How difficult/stressful is IM residency compared to Psych?

[Old Style Nanny]

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How difficult or stressful is IM residency compared to Psychiatry residency? With regards to:

1. Workload (hours/week and amount of work/day)
2. More difficult attendings to deal with
3. Amount of learning required

And once you finish residency, how do the two compare? (Assuming no fellowship and no private practice.) With regards to:

1. Workload and stress because of responsibility
2. Money earned per hour of work
3. Average work hours per week
4. Job satisfaction and overall happiness

Valuable inputs are much appreciated. Not intending to create a war of any sort. Just looking for some unbiased information.

 

[Instatewaiter]

How difficult or stressful is IM residency compared to Psychiatry residency? With regards to:

1. Workload (hours/week and amount of work/day)
2. More difficult attendings
3. Amount of learning required

And once you finish residency, how do the two compare? (Assuming no fellowship and no private practice.) With regards to:

1. Workload and stress because of responsibility
2. Money earned per hour of work
3. Average work hours per week
4. Job satisfaction

Valuable inputs are much appreciated. Not intending to create a war of any sort. Just looking for some unbiased information.

1) It depends on what program you go to but generally IM has longer hours than psych and most of it is in patient while much of psych is outpatient. Depending on the program expect to work 70-80 hours in a medicine program.

2) The attendings are going to be program specific. Where I am, the attendings are not "difficult" at all but it is clear the bar is set high.

3) I dont really know what you are driving in terms of learning required. I think that medicine probably has a larger breadth of knowledge you need to know but you could slug your way through either type of program. At the residency level the amt of learning is really driven by you. Both IM and psych probably have daily conferences/resident report that are required.

- stress is probably similar.
- IM, especially the subspecialties have the ability to make a lot of money per hour
- Hours per week... I have no idea. I bet they're close and related to how recently you finished residency. Ask Dr Google.

 

[Old Style Nanny]

Let me be honest here. I am lazy. I like IM a lot but I don't know if I can get through the apparently grueling three years of IM residency with almost no social life (correct me if I am wrong). I assumed Psych residencies would be a lot less stressful. Are they not?

Also, once I am done with the IM residency (I don't even think I will be ready to spend three more years doing a fellowship and lose the most important positive in choosing IM - the variety of cases and the challenge of diagnosing), what are my options if I want to balance maximum free time and good pay? I need the free time to do the other things I love - photography and racing. I am already a pro in one and a semi-pro in the other.

The free time was actually my main criteria for thinking about psychiatry - I could join someone's private practice and at $150 an hour for just 30 hours a week average, I could make more than enough while at the same time enjoying the perk of diagnosing, treating and caring for the patients.

Don't hate me for speaking my mind. If you do, I hope you'd keep it to yourself. If you can give me some practical advice, I would be very grateful. Thank you.

 

[infarct]

Let me be honest here. I am lazy. I like IM a lot but I don't know if I can get through the apparently grueling three years of IM residency with almost no social life (correct me if I am wrong). I assumed Psych residencies would be a lot less stressful. Are they not?

Also, once I am done with the IM residency (I don't even think I will be ready to spend three more years doing a fellowship and lose the most important positive in choosing IM - the variety of cases and the challenge of diagnosing), what are my options if I want to balance maximum free time and good pay? I need the free time to do the other things I love - photography and racing. I am already a pro in one and a semi-pro in the other.

The free time was actually my main criteria for thinking about psychiatry - I could join someone's private practice and at $150 an hour for just 30 hours a week average, I could make more than enough while at the same time enjoying the perk of diagnosing, treating and caring for the patients.

Don't hate me for speaking my mind. If you do, I hope you'd keep it to yourself. If you can give me some practical advice, I would be very grateful. Thank you.

dude...it's cool. if you're lazy, you're lazy if you're not you're not. you dont have to apologize to anybody. unfortunately i know nothing about psychiatry. i do wish you luck w/ your pursuits though. it's refreshing to hear something a little less lame!

 

[indiamacbean]

I'm sure that there is variation residency program to residency program but I would say psychiatry might be better for you in the long run. Seems more chill, easier lifestyle and the pay will likely be better in the part time model you are thinking about. There is also a decent living to be made in part time hospital medicine which doesn't require a fellowship but can be difficult to find good part time jobs. I will say though that residency is a time limited period and you shouldn't base your decision to strongly on that experience but think more about what you would enjoy doing for the rest of your professional life.

 

[staup]

imo, choose psych if you want to be lazy, it's definitely easier and less stressful. and it's ok to be lazy, as long as you're honest about it.

i'm not so sure you can easily get $150 an hour working 30 hours a week as a psychiatrist, but maybe you can.

the problem with psych though is, unless you are doing academics with research and teaching, you have to accept that your life is about prescribing meds to crazy people that may work or may just give them side effects. if you're lucky, perhaps you could get into or create a practice doing counseling for the rich, otherwise your entire practice will be 15 to 20 minute visits about meds only.

imo, the joy of diagnosis in im >>>>>>> psych. the amount you have to think in im, especially hospital medicine, is far greater than psych. but that is one factor why psych is less stressful, too.

sorry for that review of psych, but that's how i see it.

 

[infarct]

the problem with psych though is, unless you are doing academics with research and teaching, you have to accept that your life is about prescribing meds to crazy people that may work or may just give them side effects. if you're lucky, perhaps you could get into or create a practice doing counseling for the rich, otherwise your entire practice will be 15 to 20 minute visits about meds only.

that's the same as internal medicine. as someone going into internal medicine that's something we have to accept as well! not everyone does procedures.

 

[staup]

that's the same as internal medicine. as someone going into internal medicine that's something we have to accept as well! not everyone does procedures.

fortunately for me (as an IM attending), you're entirely incorrect. Hospitalists do procedures all the time, but really that's what I'm not writing about.

An IM doc thinks about the total care of the patient. Yes, we prescribe meds, but we decide whether this person needs an Xray of some sort, needs to see a specialist, has to get x or y test, etc. If you're a good IM attending, there really are tons of decisions to be made about every patient and you direct the care. It's daunting if you really think about it.

The average psychiatrist these days (especially in the outpatient private practice world not catering to the rich) literally spends almost all of their day prescribing meds and asking about side effects.

I realize I am biased here, but if you ask me which specialty requires more complex and important decisions day to day, it's not even close.

 

[VJWDO]

Comparing psych and IM at my home program psych is like an IM residents vacation. Their hardest months are the ones when they are on our services. If you are lazy then go psych cuz it will not cut it for IM.

 

[Old Style Nanny]

An IM doc thinks about the total care of the patient. Yes, we prescribe meds, but we decide whether this person needs an Xray of some sort, needs to see a specialist, has to get x or y test, etc. If you're a good IM attending, there really are tons of decisions to be made about every patient and you direct the care. It's daunting if you really think about it.

This is the one thing that keeps me on the fence. I don't know how much I will miss and regret this aspect if I choose psychiatry.

Comparing psych and IM at my home program psych is like an IM residents vacation. Their hardest months are the ones when they are on our services. If you are lazy then go psych cuz it will not cut it for IM.

Exactly what I was thinking. Thanks.

 

[staup]

This is the one thing that keeps me on the fence. I don't know how much I will miss and regret this aspect if I choose psychiatry.



Exactly what I was thinking. Thanks.

do psych. if you enjoy it and think your life will be less stressful if you do it, i think that's reason enough.

 

[PsychMedStudent]

I would do what you enjoy. If you don't truly enjoy doing psychiatry, then it will be stressful for you. If you dislike your work, you're not going to be satisfied or happy. In a way, staup's comments really show that because the way he thinks of IM as being complex and important is similar to the way I think of psychiatry. We're just different people with different interests and different ways of thinking about patients. You need to figure out what kind of person you are and what you would truly enjoy doing.

 

[staup]

I would do what you enjoy. If you don't truly enjoy doing psychiatry, then it will be stressful for you. If you dislike your work, you're not going to be satisfied or happy. In a way, staup's comments really show that because the way he thinks of IM as being complex and important is similar to the way I think of psychiatry. We're just different people with different interests and different ways of thinking about patients. You need to figure out what kind of person you are and what you would truly enjoy doing.

Definitely agree, but sometimes it's hard to know what a person enjoys, especially at the medical school stage.

I would say one thing though, and please realize I am biased here. I don't think my thought that IM is more complex and stressful is an opinion, I think it's a fact. Many times we have to deal a lot of the same stuff a psychiatrist deals with, PLUS all the medical management.

There are also different types of stress. There is a the stress of "I have a lot do and a lot of patients to see" and there is the stress of urgent/emergent patient care. It's just something different when you are trying to emergently control someone's hypotensive afib, shortness of breath, or make decisions about whether they are stable for surgery. Specialties without that stress many times really don't understand it. IM has that, especially inpatient.

And don't get me wrong, there are times psychiatry makes vital decisions about capacity, suicidal ideation, and what medication to use to control someone. But they usually don't have the stress about urgent patient care.

Finally, I think Psych is a great specialty, I almost chose it myself, I just think IM can be more stressful and complex.

 

[haitham]

for me IM is better ....I do not want to deal with patients who believe they are the president of USA or that FBI is monitoring them!

no offense intended but IM is better as I hate psych

 

[PsychMedStudent]

Definitely agree, but sometimes it's hard to know what a person enjoys, especially at the medical school stage.

I would say one thing though, and please realize I am biased here. I don't think my thought that IM is more complex and stressful is an opinion, I think it's a fact. Many times we have to deal a lot of the same stuff a psychiatrist deals with, PLUS all the medical management.

There are also different types of stress. There is a the stress of "I have a lot do and a lot of patients to see" and there is the stress of urgent/emergent patient care. It's just something different when you are trying to emergently control someone's hypotensive afib, shortness of breath, or make decisions about whether they are stable for surgery. Specialties without that stress many times really don't understand it. IM has that, especially inpatient.

And don't get me wrong, there are times psychiatry makes vital decisions about capacity, suicidal ideation, and what medication to use to control someone. But they usually don't have the stress about urgent patient care.

Finally, I think Psych is a great specialty, I almost chose it myself, I just think IM can be more stressful and complex.

Oh I definitely agree with you on all that. There is a big difference in stress level when it comes to urgent patient care. Psychiatric emergencies are rare and are straightforward when they occur. So that's something to consider for people who don't do well in emergency situations.

 

[Pansit]

Oh I definitely agree with you on all that. There is a big difference in stress level when it comes to urgent patient care. Psychiatric emergencies are rare and are straightforward when they occur. So that's something to consider for people who don't do well in emergency situations.

Psychiatric emergencies are NOT rare. If you have ever worked in an emergency room you get a good amount of Suicidal ideations and homicidal ideations. And inpatient psych is an emergency waiting to happen...those schizophrenics can snap and throw a nurse or physician across the room without warning or cause. There is a reason why they tell you not to wear a tie or never to let the patient be between you and the door in psych.

 

[PsychMedStudent]

Psychiatric emergencies are NOT rare. If you have ever worked in an emergency room you get a good amount of Suicidal ideations and homicidal ideations. And inpatient psych is an emergency waiting to happen...those schizophrenics can snap and throw a nurse or physician across the room without warning or cause. There is a reason why they tell you not to wear a tie or never to let the patient be between you and the door in psych.

I think you are vastly overstating the dangers of psychiatry. I spend most of my time in psych ERs and inpatient units and I've never been physically assaulted. I know of very few other doctors who have. The only assault I've witnessed was against a nurse. Part of the training you receive is how to watch for the warning signs and not put yourself in a bad situation. It can still happen, but it is rare.

 

[representando]

I think this is a very interesting thread. I was going to do IM for the longest time and was even going to apply to both psych and IM up until the last minute. I chose psych in the end because I enjoyed my third year rotation so much, then started to realize that there are actually plenty of options within the field including forensics (I liked IM because of all of the subspecialty options). So, obviously because I am in an IM forum I expect plenty of people to hate psych, which is fine. Lifestyle-wise psych would probably fit a lazy person better, but there are lazy people in every field and obviously not all psychiatrists are lazy.

 

[Old Style Nanny]

I agree. This has indeed become a far more interesting thread than I could have hoped for.

 

[Losername135]

I saw this thread, and it compelled me enough to sign up on this forum, and share my thoughts. I've been a long time lurker of sdn, and I find it amazing how some people with 230+ USMLE scores are asking about their chances for 'so and so' residencies. This forum is 'overachiever central'. Nothing wrong with that, but it sure does make this thread refreshing! Perhaps that's why the other users like where this thread is going too?

Let me go ahead and say it right now. Yes, others would call me a lazy man. But I like to think of it this way: I like to manage and balance my time! 😉

On a serious note, my father was (and still is) a workaholic. There is nothing wrong with being a workoholic, unless it can have negative influnces in your own life, and with your family life. I never understood him in that sense. My father doesn't have any interests outside of his profession. I'm not mad at him, but I definitely don't want to become like him.

I was attracted to psychiatry from day 1 of my 3rd year rotation. I don't think I was attracted to it because I'm a lazy person, but I think that might be part of the reason. I'm mainly interested in psych because I like where the field is going, I'm interested in the subject matter, and I find the patients very interesting. I also like semi-informal enviornment of a psychiatry office. I won't miss my stethescope much, or a lab coat.


I think OP's question is a fair one. Its ok to NOT want to dedicate your entire life to medicine. Its a shame that we go into medical school, start our residencies, and go on to work, thinking that our lives revolve around our profession. To some degree, this is true. But I think its MORE true, that our lives must be lived in a larger scope, and our jobs are only 1 part of the picture.


For these reasons, I am discouraged to go into internal medicine, where (imo) responsibility is higher, and its more of a fast paced, fast thinking, busy job. As for pay differences, I really could not care any less. As a doctor, in whatever field you go into, you are going to be banking at least 100k. If you can't live a comfortable life with that, and you need more, then that is a different story. But as for me, 100k per year is enough.

You live once. And in my lifetime, I choose not to chase money, or stress my head off! I just want to live comfortably, and enjoy myself.




Now I need to add something here. I understand there are people out there, who work a lot of hours, still maintain a family life, still have time to enjoy their other hobbies outside of medicine, don't feel burned out, and make a lot of money doing it. That is great, and its nice to know you can do all those things, and still have a good night sleep! But that life is not for everyone. And that's okay!

 

[Doc Samson]

There was a time when I would've literally combusted at some of the BS descriptions about a career in psychiatry on this thread (it's "simple", it's all meds, emergencies are rare). Whatever - if you're not drawn to the field, don't do it.

In terms of work schedule, there are plenty of psychiatry residencies that had to switch to night float in order to accommodate the 80 hour work week and now are looking at ways to accommodate the new duty hour restrictions. You can, however, likely find a low workload psychiatry residency easier than you can find a low workload medicine residency. It likely won't be at a particularly esteemed or competitive institution, but I get the sense you don't care about that.

 

[staup]

There was a time when I would've literally combusted at some of the BS descriptions about a career in psychiatry on this thread (it's "simple", it's all meds, emergencies are rare). Whatever - if you're not drawn to the field, don't do it.

In terms of work schedule, there are plenty of psychiatry residencies that had to switch to night float in order to accommodate the 80 hour work week and now are looking at ways to accommodate the new duty hour restrictions. You can, however, likely find a low workload psychiatry residency easier than you can find a low workload medicine residency. It likely won't be at a particularly esteemed or competitive institution, but I get the sense you don't care about that.

No one is saying Psych can't be stressful, we're just saying it is not as stressful or complex as IM.

 

[digitlnoize]

I am a 3rd year student in a similar boat, although without the "lazy" label. What tilted me to psych in the end is the fact that a good psychiatrist DOES think about "the whole patient" and can engage in complex medical decision making. In fact, I find it much more challenging intellectually than IM. Just 2 weeks ago, I had a patient in FM clinic who presented with fatigue, hx depression, arrythmias, arthralgias, slightly elevated liver enzymes...guess what I found: Hemochromatosis! Had been missed for at least 2 years by his FM doc, Cardiologist, and Psychiatrist. Psychiatrists are physicians first, and deal with pretty much every medical issue the IM guys do.

Also worth considering Consultation-Liason psych...

 

[staup]

I am a 3rd year student in a similar boat, although without the "lazy" label. What tilted me to psych in the end is the fact that a good psychiatrist DOES think about "the whole patient" and can engage in complex medical decision making. In fact, I find it much more challenging intellectually than IM. Just 2 weeks ago, I had a patient in FM clinic who presented with fatigue, hx depression, arrythmias, arthralgias, slightly elevated liver enzymes...guess what I found: Hemochromatosis! Had been missed for at least 2 years by his FM doc, Cardiologist, and Psychiatrist. Psychiatrists are physicians first, and deal with pretty much every medical issue the IM guys do.

Also worth considering Consultation-Liason psych...

Great you found that.

There are certainly many many psychiatrists, especially in the academic world, who think about the entire patient, make complex decisions, and do amazing research.

But for the average private practice psychiatrist verses internist, it's not even close. For the above patient, how would that diagnosis not fall under the internist's responsibility? Whether his/her internist picked it up or not, that patient would keep coming back to the internist's office, where the internist would need to find and treat all of the above plus blood pressure and whatever ailment comes up. It's just the nature of the beast, the internist is a generalist, has to treat everything, and a good internist doesn't refer for everything, they treat most everything on their own until it becomes dangerous.

Don't get me wrong, I am in no way critcising psychiatry. I almost chose it myself. But if you need me to choose what specialty is more stressful and on average requires more complex thinking, I would choose IM.

 

[Doc Samson]

Great you found that.

There are certainly many many psychiatrists, especially in the academic world, who think about the entire patient, make complex decisions, and do amazing research.

But for the average private practice psychiatrist verses internist, it's not even close. For the above patient, how would that diagnosis not fall under the internist's responsibility? Whether his/her internist picked it up or not, that patient would keep coming back to the internist's office, where the internist would need to find and treat all of the above plus blood pressure and whatever ailment comes up. It's just the nature of the beast, the internist is a generalist, has to treat everything, and a good internist doesn't refer for everything, they treat most everything on their own until it becomes dangerous.

Don't get me wrong, I am in no way critcising psychiatry. I almost chose it myself. But if you need me to choose what specialty is more stressful and on average requires more complex thinking, I would choose IM.

Stress and required complexity of thought is entirely dependent on your patient panel - you can choose how stressed and how thoughtful you have to be in either specialty. The stress level of a psychiatrist that sees a lot of chronically suicidal Borderline patients is going to have a great deal more stress than the typical internist. CL psychiatrists (like me) get to diagnose medical illness (presenting with delirium, not "depression" or "anxiety" or "psychosis" or whatever the IM team consulted me for in the first place) missed by internists every day. As far as bread and butter outpatient work goes, I'd say managing bipolar disorder and schizophrenia is more stressful and complex than managing diabetes and hypertension.

Yes, psychiatrists don't (often) have to run a code on a patient, but internists don't (often) have to worry about a patient killing them or themselves.

 

[drfunktacular]

The question as framed is misleading.

I am an IM resident and it is stressful, but the thought of being a psych resident is infinitely more stressful and painful to me for the simple reason that i don't like psychiatry, and no amount of lifestyle perks would ever make up for that. For most psych folks I imagine the reverse would be true.

The jobs are what they are; it's your experience of them that matters.

 

[gutonc]

The question as framed is misleading.

I am an IM resident and it is stressful, but the thought of being a psych resident is infinitely more stressful and painful to me for the simple reason that i don't like psychiatry, and no amount of lifestyle perks would ever make up for that. For most psych folks I imagine the reverse would be true.

The jobs are what they are; it's your experience of them that matters.

QFT.

I mean...dermatology is amazingly unstressful (from the perspective of patients dying on you) and extremely lucrative.

But since I'd be giving serious consideration to putting a bullet in my head after about 3 days of it (I actually withdrew from a derm elective as a med student for this reason) I would consider it extremely stressful.

 

[staup]

Stress and required complexity of thought is entirely dependent on your patient panel - you can choose how stressed and how thoughtful you have to be in either specialty. The stress level of a psychiatrist that sees a lot of chronically suicidal Borderline patients is going to have a great deal more stress than the typical internist. CL psychiatrists (like me) get to diagnose medical illness (presenting with delirium, not "depression" or "anxiety" or "psychosis" or whatever the IM team consulted me for in the first place) missed by internists every day. As far as bread and butter outpatient work goes, I'd say managing bipolar disorder and schizophrenia is more stressful and complex than managing diabetes and hypertension.

Yes, psychiatrists don't (often) have to run a code on a patient, but internists don't (often) have to worry about a patient killing them or themselves.

Seriously, you have to get over yourself. If you think Psychiatry is more complex or stressful than IM you're kidding yourself. Why does it even matter to you? Psych is a good specialty, just enjoy it.

If you work an an academic center, I can guarantee you only see about 1/3 or less of the delirium in that hospital. I can just imagine you critically judging internists about one or two patients of theirs you see when you are unaware of the majority of patients they successfully treat without your help.

And just go on believing your diseases require so much more thought. You may think they do, but then all you can do is titrate up the risperdal or add clozaril and try some type of therapy when you're never really treating the disease, you just suppressing symptoms. We'll treat the hyponatremic, hypertensive, infected patient with renal and heart failure and call you when their schizophrenia becomes an issue and we haven't managed it ourselves.

 

[drfunktacular]

And just go on believing your diseases require so much more thought. You may think they do, but then all you can do is titrate up the risperdal or add clozaril and try some type of therapy when you're never really treating the disease, you just suppressing symptoms. We'll treat the hyponatremic, hypertensive, infected patient with renal and heart failure and call you when their schizophrenia becomes an issue and we haven't managed it ourselves.

And who do you think I, heroic internist, called when I admitted a guy for pleural effusion, hypernatremia, volume depletion, and lithium toxicity, who was on risperidone, ziprasidone, lithium, benztropine and aripiprazole as an outpatient, and still was psychotic?

 

[digitlnoize]

And who do you think I, heroic internist, called when I admitted a guy for pleural effusion, hypernatremia, volume depletion, and lithium toxicity, who was on risperidone, ziprasidone, lithium, benztropine and aripiprazole as an outpatient, and still was psychotic?

And this is kind of what I was alluding to earlier. I actually found IM less intellectually stimulating than psych because in IM you have tests and lab values that will tell you what is wrong with the patient. You can run tests, then treat the patient according to what you find. Although IM is VERY complicated, I found myself and the doctors more often just running through the algorithms for whatever problem list the pt had. Not that all IM is "cookbook", that's not what I mean...I feel this is hard to describe and I'm not doing a very good job...

I, personally, find psych more challenging because as Dr. Funk points out, the cases are more challenging. Obviously, psychiatrists can still run labs, but more often I find they have to think a bit more about how to approach a difficult case from a different angle...

Back to the OP's question: It's really about what YOU like. Some people LOVE surgery and find that to be the least stressful field, despite the crazy work hours. Others hate psych despite the relative banker's hours.

Do what you love. There are no guarantees that anything will stay as cush or "easy" as it is now. Remember when radiologists only had to read plain films? Remember when the only anesthetic was Ether? Medicine is continually evolving, and just do what you enjoy. You'll make plenty of money in any field to be as lazy or workaholic as you want and still survive.

Speaking as someone who never made more than 15/hr in my prior career and lived just fine, anyone making >$100/hr can afford to work part-time if they so choose.

 

[staup]

And who do you think I, heroic internist, called when I admitted a guy for pleural effusion, hypernatremia, volume depletion, and lithium toxicity, who was on risperidone, ziprasidone, lithium, benztropine and aripiprazole as an outpatient, and still was psychotic?

And why do you think that patient was admitted to your medicine service and not psychiatry?

So they told you to treat the underlying illness to improve the delirium, possibly stop some of the above medications, and/or try another of the 20-30 medications they use because there's really not much else.

What do you do for someone with a HR of 24 and BP of 220/114? I guarantee most psychiatrists have no idea.

But that's not really my point. Again, I am no way saying Psych is not needed, or not a great specialty, or anything like that. I just think real IM, not someone who consults for every minor thing, is much more stressful and complex than psychiatry.

The problem is that most specialists who were never internists don't see the complexity we handle day to day and just assume it's basic stuff, maybe because internist's have the label "primary care doctors" and that somehow conveys more of a social idea than medical one. I was once on the PM&R section of this forum and noticed a thread where people we're complaining that rehab docs didn't get paid a lot more than hospitalists, explaining they should because they're "specialists". What a joke. It's a joke they get paid more to begin with.

 

[Doctor Bagel]

How difficult or stressful is IM residency compared to Psychiatry residency? With regards to:

1. Workload (hours/week and amount of work/day)
2. More difficult attendings to deal with
3. Amount of learning required

And once you finish residency, how do the two compare? (Assuming no fellowship and no private practice.) With regards to:

1. Workload and stress because of responsibility
2. Money earned per hour of work
3. Average work hours per week
4. Job satisfaction and overall happiness

Valuable inputs are much appreciated. Not intending to create a war of any sort. Just looking for some unbiased information.

I'm a psych intern currently rotating on IM wards, so I thought I'd share my thoughts. Of course, as mentioned earlier, all things are program dependent.

1. workload/stress -- The overall workload/call schedule seems a little heavier for the medicine folks, but honestly, my overall hours worked on both psych wards and IM wards have been pretty similar. We get more free weekends in psych; the medicine folks get one day off in seven (not averaged, they just get it) on wards. ICU months are apparently harder than wards months, and university wards are harder than VA wards (where I'm at), so overall, I guess medicine wins the work hours award.

Regular daytime work load is about the same. Psych is nice in that you can usually get to work at 8 instead of 7, like we do on medicine. Overall, I carried more patients each day on psych than I do on medicine because we're usually consistently capped.

2. difficult attendings: I've really haven't encountered this on either side. I'm not in a traditional east coast type of place, though. At my medical school, I'd definitely say the medicine attendings could be a little more intense.

3. amount of learning: you know, medicine probably does win here because their field is so broad.

Now, regarding stress, to me, medicine would be more stressful because dealing with acutely ill possibly dying patients stresses me out. We deal with out own stress, though -- namely in making decisions about safety concerning admissions and discharges. Our patient interactions can be more stressful, too, because inpatient psychiatry puts you in conflict with a good chunk of your patients. I feel like I get to be a lot nicer in medicine, and dude, my patients like me so much more. I'm hoping this dynamic will change, though, once I start doing outpt work.

And, of course, the big thing is that lifestyle's important, and you can find a good lifestyle in either specialty, especially doing outpt work. But enjoying your work is important. I just don't get excited about the same stuff as the medicine residents, and I find a lot of conversations about working up a patient fairly tedious.

 

[Doc Samson]

We'll treat the hyponatremic, hypertensive, infected patient with renal and heart failure and call you when their schizophrenia becomes an issue and we haven't managed it ourselves.

Hyponatremia: algorithm
Hypertension: algorithm
Infection: algorithm, maybe a consult
Renal failure: algorithm, maybe a consult
Heart failure: algorithm, maybe a consult

Schizophrenia... well, managing that might require some complex thought.

 

[Doc Samson]

you're never really treating the disease, you just suppressing symptoms.

As opposed to diabetes? Hypertension? Dyslipidemia? Renal failure? CHF? HIV? Hypothyroidism? Arthritis? Crohn's disease?

Again, my point isn't psych is better/worse than IM - it's just that in both fields you can choose the level of complexity and stress and that there are jobs in psychiatry that are just as or more stressful than jobs in medicine. A good psychiatry residency though, should beat the crap out of you on both the stress and complexity fronts.

 

[staup]

Hyponatremia: algorithm
Hypertension: algorithm
Infection: algorithm, maybe a consult
Renal failure: algorithm, maybe a consult
Heart failure: algorithm, maybe a consult

Schizophrenia... well, managing that might require some complex thought.

Just stop it, you don't understand what you're writing. You're not an internist, so you don't understand all the complexity of the day to day work.

For instance, for your "hyponatremia algorithm", what algorithm do you follow for someone with SIADH, cannot take anything PO because of a swallowing dysfuntion, and any tube feeds you can give her are hypotonic and exacerbates the SIADH. And she has heart failure. Not so easy. Plus, if you don't solve it, she dies. fast.

And then you're whole listing diagnoses that can't be cured are certainly right, but because IM covers so much, there are certainly many many that are cureable, such some of the most common of them all, like Pneumonia.

I don't doubt that there is complex theories behind treating someone with schizophrenia, but in the end, you can't do much except give them some drugs.

It's just the nature of the beast, a good internist who doesn't consult for everything under the sun, has to think with more complexity than a specialist like a psychiatrist. They have to consider everything.


Sorry.

 

[jdh71]

Hyponatremia: algorithm
Hypertension: algorithm
Infection: algorithm, maybe a consult
Renal failure: algorithm, maybe a consult
Heart failure: algorithm, maybe a consult

Schizophrenia... well, managing that might require some complex thought.

You mean like simply throwing the next anti-psych medicine that they are NOT on on board? Seriously man - NOT that complicated.

I'm glad you like psych patients because you can keep them. I don't want your job any more than you want mine, but that thing on your shoulder? It's a chip. Physician heal thyself, or continue being a bitter ass in the IM forum. Your call.

 

[Instatewaiter]

Hyponatremia: algorithm
Hypertension: algorithm
Infection: algorithm, maybe a consult
Renal failure: algorithm, maybe a consult
Heart failure: algorithm, maybe a consult

Schizophrenia... well, managing that might require some complex thought.

I think some call this a defense mechanism.

 

[drfunktacular]

Geez you guys... did a psychiatrist steal your lunch money or something?

 

[digitlnoize]

If everything was simple, then we wouldn't need IM or Psych docs. Generalists could manage their own schizophrenia and SIADH complications.

Fortunately, nothing is simple, and we need each other. If psych was as easy as just throwing the next med at it, the internists would be doing that themselves.

Back to the OP's question: Is IM residency more difficult and stressful than psych? I think most of us agree that IM works more hours and manages a wider spectrum of medical problems. Does that make it harder or more stressful? That's up for debate, apparently, and will depend greatly on your own personal opinion. Figure it out by doing rotations. Good luck!

 

[Doctor Bagel]

Geez you guys... did a psychiatrist steal your lunch money or something?

👍

I'm having some trouble understanding where all the hate is coming from.

And getting back to this whole more stressful business, can you really compare inpatient work to outpatient work? I think in both our fields, inpatient work can be significantly more stressful.

 

[Old Style Nanny]

Can you really compare inpatient work to outpatient work? I think in both our fields, inpatient work can be significantly more stressful.

By outpatient work, do you mean private practice at one's own small clinic/office?

EDIT: To the psychiatrists in the thread - is the worry about keeping yourself physically safe from the patients a very real one? How bad is it in reality? Were there any real incidences in your own practice so far?

 

[393656]

I find this entertaining. If Psych was so easy than why does IM excessively consult psychiatry in the hospital setting, they try their best to refer every psych patient out and when they do treat them they use completely terrible medicine regimens and often worsen the patient.

I cant believe every IM person is purposely practicing terrible psychiatry for the fun of it. I have lost count this week of how many IM consults for "decision making capacity" which entails asking them if they understand whats going on and that is about it. Yet IM docs cannot seem to do this for 400 bucks a pop at the patients expense. tell me if this is worth 400 dollars.
Psych-Hi do you know why your doctor asked me to see you
Pt-no he didnt even tell me you were coming
Psych-I am here to make sure you understand your medical treatment. Can you tell me why you are here and your understanding of what is going on
Pt-I am having a procedure x, y and z.
Psych-do you konw the risks v. benefits
Pt yes
Psych-thanks

Wow if IM docs find that hard than I am not sure how they got through high school.

The problem is there are bad IM and bad psych docs everywhere. I know many terriblely unthorough psych docs. This is worsened by the fact many who go into psych probably should have been psychologists as they hate medicine. However if you weed those out and take the psychiatrists who actually really love medicine as well, you are looking at an entirely different psychiatrist role.

I spend much of my time looking over their entire medical picture, fixing mistakes by IM docs who prescribe triplicates of anti-cholinergic medicines under different names and treating them with medication interactions causing a bunch of psych problems that they then call them "crazy." I order head imaging and looking for neuropathology, and we get to hunt down the 100's of medical problems that cause psychiatric disturbances that are often blown off by the IM docs because they are bias like you all are.

Then if you look at consult hospital psychiatry, we are constantly finding medical problems left and right in delirious patients who IM docs think are magically schizophrenic at the age of 75.

If psych is that easy than I would suggest you do a better job of showing the world IM can actually hack it, otherwise put a sock in it 🙂

On the flip side I think good IM docs are hard to come by as is a good psych doc and I feel no animosity towards IM in what they do. Maybe because I like IM. I think IM is simply uncomfortable with psych and when people are uncomfortable they lash out to blame others-project their inadequacy onto their patients and make it "their fault" There is some psychobabble for you folks

 

[drfunktacular]

I spend much of my time looking over their entire medical picture, fixing mistakes by IM docs who prescribe triplicates of anti-cholinergic medicines under different names and treating them with medication interactions causing a bunch of psych problems that they then call them "crazy." I order head imaging and looking for neuropathology, and we get to hunt down the 100's of medical problems that cause psychiatric disturbances that are often blown off by the IM docs because they are bias like you all are.

Then if you look at consult hospital psychiatry, we are constantly finding medical problems left and right in delirious patients who IM docs think are magically schizophrenic at the age of 75.

If psych is that easy than I would suggest you do a better job of showing the world IM can actually hack it, otherwise put a sock in it 🙂

On the flip side I think good IM docs are hard to come by as is a good psych doc and I feel no animosity towards IM in what they do. Maybe because I like IM. I think IM is simply uncomfortable with psych and when people are uncomfortable they lash out to blame others-project their inadequacy onto their patients and make it "their fault" There is some psychobabble for you folks

So you went into psych because medicine is... too easy? That's a new one.

 

[393656]

So you went into psych because medicine is... too easy? That's a new one.

Good to know some doctors are illiterate. Way to make it through this far

 

[digitlnoize]

So you went into psych because medicine is... too easy? That's a new one.

I didn't get this from that post either. He's saying that psych is hard to do well. That doesn't make IM easy 😕

I think both fields are difficult in their own ways. On average, IM does work more hours, although there are IM residencies < 65h/wk and psych residencies that push the 80h limit. After residency, it's mostly up to the individual docs how much they want to work, but in my (limited) experience, IM docs tend to work slightly more hours per week than psych.

Does working less hours per week make it easier? I don't think so. I actually found my inpatient IM months to be amongst one of the easier rotations for me as a 3rd year student. In fact, I was tempted to choose it over psych, but in the end, easier was not better for me. I simply enjoyed psych more.

So, IM may work, on average, more hours/week, but each field has its own unique challenges, and it's really a very subjective, personal experience in every other way.

 

[sideways]

And yet another pissing contest in medicine. Everyone feeling the need to place their intellect and abilities above the person sitting next to them in the lecture hall. Nice to see it extends into residency as well.

My guess is most IM docs would be piss poor psychiatrists because they are better at contemplating acid-base abnormalities than they are teasing out the subtleties of human behavior.

And most psychiatrists would end up killing their CHF patients because their eyes glaze over when you start discussing the physiology of hamburger digestion.

 

[393656]

Unfortunately that is a big problem with what is wrong with healthcare today. Overly focused care by both parties. Understand subtle psychiatric symptoms is something so important for day to day primary care docs. I cannot believe IM is even trashing psych since the IM outpatient docs (and more and more intpatient) see TONS of psych patients. The fact you are not noticing psych patients probably means your eyes are closed to it.

Subtle neuropsych symptoms can reveal all sorts of "medical" problems which are necessary to treat the underlying problem in many patients. Not to mention the basic understanding of human nature to establish a proper relationship with the patient.

Psych is embarrasing that they hate medicine except for a few. I continue to read up on medicine and practice as much as I can within reason on the inpatient unit with back-up a consult away. I do not overstep my limits but a basic repetoir of BP, diabetes, lipids, infections, thyroid stuff I am pretty comfortable and keep up to date. Beyond that I would want the true expert providing treatment for any patient-they deserve the best care and at that point it would not be from me.

I think instead of trashing one another you guys really embrace one another. At my university I established a great clinic with the IM docs and developed a great working relationship with the two departments where they were extremely appreciative of my work and we of course always had appreciated their assistance. Overall led to great interactions in the hospital and a much higher level of mutual respect.

I think IM residency is more grueling on average but as far as "thinking" I believe you can think as much or as little in both fields depending on what type of person you are. You can always plug in alogrithms for either field but if you want to take it a step further and look outside the box, look at the whole patient and put subtle pieces together, than you should be able to do that in both fields. Putting subtle medical AND psychiatric symptoms should be part of a savvy physician regardless of speciality. Treatment and management is a different story and that is when referral for help is appropriate.

 

[michaelrack]

"How difficult or stressful is IM residency compared to Psychiatry residency? With regards to:

1. Workload (hours/week and amount of work/day)
2. More difficult attendings to deal with
3. Amount of learning required"

1. When I was a med/psych resident, Medicine workload was much heavier (this was before the 80 hour limit).
2. varies
3. Definitely IM. Psychiatry is approximately equivalent to 1.5 medical subspecialties in knowledge breadth- for example, equivalent to cards plus half of pulm. An IM resident needs to know cards, pulm, neph, endo, rheum, etc.

 

[michaelrack]

"And once you finish residency, how do the two compare? (Assuming no fellowship and no private practice.) With regards to:

1. Workload and stress because of responsibility
2. Money earned per hour of work
3. Average work hours per week
4. Job satisfaction and overall happiness"

Generally, psych is better than primary care IM for 1-3. 4 depends on the individual.

 

[393656]

I do not agree wtih you about knowledge base between the two. While IM is much broader and requires many more subjects to learn (and I am totally agreeing it is a LOT), you do not end up learning the info in much depth aside from a couple topics you have ea personal interest or practice focus in.

Psych (if you are a good psychiatrist which is uncommon out there) has less information but really complicated genetics, psychopharmacology with medication interactions for all drugs and a pretty good understanding of presentations of any medical cause that can produce neuropsychiatric symptoms (which obviously is a lot)

Add to that if you are a consult psychiatrist you have to be familiar and learn about most of the fields because when you consult you have to know what is going on and recognize pathology/treatment/pharm/tests etc PLUS the psych involved that does not interact or cause problems like further supressing white cells, causing brugada syndrome or giving someone torsaddes.

Again psych is not harder but I think that view is incorrectly propogated that psych has "not much" to learn. Depth is the difference. The brain which is all fair game in psychiatry is a TON. We also have to know neurology in a big way as there is so much overlap.

The most common thing I do when I do a consult-outpatient or inpatient is get rid of polypharmacy regimens. Most consult problems are caused by 2 of the same medication or multiple meds with the same side-effects etc.

People I know in IM admittedly tell me they often do not know pharm in depth due to the wide range of knowledge they are required to spend time learning.