Last minute specialty indecision help! Neuro vs psych

[indecisivem4]

M4 at an MD school in the southeast US. Wouldn’t mind staying here but no regional preference. 24x Step 1, 24x Step 2, split HP/P, no honors, 1 psych paper, 2 other unrelated papers during med school (maybe more depending on how submission goes). Not a superstar by any means. Can get LORs from both fields, rotated in both but still need help choosing. Figured some outside perspective might help.

Pros of psych:
-Longitudinal patient care, highly in demand
-Most patients aren’t cured but tend to improve significantly in QOL
-Diseases are interesting and present differently
-Lifestyle in residency seems better than other fields, easier to moonlight
-Tend to get along with psych residents/attendings pretty well

Cons:
-Notes are super long and calling collateral can be tiring
-Having to be comfortable with involuntarily hospitalizing patients, violent patients
-Worried about becoming a psychopharm expert but forgetting the rest of medicine
-More gray areas in terms of treatment/diagnosis
-More midlevel encroachment with NPs, although I hear shortage is still high so it shouldn't matter too much (???)

Pros of neuro:
-Also longitudinal patient care and also in demand
-More tools and technology at your disposal for diagnosis/treatment
-Attending life can be as chill as psych as long as you don’t do stroke (???)
-More technical knowledge in terms of “traditional” medicine, also neuroanatomy is super cool

Cons:
-Brutal residency and fellowship becoming more common
-Spend a lot of time with patients but a good portion of that is the physical exam
-Treatments like MS and headaches are improving a lot but still seems like there's a good chunk of sad, terminal cases
-Higher salary but probably less per hour compared to psych

I’ve had multiple people tell me that if I can see myself doing psych, then to choose psych. Quality of life is also important but then I'm also told that residency is temporary. Leaning towards psych but wanted some neutral opinions. Am I wrong about any assumptions? Is neuro residency really that terrible? Should I just take the plunge and commit to psych?

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[painballer27]

Do you have LORs from both fields?

 

[DrStephenStrange]

Residency is gonna suck no matter what, so choose the specialty you like the most.

 

[indecisivem4]

Do you have LORs from both fields?

I have attendings from both fields who have agreed to write one. I know from my pre-med days that a promise doesn't always turn into a timely letter so we'll see.

Residency is gonna suck no matter what, so choose the specialty you like the most.

True, I know psych has its own challenges. I have one more neuro rotation so hopefully I'll figure it out this month...

 

[Taddy Mason]

You seem to have a longer list of cons for psych and a number of those are pervasive aspects of the field that don’t go away after training, where as your cons for neuro are limited to the training or ultimately avoidable as an attending…

Also, I’d be more concerned about “violent” patients in neuro than I would in psych.

 

[painballer27]

I have attendings from both fields who have agreed to write one. I know from my pre-med days that a promise doesn't always turn into a timely letter so we'll see

Gotcha. I am an M4 between a few specialties myself and getting the letters lined up can be tricky... but honestly I think that you have made good lists of pros and cons of each field. I think it comes down to which specialty you like the bread and butter of more. Also, at least in residency, psych is definitely more chill in terms of hours and overall stress, so if you're truly at a toss up then thats worth considering. I would not worry too much about money difference between these two fields. Truth is, if you want money, you can get it in either.

 

[odyssey2]

Both great fields, psych lifestyle in residency is probably going to be a bit cushier depending where you go. Honestly can't go wrong with either.

 

[indecisivem4]

You seem to have a longer list of cons for psych and a number of those are pervasive aspects of the field that don’t go away after training, where as your cons for neuro are limited to the training or ultimately avoidable as an attending…

Also, I’d be more concerned about “violent” patients in neuro than I would in psych.

I think I could get used to it, but that's a fair assessment. Why is there more concern for violent patients in neuro?

Gotcha. I am an M4 between a few specialties myself and getting the letters lined up can be tricky... but honestly I think that you have made good lists of pros and cons of each field. I think it comes down to which specialty you like the bread and butter of more. Also, at least in residency, psych is definitely more chill in terms of hours and overall stress, so if you're truly at a toss up then thats worth considering. I would not worry too much about money difference between these two fields. Truth is, if you want money, you can get it in either.

Yeah not too worried about money, seems like you can hit 300 in either field which is more than enough for me. Moonlighting would def help for quality of life financially while in residency though. Letters are always stressful since something always goes wrong, but fingers crossed.

 

[painballer27]

Moonlighting would def help for quality of life financially while in residency though.

Yes, I have heard of psych residents doubling or tripling their resident salary through moonlighting in pgy years 3 and 4.

 

[Taddy Mason]

I think I could get used to it, but that's a fair assessment. Why is there more concern for violent patients in neuro?

If you look at published data, the prevalence of “assault” (the definition of which tends to be quite loose when discussing this topic), psych doesn’t appear to be at any higher risk relative to other specialties. Violence from patients tends to come most often from individuals who are cognitively impaired (e.g., delirium, neurocognitive disorders, intoxication, etc.). The only times I ever had “concern” for safety in residency (and by “concern,” I mean was more actively cognizant of taking precautions than I was of something actually happening to me) were while covering the ED and I had to tell a malingering individual that they weren’t being admitted. But I let the ED staff know ahead of time and went with security so if things started to escalate I stepped out and the patient was quickly escorted to the street.

Here’s my diatribe on this topic from a relatively recent thread in the psych sub-forum: Dangers of psychiatry- resident stabbed (the title of the linked thread is misleading as it actually involved a psych resident who was seeing a neuro patient on a neuro unit).

“I worked in psych for several years in undergrad, rotated through more than one maximum security prison in med school and residency, worked on an urban ACT team with a lot of patients with psychosis and substance use issues in a low income and high crime area, currently moonlight at a maximum security prison/forensic facility specifically for individuals with psychiatric disorders and a history of violence, and my spouse worked as a psych nurse for 6-7 years. Based on our n=2 experiences 99% of the time someone was assaulted there were clear warning signs exhibited by the assailant prior to the assault that people ignored/were oblivious to or the person who was assaulted clearly provoked the assailant (not that it justifies the attack, but it could have very easily been avoided). The instances I’ve encountered where a significant assault occurred and was largely unexpected are few and far between and tended to be on child/adolescent units (vast majority), in the ED, or on acute units in state hospitals and were perpetrated by individuals with well known histories of violence and/or impulsivity. In the ED and state hospitals a common underlying factor was lack of certain safety considerations by the facility (particularly with EDs being overly stimulating environments to begin with) and the person attacked tended to be someone with little to no training in dealing with potentially violent individuals (e.g., cleaning staff, sitters, etc.). I’ve been assaulted by patients on multiple occasions (the vast majority of which occurred on the child and adolescent units of a specific hospital while working as an aide) and with the exception of one instance with a 10 year-old patient there were pretty obvious things I could’ve done differently to avoid being hit, slapped, have something thrown at me, etc., and thus take some ownership for the fact that those incidents occurred. You don’t need to go all out and always bring security or multiple staff members with you or only see patients from the doorway while standing (obviously there are exceptions, but they are just that, exceptions). Any fear or apprehension you exhibit through your behavior can easily be misinterpreted by psychotic or cognitively altered individuals and heighten their own fear, mistrust, and apprehension and trigger them to become defensive and act on impulses. Also, as another poster noted above, simply informing a patient that their behavior or demeanor is making you uncomfortable can go a long way in diffusing potentially aggressive patients. Common sense, actively appraising a situation, and being cognizant of your surroundings goes a long way and should keep you from being assaulted or reasonably injured by a patient 99.9% of the time.

As an aside, when talking about aggressive or assaultive patients there's a broad spectrum of behaviors in terms of actual harm and intent to harm that are simply lumped under the umbrella of "assault". There's a big difference between someone throwing a paper cup of water or taking a half-assed swing at someone v. breaking someone's nose or stabbing someone. The vast majority of what is labeled as assault in hospitals tends to more in line with the former than the latter.”

 

[indecisivem4]

If you look at published data, the prevalence of “assault” (the definition of which tends to be quite loose when discussing this topic), psych doesn’t appear to be at any higher risk relative to other specialties. Violence from patients tends to come most often from individuals who are cognitively impaired (e.g., delirium, neurocognitive disorders, intoxication, etc.). The only times I ever had “concern” for safety in residency (and by “concern,” I mean was more actively cognizant of taking precautions than I was of something actually happening to me) were while covering the ED and I had to tell a malingering individual that they weren’t being admitted. But I let the ED staff know ahead of time and went with security so if things started to escalate I stepped out and the patient was quickly escorted to the street.

Here’s my diatribe on this topic from a relatively recent thread in the psych sub-forum: Dangers of psychiatry- resident stabbed (the title of the linked thread is misleading as it actually involved a psych resident who was seeing a neuro patient on a neuro unit).

“I worked in psych for several years in undergrad, rotated through more than one maximum security prison in med school and residency, worked on an urban ACT team with a lot of patients with psychosis and substance use issues in a low income and high crime area, currently moonlight at a maximum security prison/forensic facility specifically for individuals with psychiatric disorders and a history of violence, and my spouse worked as a psych nurse for 6-7 years. Based on our n=2 experiences 99% of the time someone was assaulted there were clear warning signs exhibited by the assailant prior to the assault that people ignored/were oblivious to or the person who was assaulted clearly provoked the assailant (not that it justifies the attack, but it could have very easily been avoided). The instances I’ve encountered where a significant assault occurred and was largely unexpected are few and far between and tended to be on child/adolescent units (vast majority), in the ED, or on acute units in state hospitals and were perpetrated by individuals with well known histories of violence and/or impulsivity. In the ED and state hospitals a common underlying factor was lack of certain safety considerations by the facility (particularly with EDs being overly stimulating environments to begin with) and the person attacked tended to be someone with little to no training in dealing with potentially violent individuals (e.g., cleaning staff, sitters, etc.). I’ve been assaulted by patients on multiple occasions (the vast majority of which occurred on the child and adolescent units of a specific hospital while working as an aide) and with the exception of one instance with a 10 year-old patient there were pretty obvious things I could’ve done differently to avoid being hit, slapped, have something thrown at me, etc., and thus take some ownership for the fact that those incidents occurred. You don’t need to go all out and always bring security or multiple staff members with you or only see patients from the doorway while standing (obviously there are exceptions, but they are just that, exceptions). Any fear or apprehension you exhibit through your behavior can easily be misinterpreted by psychotic or cognitively altered individuals and heighten their own fear, mistrust, and apprehension and trigger them to become defensive and act on impulses. Also, as another poster noted above, simply informing a patient that their behavior or demeanor is making you uncomfortable can go a long way in diffusing potentially aggressive patients. Common sense, actively appraising a situation, and being cognizant of your surroundings goes a long way and should keep you from being assaulted or reasonably injured by a patient 99.9% of the time.

As an aside, when talking about aggressive or assaultive patients there's a broad spectrum of behaviors in terms of actual harm and intent to harm that are simply lumped under the umbrella of "assault". There's a big difference between someone throwing a paper cup of water or taking a half-assed swing at someone v. breaking someone's nose or stabbing someone. The vast majority of what is labeled as assault in hospitals tends to more in line with the former than the latter.”

Great perspective and good to know there's data about this. I think I was biased one way with a serious incident I heard about rotating through the psych ED.

 

[PugsAndHugs]

Do one more rotation in each of these specialties back to back so you can decide.

 

[Postictal Raiden]

If you like both equally go with psych

I just finished neurology residency. Went to hell and back. Only residents that worked longer hours were surgical ones.

I can’t stomach psych, but if I could I would’ve chosen it.

 

[Mad Jack]

Residency is gonna suck no matter what, so choose the specialty you like the most.

Psych residency may suck, but compared to neuro residency? It's practically a vacation.

 

[Mad Jack]

If you look at published data, the prevalence of “assault” (the definition of which tends to be quite loose when discussing this topic), psych doesn’t appear to be at any higher risk relative to other specialties. Violence from patients tends to come most often from individuals who are cognitively impaired (e.g., delirium, neurocognitive disorders, intoxication, etc.). The only times I ever had “concern” for safety in residency (and by “concern,” I mean was more actively cognizant of taking precautions than I was of something actually happening to me) were while covering the ED and I had to tell a malingering individual that they weren’t being admitted. But I let the ED staff know ahead of time and went with security so if things started to escalate I stepped out and the patient was quickly escorted to the street.

Here’s my diatribe on this topic from a relatively recent thread in the psych sub-forum: Dangers of psychiatry- resident stabbed (the title of the linked thread is misleading as it actually involved a psych resident who was seeing a neuro patient on a neuro unit).

“I worked in psych for several years in undergrad, rotated through more than one maximum security prison in med school and residency, worked on an urban ACT team with a lot of patients with psychosis and substance use issues in a low income and high crime area, currently moonlight at a maximum security prison/forensic facility specifically for individuals with psychiatric disorders and a history of violence, and my spouse worked as a psych nurse for 6-7 years. Based on our n=2 experiences 99% of the time someone was assaulted there were clear warning signs exhibited by the assailant prior to the assault that people ignored/were oblivious to or the person who was assaulted clearly provoked the assailant (not that it justifies the attack, but it could have very easily been avoided). The instances I’ve encountered where a significant assault occurred and was largely unexpected are few and far between and tended to be on child/adolescent units (vast majority), in the ED, or on acute units in state hospitals and were perpetrated by individuals with well known histories of violence and/or impulsivity. In the ED and state hospitals a common underlying factor was lack of certain safety considerations by the facility (particularly with EDs being overly stimulating environments to begin with) and the person attacked tended to be someone with little to no training in dealing with potentially violent individuals (e.g., cleaning staff, sitters, etc.). I’ve been assaulted by patients on multiple occasions (the vast majority of which occurred on the child and adolescent units of a specific hospital while working as an aide) and with the exception of one instance with a 10 year-old patient there were pretty obvious things I could’ve done differently to avoid being hit, slapped, have something thrown at me, etc., and thus take some ownership for the fact that those incidents occurred. You don’t need to go all out and always bring security or multiple staff members with you or only see patients from the doorway while standing (obviously there are exceptions, but they are just that, exceptions). Any fear or apprehension you exhibit through your behavior can easily be misinterpreted by psychotic or cognitively altered individuals and heighten their own fear, mistrust, and apprehension and trigger them to become defensive and act on impulses. Also, as another poster noted above, simply informing a patient that their behavior or demeanor is making you uncomfortable can go a long way in diffusing potentially aggressive patients. Common sense, actively appraising a situation, and being cognizant of your surroundings goes a long way and should keep you from being assaulted or reasonably injured by a patient 99.9% of the time.

As an aside, when talking about aggressive or assaultive patients there's a broad spectrum of behaviors in terms of actual harm and intent to harm that are simply lumped under the umbrella of "assault". There's a big difference between someone throwing a paper cup of water or taking a half-assed swing at someone v. breaking someone's nose or stabbing someone. The vast majority of what is labeled as assault in hospitals tends to more in line with the former than the latter.”

The idea that psychiatry is no more dangerous than other specialties is incorrect. At least two studies I know of have established that psychiatrists are at the highest risk of homicide in the course of practice, and one study showed that the only physicians more likely to be assaulted than psychiatrists were emergency physicians. The most recent one is here:

Psychiatrists the Most Common Victims of Physician Homicide

Among physicians, psychiatrists are the most likely to be killed by their patients or a family member. The most common victims of homicide among mental health workers are female case workers, new data show.

www.medscape.com

Overall, however, significant events of violence are still rare, and being on guard at all times can allow you to avoid most issues.

 

[Mad Jack]

So, my overall take on psych versus neuro, with an obvious bias toward psychiatry because I'm a psychiatrist: psych offers more opportunities for a better lifestyle, a higher income, and more flexible work than neurology. The day-to-day tends to be lower stress work than neuro in most environments. But the thing is, you're either a psych person or you're not. I'm incredibly happy with my career in psychiatry, but I love the ambiguous nature of psychiatric work, the particular challenges of the field, and the interactions that I have with my patients. Many... Well, let's just say psych makes them miserable. Neurology, on the other hand, would be a misery machine for me, aside from a couple of specific subspecialties.

Neuro can give you the satisfaction of saving lives with the 'ol TPN. It's a much less ambiguous field (LOCALIZE THE LESIONNNNN). Often you can make a better salary, albeit only by a bit and often working more hours than a psychiatrist. Demand is high, and you've got a very specialized knowledge base that leaves you (slightly) less vulnerable to midlevel encroachment. If you need to feel like a Real Doctor™ but don't get that vibe from psychiatry then neurology certainly fits the bill (though I've gotta say, any concerns I had about not feeling like an honest-to-god doctor faded very quickly after starting residency).

Oh, and with regards to the long notes, after residency most places have far more efficient charting that only hits the necessities for billing. Some places have templates that literally cut follow-up notes down to a minute or two at most.

 

[painballer27]

So, my overall take on psych versus neuro, with an obvious bias toward psychiatry because I'm a psychiatrist: psych offers more opportunities for a better lifestyle, a higher income, and more flexible work than neurology. The day-to-day tends to be lower stress work than neuro in most environments. But the thing is, you're either a psych person or you're not. I'm incredibly happy with my career in psychiatry, but I love the ambiguous nature of psychiatric work, the particular challenges of the field, and the interactions that I have with my patients. Many... Well, let's just say psych makes them miserable. Neurology, on the other hand, would be a misery machine for me, aside from a couple of specific subspecialties.

Neuro can give you the satisfaction of saving lives with the 'ol TPN. It's a much less ambiguous field (LOCALIZE THE LESIONNNNN). Often you can make a better salary, albeit only by a bit and often working more hours than a psychiatrist. Demand is high, and you've got a very specialized knowledge base that leaves you (slightly) less vulnerable to midlevel encroachment. If you need to feel like a Real Doctor™ but don't get that vibe from psychiatry then neurology certainly fits the bill (though I've gotta say, any concerns I had about not feeling like an honest-to-god doctor faded very quickly after starting residency).

Please reconcile these two statements.

 

[RangerBob]

Psych residency may suck, but compared to neuro residency? It's practically a vacation.

Psych was the one residency program that had it easier than us (PM&R) at our institution.

I’m a bit perplexed. Obviously if one likes one specialty more, go for that. But when one is equally torn between neuro and psych, it seems to me psych should be the easier choice. Better/easier residency, can hang a shingle literally in any part of the country, can easily start your own practice, great pay, even greater work-life balance.

Just look at the number of happy neurologists to psychiatrists? Haven’t met any happy psychiatrists? It’s because they’re at home or on vacation! (I jest here, and clearly different personalities go into psych vs neuro, but psych does on average seem much happier than most specialties).

For what it’s worth, my n=1, the neurologists in town just all seem to be getting unhappier.

 

[Mad Jack]

Please reconcile these two statements.

There are greater opportunities for higher income in psychiatry, but the typical psych positions you will get from hospitals and big groups pay less than the same positions offered in neurology. However it is much easier to find atypical jobs or string multiple positions together in psychiatry and make a much better salary than a neurologist while putting in the same hours or less. As an example, the big hospitals around pay about 250k for psychiatrists and 270k for neurologists. Private practice jobs in psych can land you around 250k+ for three 10 hour days, however, and you can pick up per diem work to fill your other 4 days at $200-240/hr, or pick up a residential for a few thousand a month, etc. To give you an idea: based on the offers I'm looking at, I will be making around 440k for a 50 hour work week in psych with minimal call by working 3 days in an outpatient clinic and two different per diem positions the other two weekdays, while having weekends off and 6 weeks of vacation a year.

So basically, if you want an employed or academic position at one employer, you might make slightly more in neurology. If you are willing to think outside the box or look harder for more exceptional arrangements, psychiatry can pay off.

 

[Mad Jack]

Psych was the one residency program that had it easier than us (PM&R) at our institution.

I’m a bit perplexed. Obviously if one likes one specialty more, go for that. But when one is equally torn between neuro and psych, it seems to me psych should be the easier choice. Better/easier residency, can hang a shingle literally in any part of the country, can easily start your own practice, great pay, even greater work-life balance.

Just look at the number of happy neurologists to psychiatrists? Haven’t met any happy psychiatrists? It’s because they’re at home or on vacation! (I jest here, and clearly different personalities go into psych vs neuro, but psych does on average seem much happier than most specialties).

For what it’s worth, my n=1, the neurologists in town just all seem to be getting unhappier.

I almost commented on the happiness factor but felt it might be too controversial. It is rare that I've met a happy neurologist, but perhaps that's just my region. The psychiatrists I know are pretty happy, aside from one or two exceptions.

 

[RangerBob]

I almost commented on the happiness factor but felt it might be too controversial. It is rare that I've met a happy neurologist, but perhaps that's just my region. The psychiatrists I know are pretty happy, aside from one or two exceptions.

I think I’ve met one “objectively very happy” neurologist since I started med school.

Aside from my limited interactions with neurologists (I’ve met perhaps 10-20 total, most in more limited capacities), the type of person who goes into neurology tends to be different than many specialties. They tend to be very analytical and serious. They’re usually not Patch Adams type people (at least the ones I met).

You certainly see the same personality type in psych too (they’re always the ones I'm convinced are psychoanalyzing me when I talk to them…) , but I think there are much more varied personalities in psych. Same for FM, EM, among others. Neuro and ID, among others? Not so much in my experience.

I don’t run into many unhappy psychiatrists. When I do, it’s usually because they didn’t want to be a psychiatrist—maybe it was their backup choice, maybe they were IMG/FMG and had minimal other options back when they applied to residency (like my PM&R attending who was an ortho surgeon in Eastern Europe). I think both fields are now hard to get into as an IMG/FMG, but back in t the day they weren’t.

I rarely meet a psychiatrist who’s unhappy for the same reason you run into unhappy derm/rads—because they went into it for the lifestyle/money. Perhaps that will change moving forward now that psych is catching on?

 

[DrStephenStrange]

Psych residency may suck, but compared to neuro residency? It's practically a vacation.

You're right, Neuro residency sucks more, but it's only a temporary thing that you have to endure for 4 years. The worst part is in PGY-2 year. PGY-3 and 4 is a lot better at any program. And if you really like Neuro, that shouldn't be a deal breaker.

 

[Smurfette]

Maybe the OP should consider a neuro-psych combined residency. It's longer, but I'd assume if one clearly is the "winner" after starting residency, the OP could possibly switch to neuro or psych only? Just throwing it out there...

 

[DJKitty]

So, this may be a bit biased as I am a geriatric psychiatrist, but as a M4 I was deciding between psychiatry and neurology. I will say that it is a common misconception that one will "forget the rest of medicine" as a psychiatrist; however, I do not feel that this is the case. As a geriatric psychiatrist, my patient's have numerous medical and neurological comorbidities. I practice "medicine" every day when I work with a patient with Parkinson's disease complicated by anxiety, depression and Parkinson's disease dementia. I have around 5 patients with recurrent SSRI-induced hyponatremia 2/2 SIADH and I know if a particular patient is acting strangely, his salt is probably low again and he needs to go get evaluated. Delirium and dementia are my bread and butter. C/L psychiatry, women's psychiatry and addiction psychiatry also require in depth general medical knowledge.

Also, psychiatry has a non-acgme behavioral neurology and neuropsychiatry fellowship and neurology has a behavioral neurology fellowship, so you may be able to combine your interests by doing a fellowship after residency. And as you know, there is a lot of psychiatry in neurology and a lot of neurology overlap in psychiatry. So you really can't go wrong with either choice. Good luck with your application this year!

 

[mrbreakfast]

Few comments:

Salary: I don't know what psychiatrists make, but outpatient neurology jobs are starting in mid-300s (4 days/week) before wRVU contributions, and inpatient jobs are paying $200-250/hour. Teleneurology jobs pay similarly, and there is such a need for tele that you can do it full-time. I don't think the difference in pay is too significant (unless you do mostly inpatient neurology) but to say the earning potential is higher in psychiatry is completely inaccurate (even excluding NIR, and locums) when teleneurology gigs paying $2300-2500/day aren't hard to find and you can work every day of the year (if you wanted to). But you shouldn't pick a specialty based on money.

Happiness/personality: It's all a matter of perspective. I know a LOT of neurologists, and not one is unhappy, and all are fun-loving, outgoing people. I do know plenty of burnt-out psychiatrists, though. Every field is going to say its members are happy, however, and you shouldn't pick a specialty based on others' happiness - it should be your own.

Residency workload: you will definitely work more in neurology residency, but it's not unbearable. You won't go over your hours, and you get used to a harder workload - starting residency I dreaded the idea of a 24-hour call, and by fourth year they became a proverbial walk in the park. Besides, it's just four years.


You should decide which specialty's day-to-day is more interesting to you, and which specialty you spend less time looking at the clock, waiting to be dismissed. For me, that was neurology. I loved the complexity of the cases, the problem-solving, the emergencies combined with the continuity of care. There is no field in which the dysfunction of an organ system is more palpable to the patient (loss of movement, can't think straight, have pain, etc) and you have the ability to provide great comfort and treatment emotionally as well as physically. Despite what people think, the vast majority of neurological conditions are manageable, even curable, with treatment - you might not think so if your only exposure to neurology in medical school is the catastrophic strokes and ALS/HD/CJD cases that are being referred to your med school, a tertiary care center. I personally prefer inpatient neurology - a fast-paced mix of roles similar to EM, IM, and critical care - but the vast majority of neurologists do outpatient-only. I personally was bored out of my mind on psychiatry (and even more bored on PM&R) but what I, and the other posters here, find interesting doesn't affect what you find interesting.

Maybe the OP should consider a neuro-psych combined residency. It's longer, but I'd assume if one clearly is the "winner" after starting residency, the OP could possibly switch to neuro or psych only?

Kind of. I'm not super familiar with the job prospects, but I think people do this residency with the intent to go on to do neurocognitive or neuropsychiatry, often in academics. It could certainly be something to look into, but I wouldn't be so sure you could do this residency and then apply to the same type of jobs as someone who did a "normal" neurology residency without additional fellowship training; e.g. you'd probably be a less-competitive applicant for EMG-heavy outpatient jobs, and I doubt you could get an inpatient-heavy job.

I will note that functional neurological disorders are a hot topic right now, and intersect quite well between the two fields. I imagine someone with an interest in these disorders would be highly sought-after. Regardless, there is a great deal of psychiatry involved in neurology - inpatient or outpatient - and the reverse is probably true as well.

 

[Candidate2017]

Cons:
-Notes are super long and calling collateral can be tiring
-Having to be comfortable with involuntarily hospitalizing patients, violent patients
-Worried about becoming a psychopharm expert but forgetting the rest of medicine
-More gray areas in terms of treatment/diagnosis
-More midlevel encroachment with NPs, although I hear shortage is still high so it shouldn't matter too much (???)

Notes don't have to be long. They can be short and cover a;; relevant info, billing, and medicolegal requirements. Templates also help. Long notes are a function of academia and residents who, on top of not knowing what is supposed to be in a note, are henpecked by faculty to write long notes. Collateral can be obtained by nurses, SW, residents, and you med students.

It's not a big deal to involuntarily hospitalize patients. Psychotic or manic patients usually have no recollection who you are. Violence is always a possibility though in medicine.

There's a lot of medicine in psychiatry. Or as little as you'd like. But probably more than ophtho.

Yes, lots of gray areas. Which means you can be creative.

I don't see a lot of NP encroachment in my area. They just do the inpatient jobs psychiatrists don't want to do. Or prescribe controlled substances to substance seekers. They do very little actual psychiatry, and any patient who can rub 2 cents together wants their care from a psychiatrist.

 

[Taddy Mason]

The idea that psychiatry is no more dangerous than other specialties is incorrect. At least two studies I know of have established that psychiatrists are at the highest risk of homicide in the course of practice, and one study showed that the only physicians more likely to be assaulted than psychiatrists were emergency physicians. The most recent one is here:

Psychiatrists the Most Common Victims of Physician Homicide

Among physicians, psychiatrists are the most likely to be killed by their patients or a family member. The most common victims of homicide among mental health workers are female case workers, new data show.

www.medscape.com

Overall, however, significant events of violence are still rare, and being on guard at all times can allow you to avoid most issues.

Yeah….that’s a pretty bold conclusion to hang your hat on based on the quality of the data from the linked article, which wasn’t even designed to answer the question/claim being discussed here.

In fairness, the available data on this topic honestly sucks with a lot of the studies being prone to significant methodological issues and/or results being equivocal (e.g., no strong claim can be made and it ends up being wash between multiple specialties in quantifying risk). My beef with this being the perpetuation of an unfounded perception regarding psychiatry and implicit and even explicit stigma towards mental illness.

But back on topic - OP, my 5¢:
1) Where you see yourself being happiest/most engaged/most interested in the subject matter and day-to-day, bread and butter work should be weighted most heavily in terms of deciding factors.

2) “Difficulty” of the specific field’s residency is fair to take into consideration but I would make it lower priority - residency ± fellowship is 4~6 years, your career/being an attending is likely >20 years.

3) As per @DJKitty above, “losing” medical knowledge in psychiatry is a misconception and also dependent on the individual. You always need to be on the lookout for medical/neuro issues that may present as psychiatric or go overlooked by medicine/neuro/ED/etc. because it’s “a psych patient.” Our medications cause side effects and a good psychiatrist should know what to look out for, how to work-up, and how to manage the vast majority of these without reflexively referring a patient to his/her PCP or the ED, or being unnecessarily cautious and conservative with prescribing to the detriment of appropriately treating a patient - unfortunately these happen more than they should imho. There are also primary psychiatric conditions which can require more medical management such as eating disorders and more complicated/severe catatonia. It’s really easy to overlook and not fully appreciate the above based on just a limited number of weeks of psychiatry in med school which is a big factor in perpetuating the misconception of loss of medical knowledge in psychiatry. Geri psych, C/L, and addiction psych also all lend themselves more to having to maintain a greater degree of medical knowledge.

4) Pay/earning potential between the two fields is negligible.

5) Concern for potential violence should not be a factor at all, and if it is I would re-evaluate your interest in radiology or pathology.

 

[mistafab]

Bruh, psych and neuro couldnt be more different fields.

Even the people that go into the fields are different.

You gotta be realistic with yourself, stop making lists, and decide.

 

[slowthai]

Even the people that go into the fields are different.

Do you mind elaborating on this?

 

[Mad Jack]

Do you mind elaborating on this?

 

[indecisivem4]

LOL maybe it's regional but most of the attending neurologists seem pretty nice and unlike the Glaucomflecken stereotype. Both psychiatrists and neurologists are pretty happy over here. People do seem a bit more laid back in psych. The neuro residents seem more tired on average, though I was talking to a second year who averages about 60 hours a week which doesn't seem terrible, all things considering.

Thanks for the input all! Finishing this month's rotations then making a firm decision, but leaning towards psych.

 

[NonNocere]

Huge difference between the fields. Do you want to see psych patients or neuro patients?

 

[Mass Effect]

If you look at published data, the prevalence of “assault” (the definition of which tends to be quite loose when discussing this topic), psych doesn’t appear to be at any higher risk relative to other specialties. Violence from patients tends to come most often from individuals who are cognitively impaired (e.g., delirium, neurocognitive disorders, intoxication, etc.).

All of which are seen by psychiatrists most of the time. Inpatient delirium and inpatient intoxication are almost always seen by psychiatry. Neurocognitive disorder patients are usually split between neurology and psychiatry subspecialties. Psychiatrists do have a high rate of violence relevant to other specialties (with exception of ED). Neurologists have lower rate of violence.

Please reconcile these two statements.

Psychiatry is an open field. Salaries are rising. These days, it's easy to make 300K in private practice. Add on one weekend of locums per month and you're in 400K territory depending on where you do the locums work. Do prison work and you're at 500K in a lot of places. You can also do cash only. Friend from residency is making 600K/yr cash only practice in CA charging 600/hr with no shortage of patients.

I'll give this caveat. You WILL hustle if you want to make the big bucks in psych. Most of us are satisfied with 300/yr to work 35-40 hrs a week.

 

[jambro]

All of which are seen by psychiatrists most of the time. Inpatient delirium and inpatient intoxication are almost always seen by psychiatry. Neurocognitive disorder patients are usually split between neurology and psychiatry subspecialties. Psychiatrists do have a high rate of violence relevant to other specialties (with exception of ED). Neurologists have lower rate of violence.



Psychiatry is an open field. Salaries are rising. These days, it's easy to make 300K in private practice. Add on one weekend of locums per month and you're in 400K territory depending on where you do the locums work. Do prison work and you're at 500K in a lot of places. You can also do cash only. Friend from residency is making 600K/yr cash only practice in CA charging 600/hr with no shortage of patients.

I'll give this caveat. You WILL hustle if you want to make the big bucks in psych. Most of us are satisfied with 300/yr to work 35-40 hrs a week.

Tbh im a little confused by the ludicrous hourly salaries i see sometimes. Whose paying 600/hr for their physician and why?

 

[mrbreakfast]

Whose paying 600/hr for their physician and why?

Because the patient isn't paying $600/hr, they're paying $150 for a 10 minute appointment, presumptively for prescription refills.

 

[hamstergang]

Because the patient isn't paying $600/hr, they're paying $150 for a 10 minute appointment, presumptively for prescription refills.

There's more than 1 psychiatric private practice in my area of NJ charging between $533 and $666 per hour for 30-45 minute sessions. I don't know of any place charging cash for 10 minute sessions.

Patients pay because:
1) there aren't many other options if you want to get in sooner with someone good
2) insurance out of network benefits are good for some people (particularly the state employees)
3) they have the money for 6-12 sessions per year and recognize the value provided by these practices

 

[Browns99]

All of which are seen by psychiatrists most of the time. Inpatient delirium and inpatient intoxication are almost always seen by psychiatry. Neurocognitive disorder patients are usually split between neurology and psychiatry subspecialties. Psychiatrists do have a high rate of violence relevant to other specialties (with exception of ED). Neurologists have lower rate of violence.



Psychiatry is an open field. Salaries are rising. These days, it's easy to make 300K in private practice. Add on one weekend of locums per month and you're in 400K territory depending on where you do the locums work. Do prison work and you're at 500K in a lot of places. You can also do cash only. Friend from residency is making 600K/yr cash only practice in CA charging 600/hr with no shortage of patients.

I'll give this caveat. You WILL hustle if you want to make the big bucks in psych. Most of us are satisfied with 300/yr to work 35-40 hrs a week.

Can you show proof of the $600 per hour....Those numbers seem inflated.

 

[Mass Effect]

Can you show proof of the $600 per hour....Those numbers seem inflated.

No.

 

[Mass Effect]

Tbh im a little confused by the ludicrous hourly salaries i see sometimes. Whose paying 600/hr for their physician and why?

Well many will pay $600/hr. But some will pay $300/half hour, which still means $600/hr for the psychiatrist assuming they fill which they do. Many more where she came from. But if you're looking to charge the big fees, make sure you're in a place where there are people who can afford it. If you're in somewhere in Nebraska, you're probably looking at $300/hr instead.

Here is an example. This isn't the person I talked about, but similar set up.

Fee Schedule | Psychiatric Services | Beverly Hills, CA 90210

Visit this page for details on Fee Schedule for services with Kira Stein. Therapist, Kira Stein offers counseling in Beverly Hills, CA.

westcoastlifecenter.com

This one charges 400 - 1000 per session.

Mandana Torabi, Psychiatrist, Beverly Hills, CA, 90212 | Psychology Today

Mandana Torabi, Psychiatrist, Beverly Hills, CA, 90212, (323) 370-4126, Please note: Insurance is not accepted. Out of network only. Hello, I am a dual board certified psychiatrist specializing in general adult psychatiry and child &...

www.psychologytoday.com

 

[Mad Jack]

Tbh im a little confused by the ludicrous hourly salaries i see sometimes. Whose paying 600/hr for their physician and why?

Some people have ungodly amounts of money. $600 to them is like a Big Mac to us