I don't feel like a 'doctor' :(

[Sharpie1]

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Sometimes I really miss real medicine... I'm only a couple of weeks into intern year and I know I'd hate it if I were doing anything else... but I was between psychiatry and pediatrics and some moments I just wish I chose pediatrics! Does anyone else have these feelings?

 

[vistaril]

Sometimes I really miss real medicine... I'm only a couple of weeks into intern year and I know I'd hate it if I were doing anything else... but I was between psychiatry and pediatrics and some moments I just wish I chose pediatrics! Does anyone else have these feelings?

it's something you're just going to have to get used to if you continue psychiatry. Personally I was someone who never enjoyed "real medicine" to begin with. Im puzzled as to why people who do would do psychiatry.

another thing: some of us(like myself) had no interest in doing something in other areas of medicine. Others, apparently like you, had a tough time deciding between real medicine and psychiatry. You're going to have to understand that it doesn't matter how close you were to picking pediatrics. You didn't, and that's all that matters.

 

[diagonal]

If you really love medicine, you probably wouldn't have chosen psych. I'm going to venture a guess and say that it's your ego talking. You realize you're going to lose the fluency of "real medicine" and as such will be unable to wow people you meet with your "medical" knowledge - manifested either as advice, conversation, or simply the words you use.

I'm not being raggy btw. I think it's a genuine phenomenon for someone that went through medical school. They want the world to know they're a real doctor, but when you stop dealing in the land of electrolytes, CTs, and blood cultures, people tend to second-guess your status as physician.

Over time this will go away and you'll probably be happy knowing you chose a specialty that provides genuine quality of life benefits to many patients, while simultaneously giving you control over your own life.

 

[vistaril]

If you really love medicine, you probably wouldn't have chosen psych. I'm going to venture a guess and say that it's your ego talking. You realize you're going to lose the fluency of "real medicine" and as such will be unable to wow people you meet with your "medical" knowledge - manifested either as advice, conversation, or simply the words you use.

I'm not being raggy btw. I think it's a genuine phenomenon for someone that went through medical school. They want the world to know they're a real doctor, but when you stop dealing in the land of electrolytes, CTs, and blood cultures, people tend to second-guess your status as physician.

Over time this will go away and you'll probably be happy knowing you chose a specialty that provides genuine quality of life benefits to many patients, while simultaneously giving you control over your own life.

mostly quality post......I really question how 50/50 many of these people were.

As for the "control over your own life" bit, maybe this is true in some things....like really malignant obgyn programs for example. But my fiance is a GI fellow, and although works more hours than me(in terms of my program requirements...I moonlight a ton), she has a reasonable schedule.....most people in other medical specialties do as well, with exceptions. My fiance, for example, does at home call when she is on(which is about once a week) and about 30% of the time she actually has to end up going into the hospital...which comes about to about once every three weeks. She works less than 1 weekend per month(sometimes 1, sometimes 0) and even when she does they arent full days......her schedule is not remarkably different from the other procedural based medicine fellows either.....

what Im saying is I think a lot of people tell themselves they didnt go into "real medicine" by citing lifestyle/hours, but I dont know how true this is. I think some people are ashamed to say, maybe because they did go to medical school, that "medicine stuff"
just really doesnt interest them....

 

[PistolPete]

Or you can do C-L/psychosomatics and get a nice blend of IM and psych...

 

[vistaril]

Or you can do C-L/psychosomatics and get a nice blend of IM and psych...

that's absurd.....just because you're making psych recs on medically ill patients does not mean it is "a nice blend" of IM and psych

if C-L required such, the ideal people to do it would be people with training in both medicine and psychiatry. These people arent that uncommon out there, and yet most dont even work on their depts C-L service

 

[DD214_DOC]

I like real medicine too, and I'm apparently pretty good at it judging from my intern year feedback. However, I still enjoy psychiatry a lot more. It's open to a lot of interpretation and analysis (no pun intended) and less about what you have memorized and more about applying theories to reality. It's also a lot more satisfying to help save a couple's marriage or help a man enjoy his family again than to drop someone's A1c a couple points. Today, I did individual therapy on a patient with dysthymia and restarted her meds, did marital therapy on a couple at the precipice of divorce, therapized and started a man on medications who is so depressed he has no emotional connection to his family or desire to spend time with them, and thank by a former patient in the hallway for giving her life back to her.

Plus it's nice being a specialist. Remember, psychiatrists know a little bit about medicine, but internists apparently know nothing of psychiatry.

With regards to C/L, it helps to stay abreast of your medical knowledge for many reasons, the least of which being medication interactions. Many, many medical issues have neuropsychiatric manifestations and sometimes you will be consulted on a patient with a, "psych issue" who turns out to really have a medical issue. Our C/L team has diagnosed a patient with vocal cord dyskinesia after being consulted for possible factitious disorder or panic disorder.

I wanted to add, 3 months ago on the inpatient psych ward I had a hypotensive patient I was called to evaluate. I did an evaluation, diagnosed the problem, ordered the appropriate labs and began fluid resuscitation on the patient ON THE PSYCH WARD. Because we don't have IVs on the ward available for use, I had to be creative (I called an RRT just to have them show up and get access to their stuff). I realized they also carry an iStat around and I ordered a CBC on it, knowing that they tend to read low, because I noticed some bruising on the patient that was unusual and appeared recent. Turns out she was severely hypovolemic with internal bleeding from a broken hip. I escorted her to the PCU in case she crashed. That whole time, I was the only physician available. Nobody ever said, "You're not a real doctor"

 

[whopper]

that's absurd.....just because you're making psych recs on medically ill patients does not mean it is "a nice blend" of IM and psych

If you find that absurd, that's your opinion but plenty do find a good mix with IM and psychiatry doing consults. The reason being obvious, you need to take into consideration the patient's medical history, medical treatments, and factor that into your psychiatric recommendations. Vistaril, I recommend if you find certain people's comments "absurd" explain why because without doing so it's just a step above name-calling. Citing a difference of opinion explaining your reasoning, now that's different.

You mentioned before that you found your style of "confrontation" effective. Several here don't, and I will not tolerate someone creating an atmosphere that discourages others from participating. I actually want you to continue posting your own opinions, even disagreements, but don't want you rehashing that little incident a few weeks ago where you kicked a guy while he was down when asking for advice.

Hey, what program are you in? You kept mentioning it, I'd like to know.

As for "real medicine" a lot of fields tend to get encapsulated in their own specialty. E.g. and I'm not joking, a cousin of mine has two parents that are anesthesiologists and they gave him an IV whenever he was sick as a kid. No I'm not joking.

Psychiatry, however, IMHO tends to get a bit further removed from IM vs the other medical fields. Geriatric psych you see a lot more IM with most patients having multiple medical problems.

 

[peppy]

Psychosomatic medicine requires understanding medicine well enough to evaluate if
the medical team has done a complete workup to rule out medical causes for the symptoms (no, you can't just trust the medicine team to cover all the bases) and it also requires you to make intelligent recommendations for the right medication in people who may have comorbid conditions that are contraindications to the usual medication of choice. I definitely think that someone with a strong interest in other areas of medicine would do well in psychosomatic medicine.

Another option might be looking at a fellowship in Palliative Care after you finish your psych residency. Nothing is closer to "real medicine" than trying to ease suffering if you ask me.

Sleep Medicine and Pain Medicine are tougher roads for those who started in psych from what people here say, but still potential options.

Oh, and if it's just that you miss working with kids, don't forget that Child Psych is in very high demand these days.

 

[vistaril]

If you find that absurd, that's your opinion but plenty do find a good mix with IM and psychiatry doing consults.
.

I hear that a lot, but what does the "good mix" referring to....like a specific example. The example I most hear is something like a really bad diabetic in DKA who also has some axis1 d/o. I dont have to know how to manage DKA...that would be the "mix". All I have to do is make recs that are in line with out of control diabetes. And consult or not, that's very basic knowledge about psych drugs that every psychiatrist should know at a minimum...whether they do C-L or not.


the C-L people on our faculty are fabulous imo, but they certainly dont have any training in medicine, surgery, etc.....C-L psych is in some ways a different skill set, but I would argue that those differences dont come about from the "mix" of medicine and psych but rather from the nature of the C-L service needing to work with the other service....this is, however, much different than a mix of the two.

 

[whopper]

While in residency, as a chief, I set up a lot of lectures for the IM residents on my own. The IM residents, later attendings called me up and started asking me for input on cases. The interfacing between the IM and psychiatry dept was lacking. The psych attendings didn't get along with the IM attendings and no one was doing anything to bridge that gap on the attending side.

If you become an attending in a medical hospital, you could do the same. Work in consults, good relationships with the other attendings, and be of assistance in cases where you work together. I didn't feel far removed from IM when I was doing that.

 

[vistaril]

Psychosomatic medicine requires understanding medicine well enough to evaluate if
the medical team has done a complete workup to rule out medical causes for the symptoms (no, you can't just trust the medicine team to cover all the bases)

this is applicable when I'm deciding whether I will accept a pt......but that's different than helping the medical team decide what they need in order to complete the workup.

sometimes our attendings have made recs(usually involving imaging, eeg, or lp.....neuro often does the same thing) that the medicine team has already evaluated and decided that they are not indicated. At no point has psych(and to be fair usually neuro too) every come by and done a consult and medicine's response has been: a ct? really? by golly I never thought of that for this pt...Im sure now that we've gotten it it will alter clinical course.

now medicine may actually do those things to help facilitate dispo to us or neuro....but medicine would find it hilarious that we help them determine the etiology of something. Thats not really what they are asking us to do.

 

[whopper]

I hear that a lot, but what does the "good mix" referring to....like a specific example. The example I most hear is something like a really bad diabetic in DKA who also has some axis1 d/o. I dont have to know how to manage DKA...that would be the "mix". All I have to do is make recs that are in line with out of control diabetes. And consult or not, that's very basic knowledge about psych drugs that every psychiatrist should know at a minimum...whether they do C-L or not.

Well then why call it "absurd" if you're not sure what's the reference?

Actually, you explaining your reasoning is perfectly fine and what I want you writing. What I don't want is someone making negative judgments upon others without explaining the reasoning. So long as you do that, I'm fine..(I think). Though I still disagree...

I dont have to know how to manage DKA...that would be the "mix"

I still think you do. The reasoning being that the psychiatric intervention you could recommend could be one that affects the metabolic system the least or has the least amount of negative interactions with the meds being used to treat the DKA.

 

[vistaril]

Well then why call it "absurd" if you're not sure what's the reference?

Actually, you explaining your reasoning is perfectly fine and what I want you writing. What I don't want is someone making negative judgments upon others without explaining the reasoning. So long as you do that, I'm fine..(I think).

I suppose I could have written that better.....a lot of people(usually students going into psych, residents who havent even done c-l yet, and sometimes attendings who dont do c-l) use vague phrases(like mix of medicine and psych) which suggest that C-L psychiatry involves phsyician level management of medical and psychiatric isssues. This is not true. I'm not good at medicine and have little interest in medicine, and I can confidently say I was and am pretty darn good at C-L psych. I'm the person who medicine and surgery services always want to talk to when they have a consult they really care about, and I frequently get paged when Im off service because they respect me clinical judgement so much.....

 

[Sharpie1]

Thank you for all of your posts. I think I do miss kids mostly. I actually really disliked my pediatrics rotation becuase I didn't like the medicine of it, but was able to stand it because the kids are so darn cute... and I hated all other rotations even more. I chose psychiatry because it was the only field I enjoyed, and I think I am now getting cold feet (is it too late for cold feet?) because I'm missing the kids... There's no way I'd switch to any field right now, I kept a diary of my third year rotations and upon referencing that, I see I was quite disappointed with pediatrics overall.

 

[Leo Aquarius]

I miss trying to identify lesion locations in neurology, heart murmurs in cardiology, and chemotherapy regimens in oncology. But alas I am in psychiatry and feel underwhelmed by the lack of medicine right now. My wife says it's because I'm too smart. Not sure about that. But I do love the essential aspects of psychiatry that really resonate with me...

So what did I do? I talked to an attending I feel close to and he told me how important his work is and the various ways he uses medical knowledge on a daily basis. So I keep remembering that it will get better. I'm just a month into my PGY1 year too and can relate to your pangs.

 

[michaelrack]

that's absurd.....just because you're making psych recs on medically ill patients does not mean it is "a nice blend" of IM and psych

if C-L required such, the ideal people to do it would be people with training in both medicine and psychiatry. These people arent that uncommon out there, and yet most dont even work on their depts C-L service

Docs with combined med/psych training used to do a lot more C-L before it became its own subspecialty with its own boards. A lot of older (age 38+) med/psych docs did do c-l; some including myself grandfathered into the boards.

 

[OldPsychDoc]

Thank you for all of your posts. I think I do miss kids mostly. I actually really disliked my pediatrics rotation becuase I didn't like the medicine of it, but was able to stand it because the kids are so darn cute... and I hated all other rotations even more. I chose psychiatry because it was the only field I enjoyed, and I think I am now getting cold feet (is it too late for cold feet?) because I'm missing the kids... There's no way I'd switch to any field right now, I kept a diary of my third year rotations and upon referencing that, I see I was quite disappointed with pediatrics overall.

I suppose you could find a local charity clinic to volunteer for. A couple of hours of ear checks and constipation histories, and you might just be back to loving our oppositional borderlines and goofy manics again!

 

[vistaril]

I miss trying to identify lesion locations in neurology, heart murmurs in cardiology, and chemotherapy regimens in oncology. But alas I am in psychiatry and feel underwhelmed by the lack of medicine right now. My wife says it's because I'm too smart. Not sure about that. But I do love the essential aspects of psychiatry that really resonate with me...

So what did I do? I talked to an attending I feel close to and he told me how important his work is and the various ways he uses medical knowledge on a daily basis. So I keep remembering that it will get better. I'm just a month into my PGY1 year too and can relate to your pangs.

ummm...if you're a month into your pgy-1 year you do more medicine on psych services now than you will do at any point in your career.

Right now I work in an academic hospital as a pgy-4, and I also moonlight a good bit(mostly inpatient) at a private hospital.....the amount of medicine stuff done on a psych service is more at the academic hospital. The psychiatrists who work inpatient at a private/community hospital are far more likely to consult out for even the smallest things, such as correcting someone's potassium(!)

if you're a pgy-1 now and you think you are going to be doing more medicine as your career progresses, you are very mistaken.

 

[vistaril]

Docs with combined med/psych training used to do a lot more C-L before it became its own subspecialty with its own boards. A lot of older (age 38+) med/psych docs did do c-l; some including myself grandfathered into the boards.

yep that's what I've heard as well.....I imagine people trained in med-psych would be the best at it, and could actually go beyond what the typical C-L psych does and help the medicine team figure out something, rather than(99% of the time) just help the medicine team manage something.

 

[vistaril]

and formulated ridiculous differentials when bored, such as suggesting my pregnant catatonic patient actually had a molar pregnancy throwing off anti-NMDA receptor antibodies!
!

I think you need to look for better stuff to do when you are bored at work

We are paid(or going to be paid for those of you who havent started actually working for real money yet) to do psychiatry.....not to do psychiatry and function at 40% the abilities of a good internist.

 

[vistaril]

Thank you for all of your posts. I think I do miss kids mostly. I actually really disliked my pediatrics rotation becuase I didn't like the medicine of it, but was able to stand it because the kids are so darn cute... and I hated all other rotations even more. I chose psychiatry because it was the only field I enjoyed, and I think I am now getting cold feet (is it too late for cold feet?) because I'm missing the kids... There's no way I'd switch to any field right now, I kept a diary of my third year rotations and upon referencing that, I see I was quite disappointed with pediatrics overall.

this really doesn't jive with what you wrote in the original post.

in my experience a very high number of psych residents really disliked medical rotations(except for psych), and thats why they chose psych.....

 

[digitlnoize]

this really doesn't jive with what you wrote in the original post.

in my experience a very high number of psych residents really disliked medical rotations(except for psych), and thats why they chose psych.....

I think this is multifactorial and also dependent on where you are.

At my place, and with most people I met on the interview trail, the consensus was that we all liked IM, but liked psych a lot more, for various reasons. The reasons are likely different for everyone, but most people prefer psych hours, psych pathology, or the "focused" nature of psych compared with IM...or some combo of the above.

You could add many things to this list, but I don't know if I could say it's a high number. I could've have been happy as a hospitalist...but I definitely PREFER psych.

 

[diagonal]

I think this is multifactorial and also dependent on where you are.

At my place, and with most people I met on the interview trail, the consensus was that we all liked IM, but liked psych a lot more, for various reasons. The reasons are likely different for everyone, but most people prefer psych hours, psych pathology, or the "focused" nature of psych compared with IM...or some combo of the above.

You could add many things to this list, but I don't know if I could say it's a high number. I could've have been happy as a hospitalist...but I definitely PREFER psych.

Med students, especially those sitting around in a psych interview pool, are all going to talk that BS about "liking IM too." It's so they aren't seen as someone that couldn't hack IM. Or to prove to the room that they have just as much IM aptitude as the Indian dude sitting next to them in class, but their particular flavor of genius favored psych because they're Jung incarnate.

 

[notdeadyet]

in my experience a very high number of psych residents really disliked medical rotations(except for psych), and thats why they chose psych.....

You will definitely find psych residents like this. They are heavily represented at the programs who fill with warm bodies. You will meet a couple that slip through at mediocre programs. You won't see them at the good programs.

People who make up the cadre of I-hate-all-medicine-guess-i'll-do-psych make up a small portion of psychiatrists. If you're seeing lots of them, Vistaril, you're just not at a good shop.

If I had a $0.05 every time you started a post "in my experience" and I was left wondering "where the hell is he training?..."

 

[vistaril]

You will definitely find psych residents like this. They are heavily represented at the programs who fill with warm bodies. You will meet a couple that slip through at mediocre programs. You won't see them at the good programs.

People who make up the cadre of I-hate-all-medicine-guess-i'll-do-psych make up a small portion of psychiatrists. If you're seeing lots of them, Vistaril, you're just not at a good shop.

If I had a $0.05 every time you started a post "in my experience" and I was left wondering "where the hell is he training?..."

well I don't know what to say....you're clearly either misrepresenting or a bit delusional.

 

[Leo Aquarius]

You will definitely find psych residents like this. They are heavily represented at the programs who fill with warm bodies. You will meet a couple that slip through at mediocre programs. You won't see them at the good programs.

People who make up the cadre of I-hate-all-medicine-guess-i'll-do-psych make up a small portion of psychiatrists. If you're seeing lots of them, Vistaril, you're just not at a good shop.

If I had a $0.05 every time you started a post "in my experience" and I was left wondering "where the hell is he training?..."

I have to agree. Every time I see Vistaril show up here visions of a funeral with violins playing appear. Look out, here's Debbie Downer.

 

[notdeadyet]

There is an easy way to sort this out, Vistaril:

Ask folks on SDN who go to great programs what percentage of their class couldn't stand any medical school clinical rotations and wound up in psych as a last resort. Then ask the same question of folks who go to average programs. Then ask the same question of folks who go to poor programs.

You'll find that the only folks who site "many" are going to be the ones who go to poor programs. I don't know anybody like that at the great program I go to. I don't know of folks who complain of this who go to good programs that I'm familiar with. I've heard a couple folks complain of this, but only in reference to programs that are the ones that take a warm body.

If you're really curious to broaden your experience, you could start a poll.

 

[notdeadyet]

Sometimes I really miss real medicine...

Sharpie- I said "I sure miss medicine" and "I don't feel like a real doctor" all the time during intern year.

I said it on my inpatient psych rotations. I said it during internal medicine. I said it during neurology. I said it in primary care clinic. I said it in the ER.

I said it when I was functioning as a social worker trying to work out the best dispo for my geriatric CAD patient. And as a nurse when I was trying to flush lines and find materiels to start a new IV. And playing referee in a family meeting for who would care for a newly demented woman. And pharmacist trying to identify exactly WHAT drugs my patient had OD'd on. And traffic cop trying to negotiate creative transfers that made sense to open up one more bed on my unit. And MRI machine as I did a late night neuro exam solely for the function of verifying the localization of a lesion that the MRI report was about to show. And scribe as I wrote yet another note. And priest bearing witness to the last confession of someone who was convinced he was about to die.

But you know what happens? You find that your definition of what a doctor is and what constitutes medicine changes with time. After all the hours spent doing the hands on and the grunt work, you start to learn that being a doctor is much more about leadership, ethics, accountability, compassion, and the ability to make on-the-spot decisions based on a ridiculously large number of variables that will draw off your knowledgebase, experience, and creativity. You're going to find that by the time intern year is over your definition of what constitutes being a doctor will have changed and any lingering buyer's remorse you had when you started has faded away.

Hang in there.

 

[OldPsychDoc]

Sharpie- I said "I sure miss medicine" and "I don't feel like a real doctor" all the time during intern year.

I said it on my inpatient psych rotations. I said it during internal medicine. I said it during neurology. I said it in primary care clinic. I said it in the ER.

I said it when I was functioning as a social worker trying to work out the best dispo for my geriatric CAD patient. And as a nurse when I was trying to flush lines and find materiels to start a new IV. And playing referee in a family meeting for who would care for a newly demented woman. And pharmacist trying to identify exactly WHAT drugs my patient had OD'd on. And traffic cop trying to negotiate creative transfers that made sense to open up one more bed on my unit. And MRI machine as I did a late night neuro exam solely for the function of verifying the localization of a lesion that the MRI report was about to show. And scribe as I wrote yet another note. And priest bearing witness to the last confession of someone who was convinced he was about to die.

But you know what happens? You find that your definition of what a doctor is and what constitutes medicine changes with time. After all the hours spent doing the hands on and the grunt work, you start to learn that being a doctor is much more about leadership, ethics, accountability, compassion, and the ability to make on-the-spot decisions based on a ridiculously large number of variables that will draw off your knowledgebase, experience, and creativity. You're going to find that by the time intern year is over your definition of what constitutes being a doctor will have changed and any lingering buyer's remorse you had when you started has faded away.

Hang in there.

Quality post--I think that that was one thing I found that I did love about psych--from one patient to the next moving between roles as priest/confessor, social worker, problem-solver, comforter, educator, leader, and, oh yeah, prescriber....

I could've done IM, probably would've liked it--but geez...diabetic feet. And PGY3 lifestyle?
Thought about radiology--I have a PhD in neuroanatomy--but even as a med student, it felt too lonely. (And I also learned I'm really not driven to do research.)
Ultimately, I'm just delighted that I chose psych. Wish I'd chosen it earlier in life.

 

[Shufflin]

I'm at a great program in Southern California and my intern class decided on psych as a first resort, not a last one. Many of us enjoyed other rotations in medical school, but were naturally drawn more to psych than to any other field.

I personally was strongly considering EM and neurosurgery as career choices had psych not existed.

 

[vistaril]

Quality post--I think that that was one thing I found that I did love about psych--from one patient to the next moving between roles as priest/confessor, social worker, problem-solver, comforter, educator, leader, and, oh yeah, prescriber....

I could've done IM, probably would've liked it--but geez...diabetic feet. And PGY3 lifestyle?
.

the pgy3 lifestyle in *some* IM programs is unreal good. There is a large variation between programs in how many electives they allow.

Some community IM programs literally only require 2-3 months of wards/ICU as a pgy-3, with the rest spent doing "electives" that may involve working as little as an hour or two a day and then going to moonlight. Otoh, some programs require 7+ months of wards/ICU as a pgy-3......

most decent students who are american grads shouldnt base whether to do IM based on whether they want to be an internist, but whether they want to be a cardiologist, gastoenterologist,etc......my fiance hates internal medicine and has no intention of practicing it(as you imply who wants to deal with a run of the mill diabetic foot), but the day to day work of GI she enjoys.....

 

[vistaril]

I'm at a great program in Southern California and my intern class decided on psych as a first resort, not a last one. Many of us enjoyed other rotations in medical school, but were naturally drawn more to psych than to any other field.

I personally was strongly considering EM and neurosurgery as career choices had psych not existed.

yeah...the neurosurgery vs psych dilemna really was a tough one for me too. In particular I knew I would miss gamma knife radiosurgery, but fortunately I could keep in touch with gamma knife radiosurgery and other neurosurgery related things by doing C-L......sarcasm for those of you who didnt catch it

look, Im just going to slide out of these threads in the future on issues like this. I don't think it's productive, and you guys know how I feel. I do enjoy many of the discussions relating to specific practice guidelines in psych, clinical questions, drugs, etc and will of course continue to participate in them.....

 

[Shufflin]

My interest wasn't just a whim. My research in neurosurgery became a presentation at a conference, and my strongest LOR came from a top neurosurgeon.

... it was funny, but during a residency interview the program director asked if I was secretly applying to NS programs and was using psych as a back-up. It took some talking to convince him otherwise.

 

[vistaril]

My interest wasn't just a whim. My research in neurosurgery became a presentation at a conference, and my strongest LOR came from a top neurosurgeon.

... it was funny, but during a residency interview the program director asked if I was secretly applying to NS programs and was using psych as a back-up. It took some talking to convince him otherwise.

it's just unusual that except for both dealing with the central nervous system(in a way I guess), psychiatry and neurosurgery couldn't be more different fields in about every way.

 

[notdeadyet]

it's just unusual that except for both dealing with the central nervous system(in a way I guess), psychiatry and neurosurgery couldn't be more different fields in about every way.

Very true. It's always interesting hearing folks' alternate specialty choices. For many other fields, it's pretty predictable ("I went into NSG but also thought about CT..."), but I'm always interested in hearing it from psychiatrists, as I think I've heard just about every other specialty listed by now.

Ironically, because of the give-up-the-stethoscope thing and other ego issues, I think there is a higher barrier of entry for psychiatry compared to other fields. This is probably why you see a lot more people leave other specialties and come to psychiatry (which often sounded to be their first choice) and very few people leave psychiatry and head to other specialties.

 

[dl2dp2]

Sometimes I really miss real medicine... I'm only a couple of weeks into intern year and I know I'd hate it if I were doing anything else... but I was between psychiatry and pediatrics and some moments I just wish I chose pediatrics! Does anyone else have these feelings?

If you really like children and like psychiatry but dislike pediatrics, I think child psych, rather than CL, might be a better fit for you.

The other thing is that you should realize that an outpatient psychopharm practice is actually very "doctorly". It's very similar to a primary care office, and instead of doing history/physical/lab tests, you do mental status/measurement based care instruments/a few lab tests. You write prescriptions and call in meds, and measure BP check labs and EKGs. Nobody would think of you as not a doctor. Outpatient therapy is also quite fun, and that's where the "art" aspect of the practice comes in.

And in terms of technical knowledge, sure you can practice mediocre psychopharm with bare bones knowledge, but to be a really good psychopharm you probably need to get a substantial body of experience and book smarts, which might translate to you as being "doctorly". Other more specialized fields such as child, substance, women's health, etc. clearly require a separate body of knowledge for their own set of medications issues.

 

[surftheiop]

it's just unusual that except for both dealing with the central nervous system(in a way I guess), psychiatry and neurosurgery couldn't be more different fields in about every way.

Why is it so suprising to you that a lot of people have wide interests that would make them enjoy a number of different fields for different reasons or wide skill sets that could be applied to many fields?

I've always enjoyed school/learning so going into college I considered almost everything (psychology,physics, pre-law, econ, pre-seminary, etc.), except pre-med because medicine wasn't even on my radar, but ended up doing engineering because I knew job prospects were good at the time.

I used to be an engineer (guess I still am?), and of all medical fields psychiatry is probably the thing furthest away from the engineering sterotype, but yet its the field that I find the most interesting so far. Yes, surgery/radiology (especially IR) also appeal in other ways to the engineer in me, but I don't see anything wrong with having interests in lots of different things.

 

[beezley]

From notdeadyet:
"You find that your definition of what a doctor is and what constitutes medicine changes with time. After all the hours spent doing the hands on and the grunt work, you start to learn that being a doctor is much more about leadership, ethics, accountability, compassion, and the ability to make on-the-spot decisions based on a ridiculously large number of variables that will draw off your knowledgebase, experience, and creativity. You're going to find that by the time intern year is over your definition of what constitutes being a doctor will have changed and any lingering buyer's remorse you had when you started has faded away."

Really really love this. And quite true. I actually love'd being the only MD in the room today during our DBT group facilitator weekly meeting, as the only one in a room of psychologists you have a unique perspective to offer.

I loved surgery BTW, radiology, just about everything else, but psychiatry just seemed to have a lot more fun well-rounded people in it, and I don't think a week goes by were I don't think to myself how much I love my job. (4th year resident now)

And the advocacy we do on behalf of our patients with their PCPs requires that we have a sound medical knowledge base.

 

[vistaril]

Very true. It's always interesting hearing folks' alternate specialty choices. For many other fields, it's pretty predictable ("I went into NSG but also thought about CT..."), but I'm always interested in hearing it from psychiatrists, as I think I've heard just about every other specialty listed by now.

Ironically, because of the give-up-the-stethoscope thing and other ego issues, I think there is a higher barrier of entry for psychiatry compared to other fields. This is probably why you see a lot more people leave other specialties and come to psychiatry (which often sounded to be their first choice) and very few people leave psychiatry and head to other specialties.

a lot of people transfer specialties in general because they have had some "adverse event" happen to their careers......be it addicition, substandard evals leading to remediation, etc.....

given that, when they leave(either by choice or not) their current specialty, they are obviously going to have to go "down" the competitiveness ladder.......psych, being one of the least competitive specialties, is a nice resting place.

Psych, seeing how it is seen as most unlike "real medicine", is also a good resting place for people who feel "real medicine" is not for them after starting whatever other residency......

 

[vistaril]

The other thing is that you should realize that an outpatient psychopharm practice is actually very "doctorly". It's very similar to a primary care office, and instead of doing history/physical/lab tests, you do mental status/measurement based care instruments/a few lab tests. You write prescriptions and call in meds, and measure BP check labs and EKGs. Nobody would think of you as not a doctor. Outpatient therapy is also quite fun, and that's where the "art" aspect of the practice comes in.

And in terms of technical knowledge, sure you can practice mediocre psychopharm with bare bones knowledge, but to be a really good psychopharm you probably need to get a substantial body of experience and book smarts, which might translate to you as being "doctorly". Other more specialized fields such as child, substance, women's health, etc. clearly require a separate body of knowledge for their own set of medications issues.

I dont agree with this at all.......lots of people wont view an outpt med mgt psych as a "real doctor"......

the thing about psychopharm and being "really good" at it is this: the best psychopharm guy knows 100000000000000000000x as much about psychopharm as me. But how much better(in terms of what actually translates to real effects from med differences) is he going to make on pt outcomes than me? Not a whole heck of a lot.......most of our meds don't work that well anyways, if they work at all. So the difference between a decent regimen(ie mine) and the best regimen possible isn't going to have any real difference in terms of actual clinical outcomes......at least in an outpt mood d/o setting with med mgt

 

[dl2dp2]

So the difference between a decent regimen(ie mine) and the best regimen possible isn't going to have any real difference in terms of actual clinical outcomes......at least in an outpt mood d/o setting with med mgt

LOL, that's what you think. I've seen some pretty bad regimens. And I've seen some pretty bad regimens because the patient actually has a severe personality disorder. A really good psychopharm might be only marginally better than a merely ok psychopharm, but he/she is vastly better than a substandard psychopharm, which is more frequent than you think.

I don't see how the efficacy question translates into not feeling doctorly. Neurology meds aren't that effective either. Nor are other outpt cognitive specialties like rheum or allergy. I would argue that an outpatient psychopharm practice is very similar in substance to a practice in those specialties. And i'm not sure who "a lot of people" are in not viewing most psychopharms as "real doctors". And in more specialized fields, like addiction, you do physical exams routinely (suboxone induction, HELLO?).

This, parenthetically, is the reason that brand name psychopharms make so much money. If you were that well off high functioning profession with mood d/o, It's your head, wouldn't you want the best of the best to at least be sure that they do an adequate job given that a lot of bad providers are out there? I would argue that a lot of outpatient psychopharm is more similar to a specialized cosmetic specialty, like derm or LASIK. Do you really think derm treatments are THAT effective in delaying aging? Are they not doctors? LOL I'm laughing my ass off.

Given that many of the meds are not panaceas, you would esp. need someone good to figure out exactly what is wrong and what is treatable and what isn't treatable with meds. There is a positive feedback loop between good psychopharm knowledge -> better doctor in general -> more time for the patient because of private setting -> more cases in specialized field -> more expert knowledge that makes you "doctorly", which is precisely issue ("i don't feel doctorly enough as a psychiatrist"), btw, your little rant never addressed.

 

[digitlnoize]

There is a lot of opportunity for individual variability. If you want to be the guy who never weighs your patients or never gets EKGs on people, you can get away with that.

Our medicines are fairly effective. Not wonderful, but with the right treatment algorithms, you can get 3/4 of patients better. If you dig a little deeper and are willing to be a bit more cutting edge, you can likely do much better than that.

How about L-methyl folate for monotherapy in depressed geriatrics? Almost 70% remission by itself. That's pretty good in anyone's book. Especially when we count a treatment failure as non-compliance with medication, which is a bigger problem for our patients than not.

I would also say that a large reason many psych patients don't get better is multifactorial, whether due to lack of resources, access, good doctors, money, lack of therapy, interpersonal relationship problems, or their personal disdain for medications.

Doctors make patients feel better. I feel like a doctor. I don't necessarily need a long white coat and stethoscope to do it.

 

[vistaril]

LOL, that's what you think. I've seen some pretty bad regimens. And I've seen some pretty bad regimens because the patient actually has a severe personality disorder. A really good psychopharm might be only marginally better than a merely ok psychopharm, but he/she is vastly better than a substandard psychopharm, which is more frequent than you think.

I don't see how the efficacy question translates into not feeling doctorly. Neurology meds aren't that effective either. Nor are other outpt cognitive specialties like rheum or allergy. I would argue that an outpatient psychopharm practice is very similar in substance to a practice in those specialties. And i'm not sure who "a lot of people" are in not viewing most psychopharms as "real doctors". And in more specialized fields, like addiction, you do physical exams routinely (suboxone induction, HELLO?).

This, parenthetically, is the reason that brand name psychopharms make so much money. If you were that well off high functioning profession with mood d/o, It's your head, wouldn't you want the best of the best to at least be sure that they do an adequate job given that a lot of bad providers are out there? I would argue that a lot of outpatient psychopharm is more similar to a specialized cosmetic specialty, like derm or LASIK. Do you really think derm treatments are THAT effective in delaying aging? Are they not doctors? LOL I'm laughing my ass off.

Given that many of the meds are not panaceas, you would esp. need someone good to figure out exactly what is wrong and what is treatable and what isn't treatable with meds. There is a positive feedback loop between good psychopharm knowledge -> better doctor in general -> more time for the patient because of private setting -> more cases in specialized field -> more expert knowledge that makes you "doctorly", which is precisely issue ("i don't feel doctorly enough as a psychiatrist"), btw, your little rant never addressed.

"really bad" regimens goes to the basic principle of "do no harm". Irresponsible people(be they np's, family docs, psychiatrists, whatever) who have pts on really bad regimens(say a borderline with diabetes on Seroquel whose a1c is now 11) is an example of such a thing, and goes beyond the principle of what psychiatry should be able to provide in med mgt. That's like arguing that someone is a humanitarian because they didn't commit a felony in the last month.

The lot of people not viewing psychiatrists as "real doctors" in this setting is pretty self explanatory.....just go to the lounge or whatever, type in some key words in the search engine, and you'll generally get a wide variety of opinions on psych(from mostly other medical people)- some find it a joke, some find it a profession with some positives and some negatives in terms of the medical model, and some even find it just as medical as some other fields. I didn't say everyone doesn't take psychiatry seriously; just that many people clearly don't(some people do otoh)

as for outpt psychopharm being more like cosmetic derm or LASIK, this is a bad example because it is the very procedural nature of those things which makes them feel doctorly, at least in the publics eyes.

 

[vistaril]

There is a lot of opportunity for individual variability. If you want to be the guy who never weighs your patients or never gets EKGs on people, you can get away with that.

Our medicines are fairly effective.


No, they most definately aren't........

 

[BS81]

"really bad" regimens goes to the basic principle of "do no harm". Irresponsible people(be they np's, family docs, psychiatrists, whatever) who have pts on really bad regimens(say a borderline with diabetes on Seroquel whose a1c is now 11) is an example of such a thing, and goes beyond the principle of what psychiatry should be able to provide in med mgt. That's like arguing that someone is a humanitarian because they didn't commit a felony in the last month.

The lot of people not viewing psychiatrists as "real doctors" in this setting is pretty self explanatory.....just go to the lounge or whatever, type in some key words in the search engine, and you'll generally get a wide variety of opinions on psych(from mostly other medical people)- some find it a joke, some find it a profession with some positives and some negatives in terms of the medical model, and some even find it just as medical as some other fields. I didn't say everyone doesn't take psychiatry seriously; just that many people clearly don't(some people do otoh)

as for outpt psychopharm being more like cosmetic derm or LASIK, this is a bad example because it is the very procedural nature of those things which makes them feel doctorly, at least in the publics eyes.

I think the amount of people who find it a "joke" are few and far between.

People are entitled to define what it means to be a "real doctor" for themselves. Your definitions are very narrow and definitely don't represent the mainstream, but thank you for explaining to us why you don't feel like a real doctor.

 

[vistaril]

I think the amount of people who find it a "joke" are few and far between.

People are entitled to define what it means to be a "real doctor" for themselves. Your definitions are very narrow and definitely don't represent the mainstream, but thank you for explaining to us why you don't feel like a real doctor.

On the number of people who find it a "joke", I'll guess we will have to just disagree. Like I said, tour the sdn lounges and you will find a variety of opinions on the matter. The reality is that there is a HUGE gulf between "a joke" and "100% the real thing".....most people certainly fall somewhere in between. So no, most people don't find psychiatry to be a complete joke.

As for what I "feel like", I feel like a psychiatrist. Whether or not I feel like a doctor is something that I'm not even sure is positive or negative...or neutral. I certainly don't feel like a doctor in the same way that an oncologist does, for example, and if I did I would suggest that there is something seriously wrong with the way I am practicing psychiatry.

 

[BS81]

Again, what makes a "doctor" and who gets to define it? Either way, I do agree with you that Psychiatry is the most different than any other specialty and that can be embraced as a good thing or a negative. I'm wondering if you could tell us what other specialties you considered and how you ended up picking Psych?

Sent from my DROID RAZR using SDN Mobile

 

[whopper]

This IMHO is like terrorism.

Definition: Terrorist
A brown guy that is Muslim and commits a crime.

No that is not the real definition, but that is the definition several in the public use.

The real definition is: person, usually a member of a group, who uses or advocates terrorism.

Our own President, a guy who has been wrongly accused now and then of being a terrorist even used the wrong definition of the word when that guy who crashed his plane into a government building a few years ago was described by him as not being a terrorist? Really? That guy even claimed he did it for a political reason and he wanted to strike terror.

Anyways, saying M.D.s in certain fields are not real doctors-well IMHO that's like using the first and wrong definition of terrorist. We certainly are more removed from IM than other fields, but then again, IMHO so are other fields such as neurosurgery, plastic surgery, or dermatology. It's like those guys saying synchronized swimming is not a sport. It is one, but yeah, okay, it doesn't meet the guy's visceral reaction of what he thinks is a sport.

 

[vistaril]

Again, what makes a "doctor" and who gets to define it? Either way, I do agree with you that Psychiatry is the most different than any other specialty and that can be embraced as a good thing or a negative. I'm wondering if you could tell us what other specialties you considered and how you ended up picking Psych?

Sent from my DROID RAZR using SDN Mobile

I think a popular concept of a physician is someone who treats physical illness with medications and/or procedures/surgery. Under this definition diagnostic radiologists and pathologists count because they provide answers about the dx of illness which then leads to treatment.

as for me personally, I picked psych for the same reason a lot of people pick psych: evaluating abgs or FeNA or whatever was uninterssting, surgery/procedures were not appealing, and the hours in psych seemed pretty good.