help...struggling with feeling ok in psychiatry

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drahc

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So I'm currently a PGY3 at a psychiatry program in the Midwest, and doing well resident-wise, along with some research projects. I always was interested in psychiatry but open to other fields, and did have a decent bit of difficulty deciding between psych and neuro (liked the concreteness and knowledge base in Neuro). In intern year, I had some indecision regarding psych while doing inpatient medicine, but it didn't bother me too much.

However, now, for some reason, it's been bothering me a good deal lately. I feel like I'm not really contributing to anything *that* useful with psychiatry and wondering if I should go into a field like EM,surgery, critical care, where I feel like I can more use my knowledge and "do something" and help save lives more directly. It bothers me that in psychiatry, we can prescribe a medication/therapy, have it not work, and that this is not a big deal - just try something else. Patients can miss appointments or not go to follow-up care, and they'd be fine - this isn't true in CC or surgery or some cases of EM. Also my hubris is acting up and I feel like I will "know" more in other fields (e.g. need to understand lab results, read an MRI, or figure out the best abx tx), rather than just having vague ideas of dx that vary provider to provider and purely medication based knowledge . Sure we need to work up other "medical" causes of psychiatric disorder, but this is the exception.

Now, logically, I know that DALY-wise, psychiatry is definitely important. And I definitely see psychiatry vastly improving the quality of life of patients. I'm definitely interested in the field and love the research. I'm also fairly sure that if I switch I will have something to complain about whatever I switch into, and that sometimes the acute cure is not the long-term "cure". But I still am bothered that psychiatry is not as critical to know things (yes you might provide suboptimal care but the immediate dangerousness of this is low, in general). It kills me when half my patients don't show up to clinic ("did they even need me at all?" or "am i even useful to them?"). And I recognize that psychiatry is really not that many hours of training compared to other specialties - which kinda points out that the knowledge base can not truly be that greatly necessary if you don't require as much training time.

I could just not complain and make money, which would be fine except I don't really feel fulfilled by this. I don't mind working hard and definitely could learn more about psychiatry - I just have a hard time seeing the utility. I'm talking with a therapist - but its not really helping. I thinking about this way too much - like 1-2 hours per day and it's in the back of my mind a lot. Not sure where I'm going with this, but did anyone have similar experiences/thoughts and what did you do to get rid of it?

tldr; feel psychiatry is not very helpful to anyone. Advice?
 
What was the deciding factor that had you choose psychiatry over neurology? I'm a few years behind but those were my top 2 and I felt I preferred the day to day aspects of psychiatry more and that I could do more for patients. I found the subject of neurology very interesting, but personally felt there was not alot I could do.
 
I'm not sure I fully agree with everyone's answers to basically get out of general psychiatry. I believe you are helping people and making a bigger difference than you realize. Patients missing appointments don't mean they don't need you -- I often find that when they're not doing well they've also recently missed an appointment with me.

Did you always feel this way? Did you like inpatient better?
 
drahc said:
So I'm currently a PGY3 at a psychiatry program in the Midwest, and doing well resident-wise, along with some research projects. I always was interested in psychiatry but open to other fields, and did have a decent bit of difficulty deciding between psych and neuro (liked the concreteness and knowledge base in Neuro). In intern year, I had some indecision regarding psych while doing inpatient medicine, but it didn't bother me too much.

However, now, for some reason, it's been bothering me a good deal lately. I feel like I'm not really contributing to anything *that* useful with psychiatry and wondering if I should go into a field like EM,surgery, critical care, where I feel like I can more use my knowledge and "do something" and help save lives more directly. It bothers me that in psychiatry, we can prescribe a medication/therapy, have it not work, and that this is not a big deal - just try something else. Patients can miss appointments or not go to follow-up care, and they'd be fine - this isn't true in CC or surgery or some cases of EM. Also my hubris is acting up and I feel like I will "know" more in other fields (e.g. need to understand lab results, read an MRI, or figure out the best abx tx), rather than just having vague ideas of dx that vary provider to provider and purely medication based knowledge . Sure we need to work up other "medical" causes of psychiatric disorder, but this is the exception.

Now, logically, I know that DALY-wise, psychiatry is definitely important. And I definitely see psychiatry vastly improving the quality of life of patients. I'm definitely interested in the field and love the research. I'm also fairly sure that if I switch I will have something to complain about whatever I switch into, and that sometimes the acute cure is not the long-term "cure". But I still am bothered that psychiatry is not as critical to know things (yes you might provide suboptimal care but the immediate dangerousness of this is low, in general). It kills me when half my patients don't show up to clinic ("did they even need me at all?" or "am i even useful to them?"). And I recognize that psychiatry is really not that many hours of training compared to other specialties - which kinda points out that the knowledge base can not truly be that greatly necessary if you don't require as much training time.

I could just not complain and make money, which would be fine except I don't really feel fulfilled by this. I don't mind working hard and definitely could learn more about psychiatry - I just have a hard time seeing the utility. I'm talking with a therapist - but its not really helping. I thinking about this way too much - like 1-2 hours per day and it's in the back of my mind a lot. Not sure where I'm going with this, but did anyone have similar experiences/thoughts and what did you do to get rid of it?

tldr; feel psychiatry is not very helpful to anyone. Advice?
Click to expand...

PGY-3 year is emotionally wearing because most of the outpatients at academic centers are treatment refractory cases, and most of the work is just helping them tread water (I’m not sure about you, but I had cases that were in our system for 20+ years, with basically the same note, occasionally some enterprising resident making a Hail Mary with schema therapy or finding an amazing research study that the patient half heartedly went along with before returning to the same routine). That being said, by the end you’ll be surprised by the profound impact you had on some of them (at least more than you imagined) when you bring up termination - I had a patient who I felt a deep sense of dread every time I saw because nothing changed in their life and I was a failure, who broke down and gave me the biggest hug when I left.

Also, keep in mind, this isn’t representative of private practice, or any practice where you get to handpick who you treat based on field of interest or individual case. I can honestly say as an attending, I just enjoy and am more motivated by my patients, and make a point of politely redirecting the ones that are transparently seeking out benzos or a disability eval, without the guilt of looking bad to a supervisor.

As for the other specialties, my sense is that even the most exciting field can get tedious over time and with mastery. My sense of ICU cases is that they’re often either futile or can be managed by algorithm/mid levels, but since we’re not familiar with it, everything seems novel and overwhelming, the epitome of what we studied for our Step exams (and a reminder of how far we’ve drifted from “pure” medicine). If I had to do an intubation or A-line now, I’d be living off the adrenaline for days, but I know for a fact that gets old by the 6th time (think about the first time you did a blood draw as a med student).

Finally, bear in mind that being a psychiatrist is like being a parent - it’s relatively straight forward to become one, but it’s rare to become a GREAT one. Anyone with a smartphone and access to WiFi can diagnose themselves with SOMETHING, then figure out the corresponding medicine. But think about the mentors you’ve had that really impressed you in ways that could never be Wikipedia’d. There are also the little moments where you ask a question that forces a patient to scratch their head and think, or when a patient that comes back and says “I’ve been thinking a lot about what you said...” which were admittedly rare for me as a resident (again, an aspect of the patient population), but is a little more common as an attending, and is probably the most meaningful outcome there is.
 
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One thing to bear in mind is that residency programs tend to attract the most intractable and trainwreck patients who are not actually representative of patients in the "real world"- they represent the tail end in terms of level of personality pathology and general complexity. it is also likely that your program just isn't that great. which means you will need to seek out your own additional training/learning or consider fellowship training in particular areas at a better institution.

I routinely look at and request all sorts of labs on patients, looking at imaging including MRI, FDG-PET, DaT etc, and teach my students and residents how do this this and what various findings mean. The number of disorders that can present with altered mental status, psychosis, personality, cognitive, emotional or other behavioral changes is in the tens of thousands. the true diagnosis is often missed.

also comparing outpatient psychiatry to critical care or EM is just ridiculous. of course outpatients, by definition, do not require the acuity of care that is life-or-death. it is not the same kind of patient population. if you were working with conditionally released patients, i can assure you it would be a big deal if one of your patients who had killed someone/committed some sort of violent crime in the throes of their psychosis did not turn up for their appt. but it is true there aren't really any emergencies in psychiatry. that said, i had the opposite experience of finding my patients needed me too much and were too dependent on me.They would attempt suicide or end up in the ER, or become hysterically blind etc if I went away on vacation. This is one reason I do not currently have any patients. I found it too stressful to be so relied upon when I am away quite a bit. Also I dont like doing prior-auths and refills and all that BS.

here are some psychiatry secrets:
  • you can't treat patients you don't like.
  • patients will vote with their feet.
  • most patients aren't ready for change and engagement.
  • it is okay to terminate with patients who you don't like or who aren't benefitting from your services, in order to care for patients who will benefit.

psychiatry as a specialty is a race to the bottom. this is unfortunate, but the reality is that there is a HUGE amount to psychiatry and it is not possible to learn it all or even most of it in residency. there are a lot of intricacies to psychopharmacology that most residents do not learn. there are a large number of neuropsychiatric syndromes, inborn errors of metabolism, and behavioral neurological syndromes that go undiagnosed and undetected because you don't learn about it. there are a large number of different psychotherapeutic modalities and it is not possible to master any of them during residency. there are a large number of psychological theories that help us formulate patients that you don't learn about that enrich your understanding of inner mental life and developing treatment plans. psychiatry has a rich social basis and the social and structural determinants of mental health are very important to patient care that is woefully neglected if not deliberately ignored in almost every residency program. there are complex ethical and philosophical aspects of psychiatry that come to the forefront in certain settings (e.g. C/L, forensics) that thinking about enriches our appreciation of the complexities of the field.

I think you have to figure out if it is really psychiatry that is not for you and to jump ship, or whether you are just not liking how it is currently practiced where you are right now. The former is more difficult to navigate. you are damaged goods as a psych resident, so it is not like it will be easy for you to switch specialties. then there is the question of how competitive you are and if you did well enough during your intern months to get strong letters of recommendation from medicine etc, and whether you would be able to go back to being an intern again, and do all the additional years of training for something like pulm/cc or whatever.

On the other hand, if you don't like how things are, you need to work to be the best that you can. You should read widely and voraciously, attend conferences and trainings to learn more about different areas, go bug the neuroradiologists to do wet reads on imaging for your patients, choose electives and areas that help you develop your knowledge and skill base more (for example neuroradiology, behavioral neurology, movement disorders, sleep medicine, neuropsychology, pain medicine, interventional psychiatry, medical genetics would all be interesting and relevant enriching experiences). You could then choose to do a fellowship in something somewhere better (e.g. C-L, pain, sleep, neuropsychiatry, headache, movement disorders, forensics etc) to further hone or develop your skills. Once you are out in practice you can create the kind of job that you like.
 
drahc said:
So I'm currently a PGY3 at a psychiatry program in the Midwest, and doing well resident-wise, along with some research projects. I always was interested in psychiatry but open to other fields, and did have a decent bit of difficulty deciding between psych and neuro (liked the concreteness and knowledge base in Neuro). In intern year, I had some indecision regarding psych while doing inpatient medicine, but it didn't bother me too much.

However, now, for some reason, it's been bothering me a good deal lately. I feel like I'm not really contributing to anything *that* useful with psychiatry and wondering if I should go into a field like EM,surgery, critical care, where I feel like I can more use my knowledge and "do something" and help save lives more directly. It bothers me that in psychiatry, we can prescribe a medication/therapy, have it not work, and that this is not a big deal - just try something else. Patients can miss appointments or not go to follow-up care, and they'd be fine - this isn't true in CC or surgery or some cases of EM. Also my hubris is acting up and I feel like I will "know" more in other fields (e.g. need to understand lab results, read an MRI, or figure out the best abx tx), rather than just having vague ideas of dx that vary provider to provider and purely medication based knowledge . Sure we need to work up other "medical" causes of psychiatric disorder, but this is the exception.

Now, logically, I know that DALY-wise, psychiatry is definitely important. And I definitely see psychiatry vastly improving the quality of life of patients. I'm definitely interested in the field and love the research. I'm also fairly sure that if I switch I will have something to complain about whatever I switch into, and that sometimes the acute cure is not the long-term "cure". But I still am bothered that psychiatry is not as critical to know things (yes you might provide suboptimal care but the immediate dangerousness of this is low, in general). It kills me when half my patients don't show up to clinic ("did they even need me at all?" or "am i even useful to them?"). And I recognize that psychiatry is really not that many hours of training compared to other specialties - which kinda points out that the knowledge base can not truly be that greatly necessary if you don't require as much training time.

I could just not complain and make money, which would be fine except I don't really feel fulfilled by this. I don't mind working hard and definitely could learn more about psychiatry - I just have a hard time seeing the utility. I'm talking with a therapist - but its not really helping. I thinking about this way too much - like 1-2 hours per day and it's in the back of my mind a lot. Not sure where I'm going with this, but did anyone have similar experiences/thoughts and what did you do to get rid of it?

tldr; feel psychiatry is not very helpful to anyone. Advice?
Click to expand...
I agree with looking into pain or sleep. I wish I had looked into sleep. I think the issues you’re having will continue to bother you and you’ll regret not making a change.
 
splik said:
here are some psychiatry secrets:
  • you can't treat patients you don't like.
  • patients will vote with their feet.
  • most patients aren't ready for change and engagement.
  • it is okay to terminate with patients who you don't like or who aren't benefitting from your services, in order to care for patients who will benefit.
Click to expand...
Hey splik I’ve seen you mention a couple of times that you no longer see patients. What are the best ways to arrange a work situation in psychiatry in which you do not see patients? Like you, I tend to be more interested in the intellectual side of psychiatry but not so much direct patient care and the chores that come with it. Thanks for any suggestions.
 
Wilf said:
Hey splik I’ve seen you mention a couple of times that you no longer see patients. What are the best ways to arrange a work situation in psychiatry in which you do not see patients? Like you, I tend to be more interested in the intellectual side of psychiatry but not so much direct patient care and the chores that come with it. Thanks for any suggestions.
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I should clarify I do see patients doing consultation-liaison psychiatry (I don't have any patients of my own), but I don't consider them my patients since I am not responsible for prescribing for them, or their overall care. I find it much nicer than having to be responsible for the overall care of patients or having outpatients. I really found outpatient psychiatry stressful.

Other than that I do expert witness work where there is explicitly no doctor-patient relationship (mainly criminal cases). I also do transplant psych evals on a contractual basis for living donors and potential recipients. Again, there is no doctor-patient relationship, I am merely assessing their suitability to be a donor, or be a transplant candidate from the psychosocial perspective. I really enjoy doing this kind of work, you get more time to do it, and I feel reasonably compensated for this kind of work. I also doing lots of teaching, writing, and some research for which I am not very well compensated if at all.

other kinds of things you can do is to be an expert reviewer for the state medical board (e.g. did this psychiatrist breach the standard of care? is their mental illness influencing their ability to practice safely?), medical review officer (reviewing urine toxicology results), bariatric surgery psych evals, fitness for duty evals (e.g. for pilots through the FAA), disability evals (through the state or insurance companies - this can be particularly lucrative if you set up your own company and have a bunch of people working for you), worker's comp evals (although often this can merge into treatment which I want to avoid, but round here pays pretty decent). You can also be a peer reviewer for insurance companies. You can do disability accommodation evals for the state bar exam. you can do psych evals for gender reassignment surgeries. you can get involved in mediation, executive coaching, or consulting. You can become a special master or monitor if you have correctional experience, etc etc.

It's not straightforward to get into this sort of thing (except the disability/worker's comp stuff). some of it is timing, luck, putting your name out there, asking around, advertising, talking to other people who are doing this kind of thing, getting on panels for things, doing the training for things like FFD evals, QME, or MRO work etc.
 
drahc said:
So I'm currently a PGY3 at a psychiatry program in the Midwest, and doing well resident-wise, along with some research projects. I always was interested in psychiatry but open to other fields, and did have a decent bit of difficulty deciding between psych and neuro (liked the concreteness and knowledge base in Neuro). In intern year, I had some indecision regarding psych while doing inpatient medicine, but it didn't bother me too much.

However, now, for some reason, it's been bothering me a good deal lately. I feel like I'm not really contributing to anything *that* useful with psychiatry and wondering if I should go into a field like EM,surgery, critical care, where I feel like I can more use my knowledge and "do something" and help save lives more directly. It bothers me that in psychiatry, we can prescribe a medication/therapy, have it not work, and that this is not a big deal - just try something else. Patients can miss appointments or not go to follow-up care, and they'd be fine - this isn't true in CC or surgery or some cases of EM. Also my hubris is acting up and I feel like I will "know" more in other fields (e.g. need to understand lab results, read an MRI, or figure out the best abx tx), rather than just having vague ideas of dx that vary provider to provider and purely medication based knowledge . Sure we need to work up other "medical" causes of psychiatric disorder, but this is the exception.

Now, logically, I know that DALY-wise, psychiatry is definitely important. And I definitely see psychiatry vastly improving the quality of life of patients. I'm definitely interested in the field and love the research. I'm also fairly sure that if I switch I will have something to complain about whatever I switch into, and that sometimes the acute cure is not the long-term "cure". But I still am bothered that psychiatry is not as critical to know things (yes you might provide suboptimal care but the immediate dangerousness of this is low, in general). It kills me when half my patients don't show up to clinic ("did they even need me at all?" or "am i even useful to them?"). And I recognize that psychiatry is really not that many hours of training compared to other specialties - which kinda points out that the knowledge base can not truly be that greatly necessary if you don't require as much training time.

I could just not complain and make money, which would be fine except I don't really feel fulfilled by this. I don't mind working hard and definitely could learn more about psychiatry - I just have a hard time seeing the utility. I'm talking with a therapist - but its not really helping. I thinking about this way too much - like 1-2 hours per day and it's in the back of my mind a lot. Not sure where I'm going with this, but did anyone have similar experiences/thoughts and what did you do to get rid of it?

tldr; feel psychiatry is not very helpful to anyone. Advice?
Click to expand...

One of my best friends is in neuro.... um, you can have a lot of palliation of symptom management, but for the most part, it's management. Like, no one gets cured. I don't really see going into neuro as making you happier given what you're not liking in psych. You could get someone's migraines or seizures from debilitating ---> zero. But often, it's more like migraines 3-4 times a week to 1 a week. Which still is disabling.

I would argue the patients that didn't show up, likely needed the most help. Seriously. Often they don't have their lives together enough to attend to their mental health care adequately, or they have other blockages. For adults not to cancel appointments on time suggests some degree of not having it all together.

No shows are a huge problem in a lot of specialties. FM gets a lot of no shows, and it's hardly because people don't need more primary care. EM is one of the worst specialties for feeling like you're making a difference. Obviously they do for the cases that actually belong in the ED, which isn't most of them.

I think you need to focus on the fact that outside a few fields, like the more surgical ones, MOST doctors have this issue. For various reasons, I think it hits you harder in psych.

Keep in mind, so much of the time doctors don't get to see the fruits of their labor. If the patient got what they needed, they don't usually come back!

In med school, inpt, it was AMAZING to see what antispychotics could do in a short time. Let's not get into how people boomerang, I know that, it happens in all field, tho.

Most people when I talk to them, of all the 20 specialists they have, frequently, their psychiatrist is their favorite.

Addressing somatic complaints does not equal better or happier. I frequently say it's frequently impossible to be happy if you're sick enough (physically), but how about being healthy and miserable?

This is just my opinion. Old guy who dies with pneumonia? Not that sad. Some wasting neuro disease that makes a younger person die of bed sores? Sad. Most of it is unavoidable. That's life. This recent article from Dr. Pamela Wible discusses a recent doctor suicide by jumping. "the broken body of a young beautiful doctor." That's frakking tragic.

Psychiatry saves so many lives and does so much good, but it is hard to quantify.

Everyone no matter their field goes through a phase of feeling like what they do doesn't matter as much as they had hoped it would as a pre-med and med student. You didn't get a cape and save the world.

I'm not a psychiatrist so I can't say if what ails you is beyond the typical or even how best to deal with this.

I think neuro might be mistake for someone that feels as you do, and I think very highly of psychiatrists.
 
I can't add much else beyond what's already mentioned. I myself chose psychiatry over IM. I will say that you can be better at your job and that will increase your own gratification. In my PGY-2 Class, I have the highest outpatient caseload whereas some of my coresidents who in my view perform their job more mechanically have far less patients and frequent no-shows.

In my experience, my patients seem to value their appointments highly, often calling multiple times and facing the long wait times and our incompetent scheduling department to make sure they can make their appointment. Our population greatly benefits from the time in our office, the challenge is making a strong connection, building trust and CARING (some of it comes with likability as Splik said), you will then have an easier time seeing the difference that you are making in your patients lives.
 
Also I'm not sure how helpful it is to suggest a pain fellowship, when was the last time a psych grad got into one?
 
Kind of along the same lines, I'm mildly apprehensive about wanting to go into psych in that I feel like it's pretty much 6 diagnosis all the same time. It's literally schizoaffective, bipolar 1, MDD w or w/o psychotic features, substance abuse, borderline personality disorder, and dementia. I'm kind of worried I'd get bored of hearing the 100th manic guy try to explain why they're where they are.

Like I feel like what drew me into psych stemmed from my love of psychology and wanting to kind of work out other people's etiologies and problems. I'm horribly interested in the theories and the range of hundreds of psychopathologies and how to really treat them. I love the neuro basis of path and behavior and I want to be really involved in neuropsych but feel like its usually more of a neuro reads it for you? Likewise I really love the new therapies and the ideas about how to treat diseases. But I feel like half of the time in the psych hospital it's pretty much medicate until they're stable enough for discharge.

Like I want to know whether I'm just in a place with limited cases or whether psych residency will really be just a bunch of medicate and wait till they aren't a danger to themselves or others and discharge for 4 years.

Like do you guys ever feel bored of the lack of variety?
 
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Just a patient, I don't know if this is useful to hear but i definitely feel that my dr has helped me and made a difference in my life. It's a cash PP so maybe not so relevant for you, but then again, as others who know better than I do mentioned above, the people you choose to see in a PP as an attending aren't necessarily the same as who you see as a resident, either outpatient or inpatient. If you are judging the future based solely on what you are seeing now, you may be mistaken in your assumptions. (Hm, I feel like my dr. may have said that to me once or twice...)
 
Drrrrrr. Celty said:
Kind of along the same lines, I'm mildly apprehensive about wanting to go into psych in that I feel like it's pretty much 6 diagnosis all the same time. It's literally schizoaffective, bipolar 1, MDD w or w/o psychotic features, substance abuse, borderline personality disorder, and dementia. I'm kind of worried I'd get bored of hearing the 100th manic guy try to explain why they're where they are.

Like I feel like what drew me into psych stemmed from my love of psychology and wanting to kind of work out other people's etiologies and problems. I'm horribly interested in the theories and the range of hundreds of psychopathologies and how to really treat them. I love the neuro basis of path and behavior and I want to be really involved in neuropsych but feel like its usually more of a neuro reads it for you? Likewise I really love the new therapies and the ideas about how to treat diseases. But I feel like half of the time in the psych hospital it's pretty much medicate until they're stable enough for discharge.

Like I want to know whether I'm just in a place with limited cases or whether psych residency will really be just a bunch of medicate and wait till they aren't a danger to themselves or others and discharge for 4 years.

Like do you guys ever feel bored of the lack of variety?
Click to expand...

The outpt world is very different from inpt, is one.

The other thing, is all specialties have their "bread and butter" dx. Pulm clinic? COPD & asthma. IM? COPDiabesity. Etc etc. But I'll tell you this, the difference in the range of presentations of BPAD vs COPD? Psychosis is one of the most fascinating presentations on the planet.

Infinite diversity in infinite combinations. What keeps medicine really interesting at the end of the day, no matter what field, for the most part, are people and their individual stories. The pathophys is nice and all that.

Depression as a medical entity isn't that much more boring or exciting than obesity. Both actually have some complex pathophys and genetics and pathways and etc etc. Practically speaking, dealing with them medically isn't mindblowing.

But the story of the depressed person, that can be really really interesting. Their life, how they got to their episode, how they get out of it (hopefully).
 
Crayola227 said:
The outpt world is very different from inpt, is one.

The other thing, is all specialties have their "bread and butter" dx. Pulm clinic? COPD & asthma. IM? COPDiabesity. Etc etc. But I'll tell you this, the difference in the range of presentations of BPAD vs COPD? Psychosis is one of the most fascinating presentations on the planet.

Infinite diversity in infinite combinations. What keeps medicine really interesting at the end of the day, no matter what field, for the most part, are people and their individual stories. The pathophys is nice and all that.

Depression as a medical entity isn't that much more boring or exciting than obesity. Both actually have some complex pathophys and genetics and pathways and etc etc. Practically speaking, dealing with them medically isn't mindblowing.

But the story of the depressed person, that can be really really interesting. Their life, how they got to their episode, how they get out of it (hopefully).
Click to expand...

And I think this is why psych is still my first choice over IM haha. I do think people's stories are amazing to listen to and I do really love working with mental illness and seeing how people got there. I think I just want to go to a center where I can really be stimulated by gadgets, new trends in research, neuro stuff, but also a good amount of psychotherapy training.

Thanks for the comment though. It helps with my angsty 3rd yearness.
 
Well psychoanalytic training offers a way to vastly broaden your view of what is going on in a psychiatric treatment and what it represents and what the impact of interventions are. It's a whole lot less concrete, but if it's depth you're after...
 
Drrrrrr. Celty said:
Kind of along the same lines, I'm mildly apprehensive about wanting to go into psych in that I feel like it's pretty much 6 diagnosis all the same time. It's literally schizoaffective, bipolar 1, MDD w or w/o psychotic features, substance abuse, borderline personality disorder, and dementia. I'm kind of worried I'd get bored of hearing the 100th manic guy try to explain why they're where they are.

Like I feel like what drew me into psych stemmed from my love of psychology and wanting to kind of work out other people's etiologies and problems. I'm horribly interested in the theories and the range of hundreds of psychopathologies and how to really treat them. I love the neuro basis of path and behavior and I want to be really involved in neuropsych but feel like its usually more of a neuro reads it for you? Likewise I really love the new therapies and the ideas about how to treat diseases. But I feel like half of the time in the psych hospital it's pretty much medicate until they're stable enough for discharge.

Like I want to know whether I'm just in a place with limited cases or whether psych residency will really be just a bunch of medicate and wait till they aren't a danger to themselves or others and discharge for 4 years.

Like do you guys ever feel bored of the lack of variety?
Click to expand...

No one suffers from anxiety in your neck of the woods?
 
resident1985 said:
I agree with looking into pain or sleep. I wish I had looked into sleep. I think the issues you’re having will continue to bother you and you’ll regret not making a change.
Click to expand...

Sleep is interesting but I thought the job opportunities for psych in sleep was not good since that field is controlled by pulmo and neuro.
 
Drrrrrr. Celty said:
Kind of along the same lines, I'm mildly apprehensive about wanting to go into psych in that I feel like it's pretty much 6 diagnosis all the same time. It's literally schizoaffective, bipolar 1, MDD w or w/o psychotic features, substance abuse, borderline personality disorder, and dementia. I'm kind of worried I'd get bored of hearing the 100th manic guy try to explain why they're where they are.

Like I feel like what drew me into psych stemmed from my love of psychology and wanting to kind of work out other people's etiologies and problems. I'm horribly interested in the theories and the range of hundreds of psychopathologies and how to really treat them. I love the neuro basis of path and behavior and I want to be really involved in neuropsych but feel like its usually more of a neuro reads it for you? Likewise I really love the new therapies and the ideas about how to treat diseases. But I feel like half of the time in the psych hospital it's pretty much medicate until they're stable enough for discharge.

Like I want to know whether I'm just in a place with limited cases or whether psych residency will really be just a bunch of medicate and wait till they aren't a danger to themselves or others and discharge for 4 years.

Like do you guys ever feel bored of the lack of variety?
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Despite the relative lack of different diagnostic categories, no two patients have the same story (folie a deux cases excepted, but that is very rare!). For me, it is that distinction that continues to make it interesting on a regular basis, but different work settings may not allow you the time to fully explore these issues with patients. Inpatient work dealing with the more severe end of the spectrum can boil down to medicating, discharging and waiting for the inevitable re-admission or next crisis. In this setting there isn't a lot of room or time for psychotherapy, but this is only a small part of psychiatry and not completely representative of what there is to offer.
 
UTsksk said:
Sleep is interesting but I thought the job opportunities for psych in sleep was not good since that field is controlled by pulmo and neuro.
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That I don’t know about. In my area I know of one psychiatrist that does sleep medicine full time.
 
TexasPhysician said:
I’d wager yearly. There aren’t many of us that apply, but PGY4 would be a great time to do pain away rotations and publish if interested.
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Whether or not people match into fellowships, if you're concerned about being intellectually challenged and making a substantial difference, I don't see why you would pick that specialty. Not that you can't have a fulfilling career as a pain specialist, but I feel that they have to regularly deal with some of the most futile and frustrating cases in the medical world, and would be more than happy to get a psychiatrist to offload some of their patients to.

Ironically, I think the most impactful subspecialty available to psychiatry is palliative medicine, at least in terms of making a substantial difference in a patient's life.
 
Salpingo said:
Whether or not people match into fellowships, if you're concerned about being intellectually challenged and making a substantial difference, I don't see why you would pick that specialty. Not that you can't have a fulfilling career as a pain specialist, but I feel that they have to regularly deal with some of the most futile and frustrating cases in the medical world, and would be more than happy to get a psychiatrist to offload some of their patients to.

Ironically, I think the most impactful subspecialty available to psychiatry is palliative medicine, at least in terms of making a substantial difference in a patient's life.
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Pain and sleep would be the last things I would want to do. Probably because they are good at appearing to help people and bad at actually helping people. That's really harsh and not true. Pain specialists who do indicated interventions and help to bridge people away from chronic opiates do good, as do sleep specialists (much more regularly) in identifying disordered sleep breathing and treating the underlying problem and help people refocus their attention on the disorder instead of the symptom. I suppose the problem from my end is the ubiquity in which people want an intervention which is likely to do them harm and the ubiquity in which that intervention is actually provided. I don't want to work harder than my patient to get them the treatment they actually need.
 
you can do a headache fellowship, sleep fellowship, pain fellowship..these will all give you opportunities to have more concrete patient management opportunities.
 
CL? (Sorry if someone else said this). CL in a large university setting could satisfy your appetite... maybe.
 
I think this is an interesting discussion and would love to follow along. Though I think dissatisfaction is rampant in many fields of medicine, psychiatry is where I expect people to have enough honesty to have the discussion.

I'm a medical student going into psychiatry. I know from my own experience across psychiatry rotations that there are good days and bad days and I'm struggling to work out what makes the good days good for my own sake. In my dual diagnosis addiction continuity clinic, I'm having a very bipolar experience depending on which resident/fellow I work with for the day. The addiction fellows who come in from other specialties (IM, FM) have shallow interviews that leave me utterly dissatisfied. The psychiatry residents on this rotation seem open to the interpersonal depth (likely due to their psychotherapy training) to the benefit of their patients. It is plain to see that, without that psychological bent, this work could be completely miserable. I want to be able to make the work what I need it to be.
 
MaximusMDPhD said:
I'm a medical student going into psychiatry. I know from my own experience across psychiatry rotations that there are good days and bad days and I'm struggling to work out what makes the good days good for my own sake. In my dual diagnosis addiction continuity clinic, I'm having a very bipolar experience depending on which resident/fellow I work with for the day. The addiction fellows who come in from other specialties (IM, FM) have shallow interviews that leave me utterly dissatisfied. The psychiatry residents on this rotation seem open to the interpersonal depth (likely due to their psychotherapy training) to the benefit of their patients. It is plain to see that, without that psychological bent, this work could be completely miserable. I want to be able to make the work what I need it to be.
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sounds borderline to me 😉
 
Full-time sleep positions are still available for psychiatrists on a limited basis, but you need to be geographically flexible
Although sleep as a side gig can increase your income, on a full time basis you can make more in psych
 
witzelsucht said:
if end-stage borderline PD and intractable atypical depression are what's bothering you, don't think EM will get you away from that lol
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Lol right and where do you think the police bring all those people found wandering the street naked or threatening to kill themselves? You will not get away from psych in the ED.

OP it's kind of interesting how you're thinking about this. For instance (as others have said), how does people not showing up to their appointments mean they're "doing okay"? Or how do you think that if what you're doing doesn't work it's "not a big deal"? I mean, I guess most specialities could say this if what they do doesn't directly kill someone the next day. A dermatologists' treatment for someone's acne or bad eczema might not work and it "won't be a big deal" in that it won't kill them in a week or a month but it still has a significant effect on their quality of life (as do most psychiatric disorders). When you go to sports medicine for your little meniscus tear and the initial physical therapy doesn't work you won't die tomorrow but will still be pissed your knees still hurting.

Also, critical care and EM don't have "follow up" appointments so I don't know why you're trying to compare what you're doing to them. Most patients actually would probably be fine if they didn't keep their surgery f/u appointments...most f/u appointments are for wound checks that would probably heal up fine anyway and suture/staple removals.
 
drahc said:
So I'm currently a PGY3 at a psychiatry program in the Midwest, and doing well resident-wise, along with some research projects. I always was interested in psychiatry but open to other fields, and did have a decent bit of difficulty deciding between psych and neuro (liked the concreteness and knowledge base in Neuro). In intern year, I had some indecision regarding psych while doing inpatient medicine, but it didn't bother me too much.

However, now, for some reason, it's been bothering me a good deal lately. I feel like I'm not really contributing to anything *that* useful with psychiatry and wondering if I should go into a field like EM,surgery, critical care, where I feel like I can more use my knowledge and "do something" and help save lives more directly. It bothers me that in psychiatry, we can prescribe a medication/therapy, have it not work, and that this is not a big deal - just try something else. Patients can miss appointments or not go to follow-up care, and they'd be fine - this isn't true in CC or surgery or some cases of EM. Also my hubris is acting up and I feel like I will "know" more in other fields (e.g. need to understand lab results, read an MRI, or figure out the best abx tx), rather than just having vague ideas of dx that vary provider to provider and purely medication based knowledge . Sure we need to work up other "medical" causes of psychiatric disorder, but this is the exception.

Now, logically, I know that DALY-wise, psychiatry is definitely important. And I definitely see psychiatry vastly improving the quality of life of patients. I'm definitely interested in the field and love the research. I'm also fairly sure that if I switch I will have something to complain about whatever I switch into, and that sometimes the acute cure is not the long-term "cure". But I still am bothered that psychiatry is not as critical to know things (yes you might provide suboptimal care but the immediate dangerousness of this is low, in general). It kills me when half my patients don't show up to clinic ("did they even need me at all?" or "am i even useful to them?"). And I recognize that psychiatry is really not that many hours of training compared to other specialties - which kinda points out that the knowledge base can not truly be that greatly necessary if you don't require as much training time.

I could just not complain and make money, which would be fine except I don't really feel fulfilled by this. I don't mind working hard and definitely could learn more about psychiatry - I just have a hard time seeing the utility. I'm talking with a therapist - but its not really helping. I thinking about this way too much - like 1-2 hours per day and it's in the back of my mind a lot. Not sure where I'm going with this, but did anyone have similar experiences/thoughts and what did you do to get rid of it?

tldr; feel psychiatry is not very helpful to anyone. Advice?
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What did you end up doing ? I am almost in the same situation. I love psych but I am afraid of missing medicine.
 
I don't like psychiatry either. Different reasons. I like it a little but I find it monotonous I miss the rest of medicine, so I'm applying for FP next year. Figure out what it is you want and go for it.
 
What do you love about being an emergency medicine physician?

Check out this thread. It's got a couple posts by Venko who left psychiatry to become an EM doc. I thought it was excellent. I wish I could handle the circadian disruption to be an EM doc, but alas sleep schedule shifts turns me into a moody zombie. Luckily I have a feeling I'll really enjoy psychiatry.
 
Does OP have a significant other/kids?

I could see psych (and many other specialties) a little lacking if you were trying to find all your fulfillment only from your job. But making 200k+ working 35hrs a week helping people who really need it and then getting home before 5 to spend time with your family is about as good as anyone could expect from life in my opinion.
 
Armadillos said:
Does OP have a significant other/kids?

I could see psych (and many other specialties) a little lacking if you were trying to find all your fulfillment only from your job. But making 200k+ working 35hrs a week helping people who really need it and then getting home before 5 to spend time with your family is about as good as anyone could expect from life in my opinion.
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It could always be better. I mean...Willie could stop by and start taking requests.
 
Armadillos said:
Does OP have a significant other/kids?

I could see psych (and many other specialties) a little lacking if you were trying to find all your fulfillment only from your job. But making 200k+ working 35hrs a week helping people who really need it and then getting home before 5 to spend time with your family is about as good as anyone could expect from life in my opinion.
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Well said
 
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Drrrrrr. Celty said:
So you finished Psych residency and now are applying for FM? What spurred this on specifically? Why FM v.s IM?
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FP is all ages. I knew year one of psych that I wanted FP and should have left then. I am applying next year.
 
Drrrrrr. Celty said:
Kind of along the same lines, I'm mildly apprehensive about wanting to go into psych in that I feel like it's pretty much 6 diagnosis all the same time. It's literally schizoaffective, bipolar 1, MDD w or w/o psychotic features, substance abuse, borderline personality disorder, and dementia.
Click to expand...

Friendly tip: learn more about the field before interviews. The above is representative of someone who doesn't quite understand all psych encompasses.
 
Mass Effect said:
Friendly tip: learn more about the field before interviews. The above is representative of someone who doesn't quite understand all psych encompasses.
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Admittedly, you referenced a post from like 10 months ago. I now know more and enjoy a lot more of the world beyond acute crisis psychistry.

Sent from my SM-G950U using SDN mobile
 
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