Impulsive Changes

[GOINGDUMB]

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Hi.

I'm a 4th year Med student. I think I can start applying for residencies this Saturday.

I want(ed) to apply to IM and Radiology.

I really like biochemistry, neuropharmacology!!, and thinking (like sitting alone and thinking about problems).

-But-

1. Numerous sources of data suggests IM people are miserable (Though I really enjoyed it in my 12 week rotation, but then again, can you really feel it as a student with no liability, no definite functional responsibility, etc? One told me to go into radiology if I like medicine, I went to a wedding of this rich dude (nephrologist) and all his IM buddies said they hate their lives)

2. I'm on my Rads rotation and they seem like a happy, moderately hilarious bunch (kinda dorky, and almost all of them overweight. Noon conference looks like a scene out of that movie Grandma's boy), but it seems like they are just doing static anatomy stuff all day (as opposed to all the cool $hit I hear about on TV with fMRI, angiography, and computational fluid dynamics).

So I went for a drive last night and thought about it. Hearing from and empathizing with the inpatient adult psych patients brought pangs of compassion in me I have not felt in quite some time. The counter transference was amazing (maybe its a bad thing).

I like science (Biochemistry, Physics, Fluid Dynamics, Neural Networks, Economics/ Social Science). I like helping people. I hate anatomy.

Idk what to do. Can I make a last minute play in this game and apply psych?

Thanks for letting me vent. Idk what to do


Your comments and discussion please

 

[GOINGDUMB]

Follow up Questions:

1. In internal med they have a hot market for a nocturnist.
I really dig working at night - Is there lots of work for somebody who dislikes mornings but will work hard afternoons, evenings, nights, weekends, and any other time cellphone anytime minutes work?


2. If you don't do IM, neuro, etc can you see and treat organic chronic pain, functional pain, fibromyalgia, and chronic fatigue syndrome, and not get sued?

 

[splik]

Follow up Questions:

1. In internal med they have a hot market for a nocturnist.
I really dig working at night - Is there lots of work for somebody who dislikes mornings but will work hard afternoons, evenings, nights, weekends, and any other time cellphone anytime minutes work?

I guess you could work at night admitting patients in a Psych ER or doing admits at night at a smaller hospital without residents (there are many) where they find it hard to get people to work at night.

Also we start later in psychiatry, no ridiculously early starts! And if you were working privately could set your own hours (like seeing patients in the evening after work)

2. If you don't do IM, neuro, etc can you see and treat organic chronic pain, functional pain, fibromyalgia, and chronic fatigue syndrome, and not get sued?

well there is actually a need for psychiatrists to see patients with things like chronic fatigue syndrome, it's mainly in a few academic settings at the moment. This comes under consultation-liaison psychiatry. There is also opportunities to consult psychiatrically in the pain clinic for chronic non cancer pain etc which again is very important and even help develop opiate guidelines or statewide/national guidelines influencing policy in this challenging area.

Pain medicine usually is a branch of anesthesiology academically, it is possible to do a multidisciplinary pain fellowship as a psychiatrist, most likely one which doesn't emphasize procedures (which usually make people worse).

However in choosing a specialty you must think of what is commonest and whether you can deal with that for the rest of your life. If you don't like depression or schizophrenia then you should probably not become a psychiatrist. If you don't like anatomy you should NOT become a radiologist!!!

 

[Leo Aquarius]

Great to see your post. Welcome to a very crucial revelation.

Compassion, and the therapy that comes from empathy, was the clincher for me to pursue psychiatry. It's the field where you're actually supposed to spend generous time in the interview. Listen to that inside you. Not everyone has it.

As for pain management, psych is well-suited to be involved in its treatment. I did a rotation in a pain clinic run by PM&R doctors and they wanted a psychiatrist badly in their practice. Nearly every patient had a psychiatric disorder, and pain must be treated along a psychosomatic spectrum. You can even pursue a pain fellowship.

The downside to psychiatry for me so far is how much paper work and social work there is. Some days on the inpatient unit I spend most of my time dealing with court hearings, progress notes, discharge notes, dictations, family meetings, and phone calls, but no medicine. I don't know if it will always be like this.

As for working nights, sure, any psych ER can use PM psychiatrists.

 

[shan564]

If your rec letters are generalizable, just apply for some psych programs and go to the interviews. That might help you decide.

 

[GOINGDUMB]

Bossss. Thanks for all those kind words. I just feel a little gestalt of anxiety over such a rapid and impulsive change.

I dont mind the paperwork and social work (I think a lot of it is needed). I like depression and schizophrenia manics and psychotics but the chronic fatigue fibromyalgia and addiction stuff really brings about feelings in me...

Are there any downsides?

How is job security?
Will I be replaced 20 years from now with another practitioner/professional?

How is malpractice?

Any legitimate turf wars?

Better for an extrovert or an introvert?

Is a slightly adhd and hypomanic personality ok?

Sorry Im being frank but I have to ask 🙂

Thanks everyone!

 

[Leo Aquarius]

No expert here, but here are some ideas from a resident.

Downsides - Not the highest paying specialty, but not the lowest by any means especially for the hours worked. A high salary in my opinion without killing yourself in time and stress. Other downsides: not competitive, not respected by med students, not taken seriously by some doctors, and some people don't realize that a psychiatrist is a doctor (but then again the general public doesn't know what a radiologist really does, or a PM&R doctor, or pathologist, etc.)

Job security - With the large shortage of psychiatrists in every state and in many places in the world, you won't be worrying about job security for years to come. Nurses and other doctors prefer to have the psychiatrist take over the mental health care of patients as soon as one steps into the picture. I don't sense any turf wars. Most people don't want to manage mental health patients, and don't claim to do as good a job as a psychiatrist. It's nothing like the CRNA vs. anesthesiologist civil war.

On the flip side, a few family medicine doctors and PM&R doctors have told me they would love to have a psychiatrist in their practice. We are a commodity liked by doctors who deal with mental health patients. More job security.

NOTE: I am now convinced the shortage is very real because just into my 3rd month of residency two psychiatry practices have contacted me asking that I apply when I graduate. That's awesome. I also happen to be at a program that carries a famous name.

Hours and Stress - Good hours, totally customizable. Low stress. One of the few specialties left where a cash practice is feasible. Low overhead. People don't want a record of any visit to a psych doctor so they will pay out of pocket.

Malpractice - In a recent study, psychiatry was the second LOWEST specialty in terms of malpractice payout and rate per year. So you can't beat that.

Extrovert vs Introvert - Both do well. The extroverts have to learn to reign it in, and the introverts have to learn to have confidence when facing all kinds of patients.

Overall - A+. Psychiatry treats its residents and physicians VERY well. Low stress, practice satisfaction, jobs everywhere, a high salary for the hours as far as I'm concerned, and long-term care to form close bonds with patients who become genuinely thankful for your time and therapy.

Yes, it's ok to be adhd. If you can make it through medical school, you will be fine in residency.

 

[peppy]

I dont mind the paperwork and social work (I think a lot of it is needed). I like depression and schizophrenia manics and psychotics but the chronic fatigue fibromyalgia and addiction stuff really brings about feelings in me...

I think it bodes well that you enjoy mood disorders and psychosis, since that's where the
action is in psych. 🙂
You do have an option after residency to tailor your practice to the kind of patients you enjoy seeing - although substance abuse is hard to avoid in psych (patients self-medicating for psych problems with drugs/alcohol, substance use that exacerbates an underlying psych issue, or substance abusers with no psych complaints who end up trying to get admitted to the psych unit due to their social problems).
I would say that even if drug addicts are not your favorite group to work with (which I think is probably true for most psychiatrists), I think you'll be fine if you can at least learn to be comfortable doing some motivational interviewing with them and perhaps look for something in their stories to empathize with. Many addicts are self-medicating for some source of legitimate suffering and/or have done terrible damage to their lives with their addiction - that really is sad, even though I don't condone drug use by any means.

Regarding job security, I agree with Leo that there are tons of job opportunities out there for psychiatrists right now. It's also easier to set up a private practice in psych than in many other specialties. The amount of money you can make varies regionally and private practice tends to make more than academics, but you should have no trouble making a very comfortable living with a reasonable lifestyle.

I don't think we can afford to be complacent about the issue of "turf wars" with NPs/PAs/psychologists. There is a perception that prescribing in psych is "easy" because we use a limited number of classes of meds and most people perceive SSRIs as fairly benign meds. However, the problem is that some people (even some psychiatrists) do not fully appreciate the nuances of psychopharmacology (even with the seemingly benign SSRIs). I've seen patients that have come from other providers with horrendous polypharmacy or dangerous/inappropriate medications because some people know just enough about psychopharm to be dangerous. There are a handful of states that allow psychologists to write for psych meds and I personally don't agree with that. However, at this stage, I don't think that the turf war issue has reached the level of threat that it has in Anesthesia and primary care.
The need for mental health care is enormous and at this point there is plenty of work for all of us. Even though most cases of garden variety depression and anxiety can be handled by primary care without a psych referral, I still see plenty of those patients. It's true, as Leo said, that even though many PCPs could handle more psych problems they prefer not to. Even if we did lose all those cases, though, I'm sure there would still be a role for psychiatrists with more complicated and unusual cases. I personally enjoy the challenge of treating psych problems in medically complex patients.

I agree with Leo that both extroverts and introverts can do well in psych. My experience is that different personalities mesh well with different types of patients, so we need all kinds of people in psych. 🙂

 

[GOINGDUMB]

Thanks everyone for your insights!

I dropped by where I did my psychiatry clerkship and chewed the fat with them and then went home and discovered a this guy Robert Malenka at Stanford... Freakin WOW! I want to be doing this stuff!

http://www.nimh.nih.gov/about/director/2012/the-future-of-psychiatry-clinical-neuroscience.shtml

Psychiatry is a gem.


I do have some anxiety over this turf war issue.
I'd have to say its the only thing holding me back.

I know most fields have a turf war somewhere. But at least with IM I can rest assured there is always patients and work even if it doesn't pay well (e.g. I can just get all doc-in-a-box and see simple cases). Does a similar reassurance stand in psychiatry? At mid career, will I have enough licensure and knowledge to be able to fall back onto general medicine stuff if things get messy?


Also, any thoughts on the research powerhouses for psychiatry? - I'm interested in both clinical and basic science.

 

[vistaril]

dude, you're a new intern, yet you spew all this stuff about psych that you can't possibly really be familar with.

 

[vistaril]

Thanks everyone for your insights!

I dropped by where I did my psychiatry clerkship and chewed the fat with them and then went home and discovered a this guy Robert Malenka at Stanford... Freakin WOW! I want to be doing this stuff!

http://www.nimh.nih.gov/about/director/2012/the-future-of-psychiatry-clinical-neuroscience.shtml

Psychiatry is a gem.


I do have some anxiety over this turf war issue.
I'd have to say its the only thing holding me back.

I know most fields have a turf war somewhere. But at least with IM
Also, any thoughts on the research powerhouses for psychiatry? - I'm interested in both clinical and basic science.

there are more opportunities in IM. obviously thats without even going down some IM fellowships(cards, GI) where it is feasible to make 700+ in the right practice set up.

The only way a psychiatrist is ever going to get close to that sort of income is to steal 500k in addition to working full time lol......

the other main issue in psych wrt salary is that psychiatrists are always comparing different roles in each specialty. For example, we always love to talk about how there is the opportunity to do x.y.z if you want to and make x more. Well in IM, there is the oppirtunity to do x, y, z, and then a, b, c, and d as well to make 1.75x more.

 

[Leo Aquarius]

dude, you're a new intern, yet you spew all this stuff about psych that you can't possibly really be familar with.

Assumptions. Don't make them.

I consider myself very dedicated and passionate about psychiatry and I do my research. If you have an issue with what I said, present a counterargument, but don't try to belittle me. I stand by what I say. You should have become a lawyer, and never a psychiatrist.

What you are employing is called Ad Hominem, which is attacking the person instead of attacking the argument. I would go so far as you insult as well, which is called Needling.

 

[happyoolongtea]

there are more opportunities in IM. obviously thats without even going down some IM fellowships(cards, GI) where it is feasible to make 700+ in the right practice set up.

The only way a psychiatrist is ever going to get close to that sort of income is to steal 500k in addition to working full time lol......

the other main issue in psych wrt salary is that psychiatrists are always comparing different roles in each specialty. For example, we always love to talk about how there is the opportunity to do x.y.z if you want to and make x more. Well in IM, there is the oppirtunity to do x, y, z, and then a, b, c, and d as well to make 1.75x more.

interesting. so why not IM in your case, if there are more opportunities?

and a general question, is even 200k that bad? I wonder if this point in a physician's life (the border between graduation and residency) is where greed develops. I know several people my age (mid/late 20s), outside of medicine, who are making half that now, and leading otherwise eventful lives -- starting families, traveling, buying homes while paying off loans. granted, there's likely great debt attached to those things, but there are trade-offs in life. personally, the marriage + 2.5 kids +/- pets + house with white picket fence is not desirable to me at all, but I still plan to enjoy my life. I imagine(d) with psychiatry that this would be a win win, being in a fulfilling field while making a reasonable income. but reading posts like vistaril's makes me question if my heads are really in the clouds.

 

[vistaril]

interesting. so why not IM in your case, if there are more opportunities?

.

because I had little to no interest in IM and did not like the day to day activities of it.

 

[vistaril]

Assumptions. Don't make them.
.

iirc you've already stated you just started your intern year. So your lack of experience is hardly an assumption on my part. I'm not saying you can't make nice coin practicing psychiatry, and to do so with a reasonable schedule. It is clear, however, that you're cobbling together lots of(probably) different anectodal examples and then making comparisons with other fields based on different data.

Sure, it is possible to make 250k/year as a psychiatrist working. That's about the 85th percentile for psychiatry, but it's doable. It's much harder to be in the 85th+ percentile *and* have a very interesting job *and* have a great 40 hr/week schedule. But granted, I'm sure there are examples of it(and Im sure a few people on this board fit that). But I know successful hospitalist groups who make 375k working 7 on/7 off. Is that the standard? No.....but it's possible. I know of inpatient general neurologists making that as well. Additionally, I know plenty of GI's and cards people who do work 40 hrs/week for their 750k. Most work more, but not at all.

Psychiatry has it's plusses, and heck I'd rather do it than something else. But a lot of the med student an intern expectations that are thrown around just don't represent the normal reality. If it did, then psychiatry would have a much easier time getting qualified candidates to go into psychiatry.

 

[GOINGDUMB]

Psychiatry has it's plusses, and heck I'd rather do it than something else. But a lot of the med student an intern expectations that are thrown around just don't represent the normal reality. If it did, then psychiatry would have a much easier time getting qualified candidates to go into psychiatry.

Real talk. I appreciate your input on things (honestly I do - both sides of this are important!)

Can you please elaborate on the med student and intern expectations that are thrown around?

Can you comment on the article and how far or close from reality it is:

http://www.nimh.nih.gov/about/director/2012/the-future-of-psychiatry-clinical-neuroscience.shtml

 

[Sir James Bond]

I know several MD/PhD students going into psychiatry in order to advance neuroscience in all kinds of fascinating ways. Imaging is hot, for example how drugs change parts of the brain. Neurobiomarkers and neurochemistry is growing too. Neurodevelopment is another subfield.

I think many of these MD/PhD students are interested in academic leadership positions as well, and psychiatry gives doctors enough time to become not only faculty but department chairs and hospital managers. It's hard to be a hospital CEO when you're in the OR all day long.

 

[GOINGDUMB]

It's hard to be a hospital CEO when you're in the OR all day long.

Lol. I think those surgery guys are quickly becoming monkeys and its not because of the work they do, but how they do it (120 hrs/wk, malignant personalities, hero complexes, etc). Thanks for the chuckle. No intention to flame anyone, I speak casually here like Kanye West at the VMA's.


Speaking of which can anyone chime in on Burn Out?
Are the older attendings happy?
Are people actively trying to work their way out of clinical service and doing administrative/leadership jobs (*cough* EM *cough*)?
Have any of you felt burn out or apathy or anything or that sort?

 

[OldPsychDoc]

I was once one of those starry-eyed MD/PhD types, but found out that I preferred talking to patients to doing in situ hybridization on monkey brain slices. To each their own, but for all the wonderful editorializing, the science still hasn't caught up to the complexity that is the human brain. And when it comes down to it, I'm not envisioning any advances in neurobiology that will counter the long-term effects of poverty, abuse, and other human inhumanities.

That said, I'm still happy I chose this as a career. The living and lifestyle are good, the opportunities to do what I want in my career are excellent, and working with amazing colleagues takes most of the sting out of the many headaches of the job.

 

[peppy]

Speaking of which can anyone chime in on Burn Out?
Are the older attendings happy?
Are people actively trying to work their way out of clinical service and doing administrative/leadership jobs (*cough* EM *cough*)?
Have any of you felt burn out or apathy or anything or that sort?

Someone just recently posted an article about burn out over on the EM forum: http://forums.studentdoctor.net/showthread.php?t=944244

It seems consistent with my perception that psychiatrists tend to be less likely to burn out than many other specialties are.
In my residency program, a lot of older psychiatrists are still actively working and seem to be happy. A nice thing about psych is that if you do enjoy your work, you can keep working to a ripe old age whereas that isn't necessarily possible in more physically demanding specialties.

 

[GOINGDUMB]

Fun story I had to share today on Radiology: I hung out with an attending today who told me he wanted to be a Psychiatrist. So he did his PGY-I year in psychiatry (16 years ago) and it destroyed him, he told me it was too much, it sucked the empathy out of him and he feared for his safety. So he quit and switched to Rads strictly for the money.

So I asked him what to do: He still told me psychiatry is super cerebral/philosophical/complex and didn't discourage it! He just warned me to make sure I like whatever I choose because you have to do a lot of volume. He then went on to give an awkward and visibly disinterested noon conference lecture on bone scans. Sigh.

I'm still interpreting what this all means.

 

[OldPsychDoc]

Fun story I had to share today on Radiology: I hung out with an attending today who told me he wanted to be a Psychiatrist. So he did his PGY-I year in psychiatry (16 years ago) and it destroyed him, he told me it was too much, it sucked the empathy out of him and he feared for his safety. So he quit and switched to Rads strictly for the money.

So I asked him what to do: He still told me psychiatry is super cerebral/philosophical/complex and didn't discourage it! He just warned me to make sure I like whatever I choose because you have to do a lot of volume. He then went on to give an awkward and visibly disinterested noon conference lecture on bone scans. Sigh.

I'm still interpreting what this all means.

It means that you met a radiologist who didn't have much resilience, but at least had the insight to catch it and change fields.

 

[F0nzie]

It means that you met a radiologist who didn't have much resilience, but at least had the insight to catch it and change fields.

Just to add on to OPD's comment, I believe you can learn resilience (in many ways our work aims at boosting resilience in patients) and adapt to be more empathic in your style of interacting with patients if you're up for the challenge. At least I feel my psych training has helped me in this regard. The path of least resistance isn't always the best path, but it can be for some people.

 

[GOINGDUMB]

Real talk FOnzie. I think I might just grow as a human being in so many ways in a psychiatry residency. The easiest route, as the richest route. Plus I might be able to do an executive masters degree in finance later on as a hobbie --> Coming out of residency street smart, and a soft yet malleable safe haven for any person to seek refuge and care, while being lucrative corporate manager type if all else fails?

Carib Med school itself changed me from being an open minded, every conscious entity is worth it type dreamer into being a aesthetically vain money hungry intellectually vain fellow. That rads attending was that kind of a fail left to swelter for 16 years - He admits that he has much more money than if he stayed with psychiatry but the guy looks miserable overall.

My family called me over the weekend and told me not to do psych because its for the people who cant do anything else.

My Aunt got her MD and quit. Told me she considered Psych but feared she would develop a mental illness.


So conflicted on where my heart could be. If I could just spend a few weeks before match day checking there places out.

 

[billypilgrim37]

My family called me over the weekend and told me not to do psych because its for the people who cant do anything else.

A non-zero proportion of people who go into psychiatry do so to stick it to their parents! (May or may not be true, but you can tell your parents this to mess with them!)

 

[OldPsychDoc]

.... That rads attending was that kind of a fail left to swelter for 16 years - He admits that he has much more money than if he stayed with psychiatry but the guy looks miserable overall.

So do you want to be miserable or reasonably happy 16 years from now?

My family called me over the weekend and told me not to do psych because its for the people who cant do anything else.

"Everything else" is for those who can't do psych.

My Aunt got her MD and quit. Told me she considered Psych but feared she would develop a mental illness.

Where'd she do her MD that they're teaching that mental illnesses are communicable diseases?

So conflicted on where my heart could be. If I could just spend a few weeks before match day checking there places out.

That's what interviews are for.

 

[GOINGDUMB]

.

 

[GOINGDUMB]

So do you want to be miserable or reasonably happy 16 years from now?

Reasonable happy. Money is just a means to happiness that perhaps can be mismanaged and corrupt your faculty for happiness (read: greed)

That's what interviews are for.

I mean is there a way I can do more than an interview, like see the team in action for a day or two, see if this is it, where I want to be?

 

[diagonal]

Thanks. Yeah, I kind of enjoy having this as an outlet from an otherwise unseated situation in my life.

My aunt is from the Phillipines, so uh well you know... She kind of planted it in my head that I need to be careful for my own mental health if I do it. (I mean that applies to anything though - I could have a nervous breakdown in surgery), but in psychiatry we have our hands dirty with the very modulators of minds where those dirty hands could be neglected and be left to feed us after work and in our homes.

Does the mechanic's home and the mechanic's wife have grease on them after sundown? Its such a complex medium and vector of psychosocial illness.

Being a psychiatrist is a job. Stop painting it with such romantic brushstrokes. Studying the material won't make you an enlightened human being, nor will it make you a broken one. If you have issues that precede this specialty, then get a handle on them. But please don't inflict those issues onto the specialty, anymore than a cardiologist does so with the health of their own heart.

 

[billypilgrim37]

She kind of planted it in my head that I need to be careful for my own mental health if I do it.

Getting training in CBT (a standard part of every residency curriculum) is one of the best things an individual could ever do for their own mental health. Just like cardiologists are more likely to run marathons, endocrinologists watch the sweets really closely, etc., I think psychiatrists are actually more likely to take care of their mental health than other specialties.

Now, earlier this week I was scared to death that one of my patients who identifies as a vampire (drinks a few vials per week from donor friends) was going to show up to the office and try to turn me into a vampire as well (I'm only kinda kidding), so it's not the easiest job, but at some point, not much really surprises you any more.

 

[Leo Aquarius]

Tell your family that the several hundred USA MD grads going into psych have options, could have gone into other fields, but chose psych because they wanted to.

I had high scores and used that to my advantage by putting myself into a famous program and am darn happy with that decision. Nearly went into emergency medicine or surgery.

 

[GOINGDUMB]

Tell your family that the several hundred USA MD grads going into psych have options, could have gone into other fields, but chose psych because they wanted to.

I had high scores and used that to my advantage by putting myself into a famous program and am darn happy with that decision. Nearly went into emergency medicine or surgery.

Seriously. My eyes rollllllllllllllllllllllled when my mom said that to me. Sigh, Vanity.

 

[GOINGDUMB]

Now, earlier this week I was scared to death that one of my patients who identifies as a vampire (drinks a few vials per week from donor friends) was going to show up to the office and try to turn me into a vampire as well (I'm only kinda kidding), so it's not the easiest job, but at some point, not much really surprises you any more.

Wow!

 

[GOINGDUMB]

Dude pull your head out of your ass. Being a psychiatrist is a job. Stop painting it with such romantic brushstrokes. Studying the material won't make you an enlightened human being, nor will it make you a broken one. If you have issues that precede this specialty, then get a handle on them. But please don't inflict those issues onto the specialty, anymore than a cardiologist does so with the health of their own heart.

The fisherman is what he eats, his soul as calm as the deep, his surface reflective of the sunset. Generous to most those who ask. He is becoming the calm river where he catches his fish.

<blooooooop>
ok
my heads outta my ass