I'm a PGY-3 and struggling with whether or not to enter the Match for CAP fellowship. I enjoy working with children and adults equally. I find working with adults more intellectually interesting, working with kids is more emotionally fulfilling to me. I'm not going to get granular.
You can always do a mix of adult and child. You can find the right fit for you. Some of my CAP colleagues do 1 day a week of CAP, some don't see anyone younger than 12, it can be all up to you if you find or create the right job for you. In terms of therapy, I enjoy adult > parents > teens > children > couples > family.
To me the Pros/Cons and other factors are as follows:
Pro:
-CAP can make a bigger difference in the world than adult psychiatry; this is huge for me
Cons:
-Patient work-flow is more tedious and time-consuming (what with getting collateral, CPS reporting, documenting ADHD, etc.)
I don't do much CPS reporting these days. I've written one in the past year. How is documenting ADHD different than documenting any other DSM criterion disorder? I get collateral from therapists for my adult patients just as much as I do with kids unless I'm doing both which I prefer. You're right in that you do have to have more structure (half the appointment with the kid, half with the parent for example).
-Coordinating care with other providers, like therapists, is more important in CAP than in adult
Why?
-Starting a fellowship as a "newbie" and spending an extra year in training is not appealing
You're not completely a newbie though. You have a working understanding of psychiatric nosology and psychopharmacology and can apply that to a different age group with a few minor changes. But you're right for the most part. It's a fellowship because you do learn some new skillsets like working with parents, family systems, communication skills in how to interview children and parents, how to utilize play as part of the diagnostic interview or therapeutic modality, learning how to observe more clinical signs rather than subjective history, understanding of school systems, learning developmental stages and what is normal and isn't at certain age groups, and legal considerations.
-Containing work within tight, high-walled boundaries is essential to me
This will be the case with any clinical practice.
Other Factors:
-I don't believe that CAP pays more; in fact, I'm convinced that I can make at least as much in adult because the real money is in outpatient follow-ups, and these are faster in adults than in children when done properly
In my area, CMHC pays 10% more and cash outpatient pays 50% more. If you want to do 10-15 med mgmt evals and see as many patients as possible with an insurance based practice, that can make more than CAP but you'll have to think about your own sanity. Doing 4-6 visits per hour is exhausting albeit completely possible.
-Even if one can find a truly better paying CAP job, it really takes about 15 years to make up a modest improvement in pay for CAP vs. adult, given the 1 year delay in obtaining attending pay (must factor in the time value of money to calculate this correctly)
If a fellow salary is between $50-75k and a first year attending salary is $250-300k, that means it's a difference of $175-250k for fast trackers. If you get paid 10% more, then it'll take you 7-10 years to make up the difference, not 15 years. Even less if you get paid more. The variation within adult psychiatry is also huge (I've seen anywhere from $150k-400k).
-I've seen no difference in pay for inpatient CAP vs. inpatient adult for graduates from my program(s)--CAP jobs actually paid a little less
I haven't seen that much of a difference either for inpatient. Good thing I'm not doing inpatient work.
So for me, it's a feeling that CAP is more important work, but it's a harder and more time-consuming job that requires a 25% increase in time spend in training, doing difficult work, while 4th year of residency is pretty much a cakewalk in my program.
The best way to make money in CAP is to do outpatient private practice since there are very few providers, many parents will pay whatever $$$ to get the best opportunities for their kids whereas they won't pay that much for their own care, and you can screen heavily for the most motivated patients who fit your practice style best. In my area, an insurance-based practice for CAP is not the standard of care. Cash is.
Yes, it's more training. That's why people don't want to do it.
For appointments, I don't think it
has to be more work. It can be especially at the beginning when you’re getting to know the family. However, it’s more the case that it's a different type of work. You’ll have to work with multiple people (parents and kids) so there’s more dynamics to manage though. It can be more time but for me, I bill for work with kids and then work with parents if it’s a separate appointment. I’d rather spend more time working with one family system than seeing the equivalent of 2-3 different patients.
I'm not trying to convince you that CAP is better. It's not for many people. What I want to do is counter the anti-parent stigma in this forum and in psychiatry in general. You would think from this forum that all parents hate their kids, want to damage them as much as possible, and hate doctors who are trying to poison their kids with drugs. Most parents are trying to do the best they can to raise their kids and they get sensitive when they feel like they've failed when their kid needs to see a psychiatrist. I find meaning in helping parents process and work through that guilt and try to equip them with more tools to help their child feel better.
I also want to give a perspective of why I enjoy my job as a CAP since it seems like a rarity that people enjoy their work these days.