Internal Med vs Psychiatry

[appac1010]

Help, I'm having a lot of trouble deciding which one to go into and ERAS is knocking on my door. My two favorite parts of medicine in general is talking to people, whether it is docs, nurses, or patients, and teaching. I am torn between definitvely deciding between psychiatry and internal medicine. I want to do psychiatry because the patients stories are so interesting and I feel like I am making a big impact on the quality of a persons life with my treatment. But I was thinking internal medicine because I love the challenge and problem solving of internal medicine, and like the idea of specializing in a field and becoming an expert on something.

The bads of each field is if I do psych, I am afraid that I will miss out on some parts of medicine and won't be able to diagnose a UTI or manage simple diabetes. Also, there is so much gray area in the DSM for diagnostics, and I find it much easier to have definitive answers from an algorithm. And for internal, I disliked my wards rotation mostly because of the hours and the residents and attendings appeared to be dead inside and spent most of their time complaining. My experience was odd for me, because I felt like there was a big disconnect between what internal medicine is supposed to be, and what is actually practiced. What makes it tricky is that I may have just had a bad group of docs during that period, or maybe that is just the attitude that is a result of the daily stressors of the job. I was hoping that I could get some insight from others experiences.

I was wondering if someone who has been in a similar dilemma could share some insight on how they came to a decision, and whether they made the right call. My application strength is a bit odd, because I don't have research or pubs and very little volunteering experience, but I have decent step scores (249 & 264) and I'm in the top quarter of the class. How would you approach this, and what advice do you have for me?

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[WedgeDawg]

ERAS opens saturday at 9 am... do you have letters for either of these specialties??

 

[appac1010]

ERAS opens saturday at 9 am... do you have letters for either of these specialties??

I have 3 letters for internal (1 IM doc, 2 psych). I don't have psych letters, and I was thinking of asking the 2 psych docs if they could do another letter for psych, and get an additional doc to do one before october 1st.

 

[sloop]

I had similar stats to you and applied to psychiatry.

It sounds like this is a very late decision to apply to psychiatry. I won’t go into the logistics of this as I’m a bit removed from the application process, but I will break down your post.

I want to do psychiatry because the patients stories are so interesting and I feel like I am making a big impact on the quality of a persons life with my treatment. But I was thinking internal medicine because I love the challenge and problem solving of internal medicine, and like the idea of specializing in a field and becoming an expert on something.

My experience with internal medicine is that there is far less of the diagnostic mystery stuff than people imagine. The idea that you’re more likely to be a specialist or an expert in IM than psych makes no sense. Psych itself is a specialty, and there are many subspecialties you can explore.

The bads of each field is if I do psych, I am afraid that I will miss out on some parts of medicine and won't be able to diagnose a UTI or manage simple diabetes.

This is a ridiculous concern. People don’t lose the ability to prescribe Bactrim or cipro because they became psychiatrists. Granted where I’m at has stronger medicine training than average but with this concern, I’m sure you’d be floored at the type of stuff I’ve managed overnight on the psych wards. Eating disorder patients are often in full blown refeeding syndrome and on the cusp of DKA and all sorts of badness, just as one example.

Also, there is so much gray area in the DSM for diagnostics, and I find it much easier to have definitive answers from an algorithm.

First of all, the DSM is overemphasized. I won’t go into the details of why here but, as a med student, it’s hard to get the full impression of psychiatric diagnostics apart from a simplistic nosological approach. Rest assured, there is more to it.

Second, I thought you liked the mystery of diagnosis. Why does this bother you only when it comes to psychiatry?

 

[Oh_Gee]

Help, I'm having a lot of trouble deciding which one to go into and ERAS is knocking on my door. My two favorite parts of medicine in general is talking to people, whether it is docs, nurses, or patients, and teaching. I am torn between definitvely deciding between psychiatry and internal medicine. I want to do psychiatry because the patients stories are so interesting and I feel like I am making a big impact on the quality of a persons life with my treatment. But I was thinking internal medicine because I love the challenge and problem solving of internal medicine, and like the idea of specializing in a field and becoming an expert on something.

The bads of each field is if I do psych, I am afraid that I will miss out on some parts of medicine and won't be able to diagnose a UTI or manage simple diabetes. Also, there is so much gray area in the DSM for diagnostics, and I find it much easier to have definitive answers from an algorithm. And for internal, I disliked my wards rotation mostly because of the hours and the residents and attendings appeared to be dead inside and spent most of their time complaining. My experience was odd for me, because I felt like there was a big disconnect between what internal medicine is supposed to be, and what is actually practiced. What makes it tricky is that I may have just had a bad group of docs during that period, or maybe that is just the attitude that is a result of the daily stressors of the job. I was hoping that I could get some insight from others experiences.

I was wondering if someone who has been in a similar dilemma could share some insight on how they came to a decision, and whether they made the right call. My application strength is a bit odd, because I don't have research or pubs and very little volunteering experience, but I have decent step scores (249 & 264) and I'm in the top quarter of the class. How would you approach this, and what advice do you have for me?

aren't there combined IM/psych residencies?

 

[appac1010]

I had similar stats to you and applied to psychiatry.

It sounds like this is a very late decision to apply to psychiatry. I won’t go into the logistics of this as I’m a bit removed from the application process, but I will break down your post.



My experience with internal medicine is that there is far less of the diagnostic mystery stuff than people imagine. The idea that you’re more likely to be a specialist or an expert in IM than psych makes no sense. Psych itself is a specialty, and there are many subspecialties you can explore.



This is a ridiculous concern. People don’t lose the ability to prescribe Bactrim or cipro because they became psychiatrists. Granted where I’m at has stronger medicine training than average but with this concern, I’m sure you’d be floored at the type of stuff I’ve managed overnight on the psych wards. Eating disorder patients are often in full blown refeeding syndrome and on the cusp of DKA and all sorts of badness, just as one example.




First of all, the DSM is overemphasized. I won’t go into the details of why here but, as a med student, it’s hard to get the full impression of psychiatric diagnostics apart from a simplistic nosological approach. Rest assured, there is more to it.

Second, I thought you liked the mystery of diagnosis. Why does this bother you only when it comes to psychiatry?

Thanks for the input! I've spent a lot of time thinking yesterday and I think psych really aligns better with what I want to do in medicine. I reached out and got 1 psych letter so far. Would it be bad if I submitted ERAS with only 1 psych letter and get the other 2 next week? I have 1 really strong letter, but it is geared towards internal. Any input would be appreciated

 

[NickNaylor]

For my application, I only had one psych letter and it didn't seem to be a problem - it's hard to say since I don't really know, but I ended up getting interviews at most of the programs that I applied at. I thought that getting letters from other fields showed that I wasn't a one-trick pony - i.e., I was able to get people to come to bat for me in multiple fields. I have no idea if that mattered or not.

Point being, I wouldn't be too concerned about getting a certain number of psychiatry letters. Get letters from people that can recommend you strongly and go to bat for you. Obviously, make sure they know that you're applying to psychiatry; it looks bad if the letter is talking about how great of an internist you'll be if you're actually applying into psychiatry.

 

[appac1010]

For my application, I only had one psych letter and it didn't seem to be a problem - it's hard to say since I don't really know, but I ended up getting interviews at most of the programs that I applied at. I thought that getting letters from other fields showed that I wasn't a one-trick pony - i.e., I was able to get people to come to bat for me in multiple fields. I have no idea if that mattered or not.

Point being, I wouldn't be too concerned about getting a certain number of psychiatry letters. Get letters from people that can recommend you strongly and go to bat for you. Obviously, make sure they know that you're applying to psychiatry; it looks bad if the letter is talking about how great of an internist you'll be if you're actually applying into psychiatry.

Okay, that is very reassuring to know. I actually reached out to a radiologist who knows me very well and he agreed to write me a letter so I have 1 psych and 1 rads both geared towards psych. I'll just submit what I have and try to get a PD letter or additional psych letter before october 1st. I really appreciate the help, this has been influential on my decisions.

 

[Taddy Mason]

I second what @sloop said. I was in a nearly identical situation as you last year. I was between psych, IM, and IM/psych and didn’t commit to psych until 3-5 days before ERAS opened. I opted not to apply IM/psych as one of my attendings in med school went through a combined program and talked me out of it. I liked both fields for many of the same reasons you do. The pathology, amount of time you get to spend with patients and getting to know them as individuals, and diagnostic puzzles in psych are largely what tipped me to choose to go that route over IM. I regularly questioned my decision until probably December of 4th year, but have had no regrets since. If you decide to go psych you can also look for programs with more off service months intern year or more intense off service months. Plus even when on inpatient psych you’ll be managing plenty of medical problems. Feel free to PM me if you have any questions.

 

[sloop]

I second what @sloop said. I was in a nearly identical situation as you last year. I was between psych, IM, and IM/psych and didn’t commit to psych until 3-5 days before ERAS opened. I opted not to apply IM/psych as one of my attendings in med school went through a combined program and talked me out of it. I liked both fields for many of the same reasons you do. The pathology, amount of time you get to spend with patients and getting to know them as individuals, and diagnostic puzzles in psych are largely what tipped me to choose to go that route over IM. I regularly questioned my decision until probably December of 4th year, but have had no regrets since. If you decide to go psych you can also look for programs with more off service months intern year or more intense off service months. Plus even when on inpatient psych you’ll be managing plenty of medical problems. Feel free to PM me if you have any questions.

I’d also add that I think it’s generally good for a person’s psychiatrist and internist to be different people.

I mean, as I mentioned, we get very good medical training in my program (we even have to do a few months of critical care during Intern year) and I can and do manage medical issues when they come up. That said, if there’s no good reason to, I generally try to minimize touching my patients as much as possible. If someone was a gynecologist who retrained as a psychiatrist, that’s not a good argument for doing pelvic exams on people you’re doing psychotherapy with. What type of practice does one envision in IM-Psych that can’t be done through psych alone? Again, do you really want to enter into an internist-patient relationship with your psych patients? What happens when someone needs a rectal or breast exam?

 

[michaelrack]

I’d also add that I think it’s generally good for a person’s psychiatrist and internist to be different people.

I mean, as I mentioned, we get very good medical training in my program (we even have to do a few months of critical care during Intern year) and I can and do manage medical issues when they come up. That said, if there’s no good reason to, I generally try to minimize touching my patients as much as possible. If someone was a gynecologist who retrained as a psychiatrist, that’s not a good argument for doing pelvic exams on people you’re doing psychotherapy with. What type of practice does one envision in IM-Psych that can’t be done through psych alone? Again, do you really want to enter into an internist-patient relationship with your psych patients? What happens when someone needs a rectal or breast exam?

many (not all) inpatient psychiatrists are required to perform physical exams on their patients when doing admissions. Being IM-Psych can be helpful, especially when doing inpatient psych in rural areas, but you are right that not much can be done by IM-Psych that cant be done by psych alone

 

[sloop]

many (not all) inpatient psychiatrists are required to perform physical exams on their patients when doing admissions. Being IM-Psych can be helpful, especially when doing inpatient psych in rural areas, but you are right that not much can be done by IM-Psych that cant be done by psych alone

I do admission physicals on my patients, too. I just don’t tend to do a physical after that unless they report a specific problem.

 

[Scrooge1]

The bads of each field is if I do psych, I am afraid that I will miss out on some parts of medicine and won't be able to diagnose a UTI or manage simple diabetes. Also, there is so much gray area in the DSM for diagnostics, and I find it much easier to have definitive answers from an algorithm.

I am in the EXACT same situation. I actually had to re-check my posts to see if I was the author to this post or whether it could be possible for someone else to have the same exact thought as I do.
Could you update us on what you decided on and how it went? I am having the same dilemma: I am naturally interested in the mind and the brain and the disorders and how they effect behaviour, but I don´t want to end up in a position where my friend bring their children with a simple strep throat and I have to admit that I´ve forgotten how to properly exam, diagnose and treat them.

 

[Mass Effect]

I am in the EXACT same situation. I actually had to re-check my posts to see if I was the author to this post or whether it could be possible for someone else to have the same exact thought as I do.
Could you update us on what you decided on and how it went? I am having the same dilemma: I am naturally interested in the mind and the brain and the disorders and how they effect behaviour, but I don´t want to end up in a position where my friend bring their children with a simple strep throat and I have to admit that I´ve forgotten how to properly exam, diagnose and treat them.

You shouldn't be examining, diagnosing, and treating your friend's child anyway.

These specialties are quite different in patient population. The question is, do you like psych patients? If not, then don't do psych, no matter your interest in behavior. Go the neurology route and do a fellowship in behavioral neurology. You get the behavior piece with the medicine piece. There's nothing stopping you from reading up on general medicine and keeping up to date with it, no matter which specialty you choose. In fact, as a medical doctor, that's what you should do.

 

[sloop]

I am in the EXACT same situation. I actually had to re-check my posts to see if I was the author to this post or whether it could be possible for someone else to have the same exact thought as I do.
Could you update us on what you decided on and how it went? I am having the same dilemma: I am naturally interested in the mind and the brain and the disorders and how they effect behaviour, but I don´t want to end up in a position where my friend bring their children with a simple strep throat and I have to admit that I´ve forgotten how to properly exam, diagnose and treat them.

I don’t understand why people think going into psychiatry means you forget how to handle basic medical issues. I’ve worked people up for PE and treated someone for sepsis with a lactate of 4 on the psych floor.

Granted these situations were stressful due to different nursing resources and there were some circumstances that were kind of questionable in one case as to why they were being treated for this on psych (I won’t go into it here), but I gave them good care.

 

[Scrooge1]

You shouldn't be examining, diagnosing, and treating your friend's child anyway.

These specialties are quite different in patient population. The question is, do you like psych patients? If not, then don't do psych, no matter your interest in behavior. Go the neurology route and do a fellowship in behavioral neurology. You get the behavior piece with the medicine piece. There's nothing stopping you from reading up on general medicine and keeping up to date with it, no matter which specialty you choose. In fact, as a medical doctor, that's what you should do.

I like psych patients conditions more than the patients. Does that make sense? I am more interested in their diseases and their CNS than the patients themselves.
I agree that it is what we should be doing. That is why I went into med school: to treat the whole patient (at least make an attempt until I hit the limits of my knowledge) and be able to manage common conditions: hypoglycemia,dehydration, infecitons, hypertension, ACS, stroke etc. I did not go to med school to not be able to deal with a trauma situation on the subway or someone collapsing in the middle of the street.

I don’t understand why people think going into psychiatry means you forget how to handle basic medical issues. I’ve worked people up for PE and treated someone for sepsis with a lactate of 4 on the psych floor.

Granted these situations were stressful due to different nursing resources and there were some circumstances that were kind of questionable in one case as to why they were being treated for this on psych (I won’t go into it here), but I gave them good care.

Irrespective of why they were treated for sepsis on a psych unit and not transferred to ICU: How did you go about treating them? Did you consult or did you read up on it yourself? Back when I was a medstudent, if there was so little as a low glucose on the psychiatric ward, they were transferred to IM for investigation, so what you said is all new to me.

 

[Mass Effect]

I like psych patients conditions more than the patients. Does that make sense? I am more interested in their diseases and their CNS than the patients themselves.
I agree that it is what we should be doing. That is why I went into med school: to treat the whole patient (at least make an attempt until I hit the limits of my knowledge) and be able to manage common conditions: hypoglycemia,dehydration, infecitons, hypertension, ACS, stroke etc. I did not go to med school to not be able to deal with a trauma situation on the subway or someone collapsing in the middle of the street

I hate to break it to you, but outside of Hollywood, most doctors are not going to come across a trauma situation on the subway or someone collapsing in the middle of the street and pull a MacGyver to save them. At most, you'll be doing chest compressions until 911 arrives and if you forget how to do that simply because you're a psychiatrist, there are other problems.

Irrespective of why they were treated for sepsis on a psych unit and not transferred to ICU: How did you go about treating them? Did you consult or did you read up on it yourself? Back when I was a medstudent, if there was so little as a low glucose on the psychiatric ward, they were transferred to IM for investigation, so what you said is all new to me.

The rate-limiting step on most psych wards when it comes to acute medical issues usually isn't the psychiatrist. It's usually the nurses and resources. There are med-psych units, attached to hospitals, where they handle basic medical problems (like hypoglycemia). Granted, I've never seen sepsis handled on the psych floor (nor do I think it should be), but med-psych units don't send people to medicine for everything outside psych like a stand-alone psych facility might.

 

[sloop]

Irrespective of why they were treated for sepsis on a psych unit and not transferred to ICU: How did you go about treating them? Did you consult or did you read up on it yourself? Back when I was a medstudent, if there was so little as a low glucose on the psychiatric ward, they were transferred to IM for investigation, so what you said is all new to me.

We rotate through ICU so it wasn’t my first time treating sepsis. Medicine was already following before this happened and I was in contact with them and did ask for transfer. I called them a few times but it was mostly keeping them updated as requested.

I managed them like the sepsis patient they were. I bolused them like 5 liters overnight and monitored lactate every few hours until it came down to normal. Pancultured them and started broad spectrum antibiotics. All of this actually got done overnight, but nursing was very understandably stressed about it.

 

[sloop]

Granted, I've never seen sepsis handled on the psych floor (nor do I think it should be), but med-psych units don't send people to medicine for everything outside psych like a stand-alone psych facility might.

I don’t disagree that this should have been handled elsewhere, but I tried to make that happen and in this one instance I happened to be stuck dealing with it.

 

[Scrooge1]

I don’t disagree that this should have been handled elsewhere, but I tried to make that happen and in this one instance I happened to be stuck dealing with it.

This makes me wonder why similar (although less serious) incidents can´t be managed as inpatient psych instead of referring them to IM. If this was the case the choice between IM and psych would´ve been much easier.

I hate to break it to you, but outside of Hollywood, most doctors are not going to come across a trauma situation on the subway or someone collapsing in the middle of the street and pull a MacGyver to save them. At most, you'll be doing chest compressions until 911 arrives and if you forget how to do that simply because you're a psychiatrist, there are other problems.

I totally agree that a surgeon or a IM doc would be very limited in their interventions without labs and imaging. I guess your´re right in your conclusion. And whether the psychiatrist treats a DKA or otitis inpatient depends on how willing the individual is to stay up to date and read the latest guidelines, as you said. I feel more inclined towards psych reading this and realizing this.

 

[sloop]

This makes me wonder why similar (although less serious) incidents can´t be managed as inpatient psych instead of referring them to IM. If this was the case the choice between IM and psych would´ve been much easier.

This entirely depends on where you work. At a major academic medical center/quaternary care type of psychiatric hospital, you will keep patients on your service despite all sorts of medical problems.

 

[appac1010]

I am in the EXACT same situation. I actually had to re-check my posts to see if I was the author to this post or whether it could be possible for someone else to have the same exact thought as I do.
Could you update us on what you decided on and how it went? I am having the same dilemma: I am naturally interested in the mind and the brain and the disorders and how they effect behaviour, but I don´t want to end up in a position where my friend bring their children with a simple strep throat and I have to admit that I´ve forgotten how to properly exam, diagnose and treat them.

Hey wanted to give you all an update. So I ended up picking psychiatry and got all of my paperwork in time, and I have been interviewing. Looking back, the main reason that I didn't want to give psych a chance was that deep down I think I felt like I was too good for it. My head was way too big, and it was a humbling experience to get off my high horse. But I got over that and am happily and wholeheartedly pursuing it. Although some people are great for IM, the reasons that I was doing it was moreso for other people rather than my own interests. My judgement was frequently clouded by people telling me that I'd be an excellent IM doc, or be very competitive for surgeries / derm / etc, and therefore I should pursue it. What ultimately made the choice clear is when I simplified it to "which specialty makes you happy to come in to work?" and "which specialty will you be able to handle". This new perspective focused more on my own interests and abilities rather than what others wanted of me, and the answer became clear.

I appreciate all the help offered on this forum. You have all been excellent at giving me guidance that I believe is genuine. I hope that this can help another student who is in a similar situation.

 

[MD-2022]

Hey wanted to give you all an update. So I ended up picking psychiatry and got all of my paperwork in time, and I have been interviewing. Looking back, the main reason that I didn't want to give psych a chance was that deep down I think I felt like I was too good for it. My head was way too big, and it was a humbling experience to get off my high horse. But I got over that and am happily and wholeheartedly pursuing it. Although some people are great for IM, the reasons that I was doing it was moreso for other people rather than my own interests. My judgement was frequently clouded by people telling me that I'd be an excellent IM doc, or be very competitive for surgeries / derm / etc, and therefore I should pursue it. What ultimately made the choice clear is when I simplified it to "which specialty makes you happy to come in to work?" and "which specialty will you be able to handle". This new perspective focused more on my own interests and abilities rather than what others wanted of me, and the answer became clear.

I appreciate all the help offered on this forum. You have all been excellent at giving me guidance that I believe is genuine. I hope that this can help another student who is in a similar situation.

Big mistake. Every psychiatrist I know complains about not being able to bill for certain therapies that they provide. Also, patient volume is so much lower (30 mins session). I have not met a single satisfied psychiatrist. Burnout is real. But hey, we all have that passion in the beginning. Good luck and update us in 10 years.

 

[Link0358]

Big mistake. Every psychiatrist I know complains about not being able to bill for certain therapies that they provide. Also, patient volume is so much lower (30 mins session). I have not met a single satisfied psychiatrist. Burnout is real. But hey, we all have that passion in the beginning. Good luck and update us in 10 years.

Medscape: Medscape Access

According to the Medscape survey, Psych is the 7th least burned out specialty out of 29 fields studied.

 

[Lucky Day]

Big mistake. Every psychiatrist I know complains about not being able to bill for certain therapies that they provide. Also, patient volume is so much lower (30 mins session). I have not met a single satisfied psychiatrist. Burnout is real. But hey, we all have that passion in the beginning. Good luck and update us in 10 years.

Hey everyone, where's the rolling eyes emoji?

 

[mistafab]

Which banned troll account are you a resurrection of?

Or better yet - how many?

Big mistake. Every psychiatrist I know complains about not being able to bill for certain therapies that they provide. Also, patient volume is so much lower (30 mins session). I have not met a single satisfied psychiatrist. Burnout is real. But hey, we all have that passion in the beginning. Good luck and update us in 10 years.

 

[Mad Jack]

Big mistake. Every psychiatrist I know complains about not being able to bill for certain therapies that they provide. Also, patient volume is so much lower (30 mins session). I have not met a single satisfied psychiatrist. Burnout is real. But hey, we all have that passion in the beginning. Good luck and update us in 10 years.

I don't know a single unsatisfied psychiatrist. It's a pretty great field. And lower patient volume is generally considered a plus, as it allows you time with your patients that psychiatrist types tend to enjoy

 

[Oso]

Big mistake. Every psychiatrist I know complains about not being able to bill for certain therapies that they provide. Also, patient volume is so much lower (30 mins session). I have not met a single satisfied psychiatrist. Burnout is real. But hey, we all have that passion in the beginning. Good luck and update us in 10 years.

Alternatively, you could just be happy for the guy and not be a d!ck

 

[appac1010]

Big mistake. Every psychiatrist I know complains about not being able to bill for certain therapies that they provide. Also, patient volume is so much lower (30 mins session). I have not met a single satisfied psychiatrist. Burnout is real. But hey, we all have that passion in the beginning. Good luck and update us in 10 years.

Thanks for the input. I see where you're coming from, because I know some psychotherapy is difficult to bill for, but my experience has been quite the opposite of what you have described. Nearly every psych doc I've met has been extremely satisfied. In addition, I enjoy the aspect of a lower patient volume with longer time per pt. It's interesting you mentioned burnout, because it seems like that is a much bigger concern for every other specialty besides psych. Psych seems to take a toll on you emotionally, but as long as you have supporting colleagues, it shouldn't be any more of an issue than with other specialties. And good luck to you as well, hope you find a specialty that matches you.

 

[Scrooge1]

Hey wanted to give you all an update. So I ended up picking psychiatry and got all of my paperwork in time, and I have been interviewing. Looking back, the main reason that I didn't want to give psych a chance was that deep down I think I felt like I was too good for it. My head was way too big, and it was a humbling experience to get off my high horse. But I got over that and am happily and wholeheartedly pursuing it. Although some people are great for IM, the reasons that I was doing it was moreso for other people rather than my own interests. My judgement was frequently clouded by people telling me that I'd be an excellent IM doc, or be very competitive for surgeries / derm / etc, and therefore I should pursue it. What ultimately made the choice clear is when I simplified it to "which specialty makes you happy to come in to work?" and "which specialty will you be able to handle". This new perspective focused more on my own interests and abilities rather than what others wanted of me, and the answer became clear.

I appreciate all the help offered on this forum. You have all been excellent at giving me guidance that I believe is genuine. I hope that this can help another student who is in a similar situation.

How are you feeling with your choice one year later? Any regrets?

 

[Splenda88]

Where I am training, everyone in psych seems to be happy with their choice. Most of us in IM look miserable.