Having second thoughts about continuing Child Fellowship

[winniehoney]

Hi everyone,

Been a lurker for a while, but I thought I would post as I am going through a struggle right now. I am currently doing my first year of Child Fellowship (I fast tracked). I initially thought I enjoyed working with children more than adults, however, the paperwork and the time involved in speaking to both parents as well as kids is getting to be exhausting. Though I love working with children, working with the parents is another beast. I feel like my fellowship is a bit busy at times as well.

I'm not in a good place financially either and I was hoping that the fellowship would make me more marketable if I were to go back to practice at home (San Diego). However, I've learned that it would not make any impact in my job prospects as there is a greater demand for Adult Psychiatrists. I don't feel like I'm going to be in a better position financially if I do this fellowship as I am also losing out on a lot of moonlighting opportunities and time to study for Boards. But more importantly, a lot of graduates from my fellowship end up working with adults (in prison or VA settings), which is kind of unsettling for me.

My question is, if I leave in June and I decide somewhere along the line that I want to go back to child fellowship, would I be able to get credit for the year of CAF1 and only have to do one more year to get credit?

There are a lot of personal factors that are making me feel this way (one of them is that I've been away from my parents for a long time since beginning of residency and they are not doing well with their health) and of course the demands of my fellowship don't help either. I feel like I'm always swamped with work, with very little supervision. Maybe my residency was a very hand-holdy type program, but I feel like I don't have any support or any mentorship during my fellowship months so far. Also, the didactics are terrible, it's essentially all on us to learn anything. In my residency, the attendings actually taught during didactics.

Can anyone advise me on what I should do? I'm seriously feeling like this is not for me.

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[Sushirolls]

If you jump ship, you need to make sure that you have the appropriate credit to be considered complete from the general adult residency perspective and can sit for the ABPN board. If you can't confirm or meet that threshold, probably looking at continuing the grind.

Numerous insurance companies have contingencies in their contract requiring board certification in either 3-5 years post residency. Same thing for privileges at hospitals. So if any of your prospective jobs hint at that, you'll need to satisfy that requirement.

Another thing to consider is every single hospital, medicare, medicaid, private insurance application will have residency / fellowship training questions and follow ups of "did you complete your education here?" and when check no, you then have to explain it. These forms are a pain, and even though central database repositories like CAQH exist, they still request the same stuff separately and redundantly. The pain of med school applications, residency applications, fellowship applications, state medical license applications - never ends. Completing the fellowship as painful as that sounds may have the benefit of less future headaches.

Its sad that academic elites have shaped things to emphasize board certification, and the insurance / private sector ran with it.

I feel your pain of C&A. Blessed are those who like that field.

 

[winniehoney]

If you jump ship, you need to make sure that you have the appropriate credit to be considered complete from the general adult residency perspective and can sit for the ABPN board. If you can't confirm or meet that threshold, probably looking at continuing the grind.

Numerous insurance companies have contingencies in their contract requiring board certification in either 3-5 years post residency. Same thing for privileges at hospitals. So if any of your prospective jobs hint at that, you'll need to satisfy that requirement.

Another thing to consider is every single hospital, medicare, medicaid, private insurance application will have residency / fellowship training questions and follow ups of "did you complete your education here?" and when check no, you then have to explain it. These forms are a pain, and even though central database repositories like CAQH exist, they still request the same stuff separately and redundantly. The pain of med school applications, residency applications, fellowship applications, state medical license applications - never ends. Completing the fellowship as painful as that sounds may have the benefit of less future headaches.

Its sad that academic elites have shaped things to emphasize board certification, and the insurance / private sector ran with it.

I feel your pain of C&A. Blessed are those who like that field.

Thanks for the response. I don't know if it's helpful, but I'm doing my fellowship in the same place I did my residency. I think I should be eligible to sit for the ABPN exam soon.

 

[alina_s]

I feel your pain about fellowship but my advice would be to tough it out. I don't have any experience with trying to go back to fellowship but I suspect that leaving fellowship early would close that door for good- leaving would likely burn bridges, there aren't a lot of 2nd year openings, and from the other side, the idea of going back into training sounds awful for so many reasons, not least of which is the pay cut. Since you are doing the five year pathway, there could be issues with counting your fellowship year towards the general residency, and you have probably missed out on a year of outpatient rotations, even if you've met minimum requirement. Some of that may be up to the discretion of your training director- I've heard of people in the 5 year track not getting credit for completing general residency. Even if you don't like working with kids as much as you thought, having the training will open some door for you. Some organizations don't see enough kids to hire anyone full-time but are excited about having someone who could see the few kids/teenagers who come in. Especially if you have any interest in rural/underserved populations, it can be a great advantage to have training to work with all ages.

PM me if you like.

 

[winniehoney]

I feel your pain about fellowship but my advice would be to tough it out. I don't have any experience with trying to go back to fellowship but I suspect that leaving fellowship early would close that door for good- leaving would likely burn bridges, there aren't a lot of 2nd year openings, and from the other side, the idea of going back into training sounds awful for so many reasons, not least of which is the pay cut. Since you are doing the five year pathway, there could be issues with counting your fellowship year towards the general residency, and you have probably missed out on a year of outpatient rotations, even if you've met minimum requirement. Some of that may be up to the discretion of your training director- I've heard of people in the 5 year track not getting credit for completing general residency. Even if you don't like working with kids as much as you thought, having the training will open some door for you. Some organizations don't see enough kids to hire anyone full-time but are excited about having someone who could see the few kids/teenagers who come in. Especially if you have any interest in rural/underserved populations, it can be a great advantage to have training to work with all ages.

PM me if you like.

Thanks. When you mentioned people in the 5 year track not getting credit, is it even when they completed the fellowship, they still don't credit or is it if they leave before completion of fellowship like I am considering?

 

[TexasPhysician]

If you may want to do child, I’d stick it out. Restarting pgy5 later would be a hassle and you would need your PD’s blessing. Child fellowship certainly makes you more marketable even if you mostly see adults. I’ve found private practice to be much more rewarding than in training. There is huge demand in child.

 

[Shufflin]

These children are products of, not always but most often, terrible vs negligent vs exceedingly overprotective vs abusive fill-in-the-blank parents. You will have to deal with them, and their unwillingness to face their own reflections. Would you want to be an orthopedic surgeon always treating broken arms and each patient is brought in by the thug who breaks them?

 

[michaelrack]

These children are products of, not always but most often, terrible vs negligent vs exceedingly overprotective vs abusive fill-in-the-blank parents. You will have to deal with them, and their unwillingness to face their own reflections. Would you want to be an orthopedic surgeon always treating broken arms and each patient is brought in by the thug who breaks them?

Some orthopedists would be ok with that, I am guessing

 

[calvnandhobbs68]

These children are products of, not always but most often, terrible vs negligent vs exceedingly overprotective vs abusive fill-in-the-blank parents. You will have to deal with them, and their unwillingness to face their own reflections. Would you want to be an orthopedic surgeon always treating broken arms and each patient is brought in by the thug who breaks them?

And some of us think, do we just let those people go around with busted up arms or do we try to do something to treat them? They're going to have broken arms either way so might as well do something rather than pretend like all these patients getting their arms broken don't exist.

No one is forcing you to like any specific field though, so whatever floats your boat.

 

[clausewitz2]

Some orthopedists would be ok with that, I am guessing

Yeah I mean otherwise healthy people who are also repeat customers sounds ideal for the business model.

 

[Shufflin]

And some of us think, do we just let those people go around with busted up arms or do we try to do something to treat them? They're going to have broken arms either way so might as well do something rather than pretend like all these patients getting their arms broken don't exist.

No one is forcing you to like any specific field though, so whatever floats your boat.

Being the one who can bring an ear of empathy and willingness to listen and work through some of their troubles, with some extra weaponry aka meds, is what is rewarding about C&A psychiatry. I wouldn't handle C&A as a sole practitioner. On an inpatient unit I have an army of staff to help out, and I think this is a wise way to go if C&A overwhelms you.

 

[nexus73]

I'm surprised, and wonder about your source, on child psychiatrists being in less demand than adult psychiatrists. I say stick out the fellowship. At the end, worst case scenario is you're double boarded and only see adults. Best case, you end up finding a niche in child psych you love. Or happy medium, you see mostly adults, but have a side private practice or other part time gig seeing kids.

 

[winniehoney]

I'm surprised, and wonder about your source, on child psychiatrists being in less demand than adult psychiatrists. I say stick out the fellowship. At the end, worst case scenario is you're double boarded and only see adults. Best case, you end up finding a niche in child psych you love. Or happy medium, you see mostly adults, but have a side private practice or other part time gig seeing kids.

Nearly all of the alumni from my C&A program are not seeing children in their daily line of work. Most of them are working in the Jail System or the VA. When I asked them why, they have said that it just doesn't pay well to see kids.

I'm really getting sick of working with some of these parents. I'm not getting adequate supervision in my program as to how to offer them effective strategies. The only thing that has been conveyed to me is that I need to put every kid on a stimulant, hurry up with my notes and not think outside the box at all. I feel like my attendings are possibly very overwhelmed and we have a significant lack of attendings in my program, so I don't entirely blame them. There are enough adult attendings, but for some reason they are having a hard time getting any dedicated child attendings.

 

[TexasPhysician]

Nearly all of the alumni from my C&A program are not seeing children in their daily line of work. Most of them are working in the Jail System or the VA. When I asked them why, they have said that it just doesn't pay well to see adults.

There are enough adult attendings, but for some reason they are having a hard time getting any dedicated child attendings.

Try looking at it another way. They may be struggling to recruit child attendings because they are getting great offers elsewhere. Academics pays very low. Additionally the VA does not pay particularly well for the volume and demands. Anyone taking a job with the VA is more concerned about job stability and benefits, not maximizing salary.

Some jails pay very poorly. Some pay well as few people want to work in jails. Safety is always an issue, and malingering is common.

If you want a generic employed job like with the VA, I agree that you are wasting your time from a salary perspective by doing child. If you want to maximize your salary/lifestyle in a private setting, child is a big positive.

 

[ksharp33]

Nearly all of the alumni from my C&A program are not seeing children in their daily line of work. Most of them are working in the Jail System or the VA. When I asked them why, they have said that it just doesn't pay well to see adults.

Did you mean it doesn't pay well to see children?

 

[winniehoney]

Did you mean it doesn't pay well to see children?

Yes, thats what i meant. Thanks

 

[winniehoney]

Try looking at it another way. They may be struggling to recruit child attendings because they are getting great offers elsewhere. Academics pays very low. Additionally the VA does not pay particularly well for the volume and demands. Anyone taking a job with the VA is more concerned about job stability and benefits, not maximizing salary.

Some jails pay very poorly. Some pay well as few people want to work in jails. Safety is always an issue, and malingering is common.

If you want a generic employed job like with the VA, I agree that you are wasting your time from a salary perspective by doing child. If you want to maximize your salary/lifestyle in a private setting, child is a big positive.

I see what you mean. I'm hoping that this additional training in child might help me with my adult patients too.

 

[FN9]

Here is my 2 cents worth

I was exactly where you are during my first year of CAP fellowship, then my colleagues sat me down and talked some sense into me , usually your second year is easier, you see the light at the end of the tunnel, you are applying for jobs. If you can, look into transferring as a CAP 2 near your parents, that way you get to keep an eye on them, moonlight locally which will help when you are looking for jobs the following year.


You will find more jobs in adult vs child that pay better esp in correction/VA but if/when you decide to start your practice, Child will give you an option to do cash only and fill up much faster vs adult psychiatry and command more per visit.

 

[Shufflin]

Nearly all of the alumni from my C&A program are not seeing children in their daily line of work. Most of them are working in the Jail System or the VA. When I asked them why, they have said that it just doesn't pay well to see kids.

I'm really getting sick of working with some of these parents. I'm not getting adequate supervision in my program as to how to offer them effective strategies. The only thing that has been conveyed to me is that I need to put every kid on a stimulant, hurry up with my notes and not think outside the box at all. I feel like my attendings are possibly very overwhelmed and we have a significant lack of attendings in my program, so I don't entirely blame them. There are enough adult attendings, but for some reason they are having a hard time getting any dedicated child attendings.

Now imagine you're in PP charging a hefty cash rate, would you feel somehow more pressured or incentivized to put the kid on something? your own ethical elbow room gets more cramped.

 

[Shufflin]

The fundamental challenge with child psychiatry is that the mouth and body are separated. The body belongs to the patient. But the mouth belongs to the guardian. And these two are usually out of sync, at odds, not only with each other but with you the psychiatrist. A triangle of dyads in tension. A three-way tug-o-war, and the art is knowing where to tug, how hard, and when so as to leave the child the winner without pulling over the guardian. Enjoy.

 

[Fabio001]

Winnie, have you been able to talk to you co-fellows/residents about your supervision and mentorship concerns? I'm lucky in that I'm at a C&A program (PGY-4) where our program director is super-responsive, but for me too, the increase in work-time and challenge has been unexpectedly difficult. I think a huge part of what makes the 1st year of fellowship difficult for me is that I'm suddenly back to feeling like an intern. Also fortunately, I'm able to get lots of validation from my peer colleagues, who are experiencing a lot of the same things as me.

What keeps me going? I have a huge amount of confidence that the training I get in child fellowship will help me be a better psychiatrist to the population I envision myself primarily seeing: young adults. I also like working with adolescents and feel passionate about day treatment as a modality and like having those types of resources for my patients. Additionally, that cash only superbill private practice light-at-the-end-of-the-tunnel is a reality.

In response to Shufflin's several comments highlighting the difficulties of a c&a practice, I'll just say that I've learned and been thinking a lot over the past couple months about how I could adjust my billing structure for an initial eval to include reaching out to school counselors/psychologists. I've become convinced that these folks can often be huge allies and sources of information, even when the parents don't seem to be highly reliable and motivated. The demand in c&a virtually everywhere is high enough that you can practice the way you want and fill up your patient load.

 

[winniehoney]

Winnie, have you been able to talk to you co-fellows/residents about your supervision and mentorship concerns? I'm lucky in that I'm at a C&A program (PGY-4) where our program director is super-responsive, but for me too, the increase in work-time and challenge has been unexpectedly difficult. I think a huge part of what makes the 1st year of fellowship difficult for me is that I'm suddenly back to feeling like an intern. Also fortunately, I'm able to get lots of validation from my peer colleagues, who are experiencing a lot of the same things as me.

What keeps me going? I have a huge amount of confidence that the training I get in child fellowship will help me be a better psychiatrist to the population I envision myself primarily seeing: young adults. I also like working with adolescents and feel passionate about day treatment as a modality and like having those types of resources for my patients. Additionally, that cash only superbill private practice light-at-the-end-of-the-tunnel is a reality.

In response to Shufflin's several comments highlighting the difficulties of a c&a practice, I'll just say that I've learned and been thinking a lot over the past couple months about how I could adjust my billing structure for an initial eval to include reaching out to school counselors/psychologists. I've become convinced that these folks can often be huge allies and sources of information, even when the parents don't seem to be highly reliable and motivated. The demand in c&a virtually everywhere is high enough that you can practice the way you want and fill up your patient load.

I have brought my concerns up with the chief's and the attendings say they will make changes, but it never happens. We have very limited attendings by the way. We are a smaller community program so it's not like we have a lot of faculty strength to work with.