How much pharmacology/psychopharmacology do you use/are you allowed to use as a psychiatrist?

[jacob42]

Considering whether I want to go into medicine. If I did, psychiatry is one of my major leanings as a speciality. I really love pharmacology and psychopharmacology—especially theorizing about things like augmentation strategies and visualizing how all these drugs interact in the brain, distribute through tissues, and use pharmacodynamics and pharmacokinetics to make reasonable predictions about drugs including concentrations, transporter occupancy, possible CYP450 interactions, etc.

While I think the facet of drug discovery/pharmacy in itself is quite interesting, I feel like I’d be missing the ability to actually put my “skills” to use (read: taking other psychopharmacologist’s ideas, altering them for my specific situation/patient, and then trying them out in practice and adjusting accordingly). I feel like I miss out on actually seeing these medications work in reality and forming a connection between the science of a drug and actually seeing those mechanisms come to life to improve, or even save, a life, if I were to go with a purely pharmacological path (unless on the very small chance I successfully develop a drug).

How much psychopharmacological/creative freedom like this does psychiatry afford? I suppose it’d vary from private practice vs. working in a hospital (where it might not be possible until you’re not under someone, if at all). Basically, if I take my extremely treatment-resistant cases, would it be a good and effective use of my time to research possible augmentations and even come up with some “novel” feasible ideas and try those myself?

Could I go doing “risky” things like combining MAOIs + stimulants (say in a patient with severe TRD and possibly ADHD) and set myself as a psychiatrist who’s willing to try more unorthodox but medically safe (read Ken Gillman for MAOI danger being blown out of proportion for example)? Or, would I be stuck being “forced” (either by culture if private or a higher up if in a hospital) to prescribe medications very algorithmically for disorders with no creative freedom/outside the box thinking and end up bored?

I’m really interested if anyone has talked to psychs or is a psych with an idea of these kind of things like creative freedom, and I’m sure some others are too!

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[jbomba]

Considering whether I want to go into medicine. If I did, psychiatry is one of my major leanings as a speciality. I really love pharmacology and psychopharmacology—especially theorizing about things like augmentation strategies and visualizing how all these drugs interact in the brain, distribute through tissues, and use pharmacodynamics and pharmacokinetics to make reasonable predictions about drugs including concentrations, transporter occupancy, possible CYP450 interactions, etc.

While I think the facet of drug discovery/pharmacy in itself is quite interesting, I feel like I’d be missing the ability to actually put my “skills” to use (read: taking other psychopharmacologist’s ideas, altering them for my specific situation/patient, and then trying them out in practice and adjusting accordingly). I feel like I miss out on actually seeing these medications work in reality and forming a connection between the science of a drug and actually seeing those mechanisms come to life to improve, or even save, a life, if I were to go with a purely pharmacological path (unless on the very small chance I successfully develop a drug).

How much psychopharmacological/creative freedom like this does psychiatry afford? I suppose it’d vary from private practice vs. working in a hospital (where it might not be possible until you’re not under someone, if at all). Basically, if I take my extremely treatment-resistant cases, would it be a good and effective use of my time to research possible augmentations and even come up with some “novel” feasible ideas and try those myself?

Could I go doing “risky” things like combining MAOIs + stimulants (say in a patient with severe TRD and possibly ADHD) and set myself as a psychiatrist who’s willing to try more unorthodox but medically safe (read Ken Gillman for MAOI danger being blown out of proportion for example)? Or, would I be stuck being “forced” (either by culture if private or a higher up if in a hospital) to prescribe medications very algorithmically for disorders with no creative freedom/outside the box thinking and end up bored?

I’m really interested if anyone has talked to psychs or is a psych with an idea of these kind of things like creative freedom, and I’m sure some others are too!

Take a look at what some of those creative NPs are doing pharmacologically. The sky's the limit.

 

[robellis]

What you’re describing is exactly what we do as psychiatrists, beyond the first few steps psychiatry becomes very much an art so absolutely if you are pharmacologically inclined you will thrive and you are pretty much completely free to do as you please as long as you’re not hurting people and trying your best to do things in line with the current (albeit limited) evidence base

 

[clausewitz2]

Considering whether I want to go into medicine. If I did, psychiatry is one of my major leanings as a speciality. I really love pharmacology and psychopharmacology—especially theorizing about things like augmentation strategies and visualizing how all these drugs interact in the brain, distribute through tissues, and use pharmacodynamics and pharmacokinetics to make reasonable predictions about drugs including concentrations, transporter occupancy, possible CYP450 interactions, etc.

While I think the facet of drug discovery/pharmacy in itself is quite interesting, I feel like I’d be missing the ability to actually put my “skills” to use (read: taking other psychopharmacologist’s ideas, altering them for my specific situation/patient, and then trying them out in practice and adjusting accordingly). I feel like I miss out on actually seeing these medications work in reality and forming a connection between the science of a drug and actually seeing those mechanisms come to life to improve, or even save, a life, if I were to go with a purely pharmacological path (unless on the very small chance I successfully develop a drug).

How much psychopharmacological/creative freedom like this does psychiatry afford? I suppose it’d vary from private practice vs. working in a hospital (where it might not be possible until you’re not under someone, if at all). Basically, if I take my extremely treatment-resistant cases, would it be a good and effective use of my time to research possible augmentations and even come up with some “novel” feasible ideas and try those myself?

Could I go doing “risky” things like combining MAOIs + stimulants (say in a patient with severe TRD and possibly ADHD) and set myself as a psychiatrist who’s willing to try more unorthodox but medically safe (read Ken Gillman for MAOI danger being blown out of proportion for example)? Or, would I be stuck being “forced” (either by culture if private or a higher up if in a hospital) to prescribe medications very algorithmically for disorders with no creative freedom/outside the box thinking and end up bored?

I’m really interested if anyone has talked to psychs or is a psych with an idea of these kind of things like creative freedom, and I’m sure some others are too!

While there are some things that are close to obligatory to try as treatments in psychiatry (if someone is garden variety depranxious, naive to treatment, and being started on something that is not an SSRI or wellbutrin, you better have a good reason), you really do have almost complete freedom as long as you can come up with some kind of scientific support for efficacy or safety of what you're doing. Even then the only limitation is really how likely you are to get sued for malpractice behind it and whether local pharmacists will balk at whatever you are slinging.

Unless you start getting opioid happy. Then the DEA starts to have opinions. Search this forum and you will find plenty of threads about non-standard/off-label prescribing based on exactly these sorts of considerations. Without psychopharmacology, most psychiatrists would just be mediocre therapists.

 

[birchswing]

Considering whether I want to go into medicine. If I did, psychiatry is one of my major leanings as a speciality. I really love pharmacology and psychopharmacology—especially theorizing about things like augmentation strategies and visualizing how all these drugs interact in the brain, distribute through tissues, and use pharmacodynamics and pharmacokinetics to make reasonable predictions about drugs including concentrations, transporter occupancy, possible CYP450 interactions, etc.

While I think the facet of drug discovery/pharmacy in itself is quite interesting, I feel like I’d be missing the ability to actually put my “skills” to use (read: taking other psychopharmacologist’s ideas, altering them for my specific situation/patient, and then trying them out in practice and adjusting accordingly). I feel like I miss out on actually seeing these medications work in reality and forming a connection between the science of a drug and actually seeing those mechanisms come to life to improve, or even save, a life, if I were to go with a purely pharmacological path (unless on the very small chance I successfully develop a drug).

How much psychopharmacological/creative freedom like this does psychiatry afford? I suppose it’d vary from private practice vs. working in a hospital (where it might not be possible until you’re not under someone, if at all). Basically, if I take my extremely treatment-resistant cases, would it be a good and effective use of my time to research possible augmentations and even come up with some “novel” feasible ideas and try those myself?

Could I go doing “risky” things like combining MAOIs + stimulants (say in a patient with severe TRD and possibly ADHD) and set myself as a psychiatrist who’s willing to try more unorthodox but medically safe (read Ken Gillman for MAOI danger being blown out of proportion for example)? Or, would I be stuck being “forced” (either by culture if private or a higher up if in a hospital) to prescribe medications very algorithmically for disorders with no creative freedom/outside the box thinking and end up bored?

I’m really interested if anyone has talked to psychs or is a psych with an idea of these kind of things like creative freedom, and I’m sure some others are too!

Read board sanctions to get an idea of what you're allowed to do.

If creativity is your concern, you need to be a real Jackson Pollock with prescribing to even get noticed.

 

[Stagg737]

OP, where are you at in your training? It's easier to help when we know what level you're at.

taking other psychopharmacologist’s ideas, altering them for my specific situation/patient, and then trying them out in practice and adjusting accordingly). I feel like I miss out on actually seeing these medications work in reality and forming a connection between the science of a drug and actually seeing those mechanisms come to life to improve, or even save, a life, if I were to go with a purely pharmacological path (unless on the very small chance I successfully develop a drug).

This is literally what we do and seeing manic patients rapidly become stable (in days to weeks) is what initially attracted me to psych.

How much psychopharmacological/creative freedom like this does psychiatry afford? I suppose it’d vary from private practice vs. working in a hospital (where it might not be possible until you’re not under someone, if at all). Basically, if I take my extremely treatment-resistant cases, would it be a good and effective use of my time to research possible augmentations and even come up with some “novel” feasible ideas and try those myself?

A lot, and I'd argue that psych is one of the fields least suited to algorithms. Keep in mind we're "specialists", so a lot of referrals to psych are because the PCP tried the algorithms and they don't know what to do/don't want to do it themselves. To the bolded: Yes. Researching augmentation methods should be a primary goal of every resident once they've got the basics down. "Novel" ideas are usually welcome once the evidenced-based options have failed, though I don't think it's too common to really come up with something novel unless you're reaching for meds not generally considered psych meds.

Could I go doing “risky” things like combining MAOIs + stimulants (say in a patient with severe TRD and possibly ADHD) and set myself as a psychiatrist who’s willing to try more unorthodox but medically safe (read Ken Gillman for MAOI danger being blown out of proportion for example)?

Paging Dr. @splik and Dr. @clausewitz2

 

[Crayola227]

I don't know why, but reading what you wrote and the tone, you'll probably be OK but remember to keep in mind the point of medicine isn't to go off the beaten track and do fascinating experiments on your patients. They're human beings, and hopefully the first time you harm someone doing something routine that you expected to go over quite well, will somewhat damper your enthusiasm to "try new things." Which isn't to say that you shouldn't at times. Everything needs to be balanced by the evidence and experience and expectations for good for the patient, as much as possible.

I've always ran on the side of being an earlier adopter of things, things that are off-label, etc, but the first time I had a patient suffer predictable and not even serious side effects from something arguably not totally necessary (depending how you look at pain control, they were in significant pain but not pushing for better control), well let's just say your desire to intervene needs to be tempered by first do no harm.

Keep that forefront.

 

[Bartelby]

Seconding Crayola. Clinicians are not doing research, we are (or should be) implementing evidence based interventions. Becoming "creative" with pharmacology can easily stray into harmful and speculative polypharmacy. You want to avoid magical thinking about medications, and make sure medications are not the hammer that turns every problem into a nail.

With that said, there of course remains a fair amount of grey in prescribing, and a passion for learning everything you can about all relevant psychopharmacological options can serve your patients well.

 

[hallowmann]

Seconding Crayola. Clinicians are not doing research, we are (or should be) implementing evidence based interventions. Becoming "creative" with pharmacology can easily stray into harmful and speculative polypharmacy. You want to avoid magical thinking about medications, and make sure medications are not the hammer that turns every problem into a nail.

With that said, there of course remains a fair amount of grey in prescribing, and a passion for learning everything you can about all relevant psychopharmacological options can serve your patients well.

Just to clarify, when @Bartelby says clinicians aren't doing research, that is true, obviously outside the realm of clinical research. Plenty of people doing studies regulated through their IRBs that are using novel treatments or potentially novel applications of old treatments on certain patient groups.

That said, you as an individual clinician are not meant to be experimenting on patients because you find it interesting. Everytime I use something even a 3rd line or beyond, I have a very extensive conversation with patients about it, potential risks, and alternatives (all patients get some amount of conversation of this with any treatment).

 

[Mass Effect]

I don't know why, but reading what you wrote and the tone, you'll probably be OK but remember to keep in mind the point of medicine isn't to go off the beaten track and do fascinating experiments on your patients. They're human beings, and hopefully the first time you harm someone doing something routine that you expected to go over quite well, will somewhat damper your enthusiasm to "try new things." Which isn't to say that you shouldn't at times. Everything needs to be balanced by the evidence and experience and expectations for good for the patient, as much as possible.

I was reading this thread thinking exactly the same thing.

OP, we don't experiment on our patients. If that's what you want to do, then a career in research seems more appropriate for you. The above posters are right that we sometimes try things, but it should always be in the course of evidence-based options. If you're reaching for metformin monotherapy to treat paranoia associated with schizophrenia, you better be going off something, not just some wild experiment on a patient who's suffering. You also have to explain to patients the risks of such treatments, especially if there's lack of evidence for it.

 

[OldPsychDoc]

Maybe instead of posing it as "experimentation" or "research", which carry pretty specific meanings outside of daily clinical practice, one could frame it as building an alliance, working to understand the full biopsychosocial make up of these unique individuals, and applying our specific knowledge to designing customized treatment plans that fit their unique situations.

If you were to see for the first time a 40-something woman with schizophrenia who is having command hallucinations to kill herself despite therapeutic levels of clozapine augmented with aripiprazole and adequate social supports, you'll probably just want to hospitalize her and snow her with haldol until the voices go away. But if you've been treating her for 10 years (as I have), talk to her mother and PCAs at every visit, know the history of each med we've tried and failed, know her medical issues, know the things that make her happy and sad, etc...THAT's PSYCHIATRY, and I think that that kind of N of 1 "experimentation", based on rational drug choices, is what the OP is asking about.

 

[NickNaylor]

Going off-label and venturing into territories where there is little evidence is not unusual depending on the patients that you're seeing. That said, being "creative" or "testing your skills" (I don't even know what that means) is a potential recipe for bad news if you can't rationally justify what you're doing. I wouldn't see using off-the-wall pharmacotherapy regimens as experimenting. However, sometimes the evidence base will not speak to a particular clinical situation - you might see this in odd presentations or treatment-refractory patients - and you may need to be more "creative" in these cases. These should be the exception rather than the rule, otherwise you're likely just being a poor clinician. And certainly these "creative" practices should always prioritize patient safety.

 

[luckrules]

Can we get someone in here who can speak on the MAO-I + stimulants example? Or just MAO-I in general. I am curious to try MAO-I's in my TRD patients based on some limited readings I've done but have had most supervisors shy away. Ken Gilman's website is pretty low tech but he is certainly compelling in his argument.

 

[robellis]

Can we get someone in here who can speak on the MAO-I + stimulants example? Or just MAO-I in general. I am curious to try MAO-I's in my TRD patients based on some limited readings I've done but have had most supervisors shy away. Ken Gilman's website is pretty low tech but he is certainly compelling in his argument.

Using an MAOI is standard it’s certainly not 1st line but it’s not that out of bounds in terms of treatment for TRD patients

 

[Stagg737]

Can we get someone in here who can speak on the MAO-I + stimulants example? Or just MAO-I in general. I am curious to try MAO-I's in my TRD patients based on some limited readings I've done but have had most supervisors shy away. Ken Gilman's website is pretty low tech but he is certainly compelling in his argument.

Type "Phenelzine" into the search bar and limit results to this forum and you'll find several links (most recent by splik and clausewitz2) on this.

 

[jacob42]

OP, where are you at in your training? It's easier to help when we know what level you're at.



This is literally what we do and seeing manic patients rapidly become stable (in days to weeks) is what initially attracted me to psych.




A lot, and I'd argue that psych is one of the fields least suited to algorithms. Keep in mind we're "specialists", so a lot of referrals to psych are because the PCP tried the algorithms and they don't know what to do/don't want to do it themselves. To the bolded: Yes. Researching augmentation methods should be a primary goal of every resident once they've got the basics down. "Novel" ideas are usually welcome once the evidenced-based options have failed, though I don't think it's too common to really come up with something novel unless you're reaching for meds not generally considered psych meds.




Paging Dr. @splik and Dr. @clausewitz2

Hello!

Thank you very much for your thoughtful response! It’s greatly appreciated. I’m currently a sophomore undergrad, so maybe I shouldn’t be asking/trying to decide this late in my college career (haven’t even started the years-long pre-med pathway, although I’ve been taking some of the courses already just in case). But these responses are extremely informative so maybe it’ll help my indecision out.

Honestly even if it wasn’t a day-to-day thing, but a possibility of doing such things every so often which is somewhat common as you say, then that might be exciting enough to go from engaged to ENGAGED with psych, creating a kind of cyclical system where I learn from patients over the years as they get better, which sounds like a win-win if it’s even somewhat common.

 

[jacob42]

Can we get someone in here who can speak on the MAO-I + stimulants example? Or just MAO-I in general. I am curious to try MAO-I's in my TRD patients based on some limited readings I've done but have had most supervisors shy away. Ken Gilman's website is pretty low tech but he is certainly compelling in his argument.

From what I’ve read MAOIs are superior to TCAs in depression, specially the old definition of “atypical depression” (appetite INcrease, some emotional reaction to positive stimuli, anxious comorbidity, etc.), but something like TCAs might be better for melancholic/“typical” depression and are prioritized over MAOIs (or used to be when these drugs were more used) in cases of suicidality due to quicker response time.

While Gillman has said some wrong things over the years, he’s generally pretty good I think in his overall analysis of drug classes if not the pharmacology itself since he treated patients for decades with these combos as a clinician too. His article on stimulants seems to indicate that NDRIs/DAT inverse agonists like methylphenidate are relatively safe with MAOIs due to lower ability to efflux dopamine vs. amphetamine, which itself has been shown to produce cranial bleeding and death as Gillman mentions in that article I believe. However, he says the risk is a bit overblown (this is his philosophy with everything lol) for MAOI + stimulant therapy, especially methylphenidate. It seems that either stimulant could be used given lower starting doses, slow titrations, and starting both at the same time/doing MAOI washout if needed before.

For example, I’ve seen quite a few TRD case reports with TCP+d-AMP, but obviously this kind of last line despite possible powerful efficacy. Fascinating stuff.

 

[jacob42]

Thank you for the replies everyone! This is extremely informative. It seems there’s a schism here, with some saying that psychopharmacology is part of the job description (or part of distinguishing oneself/improve response rates at least), while people on the other end are saying that this type of application is more of the exception than a rule. I suppose I might have blown my expectations out of proportion, but this schism is still intriguing.

Perhaps working with in-patients would provide me with more extreme cases and therefore warrant more complicated augmentation, but also possibly restrict me on the other hand since creative freedom with these people might be risky. With out-patients I’m guessing it’d be a smorgasbord of patients, some of whom are receptive/warranted for creative “experiments” (as in off-label/pre-adoptive or novel but otherwise safe rather than literal random ideas 😛 ) and other patients not. Im not sure if one sub-type of psych would provide more or less of this type of creative freedom.

On research, I considered/am still considering I guess an MD/PhD, but from what I understand that’s mostly if you’re into research but I suppose there are exceptions and I could be wrong about this. I’m trying to find which I’d like better (research or clinical work), but it seems to me that clinical work with a “research” mindset could produce a higher floor and median of career satisfaction even though maybe not a higher ceiling of satisfaction as compared to a researcher with a “clinical” mindset (the ceiling being I discover some profound research, which might be less likely).

I love the intersection of psychiatry and psychopharmacology so it’s definitely a tough call. Thank you all again for your responses. You’ve all given me good points to think about.

Another factor would be boredom/repetitiveness. Clinical work has the exciting prospect of new and diverse patients since every patient is different, but of course this novelty could wear off as I start to schematize patient symptoms. Another potential positive is the “creative freedom,” but I didn’t know the degree of this (hence this post). Also as a clinician I’d have more independent and not be subject to grant-writing and approval whims for what I wanted to do.
Research work on the other hand I might be “stuck” doing things I don’t want to for a while at least, but I’m guessing once I’d been in it for a while I’d get more control/freedom, but again not sure.

It’d be nice if I could pick one, say clinical, and establish a niche with psychopharmacology.

 

[jacob42]

I don't know why, but reading what you wrote and the tone, you'll probably be OK but remember to keep in mind the point of medicine isn't to go off the beaten track and do fascinating experiments on your patients. They're human beings, and hopefully the first time you harm someone doing something routine that you expected to go over quite well, will somewhat damper your enthusiasm to "try new things." Which isn't to say that you shouldn't at times. Everything needs to be balanced by the evidence and experience and expectations for good for the patient, as much as possible.

I've always ran on the side of being an earlier adopter of things, things that are off-label, etc, but the first time I had a patient suffer predictable and not even serious side effects from something arguably not totally necessary (depending how you look at pain control, they were in significant pain but not pushing for better control), well let's just say your desire to intervene needs to be tempered by first do no harm.

Keep that forefront.

Thank you! You and the few following comments serve as a reality check. I’ll try to keep this all in mind as I’m deciding. It’s definitely a lot of factors to think about!

 

[jacob42]

Maybe instead of posing it as "experimentation" or "research", which carry pretty specific meanings outside of daily clinical practice, one could frame it as building an alliance, working to understand the full biopsychosocial make up of these unique individuals, and applying our specific knowledge to designing customized treatment plans that fit their unique situations.

If you were to see for the first time a 40-something woman with schizophrenia who is having command hallucinations to kill herself despite therapeutic levels of clozapine augmented with aripiprazole and adequate social supports, you'll probably just want to hospitalize her and snow her with haldol until the voices go away. But if you've been treating her for 10 years (as I have), talk to her mother and PCAs at every visit, know the history of each med we've tried and failed, know her medical issues, know the things that make her happy and sad, etc...THAT's PSYCHIATRY, and I think that that kind of N of 1 "experimentation", based on rational drug choices, is what the OP is asking about.

Thank you for your reply! I think you’ve hit the nail on the head in some respect. In my initial post, I referred to it as research and experimentation, but I guess I made it sound like “experiment” ON patients (for my gain) rather than “experiment” FOR/WITH patients (for both our gains, but more importantly theirs).

I think what I meant in retrospect was doing specific research on different medications (from nth-line to off-label to even novel yet safe/possibly indicated) for particular symptoms or symptom clusters my patient might have and trying/experimenting with such meds to optimize the living hell out of their brain (I’m a fan of hyperbole if you can’t tell 🙂 ) and improve their quality of life

I suppose the goal of this “research” would also be to create a mental collective of experiential and anecdotal successes/failures I see with given med/condition/way condition presents combos across many patients to better individualize and optimize treating individual patients, rather than just testing out medication combos just for the sake of discovery alone as in a traditional research role.

PS:
Although I wouldn’t mind being able to direct or at least help run RCTs once in a while for more novel/experimental treatments, if that’s even possible from a clinical standpoint. 😛 I feel like a clinical perspective might give insight into this process and could be synergistic. (And maybe I could use that to help out my severely TRD patients who’ve tried everything else by enrolling them.)

 

[Liquid8]

One of the things that attracted me to psychiatry was that if we take a broad overview, there are only a few diagnostic categories and relatively few classes of treatments available for each. On a basic level the majority of patients will fall into one or more of mood, psychotic or anxiety disorders. The main treatment options can be divided into antidepressants, mood stabilisers, antipsychotics and anxiolytics. There is often some overlap, as you might use an antidepressant in bipolar with mood stabiliers coverage or use drugs like lithium or abilify to augment antidepressants.

Within that space however, is the opportunity to individualise a patient’s treatment. For instance, I have a bipolar patient who gets highly agitated on benzos, can’t take antidepressants and while lithium helps, there is little room to adjust this due to gastrointestinal side effects. Managing her depressive states is different from another bipolar patient where those restrictions don’t apply.

I’d also say “extreme” psychopharmacology is the exception, but those are the ones I remember most because I’ve also had to think about them more. If I only have to switch someone’s SSRIs this happens fairly regularly and there’s little to worry about so it’s not going to register.

OTOH, if a patient doesn’t respond to multiple trials, various augmentation strategies, TCAs, ECT etc – and I have organised a second opinion for a MAOi then I’m not forgetting anytime soon. Those are patients I’m likely to have known for a long period, so would also have a good idea about whether a MAOi is suitable. Other considerations like if there’s a level of impulsiveness and they’re prone to increasing their doses versus being more cautious, or are they able to stick with the dietary restrictions are going to factor into the decision making process but these aren’t things you’ll read about in any treatment algorithm.

Here we have some practitioners who utilise “professorial” doses (Eg. venlafaxine 600mg/day) and on occasion I have sought their opinions on tricky cases that haven’t responded in an expected way. Amongst my peers these figures can be controversial, with some feeling it is only their academic reputation and status that lets them get away with such practices. The one I work with only accepts referrals from other psychiatrists.

 

[J ROD]

Why I put my pharmacy with psychiatry.....

 

[Stagg737]

Hello!

Thank you very much for your thoughtful response! It’s greatly appreciated. I’m currently a sophomore undergrad, so maybe I shouldn’t be asking/trying to decide this late in my college career (haven’t even started the years-long pre-med pathway, although I’ve been taking some of the courses already just in case). But these responses are extremely informative so maybe it’ll help my indecision out.

Honestly even if it wasn’t a day-to-day thing, but a possibility of doing such things every so often which is somewhat common as you say, then that might be exciting enough to go from engaged to ENGAGED with psych, creating a kind of cyclical system where I learn from patients over the years as they get better, which sounds like a win-win if it’s even somewhat common.

The first thing you need to decide is whether you want to be a physician or not. Keep in mind, it's a long way to psychiatry residency with pretty minimal exposure to the field along the common medical education path before this. Do you enjoy anatomy and physiology? Cell bio and biochemistry? Microbiology? Before that physics and chemistry? If not, then your path to psychiatry will be much rougher and likely miserable.

Imo the bolded is part of any field of medicine, but I think psych is particularly suited to this because we deal with more subjective areas of health and there's are many areas where strong data is lacking. There are many pros and cons to this, but it does lend to psychiatry being more flexible in terms of treatment as well as learning from our patients.

 

[ObligateOtter]

Seconding Crayola. Clinicians are not doing research, we are (or should be) implementing evidence based interventions. Becoming "creative" with pharmacology can easily stray into harmful and speculative polypharmacy. You want to avoid magical thinking about medications, and make sure medications are not the hammer that turns every problem into a nail.

With that said, there of course remains a fair amount of grey in prescribing, and a passion for learning everything you can about all relevant psychopharmacological options can serve your patients well.

I'm an M0 so I know I'm naive, but is there a place for instead of experimenting leading to polypharmacy, to experiment with the means of reducing it? I think about the kids dx'd with bipolar who are on like eight meds at a time, and I think it would be really interesting to be the psychiatrist who weans them off it and find a med regimen that fits their needs.

 

[jacob42]

The first thing you need to decide is whether you want to be a physician or not. Keep in mind, it's a long way to psychiatry residency with pretty minimal exposure to the field along the common medical education path before this. Do you enjoy anatomy and physiology? Cell bio and biochemistry? Microbiology? Before that physics and chemistry? If not, then your path to psychiatry will be much rougher and likely miserable.

Imo the bolded is part of any field of medicine, but I think psych is particularly suited to this because we deal with more subjective areas of health and there's are many areas where strong data is lacking. There are many pros and cons to this, but it does lend to psychiatry being more flexible in terms of treatment as well as learning from our patients.

I loved chemistry and physics, though especially chemistry when I studied it in HS and now on my own a bit. I admit I didn’t really like biology at first as a high school freshman, but now that I’m older and in college (and currently taking bio for the first time in years) I’ve grown a new appreciation for it. Especially since psychopharmacology is so rooted in both chemistry and biology that it became extremely interesting to see the intersection. And then that flows into biochem too (which I’ve not taken).

I don’t really have familiarity with anatomy or physiology, but if I looked at it from the perspective I did for biology, where I keep adding on top of related sciences (like for biology I used chem and biochem as a bridge) to see more angles to look at things, I think I would like these as well. I view those different, more specific subjects (like microbiology) as a different, more specific flavor of a subject I already have some familiarity with, and having even a basic background makes the information a lot more connected and engaging. I think I’d be able to keep this going and that is never be bored since I could always find a certain part that I like and can relate to other things.

The niche flexibility of learning potential and treatment in psychiatry like you describe is definitely interesting. Academics isn’t really the main deciding factor of being a physician but more of finding the best fit. I’m in undergrad now, but it’s come to a point where divergence from core classes is necessary.

I think I could see myself as a physician or a researcher—if I was a researcher I’d be happy I think, but not be able to see and feel the direct effect of my work unless I make major discoveries. I wonder that I’d make a bigger impact and take more happiness away from using the existing research and even coming up with some on my own (the “flexibility”/“experimenting”/“research” discussed above, even if it’s only a part of and not the entire job) as a physician, able to make “major discoveries” in/with patients that help them directly respond, both medicinally and therapeutically, than making “major discoveries” by assaying medical data and just hoping I find a result and can identify a novel pattern in data that points me where to research.

It’s also kind of like a both vs only one scenario where as a physician I could utilize a research/psychopharmacological perspective to augment my results, knowledge, and interest in the clinical side with patients. Whereas with research alone, I think the converse isn’t as true—I can’t take my research findings and then apply them directly clinically—I could only submit my work and hope clinicians utilize it or experiment in trials and by surveying only rather than making decision on how best to treat. I can certainly make a decision on what to research, and that does seem to offer more freedom than a clinician (provided I could get funding for my crazy ideas lol), but then the freedom is more limited to the world of research.

There is also the option of a physician-scientist which ought to be perfect in theory—MD/PhD—but from my understanding it’s more of research and then doing clinical work as a side thing to explore different avenues of intellect (which is tempting on its own), but lacks the focus of utilizing research in the clinical setting. I doubt many physician-scientists go from the lab with a new idea treatment idea and then apply it clinically—the timeframe from research to practice is very long and they’d probably be studying more abstract things anyway that weren’t related to psychopharmacology or whatever they did as a clinical as well, where I think my main interest lies—learning and then applying—and doing that in a cyclical nature.

But then there’s the anxiety: would I be good at it? That’s tougher for me to know. I think anyone can be good at anything if they try hard enough, and I like a lot of the field to where I’d no doubt end up liking it, but it seems there’s no way to know if you’d be “good” at something removed from 4 years of information and 3-4 more years of residential practice to test that effect. Looking from the outside in is hard.

 

[90sportsfan]

I loved chemistry and physics, though especially chemistry when I studied it in HS and now on my own a bit. I admit I didn’t really like biology at first as a high school freshman, but now that I’m older and in college (and currently taking bio for the first time in years) I’ve grown a new appreciation for it. Especially since psychopharmacology is so rooted in both chemistry and biology that it became extremely interesting to see the intersection. And then that flows into biochem too (which I’ve not taken).

I don’t really have familiarity with anatomy or physiology, but if I looked at it from the perspective I did for biology, where I keep adding on top of related sciences (like for biology I used chem and biochem as a bridge) to see more angles to look at things, I think I would like these as well. I view those different, more specific subjects (like microbiology) as a different, more specific flavor of a subject I already have some familiarity with, and having even a basic background makes the information a lot more connected and engaging. I think I’d be able to keep this going and that is never be bored since I could always find a certain part that I like and can relate to other things.

The niche flexibility of learning potential and treatment in psychiatry like you describe is definitely interesting. Academics isn’t really the main deciding factor of being a physician but more of finding the best fit. I’m in undergrad now, but it’s come to a point where divergence from core classes is necessary.

I think I could see myself as a physician or a researcher—if I was a researcher I’d be happy I think, but not be able to see and feel the direct effect of my work unless I make major discoveries. I wonder that I’d make a bigger impact and take more happiness away from using the existing research and even coming up with some on my own (the “flexibility”/“experimenting”/“research” discussed above, even if it’s only a part of and not the entire job) as a physician, able to make “major discoveries” in/with patients that help them directly respond, both medicinally and therapeutically, than making “major discoveries” by assaying medical data and just hoping I find a result and can identify a novel pattern in data that points me where to research.

It’s also kind of like a both vs only one scenario where as a physician I could utilize a research/psychopharmacological perspective to augment my results, knowledge, and interest in the clinical side with patients. Whereas with research alone, I think the converse isn’t as true—I can’t take my research findings and then apply them directly clinically—I could only submit my work and hope clinicians utilize it or experiment in trials and by surveying only rather than making decision on how best to treat. I can certainly make a decision on what to research, and that does seem to offer more freedom than a clinician (provided I could get funding for my crazy ideas lol), but then the freedom is more limited to the world of research.

There is also the option of a physician-scientist which ought to be perfect in theory—MD/PhD—but from my understanding it’s more of research and then doing clinical work as a side thing to explore different avenues of intellect (which is tempting on its own), but lacks the focus of utilizing research in the clinical setting. I doubt many physician-scientists go from the lab with a new idea treatment idea and then apply it clinically—the timeframe from research to practice is very long and they’d probably be studying more abstract things anyway that weren’t related to psychopharmacology or whatever they did as a clinical as well, where I think my main interest lies—learning and then applying—and doing that in a cyclical nature.

But then there’s the anxiety: would I be good at it? That’s tougher for me to know. I think anyone can be good at anything if they try hard enough, and I like a lot of the field to where I’d no doubt end up liking it, but it seems there’s no way to know if you’d be “good” at something removed from 4 years of information and 3-4 more years of residential practice to test that effect. Looking from the outside in is hard.

Being a "researcher" is extremely tough nowadays. To get and keep a job (get tenure), you need to bring in federal funding (NIH), and continually bring in grants. It is a rough and tough process for pure researchers. The good thing about being a physician in academics is that because we see patients, we don't have the pressure of chasing after grants (not to mention our pay is significantly higher). We can do research, but except for the rare tenure-track physician-scientist, we can do research that interests us without the pressure of chasing after competitive grants to keep a job. I know some researchers and their lives are brutal.

 

[jacob42]

Being a "researcher" is extremely tough nowadays. To get and keep a job (get tenure), you need to bring in federal funding (NIH), and continually bring in grants. It is a rough and tough process for pure researchers. The good thing about being a physician in academics is that because we see patients, we don't have the pressure of chasing after grants (not to mention our pay is significantly higher). We can do research, but except for the rare tenure-track physician-scientist, we can do research that interests us without the pressure of chasing after competitive grants to keep a job. I know some researchers and their lives are brutal.

Oh this is interesting. Is this referring to an MD/PhD role or just a clinician doing research at the same time, with just MD?

 

[90sportsfan]

Oh this is interesting. Is this referring to an MD/PhD role or just a clinician doing research at the same time, with just MD?

Being an MD/PhD is not a "role." It just means you have both degrees. I'm assuming you are thinking about a tenure track physician-scientist when you say "role" (which you have to earn through your research credentials and won't automatically get just by being a MD/PhD).

An MD/PhD puts you in a better position to secure a physician-scientist track during residency and depending on whether or not you are successful after residency/fellowship in securing a K grant (which are very competitive and hard to get even for MD/PhDs) , it may put you in a good position to get a rare tenure track position that allows for a lot of protected research time (I.e. a physician-scientist position). That is the "role" you seem to be referring to.

If you're lucky enough to get that competitive role, you will then need to bring in NIH funding (get grants) to achieve tenure and keep that "role." NIH funding is cutthroat and you will be competing against the best of the best so it's not easy and many do not achieve tenure. They will then need to go back to a more traditional clinical patient load (I.e, they will lose the protected reasearch time). But that is a better outcome than the pure PhD who is let go of they don't achieve tenure......

 

[Mass Effect]

Perhaps working with in-patients would provide me with more extreme cases and therefore warrant more complicated augmentation, but also possibly restrict me on the other hand since creative freedom with these people might be risky. With out-patients I’m guessing it’d be a smorgasbord of patients, some of whom are receptive/warranted for creative “experiments” (as in off-label/pre-adoptive or novel but otherwise safe rather than literal random ideas 😛 ) and other patients not. Im not sure if one sub-type of psych would provide more or less of this type of creative freedom.

On research, I considered/am still considering I guess an MD/PhD, but from what I understand that’s mostly if you’re into research but I suppose there are exceptions and I could be wrong about this. I’m trying to find which I’d like better (research or clinical work), but it seems to me that clinical work with a “research” mindset could produce a higher floor and median of career satisfaction even though maybe not a higher ceiling of satisfaction as compared to a researcher with a “clinical” mindset (the ceiling being I discover some profound research, which might be less likely).

I love the intersection of psychiatry and psychopharmacology so it’s definitely a tough call. Thank you all again for your responses. You’ve all given me good points to think about.

Another factor would be boredom/repetitiveness. Clinical work has the exciting prospect of new and diverse patients since every patient is different, but of course this novelty could wear off as I start to schematize patient symptoms. Another potential positive is the “creative freedom,” but I didn’t know the degree of this (hence this post). Also as a clinician I’d have more independent and not be subject to grant-writing and approval whims for what I wanted to do.

I don't know dude, your posts are rubbing me the wrong way. These people are very sick and vulnerable and passages like what I bolded above and "Also as a clinician I’d have more independent and not be subject to grant-writing and approval whims for what I wanted to do" makes it sound like the only reason you want to be a psychiatrist is to have "creative freedom" and experiment without the hassle of doing legitimate IRB-approved research. It legit sounds like you get a rush from the experimentation and that actually scares me and makes me want to tell you to go into another field where the patients aren't as cognitively impaired as some psych patients are.

 

[Mass Effect]

I'm an M0 so I know I'm naive, but is there a place for instead of experimenting leading to polypharmacy, to experiment with the means of reducing it? I think about the kids dx'd with bipolar who are on like eight meds at a time, and I think it would be really interesting to be the psychiatrist who weans them off it and find a med regimen that fits their needs.

This is literally what we do every single day. I've never seen 8 meds to treat bipolar disorder (maybe some meds to treat the side effects of the main bipolar med(s)). No psychiatrist worth their salt is keeping people on 8 meds to treat one disorder. Some NPs maybe or super terrible psychiatrists who shouldn't be practicing. The rest of us are all trying to "find a med regimen that fits their needs". This isn't novel.

 

[LaSabre]

I use drugs to modulate dopamine, serotonin, norepinephrine, muscarinic, histaminergic, NMDA, AMPA, and alpha receptors on a daily basis.

I also prescribe drugs that modulate glucagon and beta cells when I treat diabetes, alpha and beta receptors and HMG-CoA reductase when I treat hypertension.

Lastly, I give drugs that modulate calcium channels, opiate and NMDA receptors, cyclooxygenase enzymes, prostaglandin, substance P, norepinephrine and serotonin pathways when I treat pain.

Psych issues, hypertension, diabetes and pain are the most common things I treat in psychiatry.

 

[90sportsfan]

I don't know dude, your posts are rubbing me the wrong way. These people are very sick and vulnerable and passages like what I bolded above and "Also as a clinician I’d have more independent and not be subject to grant-writing and approval whims for what I wanted to do" makes it sound like the only reason you want to be a psychiatrist is to have "creative freedom" and experiment without the hassle of doing legitimate IRB-approved research. It legit sounds like you get a rush from the experimentation and that actually scares me and makes me want to tell you to go into another field where the patients aren't as cognitively impaired as some psych patients are.

Yeah, it sounds like (as he mentioned in his OP) he is just considering medicine at this point, but isn’t very sure. But I think you hit the nail on the head that if he’s considering medicine, his primary interest should be patient care and clinical medicine. That’s what you are trained in. If he’s leaning towards research, the PhD is the better route but that comes with its own set of challenges (mainly the pressures of securing federal funding to get tenure).

It sounds like he’s considering medicine to avoid some of those pressures, but that isn’t a good reason to pursue medicine IMO. If you are interested in patient care aspects of Psych and have a research interest, that is great. But being an MD, our primary focus is patient care and even in an academic/research career you are going to have to do a good amount of clinical medicine (unless you are a research all-star who can secure a few R01s and buy out your clinical time- which is extremely rare and difficult).