Help an MS4 pick Neurology over Psychiatry (or vice versa)

[Cinnameg]

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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. This year I went to the full week of the AAN meeting in Toronto, and loved it! 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!

 

[PhakeDoc]

I too was in a similar boat as you. I had plenty of training in the neurosciences beforehand. I loved my psych rotation and thought I could be a very effective psychiatrist, especially if I went to a place that emphasized psychoanalysis (Columbia to name just one off the top of my head). However, after seeing more and more patients in the outpt setting, I realized it was the pts who came from well-to-do homes, etc., and were educated, but had issues, wanted to talk about them, but didn't do what it took to get over them/resolve them/adapt frustrated me the most. I realized that over time this would begin to really bug me, and that I wouldn't be able to leave my work at home.

Although this is a huge simplification/generalization and I apologize for not stating this better, most of the neurology patients you see, while they might have some of the "self-affected" conditions you see in psych - depression to name one - are usually suffering from primarily physiological conditions that they can't quite readily influence. You can't exactly will yourself to have a stroke or have myasthenia gravis or Parkinsons or AD. These conditions I could go home at night and not worry about overnight. And, I could still interface with lots of the parts that overlapped with psych. Plus, you have to ask yourself what would get you out of bed in the middle of the night? For me, answering a stroke page, myasthenic crisis, acute GBS, etc., were at the top of the list.

As far as the dual-residency, I think it really depends on your area of interest, desired clinical or academic practice, and frankly how busy you want to be. You could do a cognitive neuro fellowship and end up seeing many of the same types of pts as the psych docs - AD, PD, etc., but from a different perspective.

Either way, I don't think you can go wrong. You just have to prioritize what your goals are and what'll make you [begrudgingly happy] get out of bed to answer a pager. With either, I think you can dabble in the other, though with different caveats. For my interests, I'd rather be on the neuro side and then cross over for certain things.

I chose neurology and at this point - just graduated med school - couldn't be happier.

 

[typhoonegator]

Courtesy of our favorite friend, the search function, here are some threads you might find helpful. You are not the first person to grapple with this decision on these boards.

http://forums.studentdoctor.net/showthread.php?t=730303&highlight=neurology+psychiatry

http://forums.studentdoctor.net/showthread.php?t=677880&highlight=neurology+psychiatry

http://forums.studentdoctor.net/showthread.php?t=630455&highlight=neurology+psychiatry

http://forums.studentdoctor.net/showthread.php?t=605009&highlight=neurology+psychiatry

http://forums.studentdoctor.net/showthread.php?t=587924&highlight=neurology+psychiatry

http://forums.studentdoctor.net/showthread.php?t=445134&highlight=neurology+psychiatry

http://forums.studentdoctor.net/showthread.php?t=483622&highlight=neurology+psychiatry

 

[cyneuron]

Courtesy of our favorite friend, the search function, here are some threads you might find helpful. You are not the first person to grapple with this decision on these boards.

http://forums.studentdoctor.net/showthread.php?t=730303&highlight=neurology+psychiatry

http://forums.studentdoctor.net/showthread.php?t=677880&highlight=neurology+psychiatry

http://forums.studentdoctor.net/showthread.php?t=630455&highlight=neurology+psychiatry

http://forums.studentdoctor.net/showthread.php?t=605009&highlight=neurology+psychiatry

http://forums.studentdoctor.net/showthread.php?t=587924&highlight=neurology+psychiatry

http://forums.studentdoctor.net/showthread.php?t=445134&highlight=neurology+psychiatry

http://forums.studentdoctor.net/showthread.php?t=483622&highlight=neurology+psychiatry

thank yo so much sir for such a helpful list...

reading through these posts made me even more sure of going into psychiatry...

thanks a ton again.

 

[Head]

I went into med school thinking I would go into Psychiatry. I wanted to get to know my patients on a deeper level, feeling that that would give me some fulfillment. During my third year rotations I loved both Psych and Neuro, but strangely discovered that I think much more like a Neurologist. When something is wrong, I want to figure out exactly where the problem is, and potentially come up with a way to fix it. The practice of Psychiatry is much more murky in my opinion. Drugs are administered without knowing how or why they work (Lithium for example). Psychiatry is much more focused on the changes in various neurotransmitters in the brain and how certain drugs change them. In my opinion this is still very poorly understood (recent studies suggesting that antidepressants no better than placebo). Neurology, on the other hand, is much more cut and dry. So I think the question is whether you have to have the answers (Neuro) or you are OK living in the gray area (Psych).

From a research perspective, the two fields are starting to merge on the cognitive front. You just need to decide which you would prefer to practice clinically.

 

[BrianUM]

kind of in the same boat except that i settled on Neuro

I think psych is fascinating and entertaining but the prob i had with is that a lot of times coming up with the correct diagnosis doesnt matter and they often have no idea how and why drugs work for certain diseases...and i would lose all my medicine training

i think that with neuro, you can still prescribe a lot of the psych meds and deal with many psych issues

i am thinking about doing a fellowship in Sleep followed by Behavioral since both these deal with psychiatric/neurologic interface issues...hopefully open up my own sleep clinic and make bank and then transition into academic sleep/behavioral neuro

 

[undecided3yr]

You should rotate with neuropsych and behavioral neurology before your decision and at least a subI in one if not both specialties if possible while you get your application together.

Also take into consideration which field, psych vs neuro, your prefer overall in the more generalist role and/or other subspecialties you may prefer in case you later decide on a different track than cognitive/neuropsych subspecialization during your residency.

Take into account the patient population as well. Personally, I found psych fascinating to study and discuss the pathology, but found working with the population very frustrating and unfulfilling. Retrospectively, this is most likely due to the lack of elegant diagnostics and therapeutics.

 

[Head]

i am thinking about doing a fellowship in Sleep followed by Behavioral since both these deal with psychiatric/neurologic interface issues...hopefully open up my own sleep clinic and make bank and then transition into academic sleep/behavioral neuro

Sorry this is off topic from the original post, but couldn't help it. BrianUM - I'm not trying to discourage you, but want to give you a little perspective on your sleep --> cognitive plan. You could certainly do a 1 yr sleep fellowship and then do sleep studies for a few years. This would be fairly lucrative, as you say, but totally boring. >95% of what you'd see in clinical practice would be sleep apnea. Practicing sleep in an academic setting would be much more interesting and you could focus on other things, but in the private world you'd be wading through a sea of OSA.

Going back to behavioral in an academic setting would be extremely difficult, regardless of whether you did a cognitive fellowship before or after this sleep foray. For one thing, after a couple of years you'd get used to the money in the sleep practice, making it painful to return to academics. For another, most cognitive fellowships are extremely academic. They expect 1yr clinical and at least 1 yr. of research. If you did this right after the sleep fellowship then you would have to cut your research off right as you're about to get some grants. I don't know of any cognitive academicians who aren't working off of grants, so this is a big deal.

My advice would be to pick one or the other. I'm sure this plan came to fruition due to huge med school loans. I feel your pain. Look into the NIH loan repayment program.

 

[95439]

Head hit the nail on the head: "The practice of Psychiatry is much more murky". Neurology = fact, Psychiatry = theory, in my opinion.

 

[Mattchiavelli]

Head hit the nail on the head: "The practice of Psychiatry is much more murky". Neurology = fact, Psychiatry = theory, in my opinion.

I would say it more like
Neurology = identifiable pathological lesions/processes
Psychiatry = theories and beliefs that might change with DSM V

I think one of the interesting differences is there are many processes neurologists deal with that can translate to animal models and can be more readily researched compared with psychiatrists (are you going to ask a mouse if they are experiencing command hallucinations?)

 

[igottaquestion]

Sure, with psych the science isn't quite there, but its clinical effectiveness in preventing suicide and returning people to function justifies it as a specialty enough for me. There are people that need the help of psychiatry, and dealing with the ambiguity in the specialty is part of the "cost" of doing so (but can also be a source of interesting discussion).

And DSM consists of descriptive guidelines for classification. Of course it's man-made and hence has an arbitrary element. I don't think a decent psychiatrist would deny this, nor view it as a resource for theory or even belief.

 

[MellowYellowCA]

I'd like to keep this thread alive, any more thoughts?

How much overlap is there between psych and neurology? how comfortable are neurologists in giving psych meds? which disorders are neurologists comfortable treating - autism, for example?

 

[typhoonegator]

Hmm. I wasn't aware that autism was a psychiatric disorder. Pediatric neurologists, behavioral neurologists, neurogeneticists, OT/PT/speech therapists, and psychiatrists all care for patients with this pervasive developmental disorder. There are many multidisciplinary autism/PDD programs throughout the country, but the LADDERS program at MGH is a good paradigm.

http://www.massgeneral.org/children/specialtiesandservices/ladders/

Check out any pedi behavioral neuro clinic and you'll see neurologists managing a wide variety of behavioral problems with many different medications and therapeutic interventions. Some have definable developmental disorders with grossly abnormal brains, and some don't.