Is it Worth it to do a Second Residency in Psychiatry?

[IMPGY2]

Good day. I'm currently a second year internal medicine resident. I applied twice to psychiatry in the past without success and went into IM which was my backup field. I am very unhappy in IM and I'm trying to gauge whether it is worth it to consider applying again to psychiatry. I live in a rural area and know that I could try to find fulfillment offering whatever mental healthcare I can as an outpatient PCP. However, I am really interested in working in inpatient psychiatry and there are basically no paths to doing that without first completing a psychiatry residency. I really liked my addiction medicine rotation and for much of the past year was thinking about applying to addiction medicine fellowship vs reapplying to psychiatry. As PGY-3 year approaches and fellowship applications open in just a few months, I feel like I really need to make a decision.

I am a USIMG and don't have the most competitive resume. However, I passed all my steps on first attempt and believe I am an average resident. I feel like I could get much better letters of recommendation than I obtained when I was a medical student as well. I am leaning towards applying to addiction medicine fellowship to hopefully increase my competitiveness for psychiatry and maybe gain some connections at a hospital with a psych residency (my hospital has no other training programs). I know it would make the most sense to apply directly to psychiatry but I am just worried about not matching again and being shut out of fellowship as well. I don't have a family or any financial constraints, but am nearing 30 and wonder if adding on 4 years to my training would be a foolish decision. I'd really appreciate some input as to whether I should move forward with this plan or just cut my losses with psychiatry.

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[Celexa]

How do you know you're interested in inpatient psychiatry? It's such a small slice of our field.

Plenty if people start medical school in their mid 20s and are around your age when they graduate, so I don't think doing a second residency is entirely unreasonable, but I would be hesitant to recommend that if the reason to do so is to work in an area that is a small minority of the field unless you already have extensive experience with inpatient psych in another role. The grass is not always greener.

Doing an addiction med fellowship and then continuing to pursue mental health learning opportunities afterward, and potentially working in inpatient or intensive outpatient rehab settings, is certainly a viable path that might equally satisfy your goals.

 

[IMPGY2]

How do you know you're interested in inpatient psychiatry? It's such a small slice of our field.

Plenty if people start medical school in their mid 20s and are around your age when they graduate, so I don't think doing a second residency is entirely unreasonable, but I would be hesitant to recommend that if the reason to do so is to work in an area that is a small minority of the field unless you already have extensive experience with inpatient psych in another role. The grass is not always greener.

Doing an addiction med fellowship and then continuing to pursue mental health learning opportunities afterward, and potentially working in inpatient or intensive outpatient rehab settings, is certainly a viable path that might equally satisfy your goals.

Psychiatry core rotation in 3rd year and additional 4th year electives in med school. Of course I'm also interested in outpatient psych as well.

 

[Celexa]

Psychiatry core rotation in 3rd year and additional 4th year electives in med school. Of course I'm also interested in outpatient psych as well.

You could try and find a pgy2 position outside the match. If you have a good reputation as a resident that might be easier than trying to match again.

 

[dl2dp2]

Addiction med fellowship would make you marketable for an inpatient addiction job without doing any psychiatry training. This type of job is reasonably plentiful such that you can probably be certain to get a job at any metro. However, they usually don't pay well.

Similarly, you can practice outpatient addiction medicine, which consists primarily of buprenorphine treatment with a touch of alcohol and off-label for cocaine, usually in the context of an addiction "mill". Little psychiatry is practiced and often clinics outsource psychiatry to a psychiatrist. These jobs also often don't pay well.

If these jobs scratch enough psychiatry itch for you, then I'd go with an addiction med fellowship after IM.

Cash-based private practice in addiction medicine is much easier to achieve if you have a psychiatry residency + fellowship, as most outpatient addiction medicine is psychiatry rather than IM. Job market for psychiatry at large is much better than for addiction medicine, and addiction psychiatry jobs (read inpatient dual diagnosis units) are in extremely high demand. These jobs tend to pay somewhat better than the options above. But this obviously requires additional training as you know and you may not match again.

If I were you I would consider dually apply and get a vibe before making a final decision.

 

[nexus73]

Agree with Celexa. The move is finding a PGY2 spot so you only have to do 3 years of psych residency.

It has been several years, but we had several people in my psych residency entering from other fields, many retraining later in their careers (think early 50s) coming from other specialties. It seemed that while these were good residents, the competitiveness of PGY2 spots was not the same level as the standard match into PGY1.

This is assuming you are well regarded in your current IM program and can get good letters.

 

[IMPGY2]

Agree with Celexa. The move is finding a PGY2 spot so you only have to do 3 years of psych residency.

It has been several years, but we had several people in my psych residency entering from other fields, many retraining later in their careers (think early 50s) coming from other specialties. It seemed that while these were good residents, the competitiveness of PGY2 spots was not the same level as the standard match into PGY1.

This is assuming you are well regarded in your current IM program and can get good letters.

I have thought about applying for PGY-2 openings outside of the match when I was an intern, but the problem I had with it is that I would need to abandon my current training program and would lose the progress I've made in internal medicine. I also feel like doing this would require me to relinquish a significant amount of job security. I only have about a year left and at this point would prefer to obtain board certification in IM (in the event I am fired from psychiatry residency, etc). Are these openings ever available to start in July, like PGY-1 positions do? Also, is it possible to apply to a PGY-2 spot through the regular match?

 

[Celexa]

I have thought about applying for PGY-2 openings outside of the match when I was an intern, but the problem I had with it is that I would need to abandon my current training program and would lose the progress I've made in internal medicine. I also feel like doing this would require me to relinquish a significant amount of job security. I only have about a year left and at this point would prefer to obtain board certification in IM (in the event I am fired from psychiatry residency, etc). Are these openings ever available to start in July, like PGY-1 positions do? Also, is it possible to apply to a PGY-2 spot through the regular match?

You could finish your program, find a hospitalist job for a year, use that year to look for a pgy2 position, and then start as a pgy2 and graduate at the same time you would have if you matched and tacked on the four years. Youd also still have the option of applying to the match the year after.

If you are truly set on psychiatry that is probably what I would do.

 

[nexus73]

I have thought about applying for PGY-2 openings outside of the match when I was an intern, but the problem I had with it is that I would need to abandon my current training program and would lose the progress I've made in internal medicine. I also feel like doing this would require me to relinquish a significant amount of job security. I only have about a year left and at this point would prefer to obtain board certification in IM (in the event I am fired from psychiatry residency, etc). Are these openings ever available to start in July, like PGY-1 positions do? Also, is it possible to apply to a PGY-2 spot through the regular match?

We had a family med doc who applied to psych during his PGY3 FM year and started psych PGY2 with no gap in between. PGY2 psych would typically start in July same time as all residencies.

 

[witzelsucht]

Can EM switch into PGY2 psych without the prelim year?

 

[Celexa]

Can EM switch into PGY2 psych without the prelim year?

We don't have a prelim year in psych. Off service rotations are four months general medicine (usually inpatient medicine or sometimes peds, sometimes a month of EM) and two months of neurology.

There's a lot of flexibility in psych residencies so most people starting as pgy2s can cram everything into 3 years without delaying graduation, they just sacrifice most or all of their elective time. If you have neuro rotations under your belt from EM you'd be well positioned to not have to do much off service in psych.

 

[tr]

You could finish your program, find a hospitalist job for a year, use that year to look for a pgy2 position, and then start as a pgy2 and graduate at the same time you would have if you matched and tacked on the four years. Youd also still have the option of applying to the match the year after.

If you are truly set on psychiatry that is probably what I would do.

I'm not 100% sure on this but I think there is some rule about the federal funding for residency programs, such that the hospital can only get funding for one full program per individual resident.

So if you have already completed a program and then apply to a different program as a PGY1 or PGY2, my understanding is the hopsital cannot get government support for your position and would have to fund it entirely on their own dime, which is a significant barrier to them accepting you.

For that reason the OP might have better luck trying to switch into a PGY2 psych position now vs after completing a full IM residency.

 

[clausewitz2]

I'm not 100% sure on this but I think there is some rule about the federal funding for residency programs, such that the hospital can only get funding for one full program per individual resident.

So if you have already completed a program and then apply to a different program as a PGY1 or PGY2, my understanding is the hopsital cannot get government support for your position and would have to fund it entirely on their own dime, which is a significant barrier to them accepting you.

For that reason the OP might have better luck trying to switch into a PGY2 psych position now vs after completing a full IM residency.

There are actually a lot of threads about this on SDN. The short version is that when you start a residency program, you get a pot of training money that follows you around based on the number of years of the residency you initially started would take. This is not a negligible sum of money but it is a much smaller piece of the GME budget in some places than others. So for some programs it is a deal-breaker, some programs don't really care.

 

[Wilf]

Good day. I'm currently a second year internal medicine resident. I applied twice to psychiatry in the past without success and went into IM which was my backup field. I am very unhappy in IM and I'm trying to gauge whether it is worth it to consider applying again to psychiatry. I live in a rural area and know that I could try to find fulfillment offering whatever mental healthcare I can as an outpatient PCP. However, I am really interested in working in inpatient psychiatry and there are basically no paths to doing that without first completing a psychiatry residency. I really liked my addiction medicine rotation and for much of the past year was thinking about applying to addiction medicine fellowship vs reapplying to psychiatry. As PGY-3 year approaches and fellowship applications open in just a few months, I feel like I really need to make a decision.

I am a USIMG and don't have the most competitive resume. However, I passed all my steps on first attempt and believe I am an average resident. I feel like I could get much better letters of recommendation than I obtained when I was a medical student as well. I am leaning towards applying to addiction medicine fellowship to hopefully increase my competitiveness for psychiatry and maybe gain some connections at a hospital with a psych residency (my hospital has no other training programs). I know it would make the most sense to apply directly to psychiatry but I am just worried about not matching again and being shut out of fellowship as well. I don't have a family or any financial constraints, but am nearing 30 and wonder if adding on 4 years to my training would be a foolish decision. I'd really appreciate some input as to whether I should move forward with this plan or just cut my losses with psychiatry.

What is it that you don’t like about IM? I actually wish I could have done an IM/psychiatry residency but I felt I needed to start making real money given my age. I found IM very interesting and I still try to keep my IM knowledge sharp even though I’ve been out of training for over 6 years.

 

[IMPGY2]

What is it that you don’t like about IM? I actually wish I could have done an IM/psychiatry residency but I felt I needed to start making real money given my age. I found IM very interesting and I still try to keep my IM knowledge sharp even though I’ve been out of training for over 6 years.

I don't hate internal medicine, I am just not interested in the types of diseases commonly encountered in IM. I find it extremely boring and much of the time feel like I am treating lab values instead of people. Whether inpatient of clinic, treatment is almost always guideline based and very rigid. It also tends to ignore the psychological component of the disease process. I could never see myself enjoying going to a conference for something related to IM or taking part in any kind of research of CME activity.

 

[comp1]

Second residencies are...rare indeed because of the funding issue mentioned above. PGY-2 slots in psych are also rare. Consider addiction medicine! Or, if you want, you can probably cobble together a full time job doing medical management at a large inpatient psychiatric hospital.

 

[clausewitz2]

Second residencies are...rare indeed because of the funding issue mentioned above. PGY-2 slots in psych are also rare. Consider addiction medicine! Or, if you want, you can probably cobble together a full time job doing medical management at a large inpatient psychiatric hospital.

I have known several people with precisely that job at a few different institutions, and they have typically been FM folks.