll get exposure to autism through the peds part and most of the places that have med/peds are big academic institutions, so likely to have a developmental and behavioral pediatrics department. Look for a place that has a strong developmental/behavioral peds department (or at least has one) +/- a place that has an adult intellectual disabilities clinic/person.

 

[calvnandhobbs68]

Insurance would reimburse you, no different than any other provider that submits a bill. The issue would be credentialing and recruitment of patients, not legality or billing.

This is straight up not true. Insurance does reimburse you differently depending on your credentialing. Ask PCPs how much they get reimbursed for derm billing codes when they prescribe stuff for acne, eczema, etc. I've looked at both sets of bills myself, derm definitely gets reimbursed more for management of the same condition (no procedures involved). Same goes for most sub specialties.

 

[Can'tdecide111]

You'll get a LOT more exposure to autism in pediatrics than in internal medicine if that's one of your big interests (and it's awesome that it's an interest for you!). I don't even know how you would get exposed to autism in a general IM residency...maybe if you have a big institution that has an adult developmental disabilities clinic? But even then that would likely be part of the psychiatry/neurology/developmental department. Peds gets tons of exposure to autism screening, autism evals, management, behavioral management, etc. If you go to a big institution, the developmental and behavioral peds department will see a LOT of older teenagers and adults with autism, since there aren't many places for them to be seen. Big institutions often also have an autism diagnostic/management center although this is also usually within the peds/neuro/psych departments (not IM).

If you don't want to just do kids and get some adult training too, I would definitely choose med/peds over IM. You'll get exposure to autism through the peds part and most of the places that have med/peds are big academic institutions, so likely to have a developmental and behavioral pediatrics department. Look for a place that has a strong developmental/behavioral peds department (or at least has one) +/- a place that has an adult intellectual disabilities clinic/person.

So maybe 2 years of peds after IM residency. That might be interesting.

dentists can specialize in treating autistic patients, so i don't see why you couldn't be an internist who specializes in autism. you could certainly with additional training and experience manage psychotropic medications in this population as an internist. you would have a lot of grateful parents i am sure. one thing you want to bear in mind is if you are working with more impaired autistic patients who can't work, then they will likely have medicaid, especially if they're over 26 and can;t be on their parents' insurance, so your reimbursement would be poor. Unless you were catering to wealthy families with an autistic child etc.

Money is always nice. But I'm in this profession to make some change for people around me. So I can take the reimbursement being lower if it needs to be.

 

[michaelrack]

So maybe 2 years of peds after IM residency. That might be interesting.

or do a combined (4 years) Med-Peds residency

 

[rokshana]

or do a combined (4 years) Med-Peds residency

the OP is in the current match and applied and interviewed at IM and Psych programs and did not apply to med- peds programs...little late to now apply.

however OP, you may consider ranking the places you did interview that have med-peds programs high on your list and then after you match and start as an intern, see if you can transfer over to the med- peds program. Or go through psych and see if there is a child/psych program you can apply to (usually in the 2nd or 3 rd year of psych i think) that then would give you a decent foundation to treat pts with autism..maybe even be able to develop a sub fellowship at a place that has a great deal of autism.

 

[Can'tdecide111]

the OP is in the current match and applied and interviewed at IM and Psych programs and did not apply to med- peds programs...little late to now apply.

however OP, you may consider ranking the places you did interview that have med-peds programs high on your list and then after you match and start as an intern, see if you can transfer over to the med- peds program. Or go through psych and see if there is a child/psych program you can apply to (usually in the 2nd or 3 rd year of psych i think) that then would give you a decent foundation to treat pts with autism..maybe even be able to develop a sub fellowship at a place that has a great deal of autism.

Wouldn't transferring to another residency anger the Program Director though? I don't want to get on my Program Director's bad side

 

[calvnandhobbs68]

Wouldn't transferring to another residency anger the Program Director though? I don't want to get on my Program Director's bad side

No like transfer to the med peds program in the same place. You have a valid reason for it and the PD likely wouldn’t care that much since he/she would still get 2 years of IM out of you.

 

[Crayola227]

I talked to a pediatric neurologist still in training about this.

Developmental peds would be best for autism - it's a developmental disorder, and a lot of the heavy intervention is early in life. They often follow those kids until they develop adult medical problems that they can't manage. Peds is not a bad bet too. Both coordinate a lot of the diagnosis and care of those with autism - often there is a multidisciplinary team.

Neurology is in general a HORRIBLE field for what OP suggest they want to do, neuro does see a lot of MR and such, but what they manage is narrow and they don't really do autistic kids anymore than any other specialty might.

Psychiatry would not be good at all - they don't really do anything besides manage the cocktails of psych drugs for behavioral issues that some patients end up on - because managing psych cocktails, because of any specialist psych drugs are the best for that.

If you want to do adults with autism, though, developmental peds might not be the best fit. If you're stuck on the pathway of either IM or psych, go IM. You can create a practice that matches your post that way.

The irony is that my friend is in a combined peds program (not IM/peds, but alongside it), and questions the utility of IM/peds outside inpt setting, and even then.... though they think that perhaps that would built the foundation for the sort of practice you envision ultimately. They liked my idea of IM and then look to work in a combined IM/peds clinic, which do exist, if you really want breadth of practice with adults. In that framework it likely wouldn't be difficult to try to get more autistic patients on your panel and care for them.

 

[Crayola227]

No like transfer to the med peds program in the same place. You have a valid reason for it and the PD likely wouldn’t care that much since he/she would still get 2 years of IM out of you.

A few issues. There's only so many places that have the combined program. Many you needed to apply and interview and be accepted to both. Some you rank and might only get into one.

The other is that combined training programs tend to be shorter than what the separate programs combined would otherwise be - for example, neuro is 4, peds, 3, but peds neuro 5. The way that happens is unique, so there are potentially major issues with you starting on one track and then trying to switch over. That can work at some institutions and specialties but not all.

Going from one program at one institution to a combined program elsewhere, could be done, but it's not that much different than any other transfer (which are bitches to do, btw), except you might get more credit in the transfer for your rotations than you would otherwise. Kind in mind most people don't get total credit. Again, the scheduling can be a bit of nightmare.

 

[rokshana]

you forgot your * stating that you really are just doing a stream of consciousness and don't really now about things. though i "guess" you talking to a peds neurology resident is suppose to cover that?

you really don't have to comment on other peoples' opinions (though i don't really remember anyone telling the OP to do Neurology)

but your respect for psych is ...i don't know...especially since the OP has already applied to psych and obviously has an interest in it.

 

[rokshana]

Wouldn't transferring to another residency anger the Program Director though? I don't want to get on my Program Director's bad side

no, you would be transferring per se..the if there is a med/peds program at the places that you have interviewed for IM, then you maybe able to discuss the option of being able to add the peds portion to your training...not to say that will happen since funding could be an issue, but it has potential for you to get the peds component in to help with population you are interested in. Doesn't help with the psych component, but you may be able to do the as another residency once you finish IM or med -peds...there are some IM/Psych residencies and same would be a potential to transfer over to the IM/Psych program...but these are rarer than med/peds. If there is a programs or hospitals that focus on autism, you could talk to someone there to see what would be a good route and whether you could develop a fellowship after that could potentially fill in the holes...the fact that you are enthusiastic will peak someone's interest, especially if they to have a passion for the field.

 

[calvnandhobbs68]

I talked to a pediatric neurologist still in training about this.

Developmental peds would be best for autism - it's a developmental disorder, and a lot of the heavy intervention is early in life. They often follow those kids until they develop adult medical problems that they can't manage. Peds is not a bad bet too. Both coordinate a lot of the diagnosis and care of those with autism - often there is a multidisciplinary team.

Neurology is in general a HORRIBLE field for what OP suggest they want to do, neuro does see a lot of MR and such, but what they manage is narrow and they don't really do autistic kids anymore than any other specialty might.

Psychiatry would not be good at all - they don't really do anything besides manage the cocktails of psych drugs for behavioral issues that some patients end up on - because managing psych cocktails, because of any specialist psych drugs are the best for that.

If you want to do adults with autism, though, developmental peds might not be the best fit. If you're stuck on the pathway of either IM or psych, go IM. You can create a practice that matches your post that way.

The irony is that my friend is in a combined peds program (not IM/peds, but alongside it), and questions the utility of IM/peds outside inpt setting, and even then.... though they think that perhaps that would built the foundation for the sort of practice you envision ultimately. They liked my idea of IM and then look to work in a combined IM/peds clinic, which do exist, if you really want breadth of practice with adults. In that framework it likely wouldn't be difficult to try to get more autistic patients on your panel and care for them.

You're missing the point. The point is that OP needs to get exposure to these patients while he is still in training. When you're an attending is not the time to be trying to get exposure to a patient population you've never worked with before. It's going to be very tough to get dedicated (or any) exposure to adults with autism in a general IM program. Most of what you're saying is generally incorrect as well. If you happen to see a few adults with autism/DD in the general IM resident clinic, you're likely going to be referring away a lot of their management to (gasp) psychiatry. The time for detection and treatment (ABA) is over by the time you're an adult. You can coordinate/manage some medical problems they might have but by adulthood it's unlikely you're going to be able to impact the core symptoms of autism. Most of the actual medication management at that point (and TBH in childhood as well) is for essentially psychiatric disorders. Inattention, hyperactivity, aggression. You will absolutely get exposure to this in child psychiatry, whether you want to or not. Not to mention you'd get a lot of exposure in basic ADHD management in a general pediatrics residency as well (a lot of autistic patients end up on ADHD medications to help improve their focus, especially high functioning ones).

 

[Can'tdecide111]

You're missing the point. The point is that OP needs to get exposure to these patients while he is still in training. When you're an attending is not the time to be trying to get exposure to a patient population you've never worked with before. It's going to be very tough to get dedicated (or any) exposure to adults with autism in a general IM program. Most of what you're saying is generally incorrect as well. If you happen to see a few adults with autism/DD in the general IM resident clinic, you're likely going to be referring away a lot of their management to (gasp) psychiatry. The time for detection and treatment (ABA) is over by the time you're an adult. You can coordinate/manage some medical problems they might have but by adulthood it's unlikely you're going to be able to impact the core symptoms of autism. Most of the actual medication management at that point (and TBH in childhood as well) is for essentially psychiatric disorders. Inattention, hyperactivity, aggression. You will absolutely get exposure to this in child psychiatry, whether you want to or not. Not to mention you'd get a lot of exposure in basic ADHD management in a general pediatrics residency as well (a lot of autistic patients end up on ADHD medications to help improve their focus, especially high functioning ones).

Didn't @splik say that I could work with this population of patients as an internist? I'm assuming he is one of the psychiatrists in this forum.

What is the problem with getting subsequent exposure to a population of patients after you do residency? I want to fully understand that. Even if I were to not get exposure who autistic patients in residency, I still would be trained in handling medical management. And I'm certain that these patients would need medical management at some point in time.

 

[smq123]

Didn't @splik say that I could work with this population of patients as an internist? I'm assuming he is one of the psychiatrists in this forum.

What is the problem with getting subsequent exposure to a population of patients after you do residency? I want to fully understand that. Even if I were to not get exposure who autistic patients in residency, I still would be trained in handling medical management. And I'm certain that these patients would need medical management at some point in time.

You're often too busy actually seeing patients to be able to learn; if you do learn, it's usually by the seat of your pants. Essentially - if you didn't learn to do it during residency, don't count on being able to take the time to learn it as an attending.

 

[calvnandhobbs68]

Didn't @splik say that I could work with this population of patients as an internist? I'm assuming he is one of the psychiatrists in this forum.

What is the problem with getting subsequent exposure to a population of patients after you do residency? I want to fully understand that. Even if I were to not get exposure who autistic patients in residency, I still would be trained in handling medical management. And I'm certain that these patients would need medical management at some point in time.

Because people aren’t expecting you to be “practicing” on patients as an attending anymore. Unless you make it clear that you’re in a learning position, you’re the one the buck stops with.

It’s just kind of unclear what you want to do here. Do you just want to handle routine medical issues in people who also happen to be autistic? A general IM residency would be fine for that. It doesn’t take much training (or an hour long appointment) to ask how often someone poops and prescribe them some miralax (since you’re using that article as an example).

Just FYI again this shows the benefits of a peds residency over IM when dealing with autistic individuals, especially lower functioning ones. Half your patients in peds are nonverbal. Also, most people with at least some exposure to autistic patients would know that GI issues are pretty common (from texture intolerances to pica to picky eating to the point where they get vitamin deficiencies to constipation) as much as it seemed like a revelation to that doctor for some reason.

 

[Crayola227]

It probably makes no difference that my close family member that I practically raised from infancy and is now an adult, has nonverbal low-functioning autism, and that I have directed a lot of their medical care.

I agreed that peds would have been best.

Most of the management of my relative has been by - GASP - an FM doc. There have been referrals, and psych was never involved. Never a cocktail of psych meds. Believe it or not, some generalists do some behavioral management, and with some meds, too.

However, maybe you guys have lost sight of the fact that OP applied and interviewed psych and IM, and based on EVERYTHING he said he wanted to manage, beyond autism but things like HTN, DM, obesity, primary care psych (ffs, all he had to add was COPD, substance abuse, and the sniffles and I would have said he was born to do FM/IM), that IM gives him more chances to follow all his interests

I still stand by the fact that psych is not a good fit for this OP. I will admit I had not considered child psych. I've spent more than the average amount of time in both developmental peds and psych. I'm not impressed with how much autism is part of the psych experiences I've seen.

I have had autistic patients in my clinic, and I feel like as a PCP you can do a lot more for the patient in caring for the whole patient, even if that care might not be terribly specialized in nature.

I would rank the following if I had interest in autism:
developmental peds
peds
FM
IM
psych

 

[Crayola227]

You're missing the point. The point is that OP needs to get exposure to these patients while he is still in training. When you're an attending is not the time to be trying to get exposure to a patient population you've never worked with before. It's going to be very tough to get dedicated (or any) exposure to adults with autism in a general IM program. Most of what you're saying is generally incorrect as well. If you happen to see a few adults with autism/DD in the general IM resident clinic, you're likely going to be referring away a lot of their management to (gasp) psychiatry. The time for detection and treatment (ABA) is over by the time you're an adult. You can coordinate/manage some medical problems they might have but by adulthood it's unlikely you're going to be able to impact the core symptoms of autism. Most of the actual medication management at that point (and TBH in childhood as well) is for essentially psychiatric disorders. Inattention, hyperactivity, aggression. You will absolutely get exposure to this in child psychiatry, whether you want to or not. Not to mention you'd get a lot of exposure in basic ADHD management in a general pediatrics residency as well (a lot of autistic patients end up on ADHD medications to help improve their focus, especially high functioning ones).

If your point is that he do child psych so that he gets the most direct treatment of autistic issues, I don't know what to say to that. Great.

I didn't get the sense he wanted to cure autism, detect it, or treat the core symptoms. Sounded like he just wanted to work with that population. When you're a PCP, there will definitely be patients out of your purview that you never treat as a PCP, but otherwise, the beauty is that you pretty much see everyone, so if you just want a little more of this or that, you can.

I see plenty of PCPs managing ADHD meds, even behavioral issues and medication for that, and aggression in MR and autism.

And what you say about post-grad training for PCPs is also total crap. That's how I know an FM doc that does acupuncture and c-sections, another that runs a suboxone clinic and group counseling, another that is MD and does OMM, one that does hormonal transgender transitioning, and still more that do adolescent medicine. I know an IM doc that made a point of getting enough training for vasectomies, which they don't traditionally do. It's not easy but it's done. And no where did I suggest the OP do anything as a PCP that, well, a PCP can't do.

Maybe we just need to agree to disagree on what ability/benefit a PCP can have with autistic patients, and perhaps OP would be better off in child psych.

 

[mvenus929]

A few issues. There's only so many places that have the combined program. Many you needed to apply and interview and be accepted to both. Some you rank and might only get into one.

The other is that combined training programs tend to be shorter than what the separate programs combined would otherwise be - for example, neuro is 4, peds, 4, but peds neuro 5. The way that happens is unique, so there are potentially major issues with you starting on one track and then trying to switch over. That can work at some institutions and specialties but not all.

Going from one program at one institution to a combined program elsewhere, could be done, but it's not that much different than any other transfer (which are bitches to do, btw), except you might get more credit in the transfer for your rotations than you would otherwise. Kind in mind most people don't get total credit. Again, the scheduling can be a bit of nightmare.

Peds is 3 years (except maybe in Canada?). You need 2 years to be eligible for board certification if you're doing a combined program, but you lose out on basically all elective time by doing that (essentially, your elective time becomes your other specialty). I imagine Neuro, IM, etc are similar.

 

[Crayola227]

Peds is 3 years (except maybe in Canada?). You need 2 years to be eligible for board certification if you're doing a combined program, but you lose out on basically all elective time by doing that (essentially, your elective time becomes your other specialty). I imagine Neuro, IM, etc are similar.

Yeah, my friend in peds neuro was telling me that essentially they just cut out elective time in both and then smoosh them together. I think they may even cut out some outpt time that would otherwise be present in a "full" program. I'll check with my friend.

People forget doing a combined program isn't just smooshing two residencies together. And that there is some coordination for making the peds/neuro people fit into working alongside the peds people and scheduling to have the appropriate supervision (how many interns/juniors/seniors/fellows (what they call the residents who have finished either the neuro or peds portion of training, I can't recall)) and then how that fits into the neuro program as well, since all combined programs have to have the specialties in the combined program as standalone programs alongside under the same GME umbrella.

Great point you make that completion of a combined residency lets you board certified in either specialty alone. My friend doing peds neuro will only bother to be boarded in neuro and not peds despite eligibility, because they will not have gen peds in their practice, only child neuro. They could see adult neuro but won't (they would have the option of following kids into adulthood if that made sense to do).

Doing a combined program from what I'm told doesn't make sense to do just to "keep options open." Because in reality it is best used if you have a clear idea that the sorts of practice scenarios it prepares you to do is what you want.

Despite my friend doing peds/neuro and having electives taken out, they could do peds on graduation if they chose to be boarded. But they admitted to me, that they quite literally aren't as well trained as a gen peds person to do gen peds. They could and I'm sure they'd practice in a safe manner, but the transition might be more difficult. But I think the peds portion of the training is skewed to inpt (certainly, in any case since electives are cut, and a lot of electives tend to outpt or consult).

This comes up in IM, that with inpt heavy programs we seem to think since what is seen is more complex, sicker, higher acuity, that it would translate well to outpt practice. That isn't necessarily the case. Hence the primary care IM tracks we see.

This is another reason not to do a combined program if you are going to just end up in general and especially outpt practice in only one field. People do, don't get me wrong.

But having trained in only psych or IM makes you more prepared to either. If you do psych/IM, you will best trained for what the combo trains you to do, than to open a general psych outpt practice doing psychotherapy.

Pyschotherapy I keep reading on these boards, is hard, and many feel that even a gen psych program isn't all across the board great at every program and even when it is, it's hard and it's hard when you start as an attending (if your practice includes that). My understanding is that a psych/IM program tends to be light on psych outpt training, psychotherapy, and IM outpt training. Please correct me if I am wrong.

To my knowledge, most of the management of autism happens outpt.

My understanding, which comes from a psych/IM doubleboarded doc, is that it is best used inpt to manage complex patients where the cocktail of meds they are on and how that affects the cocktail they are on for their complex medical problems, is best tweaked and managed by someone trained to deal with both simultaneously, because that is what is needed. What someone in IM or psych alone might have difficulty addressing.

I also have seen this mix in academia, where the combined boarding facilitates research. I saw it in an IM outpt resident clinic at a research institution, where the psych/IM doc did med management for the most part, but again, the IM portion of their training was meant to greater inform their practice, research, and training of IM and psych residents. They were also well-poised to manage geriatic psych inpts because of the multiple c0-morbidities. Also nursing home where again, multiple morbidities and lots of meds on board.

I could be totally wrong on a number of points, I'm not in peds/neuro or IM/psych. Just reporting what I have learned from general research and close discussion with just a few people with the combined program, which there aren't a huge number of walking around.

I can't say anything about child psych as I am not a psychiatrist nor have I learned much about it or discussed at length with them about what they do.

I know slightly more about developmental peds, but not much. Except they did loads of MR and autism and other developmental conditions diagnosis. Not so much direct treatment as often they were just the head of a team that included SLP, PT/OT, etc, which they would order, and then review, then refer some more. My friend in peds neuro definitely did some rotations with them.

In his experience, most of the management was done by PCPs (peds or FM) based on quarterly or semi-annual reviews from developmental peds. If they were not on a cocktail of psych meds, basic management of basic meds was done by the developmental peds docs. The PCPs actually did initiate quite a bit, and were more turning to developmental peds for more experienced or complex input and tuning.

Most management of these patients was done by peds. However, when they would "age out" they would be transitioned to FM/IM for PCPs. Some continued to be seen by developmental peds as appropriate.

I saw plenty of MR, Down's, autistic patients, and some others, in clinic or the hospital. Those conditions definitely impacted treatment despite me being neither psych or peds. I would say that any diagnosis or complex med management was done.

 

[clausewitz2]

While motivational interviewing is certainly a legitimate therapeutic technique and thus it is not insane to say it is a kind of psychotherapy, "counseling" the way most physicians do it and the giving of direct advice =! therapy.

 

[michaelrack]

Doing a combined program from what I'm told doesn't make sense to do just to "keep options open." Because in reality it is best used if you have a clear idea that the sorts of practice scenarios it prepares you to do is what you want.

This comes up in IM, that with inpt heavy programs we seem to think since what is seen is more complex, sicker, higher acuity, that it would translate well to outpt practice. That isn't necessarily the case. Hence the primary care IM tracks we see.

This is another reason not to do a combined program if you are going to just end up in general and especially outpt practice in only one field. People do, don't get me wrong.

But having trained in only psych or IM makes you more prepared to either. If you do psych/IM, you will best trained for what the combo trains you to do, than to open a general psych outpt practice doing psychotherapy.

Pyschotherapy I keep reading on these boards, is hard, and many feel that even a gen psych program isn't all across the board great at every program and even when it is, it's hard and it's hard when you start as an attending (if your practice includes that). My understanding is that a psych/IM program tends to be light on psych outpt training, psychotherapy, and IM outpt training. Please correct me if I am wrong.


My understanding, which comes from a psych/IM doubleboarded doc, is that it is best used inpt to manage complex patients where the cocktail of meds they are on and how that affects the cocktail they are on for their complex medical problems, is best tweaked and managed by someone trained to deal with both simultaneously, because that is what is needed. What someone in IM or psych alone might have difficulty addressing.

I also have seen this mix in academia, where the combined boarding facilitates research. I saw it in an IM outpt resident clinic at a research institution, where the psych/IM doc did med management for the most part, but again, the IM portion of their training was meant to greater inform their practice, research, and training of IM and psych residents. They were also well-poised to manage geriatic psych inpts because of the multiple c0-morbidities. Also nursing home where again, multiple morbidities and lots of meds on board.

I did a combined IM/Psych residency, followed by a sleep fellowship. I am a diplomate of the ABIM in Internal Medicine and Sleep Medicine, and of the ABPN in Psychiatry and Psychosomatics (I guess they just renamed Psychosomatics consult liaison psychiatry). I am meeting MOC in all of these, and just recertified in Sleep and Psychiatry, and will be taking the Consult Psychiatry recertification exam in April.

The combined IM/Psych residency prepares one well for inpatient psychiatry, especially for geriatric patients and for those undergoing complicated substance withdrawal, including the DT's. I am not a great psychotherapist and don't currently do outpatient psychiatry, but there is no reason a combined doc couldn't do a psych med management clinic with limited therapy. I do some limited medicine on weekend moonlighting assignments (coverage of an inpatient psych ward)- including ruling out MI's, treating asthma, managing unstable DM, treating electrolyte abnormalities, etc.
At my main job, In addition to doing inpatient psychiatry, I supervise the NP who does the medical H and P's on psych patients. My IM training gives added credibility to my position as chief of the dept of psychiatry.
I disagree that the combined residency is light on IM outpt training, It is a little light on IM in general.
Combined IM/psych does help when dealing with complex drug interactions, and in the psychiatric tx of medically compromised patients.
my background also helped me get a part-time job as director of a methadone clinic, without any formal addictions training (other than as part of residency).

 

[rokshana]

I did a combined IM/Psych residency, followed by a sleep fellowship. I am a diplomate of the ABIM in Internal Medicine and Sleep Medicine, and of the ABPN in Psychiatry and Psychosomatics (I guess they just renamed Psychosomatics consult liaison psychiatry). I am meeting MOC in all of these, and just recertified in Sleep and Psychiatry, and will be taking the Consult Psychiatry recertification exam in April.

The combined IM/Psych residency prepares one well for inpatient psychiatry, especially for geriatric patients and for those undergoing complicated substance withdrawal, including the DT's. I am not a great psychotherapist and don't currently do outpatient psychiatry, but there is no reason a combined doc couldn't do a psych med management clinic with limited therapy. I do some limited medicine on weekend moonlighting assignments (coverage of an inpatient psych ward)- including ruling out MI's, treating asthma, managing unstable DM, treating electrolyte abnormalities, etc.
At my main job, In addition to doing inpatient psychiatry, I supervise the NP who does the medical H and P's on psych patients. My IM training gives added credibility to my position as chief of the dept of psychiatry.
I disagree that the combined residency is light on IM outpt training, It is a little light on IM in general.
Combined IM/psych does help when dealing with complex drug interactions, and in the psychiatric tx of medically compromised patients.
my background also helped me get a part-time job as director of a methadone clinic, without any formal addictions training (other than as part of residency).

OoooOooo...i think there needs to be a mic drop emoticon...

 

[PlutoBoy]

It's also a relative thing. IM is almost exclusively one or all of those three things.

Uh... not really. Don't get me wrong. I do see a lot of DM and HTN. And hey, this is America. Every other patient is obese. That's just the way it is.

However, saying that this is all internists see is simply not true (I wish it was because I like managing those conditions).

On a regular basis, I see skin and soft tissue infections, flu, pneumonia, your run off the mill sinusitis, otitis, UTIs, vaginosis, sexually transmitted infections. Keep in mind that this is on a regular basis. I see much more than that.

I also manage DVTs/PEs using NOACS or warfarin.

I manage migraines and other headache syndromes as well as peripheral neuropathy.

We manage a lot of MSK complaints and I mean a lot.

We manage hypogonadism, hypothyrodism, thyroid nodules, and DM on a regular basis.

A fib, HTN, CAD, hypotension and orthostasis...

COPD, asthma, allergic rhinitis.

IBS, diarrhea, constipation, c diff, diverticulitis, chronic pancreatitis, evaluation of transaminitis, fatty liver.

Anemia, polycythemia.

Erectile dysfunction, BPH, epididymitis, urinary incontinence.

Skin rashes, skin moles.

Depression, anxiety, dementia, sleep disorders.

Lung cancer screening, prostate cancer screening, colon cancer screening, cervical cancer screening, breast cancer screening, melanoma screening, AAA screening and monitoring (if positive).

I could go on. I wish you were right. My job would be much easier.

 

[Crayola227]

I disagree that the combined residency is light on IM outpt training, It is a little light on IM in general.

Thank you for sharing.

I probably didn't make it clear that IM outpt training is light in most IM-only programs, and that while IM docs end up outpt all the time, the skew and comfort level is definitely towards inpt. Hence the "great hospitalist movement" for those who only complete gen IM training, and the emergence of IM primary care tracks, that try to get more outpt training in the program.

I assumed that an IM/psych program likely wouldn't do one better on the IM outpt front. You would know better than I if there is a sacrifice of more IM outpt training in constructing the combined program.

In no way do mean to slam on IM/psych, as you describe, it makes one better trained for important niches.

And it could be my opinion, that it's best pursued for people that want that sort of career, not people that just can't choose either IM or psych, do both, then decide at the end of residency that they only want to practice only one or the other, and in an outpt setting, no less. This happens, but I personally don't think that's an awesome plan to go into a combined program. It's one thing to start such as program because you want what it gives you, and then later decide you want something else.

I just think it's silly that people do combined programs because they're not being decisive in the match. Indecision leading to a combined program, really makes me wonder how well that's going to be sort out in the combined program.

Personally I wouldn't want a combined program that trains me in peds neuro, and then decide at the end to do only peds or neuro. My friend in the combined program confided in me, that the boiled down peds portion of the training would allow him to be a gen ped outpt, but not nearly as well as his colleagues in the peds only program where they get more outpt. And that as a neuro only doc, they would just feel less comfortable with adults.

Ergo, they are trained to be peds neuro, not one or the other so well. That's what people forget. It isn't two residencies in one. It is a hybrid, it is its own thing.

Admittedly I am not as familiar with IM/psych, although I explored that option. And my info on peds/neuro is secondhand.

 

[Crayola227]

I did a combined IM/Psych residency, followed by a sleep fellowship. I am a diplomate of the ABIM in Internal Medicine and Sleep Medicine, and of the ABPN in Psychiatry and Psychosomatics (I guess they just renamed Psychosomatics consult liaison psychiatry). I am meeting MOC in all of these, and just recertified in Sleep and Psychiatry, and will be taking the Consult Psychiatry recertification exam in April.

The combined IM/Psych residency prepares one well for inpatient psychiatry, especially for geriatric patients and for those undergoing complicated substance withdrawal, including the DT's. I am not a great psychotherapist and don't currently do outpatient psychiatry, but there is no reason a combined doc couldn't do a psych med management clinic with limited therapy. I do some limited medicine on weekend moonlighting assignments (coverage of an inpatient psych ward)- including ruling out MI's, treating asthma, managing unstable DM, treating electrolyte abnormalities, etc.
At my main job, In addition to doing inpatient psychiatry, I supervise the NP who does the medical H and P's on psych patients. My IM training gives added credibility to my position as chief of the dept of psychiatry.
I disagree that the combined residency is light on IM outpt training, It is a little light on IM in general.
Combined IM/psych does help when dealing with complex drug interactions, and in the psychiatric tx of medically compromised patients.
my background also helped me get a part-time job as director of a methadone clinic, without any formal addictions training (other than as part of residency).

So question for you, was the amount of IM oupt training in your combined program more or less the same amount as an IM only program?

 

[Bernardo_11]

I've skimmed through most of this thread today and I want to give you the best answer possible with what I think may be a best fit for your future plans.

First off, I am a board certified Developmental/Behavioral pediatrician. If ADHD is our bread, Autism is our butter. In fact, a few times I have had patients with parents concerned with their child's hyperactive behaviors (i.e. thinking they have ADHD), and after getting a good history and astute observation during the visit, they actually had high functioning ASD. You cannot have a good foundation whatsoever with Autism Spectrum Disorders without a decent foundation of child social/language/communication development... and at what age those concerns first appear. You will not get that with IM training alone. You might with pediatrics depending on the quality of your Developmental/Behavioral rotation; but even for me, that was not enough. I wanted to improve my abilities in identifying and managing children ASD which is why I did the fellowship. I once diagnosed a 23 year old young man with high functioning ASD (i.e. formerly Asperger's); but I would not have been able to do this without really getting to the nitty-gritty of his social developmental progression.

What has become increasingly problematic in our field is that our patients frequently live after 18-23 years of age (go figure, right?). And so transitioning care into the adult medical field has been difficult (both for patients with ASD and other developmental disabilities). You seem to be the perfect type of person to fill in this gap, being that you desire both a good understanding of developmental disabilities and the capacity to take care of their frequent adult medical needs.

So my best advice for you is to do a Med/Peds residency. After finishing the residency try to get into a Developmental/Behavioral pediatric fellowship. Frankly, most of the DB fellowship programs would love you, since WE are all aware of this gap in medical care. I think it would fit both your desire to work with ASD adults as well as taking care of their medical needs. Feel free to PM me if you want more info.

Nardo

 

[Bernardo_11]

Also, many of us are able to do psychopharmacology with our management of ASD patients, we do though try to use behavioral strategies as a first line basis. Psychotherapy we tend to refer out, if needed. You actually manage a lot of the behavioral problems with a good understanding of Applied Behavioral Analysis... which is part of the DB peds training.

Nardo

 

[michaelrack]

So question for you, was the amount of IM oupt training in your combined program more or less the same amount as an IM only program?

I am sorry. I finished residency over 15 years ago and that was before the hospitalist movement took off. My memory is fading and I think combined residency programs have also changed, especially since psychosomatics (consult Psychiatry) became an official subspecialty. I can say that my residency left me less prepared to function in an ICU setting than a straight IM doc.... I had a weekly med/psych (predominantly med) continuity clinic through out 5 years of residency that was a good experience. I suck at procedures (both inpatient and outpatient procedures), but otherwise feel that I was well prepared to be an outpatient IM doc at the time

 

[mvenus929]

Uh... not really. Don't get me wrong. I do see a lot of DM and HTN. And hey, this is America. Every other patient is obese. That's just the way it is.

However, saying that this is all internists see is simply not true (I wish it was because I like managing those conditions).

On a regular basis, I see skin and soft tissue infections, flu, pneumonia, your run off the mill sinusitis, otitis, UTIs, vaginosis, sexually transmitted infections. Keep in mind that this is on a regular basis. I see much more than that.

I also manage DVTs/PEs using NOACS or warfarin.

I manage migraines and other headache syndromes as well as peripheral neuropathy.

We manage a lot of MSK complaints and I mean a lot.

We manage hypogonadism, hypothyrodism, thyroid nodules, and DM on a regular basis.

A fib, HTN, CAD, hypotension and orthostasis...

COPD, asthma, allergic rhinitis.

IBS, diarrhea, constipation, c diff, diverticulitis, chronic pancreatitis, evaluation of transaminitis, fatty liver.

Anemia, polycythemia.

Erectile dysfunction, BPH, epididymitis, urinary incontinence.

Skin rashes, skin moles.

Depression, anxiety, dementia, sleep disorders.

Lung cancer screening, prostate cancer screening, colon cancer screening, cervical cancer screening, breast cancer screening, melanoma screening, AAA screening and monitoring (if positive).

I could go on. I wish you were right. My job would be much easier.

Apologies. That was poor wording on my part. I did not mean to imply that IM ONLY dealt with those things (that'd be like saying peds only sees well children), but rather the vast majority of their patients have one or more of those things (DM, HTN, obesity). Whereas a very small portion of my population has them (though, sadly, the incidence is increasing). That is to say, most of my patients are healthy at baseline, while most of your patients have some sort of chronic illness.

 

[Bernardo_11]

So after reading more of this thread in further detail I am seeing a few possible options for your (the OP) at this point. Though I wish you'd have applied to med/peds residencies from the get go, I understand it's kinda moot at this point. Your possible paths seem to start at either an IM or psych residency depending on your match results.

If you rank IM programs, try ranking those with an associated med/peds program, and try to transfer into them after matching. That way it could improve your likelihood of being eligible to apply and complete a DB peds fellowship which follows our original plan.

If you rank psch programs, try to do as much IM electives as possibly allowed by your program, especially any outpatient I'M elective involved in chronic care. Then try to match into a child psych fellowship that does a lot of training for those with developmental disabilities. Probably not the best option of the two but you should still get some experience in managing those with ASD conditions.

I still think though the med/peds route is your best starting point, either from doing a 4 yr combined residency or doing what you need to meet the peds requirements to enter the DB peds fellowship.

Nardo