I'm a third-year DO student having some trouble deciding between IM, FM, and Psych. I've always been drawn to primary care, especially for underserved populations. After having rotations in all three, I noticed that I thought about psych patients the most at the end of the day. So, I've been telling myself for the past few months that I'd apply to psychiatry and make it simple. However, I cannot convince myself to "hang up the stethoscope". I don't think it's because of the stigma of psychiatry either. I'm genuinely drawn to primary care. During my FM/outpatient IM rotations, I wanted to be the psychiatrist that patients were referred to when they failed 1 or 2 trials of SSRIs. However, during my psych rotation, I wanted to be the primary care physician that monitored their A1c or treated their rash.
I've looked into combined IM/Psych or FM/Psych, which sound wonderful to me. But I'm worried about the limited spots (only ~20 residencies between the two), and I've heard over and over again that the combined programs aren't for those who "can't hang up the stethoscope".
Questions: I want to live in a city>100k and be a 'primary care psychiatrist' with a focus on underserved populations and community medicine. Would it make sense to pursue combined training? Or should I keep soul searching until one of those 3 specialties emerges? Boards are >235/650 for step/level 1. Thanks for your help.
It sounds like Psych is in your heart. In your position, I'd apply FMP and Psych. Let your interviews/experiences on the trail dictate how you rank and ultimately where you go. If you really want primary care psych you can do it through either of those.
You can also keep medicine involved by doing FMP or Psych+CL/psychosomatic (or just practice - fellowship not necessarily required for this) or primary care fellowship.
For FMP there are as of this year 6 programs (12 spots) that you could apply to, so it wouldn't be a huge added cost. If you really want outpatient PC, then I don't think IMP is appropriate. If you do plan to apply combined, it's strongly recommended to go to the AMP conference.
Most of what you described can be accomplished through psych, and it sounds like at the very least you want psych in there somewhere.
We don't hang up our stethoscope in psych. Psych meds can induce dangerous or life threatening derm, cardiac, hepatic, renal, endo, neuro, ophtho, heme, fetal issues that we have to watch out for. Additionally psych patients come in with terrible chronic issues that may need to be addressed and many psych diagnoses are diagnoses of exclusion.
I've treated rashes, skin infections, scabies, pneumonia, UTIs, BP issues, anemia, and monitor wounds, follow labs, read EKGs and imaging etc on our inpatient psych wards. I do the same thing on my off service FM, IM rotations; the difference is I cannot adequately treat psychiatric illnesses due to limited time and/or an attending with no psych training who believes easy access to SSRIs, benzo, opioids and stimulants is the answer. Personally I do not think treating patients' primary care needs on a regular basis is a good thing for the patient. Part of every psychiatric treatment plan is having the patient take control of their medical care and establish and maintain a relationship with a PCP.
I will point out that people who do combo IM or FM/psych end up practicing psych only. Make of that what you will. Psych is much underserved if that's your thing. If you go into primary care, please strive to be different from most PCPs and decline to make a psych dx based on a 15 minute PCP appointment and refer potential psych issues out to a psychiatrist instead of throwing pills.
There's a lot in here that seems to come from some baggage not necessarily inherent to either field.
Sure, on inpatient psych you'll see lots of primary care issues, but how much you actually treat them depends heavily on you. There are plenty of psychiatrists that "hang up their stethoscope" and defer rashes, uncomplicated UTIs, anemia, EKG readings, etc. Sure, I have some attendings that are brave enough to treat that UTI with a 3-day course of Abx, but more than half (probably more than 2/3) consult medicine. It depends on what you are comfortable with. Sure, you're taught to recognize when things go wrong (and then refer), but most psychiatrists don't feel comfortable managing even basic medical needs, especially those in outpatient practice. Just like anything else they're comfortable within their scope of training. As a result it will depend heavily on where they are training and who their attendings are. There are specific exceptions obviously (eating disorders, delirium differentials, neuro, etc.), but even so the medical scope will not be much broader, outside of maybe an inpatient/academic setting.
As for combined training leading to only practicing psych, you may be working from old data, data related to other combined fields, or on anecdotes. Here's the
AMP Medical Student FAQs, it addresses this point in the second question. Here's an excerpt: "While it certainly can be true that combined physicians eventually lateralize to one field or the other, it is less likely to occur in physicians with combined training in Psychiatry. In fact, a survey done of combined grads showed that >75% practice both specialties."
One of the problems with other studies in the past, was that it only addressed things like 50/50 splits of practice types as meaning "using both" or would look primarily at a specific work setting. People will always lean one way or the other, but in reality those with combined training, especially in psych, tend to find positions where they regularly integrate both.
As for the bolded, I'm pretty sure most PCPs would love to refer every depressed or anxious or borderline patient to psych. The only problem is almost all psychiatrists in every area I've lived in book out 3-6 mos for new referrals. Thats a pretty long time to let someone sit depressed. Add to it that up to 45% of patients that complete suicide see their PCP within a month of killing themselves, and you want PCPs not to start meds and to wait to see a psychiatrist. If anything, the trend currently is to promote better training of primary care physicians to prescribe even more psych meds. They're the first ones to identify the problem afterall, even if they mix up MDD with BPD or something.
Psych. If you feel like you miss your stethoscope, go moonlight in an urgent care.
He'd be better off doing CL, then he could do psych and keep his stethoscope with him.
Similar boat to you. Choose psych but I love medicine as well. Geriatric psych and C/L can allow you to mix your psych and your med pretty well.
Truth. As always MJ.
That’s actually really surprising to me. I’ve always been drawn to psych but literally every psychiatrist I’ve ever met (and I’ve known many - probably half of the doctors I’ve known are psychiatrists) have said that the opposite. They’ve all told me that I would not be practicing anything resembling diagnostic medicine, that they use virtually nothing they learned in medical school, and that physiology and pathology are subjects virtually never touched upon... at least in clinical psych.
Unless you’re in your intern year? That would make sense- I was under the impression that psych interns actually do a lot of medicine stuff.
Psych residents in general could do a lot of medicine, save 3rd yr, depending on their residency program. Lots of psychiatrists do little more than basic physical exams (probably solid Neuro) and then refer out if medical evaluation/treatment is required.
