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M3 here who has done her neuro (only child) and psych rotations, current top choices.

What I love about neuro are the anatomy/neuroimaging and the physical exam. I could spend days and nights reading up on anatomy and the lesions since I am a very visual person. Surgery was intensely satisfying to me in the same way. Ruled out DR and pathology due to my STEP score and job market, and I love the nervous system.

But I’m thinking psychiatry because I would rather educate patients on current research on pharmacology, therapy and coping skills, and other psychoeducation. I disliked my medicine rotation. In neuro, I was less excited about giving education on pills or how to manage their neuro lesions, instead wanting to talk about their coping skills during this process. I feel the psych portion is more transformative. And residency in neuro frankly sucks, my app so far has been towards psych, and the income ceiling for psych in a private practice for example is so high.

However I was uncomfortable in 70% of my inpatient child psych and adult psych rotations. I disliked the psychotic patients who didn’t want my treatment and had a looming fear in every patient interaction that the pharm changes I’m making are doing them more harm longterm than good. The latter is intertwined with my dislike that we don’t tell patients how little we know about the psych pathophysiology or how drugs work, the lack of more evidence-based guidelines so that everything feels like trial and error, involuntary stays, etc. One patient we were throwing antipsychotics at and sometimes going back and forth on our recs according to what he wanted to take. I dislike the high chance we are putting someone on the wrong medication we don’t know a lot about due to a wrong diagnosis longterm. I feel like not explaining research outcomes to non-psychotic patients is like saying we have to do surgery on them without teaching them the anatomy, because I feel that is our anatomy.

My discomfort was assuaged when I taught non-psychotic young adults with mood disorders the studies behind my decisions to change their medications and taught life-changing basic psychoeducation. Patient populations I may feel most comfortable with are children with autism since most parents agree managing their behavior is necessary and maybe adults with mood disorders as long as I also do therapy. I’m sure there are others. But I’ll miss neuroanatomy.

I don’t know much about neuropsychiatry outpatient or how close it brings me to neuroanatomy and the physical exam. But reading the inpatient notes on treating dementia patients who are throwing poop and not wanting to be treated sounds awful. I haven’t explored C/L either, but I may miss longterm interaction.
The entire first two years of psych residency is inpatient dealing with patients who do not want to be there, psychotic patients, personality disordered patients, etc. you can of course as an attending have a practice with high functioning patients but you’ll have to be able to get through residency as that’s a majority of psych. Also Neuro can make a lot of money depending on how much you work, on average they’re probably the same in terms of income..also not explaining research to patients is definitely not like the surgery analogy you gave. We actually don’t know a lot of how these drugs work and we don’t have good evidence for a LOT of what we use them for as we use them off label, so when we don’t explain how things work it’s because we don’t know how they work..psychiatry is probably the field with the most unknown of any part of medicine, if you’re not excited by that or at least ok with it I would recommend something else
 
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I think you may also have an erroneous view of what surgeons do when they are not rounding with learners. Of course they have to explain the basics of a procedure to people for informed consent but most patients don't actually want an anatomy and physiology lecture in most circumstances.

You can always split the difference and get a fair amount of the experience of what psychiatry with strictly voluntary folks is like and do a lot of addressing psychological/emotional issues if you went into neuro and focused on epilepsy or movement disorders or headache. Many neuro folks especially seem to dislike outpatient epilepsy and headache so it's a fairly safe niche. Plus you often end up doing things with pharmacology that have a lot of the same feel of what psychopharmacology beyond the most basic algorithms is like.
 
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M3 here who has done her neuro (only child) and psych rotations, current top choices.

What I love about neuro are the anatomy/neuroimaging and the physical exam. I could spend days and nights reading up on anatomy and the lesions since I am a very visual person. Surgery was intensely satisfying to me in the same way. Ruled out DR and pathology due to my STEP score and job market, and I love the nervous system.

But I’m thinking psychiatry because I would rather educate patients on current research on pharmacology, therapy and coping skills, and other psychoeducation. I disliked my medicine rotation. In neuro, I was less excited about giving education on pills or how to manage their neuro lesions, instead wanting to talk about their coping skills during this process. I feel the psych portion is more transformative. And residency in neuro frankly sucks, my app so far has been towards psych, and the income ceiling for psych in a private practice for example is so high.

However I was uncomfortable in 70% of my inpatient child psych and adult psych rotations. I disliked the psychotic patients who didn’t want my treatment and had a looming fear in every patient interaction that the pharm changes I’m making are doing them more harm longterm than good. The latter is intertwined with my dislike that we don’t tell patients how little we know about the psych pathophysiology or how drugs work, the lack of more evidence-based guidelines so that everything feels like trial and error, involuntary stays, etc. One patient we were throwing antipsychotics at and sometimes going back and forth on our recs according to what he wanted to take. I dislike the high chance we are putting someone on the wrong medication we don’t know a lot about due to a wrong diagnosis longterm. I feel like not explaining research outcomes to non-psychotic patients is like saying we have to do surgery on them without teaching them the anatomy, because I feel that is our anatomy.

My discomfort was assuaged when I taught non-psychotic young adults with mood disorders the studies behind my decisions to change their medications and taught life-changing basic psychoeducation. Patient populations I may feel most comfortable with are children with autism since most parents agree managing their behavior is necessary and maybe adults with mood disorders as long as I also do therapy. I’m sure there are others. But I’ll miss neuroanatomy.

I don’t know much about neuropsychiatry outpatient or how close it brings me to neuroanatomy and the physical exam. But reading the inpatient notes on treating dementia patients who are throwing poop and not wanting to be treated sounds awful. I haven’t explored C/L either, but I may miss longterm interaction.
It seems clear that neuro is a much better fit. Don’t worry about residency. It’s a short period of time and your career is decades. You’ll be fine.
 
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Thank you for your reply and pointing out the first two years of psych residency, being a psych attending, and that we use many psych medications off label. Now I wonder if it would be worth it for me to stick out the first two years. According to how I felt during my psychiatry rotation, I feel I can still maintain a lot of empathy during my first two years and tolerate my discomfort.

Also, then I still wonder why most psychiatrists I’ve worked with don’t let patients know, perhaps more for voluntary patients, about the lack of good evidence for the drugs we prescribe them? I also feel like if I were a psychiatrist, I would make our limitations very clear in each initial encounter with my patients that for example, only 1/3rd of patients reach remission from MDD with 1 SSRI alone and many get better only after multiple trials of different medications (STARD) and that we don’t know exactly how they affect the brain, etc... I feel like 30-50% of my initial conversation would be on these facts so that I feel MDD patients can give full consent. I’m wondering that if I do become a psychiatrist and I do this, would get pushback from somewhere in the field or residency?
Depending on your program you could be for the chop (i.e. be terminated) if you were overzealous about pointing out the limitations or harms of psychiatric interventions or had difficulty with civil commitment.

that said, telling patients your treatments aren’t going to likely help them makes no sense at all. A lot of what physicians do is build expectancy and hope. This is what we call contextual healing and helps to maximize placebo effects. If you are communicating the opposite to patients then none of them will get better.
 
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Thank you for your reply and pointing out the first two years of psych residency, being a psych attending, and that we use many psych medications off label. Now I wonder if it would be worth it for me to stick out the first two years. According to how I felt during my psychiatry rotation, I feel I can still maintain a lot of empathy during my first two years and tolerate my discomfort.

Also, then I still wonder why most psychiatrists I’ve worked with don’t let patients know, perhaps more for voluntary patients, about the lack of good evidence for the drugs we prescribe them? I also feel like if I were a psychiatrist, I would make our limitations very clear in each initial encounter with my patients that for example, only 1/3rd of patients reach remission from MDD with 1 SSRI alone and many get better only after multiple trials of different medications (STARD) and that we don’t know exactly how they affect the brain, etc... I feel like 30-50% of my initial conversation would be on these facts so that I feel MDD patients can give full consent. I’m wondering that if I do become a psychiatrist and I do this, would get pushback from somewhere in the field or residency?
You’re talking to a patient with a mood disorder, not having an intellectual conversation with a physician scientist. I think that’s a bit much. You could say historically we may need to try a few different meds to find the right one for you, sure. But the rest is too much.
 
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Thank you for your reply, especially your point on residency being short. I was wondering if you could comment on how much neuroanatomy and physical exam is involved with neuropsychiatry, if I tried to work with only voluntary patients?
I don’t know. My guess is little. Don’t force anything. You wrote that you were uncomfortable 70% of the time on your psych rotation. That’s an extremely clear signal psych is not it for you.
 
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Thank you for your reply, especially your point on residency being short. I was wondering if you could comment on how much neuroanatomy and physical exam is involved with neuropsychiatry, if I tried to work with only voluntary patients?
I am a neuropsychiatrist and while I might use a reflex hammer more often than a general psychiatrist, I don’t often do a full neuro exam. Typically we are focusing on the neurobehavioral exam. Neuroanatomy is important but there is still a lot of hand waving and the evidence base for neuropsychiatric disorders and interventions is even slimmer than in psychiatry as a whole. Dementia, TBI, movement disorders, epilepsy, MS, autoimmune encephalitis and functional neurological disorders are the main sorts of disorders neuropsychiatrists deal with focusing on disturbances of mood, thinking, behavior, perception, memory and learning.
 
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Hey everybody, not the OP but I had a similar sort of question about discomfort. I find psych fascinating but I had a question about an experience during my inpatient rotations. I noticed I would feel a little anxious and my heart rate increase when the unit was louder than normal or when talking to an escalating patient. Is this normal? Does it go away? In my personal life I don't like confrontation and am I somewhat easily flustered but I have been working on this. Should I be concerned about going into psych with these feelings?
 
Hey everybody, not the OP but I had a similar sort of question about discomfort. I find psych fascinating but I had a question about an experience during my inpatient rotations. I noticed I would feel a little anxious and my heart rate increase when the unit was louder than normal or when talking to an escalating patient. Is this normal? Does it go away? In my personal life I don't like confrontation and am I somewhat easily flustered but I have been working on this. Should I be concerned about going into psych with these feelings?
You will get more comfortable the more you do it as with everything else in life
 
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Hey everybody, not the OP but I had a similar sort of question about discomfort. I find psych fascinating but I had a question about an experience during my inpatient rotations. I noticed I would feel a little anxious and my heart rate increase when the unit was louder than normal or when talking to an escalating patient. Is this normal? Does it go away? In my personal life I don't like confrontation and am I somewhat easily flustered but I have been working on this. Should I be concerned about going into psych with these feelings?
Totally normal to feel anxious when someone is escalating and helpful to the degree that it a)keeps you safe and b) gives you a clue to understanding what is going on with your patient.

In regards to getting flustered. That will likely be a challenge in every area of medicine as intense situations occur in every field. The fact that you are aware of this in yourself and are working on it indicates you have a degree of psychological-mindedness which in general bodes well for a career in psychiatry.
 
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I still experience sympathetic activation when someone is escalating. That doesn't stop me from responding appropriately. I think someone who can sit 100% unperturbed while a patient starts to yell or potentially become violent is pretty unusual.
 
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When I was a medical student, I also had reservations about psychiatry, given that a majority of medical school experiences were focused on acute/inpatient care.

I'd highly recommend looking into Austen Riggs medical student elective in psychodynamic psychiatry. It's a unique opportunity because there's difficulty getting experience in private practice and/or psychotherapy during MS1-4. I'm biased but these are the elements of psychiatry that make it a pretty cush and cool specialty.

 
When I was a medical student, I also had reservations about psychiatry, given that a majority of medical school experiences were focused on acute/inpatient care.

I'd highly recommend looking into Austen Riggs medical student elective in psychodynamic psychiatry. It's a unique opportunity because there's difficulty getting experience in private practice and/or psychotherapy during MS1-4. I'm biased but these are the elements of psychiatry that make it a pretty cush and cool specialty.

Austen Riggs has some wonderful qualities but it is representative of exactly zero other treatment settings. An elective there will give you good insight into what its like working at Austen Riggs.
 
Austen Riggs has some wonderful qualities but it is representative of exactly zero other treatment settings. An elective there will give you good insight into what its like working at Austen Riggs.
I had never heard of a place like that before. It sounds wonderful. When I've read the policies of inpatient places before, they sound like they're designed to make people go insane. I had been close to going inpatient before, and a therapist told me I'd never make it inpatient and would be traumatized, which is bizarre to think about. If you had chest pain, would a medical doctor tell you to avoid a hospital and try to ride it out because the hospital would be too traumatizing? The only inpatient place near me has reviews that make your blood curdle. And has been in the news: sexual assault cases and a case of negligent homicide where the patient begged the staff to call 911 and didn't (it's not connected to a hospital and they just have techs working there much of the time). This place sounds completely different. I used to wish there were some place I could go and develop as a person in ways I can't in my circumstances. The only place I could think of would be to somehow immigrate to Norway, get convicted of a crime, and grow personally in a Norwegian prison. This place sounds a lot like a Norwegian prison, which is actually a compliment to its humanism. Probably a lot more expensive, though. It says the average stay is 5 months. I don't even want to know how much that would cost.

Why are there not more places like this Austen Riggs?

The only other fantasy place like this that comes to mind was in an episode of Sex and the City where Carrie dates a guy who who voluntarily checked himself into an open inpatient facility to work out his life issues. Was completely unrealistic, until hearing about this place.
 
I had never heard of a place like that before. It sounds wonderful. When I've read the policies of inpatient places before, they sound like they're designed to make people go insane. I had been close to going inpatient before, and a therapist told me I'd never make it inpatient and would be traumatized, which is bizarre to think about. If you had chest pain, would a medical doctor tell you to avoid a hospital and try to ride it out because the hospital would be too traumatizing? The only inpatient place near me has reviews that make your blood curdle. And has been in the news: sexual assault cases and a case of negligent homicide where the patient begged the staff to call 911 and didn't (it's not connected to a hospital and they just have techs working there much of the time). This place sounds completely different. I used to wish there were some place I could go and develop as a person in ways I can't in my circumstances. The only place I could think of would be to somehow immigrate to Norway, get convicted of a crime, and grow personally in a Norwegian prison. This place sounds a lot like a Norwegian prison, which is actually a compliment to its humanism. Probably a lot more expensive, though. It says the average stay is 5 months. I don't even want to know how much that would cost.

Why are there not more places like this Austen Riggs?

The only other fantasy place like this that comes to mind was in an episode of Sex and the City where Carrie dates a guy who who voluntarily checked himself into an open inpatient facility to work out his life issues. Was completely unrealistic, until hearing about this place.

Check out the cost of treatment tab under admissions and it will quickly become clear why there are not very many more places like this.
 
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Why are there not more places like this Austen Riggs?
There are several programs like this though not necessarily psychosnalyticslly focused including McLean, Sheppard Pratt, Brattleboro Retreat, Menninger and Sierra Tuscon. These programs for patients with severe personality disorders are expensive and often not covered by insurance. Thus they are a niche market and they are usually a lower level of care than inpatient.

there are also residential treatment programs which are open and voluntary and often covered by insurance.

there are lots of bougie programs for patients with eating disorders and addictions.

for the ultra wealthy, you don’t even have to slum it and do a group based program. There are some customized individual one on one programs like privé suisse where you get the place to yourself and a selected army of professionals to work with you

ETA: to really understand the death of open ended psychoanalytically based hospitalizations look up the case of Osheroff v Chestnut Lodge. It was a very important turning point in the acceleration towards managed care in psychiatric treatment
 
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Also, then I still wonder why most psychiatrists I’ve worked with don’t let patients know, perhaps more for voluntary patients, about the lack of good evidence for the drugs we prescribe them? I also feel like if I were a psychiatrist, I would make our limitations very clear in each initial encounter with my patients that for example, only 1/3rd of patients reach remission from MDD with 1 SSRI alone and many get better only after multiple trials of different medications (STARD) and that we don’t know exactly how they affect the brain, etc... I feel like 30-50% of my initial conversation would be on these facts so that I feel MDD patients can give full consent.
You can choose to hammer patients with one study that shows Celexa alone did not work most of the time, in that study. Or you can realize that study actually shows antidepressants work and most depressed patients will remit.

And why are you twisted in knots specifically about psychiatry but not other specialties like FM, IM, or cardiology or nephrology? They prescribe tons of meds like ACEI and statins without ever explaining to patients the high number needed to treat. Perhaps psychiatry is not for you.
 
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One patient we were throwing antipsychotics at and sometimes going back and forth on our recs according to what he wanted to take. I dislike the high chance we are putting someone on the wrong medication we don’t know a lot about due to a wrong diagnosis longterm.
The strength of evidence is very high, as to better compliance and outcomes for psychotic disorders, if patient preference is taken into account as to their choice of antipsychotic.
 
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There are several programs like this though not necessarily psychosnalyticslly focused including McLean, Sheppard Pratt, Brattleboro Retreat, Menninger and Sierra Tuscon. These programs for patients with severe personality disorders are expensive and often not covered by insurance. Thus they are a niche market and they are usually a lower level of care than inpatient.

there are also residential treatment programs which are open and voluntary and often covered by insurance.

there are lots of bougie programs for patients with eating disorders and addictions.

for the ultra wealthy, you don’t even have to slum it and do a group based program. There are some customized individual one on one programs like privé suisse where you get the place to yourself and a selected army of professionals to work with you

ETA: to really understand the death of open ended psychoanalytically based hospitalizations look up the case of Osheroff v Chestnut Lodge. It was a very important turning point in the acceleration towards managed care in psychiatric treatment
Are those programs really like Riggs? Brattleboro retreat definitely is not. Riggs has patients that can stay for 2-3 years, average is 6 months. Patients are in analysis. They can walk freely around Stockbridge. I think it’s totally unique, but let me know if I’m wrong for sure.
 
M3 here who has done her neuro (only child) and psych rotations, current top choices.

What I love about neuro are the anatomy/neuroimaging and the physical exam. I could spend days and nights reading up on anatomy and the lesions since I am a very visual person. Surgery was intensely satisfying to me in the same way. Ruled out DR and pathology due to my STEP score and job market, and I love the nervous system.

But I’m thinking psychiatry because I would rather educate patients on current research on pharmacology, therapy and coping skills, and other psychoeducation. I disliked my medicine rotation. In neuro, I was less excited about giving education on pills or how to manage their neuro lesions, instead wanting to talk about their coping skills during this process. I feel the psych portion is more transformative. And residency in neuro frankly sucks, my app so far has been towards psych, and the income ceiling for psych in a private practice for example is so high.

However I was uncomfortable in 70% of my inpatient child psych and adult psych rotations. I disliked the psychotic patients who didn’t want my treatment and had a looming fear in every patient interaction that the pharm changes I’m making are doing them more harm longterm than good. The latter is intertwined with my dislike that we don’t tell patients how little we know about the psych pathophysiology or how drugs work, the lack of more evidence-based guidelines so that everything feels like trial and error, involuntary stays, etc. One patient we were throwing antipsychotics at and sometimes going back and forth on our recs according to what he wanted to take. I dislike the high chance we are putting someone on the wrong medication we don’t know a lot about due to a wrong diagnosis longterm. I feel like not explaining research outcomes to non-psychotic patients is like saying we have to do surgery on them without teaching them the anatomy, because I feel that is our anatomy.

My discomfort was assuaged when I taught non-psychotic young adults with mood disorders the studies behind my decisions to change their medications and taught life-changing basic psychoeducation. Patient populations I may feel most comfortable with are children with autism since most parents agree managing their behavior is necessary and maybe adults with mood disorders. I’m sure there are others. But I’ll miss neuroanatomy.

I don’t know much about neuropsychiatry outpatient or how close it brings me to neuroanatomy and the physical exam. But reading the inpatient notes on treating dementia patients who are throwing poop and not wanting to be treated sounds awful. I haven’t explored C/L either, but I may miss longterm interaction.
It sounds like psychiatry may not be the best fit. For the vast majority of patients in any field, you will not be educating them on pharmacology beyond the basics. As for coping skills and psychoeducation, you will be able to do plenty of that in a specialty neurology clinic (movement disorders, dementia, epilepsy, neuroimmunology, etc.).

The main problem is that if you're uncomfortable with uncertainty, psychiatry will be a tough field. We don't know much about what causes psychiatric disorders, how medications work, or even how the brain works. There will be a lot of trial and error with medications, complicated by patient nonadherence to medications. Diagnostic clarification (not that the DSM diagnostic categories are really accurate representations of disease entities) will take time and require prolonged outpatient follow-up. This uncertainty may change in the future, but I imagine it will probably take decades.

I would recommend doing more neurology rotations in subspecialties, if the only exposure you had was child neurology. You seem like a better fit for neurology, if you can tolerate the grueling residency. If you have the stats to get in somewhere good, I wouldn't rule out radiology either. Their job market is improving and will probably get better with the aging population requiring more imaging.
 
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It sounds like psychiatry may not be the best fit. For the vast majority of patients in any field, you will not be educating them on pharmacology beyond the basics. As for coping skills and psychoeducation, you will be able to do plenty of that in a specialty neurology clinic (movement disorders, dementia, epilepsy, neuroimmunology, etc.).

The main problem is that if you're uncomfortable with uncertainty, psychiatry will be a tough field. We don't know much about what causes psychiatric disorders, how medications work, or even how the brain works. There will be a lot of trial and error with medications, complicated by patient nonadherence to medications. Diagnostic clarification (not that the DSM diagnostic categories are really accurate representations of disease entities) will take time and require prolonged outpatient follow-up. This uncertainty may change in the future, but I imagine it will probably take decades.

I would recommend doing more neurology rotations in subspecialties, if the only exposure you had was child neurology. You seem like a better fit for neurology, if you can tolerate the grueling residency. If you have the stats to get in somewhere good, I wouldn't rule out radiology either. Their job market is improving and will probably get better with the aging population requiring more imaging.

The job market in radiology is hot right now but from reading their forums it seems like private equity firms are starting to buy up private practices and drive salaries down. Also seems like it would be easy to just constantly push to read faster and faster for the same pay. Psychiatry I feel like is immune to just grinding physicians because there's so much need and so many different practice options. Do you feel this is true? I dual applied psychiatry and radiology but I think I'm going to rank my psych programs higher. Its more interesting, seems harder to make you a workhorse just grinding through things, pay has been increasing, sounds like 300k for 40-45 hrs/week is doable vs. 400k busting it at 55hrs/week in rads
 
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The job market in radiology is hot right now but from reading their forums it seems like private equity firms are starting to buy up private practices and drive salaries down. Also seems like it would be easy to just constantly push to read faster and faster for the same pay. Psychiatry I feel like is immune to just grinding physicians because there's so much need and so many different practice options. Do you feel this is true? I dual applied psychiatry and radiology but I think I'm going to rank my psych programs higher. Its more interesting, seems harder to make you a workhorse just grinding through things, pay has been increasing, sounds like 300k for 40-45 hrs/week is doable vs. 400k busting it at 55hrs/week in rads
How does one dual apply psych and radiology..Those seem like completely opposite fields..focus on what you enjoy because the day to day is pretty much opposite
 
I have no experience in radiology beyond one rotation in med school, so I can't comment on how much of a grind it is. I would agree that the grind can't get much worse in psychiatry because a lot of people are already doing it (ex. 15 minute med checks). Honestly, even 30 minute outpatient follow-ups plus the notes and other paperwork can feel like a grind too sometimes if you are seeing 15 patients a day. How does that compare to an average day in radiology? I don't know.

PE is also buying up dermatology practices, but derm is as hot as ever. Regardless, do something you enjoy, because no one can predict the future. Psychiatry is hot right now, but who know what will happen in 5 years.

Also, a job paying 300k for 40-45 hours is not the norm in psychiatry. People on this forum report very high earnings, but the average psychiatrist does not earn 300k for 40-45 hours of work. It will depend heavily on where you want to end up geographically.
 
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Depending on your program you could be for the chop (i.e. be terminated) if you were overzealous about pointing out the limitations or harms of psychiatric interventions or had difficulty with civil commitment.

that said, telling patients your treatments aren’t going to likely help them makes no sense at all. A lot of what physicians do is build expectancy and hope. This is what we call contextual healing and helps to maximize placebo effects. If you are communicating the opposite to patients then none of them will get better.
Doesn't this seem... dishonest towards the patient? How are you supposed to have appropriate shared decision making if you are not sharing all of the information? How is a patient supposed to decide whether the possible side effects are worth the benefit without knowing the likelihood a medication is going to work? I understand there is a tension here with the role the physician plays in the placebo effect (or a nocebo effect), but I've had similar discomfort as OP concerning discussions with patients.
 
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Doesn't this seem... dishonest towards the patient? How are you supposed to have appropriate shared decision making if you are not sharing all of the information? How is a patient supposed to decide whether the possible side effects are worth the benefit without knowing the likelihood a medication is going to work? I understand there is a tension here with the role the physician plays in the placebo effect (or a nocebo effect), but I've had similar discomfort as OP concerning discussions with patients.
It can be incredibly transparent, as well. And then everything backfires. I've had some pretty hamfisted attempts tried on me, but they were all from one particular practitioner who was perhaps delusional, so I'm not entirely sure how much it was an attempt at placebo versus her self-belief in very alternative therapies. Either way, I didn't trust her.

It's the same as how the government should have trusted the public with good information on masks. I think the vast majority would have understood. Explaining later that they had to lie or omit facts in order to preserve resources severed trust with some. Probably not all or most. But some.

The placebo effect reminds me of some movie I saw so long ago I can't even remember the plot. This guy was jonesing out of his mind for a med his previous doctor had prescribed and was ransacking a pharmacy. And he showed the pharmacist the tablet, and it ended up being something like a multivitamin. But that was a movie. It was Matchstick Men. Again, I don't remember anything about the plot of the movie except for that scene. I should probably check it out again.
 
PE is also buying up dermatology practices, but derm is as hot as ever. Regardless, do something you enjoy, because no one can predict the future. Psychiatry is hot right now, but who know what will happen in 5 years.

Also, a job paying 300k for 40-45 hours is not the norm in psychiatry. People on this forum report very high earnings, but the average psychiatrist does not earn 300k for 40-45 hours of work. It will depend heavily on where you want to end up geographically.

Hopefully not a giant city or the Northeast/parts of the Midwest.
 
M3 here who has done her neuro (only child) and psych rotations, current top choices.

What I love about neuro are the anatomy/neuroimaging and the physical exam. I could spend days and nights reading up on anatomy and the lesions since I am a very visual person. Surgery was intensely satisfying to me in the same way. Ruled out DR and pathology due to my STEP score and job market, and I love the nervous system.

But I’m thinking psychiatry because I would rather educate patients on current research on pharmacology, therapy and coping skills, and other psychoeducation. I disliked my medicine rotation. In neuro, I was less excited about giving education on pills or how to manage their neuro lesions, instead wanting to talk about their coping skills during this process. I feel the psych portion is more transformative. And residency in neuro frankly sucks, my app so far has been towards psych, and the income ceiling for psych in a private practice for example is so high.
I mean, I'm a bit of a broken record on this site, but have you considered Sleep Medicine, through Psychiatry? I went in loving neuro, but knowing I wanted the Venn diagram of sleep disorders that overlapped with psych. It was much more intuitive for me to learn neurotransmitters and neurophys through sleep medicine than it was through psych, so I tailored my residency as such. I did a year in neurobehavior clinic to buttress my skills in both and today one of my favorite parts of clinical practice is providing education to my sleep patients about the neurology of their disorder.

Neurobehavior was interesting, but the real life clinical aspect was unfortunately not The Man Who Mistook His Wife For A Hat 24/7.

And it helped me on the boards - perfect score on neuro (not even a humblebrag).
 
Doesn't this seem... dishonest towards the patient? How are you supposed to have appropriate shared decision making if you are not sharing all of the information? How is a patient supposed to decide whether the possible side effects are worth the benefit without knowing the likelihood a medication is going to work? I understand there is a tension here with the role the physician plays in the placebo effect (or a nocebo effect), but I've had similar discomfort as OP concerning discussions with patients.

So what do you tell a patient with schizophrenia, for instance, regarding the likelihood that an atypical antipsychotic works for them vs. the likelihood that they develop diabetes or suffer other metabolic side effects? I mean, what percentage figures would you give that add anything meaningful to this discussion?

True informed consent is an unachievable ideal. It is limited both by what we (don't) know about our treatments as well as our patient's ability to understand and weigh what we tell them. Every patient's knowledge base and ability to comprehend and manipulate information is different and must be considered when explaining their care. We are constantly making choices about what information to give and what to withhold. There is such a thing as providing too much information.
 
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So what do you tell a patient with schizophrenia, for instance, regarding the likelihood that an atypical antipsychotic works for them vs. the likelihood that they develop diabetes or suffer other metabolic side effects? I mean, what percentage figures would you give that add anything meaningful to this discussion?

True informed consent is an unachievable ideal. It is limited both by what we (don't) know about our treatments as well as our patient's ability to understand and weigh what we tell them. Every patient's knowledge base and ability to comprehend and manipulate information is different and must be considered when explaining their care. We are constantly making choices about what information to give and what to withhold. There is such a thing as providing too much information.
Of course a person with frank psychosis is very different than the typical person you are considering to start on an SSRI. That is not an enlightening example.

I agree that every patient is different, in their ability to understand as well as their interest in the details. You will not have an hour long journal club discussion on the nuances of the research with your patients. But I think most people would like to have some ballpark of how likely it is the medication will make them feel better and how likely they are to have side effects.

if you have ever ventured into the antipsychiatry portions of the internet, they often feel deceived by their doctors who oversold the efficacy or underplayed the side effects. I think we need to be careful to not condescend our patients.
 
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Of course a person with frank psychosis is very different than the typical person you are considering to start on an SSRI. That is not an enlightening example.

I agree that every patient is different, in their ability to understand as well as their interest in the details. You will not have an hour long journal club discussion on the nuances of the research with your patients. But I think most people would like to have some ballpark of how likely it is the medication will make them feel better and how likely they are to have side effects.

if you have every ventured into the antipsychiatry portions of the internet, they often feel deceived by their doctors who oversold the efficacy or underplayed the side effects. I think we need to be careful to not condescend our patients.

Ok, so what do you tell a patient with MDD, for instance, regarding the likelihood that an SSRI works for them vs. the likelihood that they have sexual side effects or withdrawal if they stop? Again, what figures are you giving to your patients and how are you coming up with them?

I completely agree with being up front, realistic, and honest regarding risks/benefits, but I'm not sure people want or can meaningfully apply statistics to their life. What I think is important is giving an overview of potentially dangerous short and long term side effects, talking about the fact that any individual medication may not be effective, and assuring the patient that we will be working together through their problem.
 
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I imagine a patient with MDD and suicide ideation seeking help. Then you tell him the meds are not likely to work, plus he may get sexual dysfunction out of it. I can't see how this may sound like a good idea.

I think the OP had some bad runs with his psych, and that is affecting his judgment. If you do pursue psych, I strongly suggest therapy, if you are not already doing it.
 
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Doesn't this seem... dishonest towards the patient? How are you supposed to have appropriate shared decision making if you are not sharing all of the information? How is a patient supposed to decide whether the possible side effects are worth the benefit without knowing the likelihood a medication is going to work? I understand there is a tension here with the role the physician plays in the placebo effect (or a nocebo effect), but I've had similar discomfort as OP concerning discussions with patients.
Of course a person with frank psychosis is very different than the typical person you are considering to start on an SSRI. That is not an enlightening example.

I agree that every patient is different, in their ability to understand as well as their interest in the details. You will not have an hour long journal club discussion on the nuances of the research with your patients. But I think most people would like to have some ballpark of how likely it is the medication will make them feel better and how likely they are to have side effects.

if you have ever ventured into the antipsychiatry portions of the internet, they often feel deceived by their doctors who oversold the efficacy or underplayed the side effects. I think we need to be careful to not condescend our patients.

Not sure what field you're in or where you're at in the journey, but I think you're arguing points that are true to all medicine and applying them only to psych. When a patient comes into the ER with a possible PE, do you tell them that the CT you're ordering has about a 10% chance of missing a PE? Are you telling patients you start on anti-hypertensives that they'll likely only decrease their MAP by about 10? Are you warning patients you give Tylenol or Ibuprofen to that they're at risk of developing SJS?

Realistically, giving specific statistics is typically unnecessary compared to just educating patients on the most likely risks, the most dangerous ones, and what to expect with their treatment. I also tell patients what my goal of prescribing the medication is, what we can do if that trial fails, and then allow them to ask any questions they want. We don't give people a "ballpark" of how effective any treatment in any area of medicine will be unless they ask or it's a particularly dangerous treatment, and oftentimes we can't really provide an accurate number for that specific patient anyway.
 
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I imagine a patient with MDD and suicide ideation seeking help. Then you tell him the meds are not likely to work, plus he may get sexual dysfunction out of it. I can't see how this may sound like a good idea.

I think the OP had some bad runs with his psych, and that is affecting his judgment. If you do pursue psych, I strongly suggest therapy, if you are not already doing it.
This is why we need TMS to become more commonly used.
 
It doesn't cause the weight gain or sexual side effects, right? It isn't always effective but neither are antidepressants and/or psychotherapy. I haven't had any exposure to it on my clinical rotations but I'm pretty excited reading about it. It seems like another options we could offer?

I know it isn't widely available and financially doesn't work which is why I suggested it would be good to improve access.
 
Ok, so what do you tell a patient with MDD, for instance, regarding the likelihood that an SSRI works for them vs. the likelihood that they have sexual side effects or withdrawal if they stop? Again, what figures are you giving to your patients and how are you coming up with them?

I completely agree with being up front, realistic, and honest regarding risks/benefits, but I'm not sure people want or can meaningfully apply statistics to their life. What I think is important is giving an overview of potentially dangerous short and long term side effects, talking about the fact that any individual medication may not be effective, and assuring the patient that we will be working together through their problem.

I tell them the point at which we can expect to see some change if it is going to work at all and emphasize that if it does not work we are only beginning to scratch the surface of the available options. I also tell them that about 30% of people taking them are going to develop sexual side effects of some description but they should tell me about this if it happens because we have ways to address it.
 
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It doesn't cause the weight gain or sexual side effects, right? It isn't always effective but neither are antidepressants and/or psychotherapy. I haven't had any exposure to it on my clinical rotations but I'm pretty excited reading about it. It seems like another options we could offer?

I know it isn't widely available and financially doesn't work which is why I suggested it would be good to improve access.

Eh, there's other problems with it beyond access. At our place, it's a 30-session treatment course occurring in 6-10 weeks. So unless you can come in for several hours at least 3 times per week, it's not realistic. Some other problems I've seen is that some patients can't handle the treatment itself d/t paresthesias or discomfort, some have to have lower frequencies or shorter sessions which can impact efficacy, sometimes we find that the wrong spot was initially identified and location has to be adjusted after a few sessions. The biggest issue is the practicality of it. It may be a good option for some patients with severe depression who have open schedules and means to pay, but for most of the patients I talk about it with they just can't logistically do it.

It's not totally benign either. Some patients develop headaches from it which can occasionally be fairly significant, jaw or head pain (separate from headaches) can occur, dizziness/lightheadedness can happen, and ear pain or hearing problems can occur. Patients can also rarely have seizures (fortunately I have not seen this) or rarely (hypo)mania. It's certainly an option, but I only bring it up when patients have failed multiple other therapies and typically talk about ECT or ketamine first if we're going to consider procedures for depression.
 
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What about the much more common scenario of a person given an atypical antipsychotic for an off-label use and not being told the side effects?

I was called a spaz for being concerned about my rising blood sugar and weight gain over the years. I was put on Seroquel for Tourette's tics and never given informed consent. I developed diabetes. I didn't even start to ask for my blood sugar to be checked until I was on it for 10 years even though I had immediate weight gain, and then when it was discovered told to exercise and eat better.

For years I also had extremely low testosterone (as in total testosterone of 80) and had all sorts of work-ups including an MRI of the sella. After stopping Seroquel my testosterone is finally in the normal range. Blood sugar is normal. And my tics are exactly the same--no better or worse. At every visit with my psychiatrist I would ask if it was possible any of the meds I was taking were contributing to the low testosterone and was told it was impossible. It's only recently I've found literature connecting Seroquel to low testosterone (admittedly not a lot of research and it's conflicting, but in my particular case it seems to be the only explanation).

I would be curious to know how many people are actually taking atypical antipsychotics for reasons where they are too unstable to give truly informed consent versus people who are prescribed them for literally almost any reason under the sun.

Edit: Not to pile on, but also wondering how many times the drug reps told doctors that side effects were overstated, not to worry about them, why don't you try it for X, Y, and Z, etc., when the doctor was obviously in no position to be harmed by knowing the side effects. I remember one time hearing through a doctor that a drug rep said to take Seroquel with two cups of water. Why two cups of water? It fills you up! Well, I have taken Seroquel (and I took at night because I couldn't handle it in the day but I didn't take it for sleep), and two cups of water is not what your brain is craving after you take Seroquel. I would stumble to the kitchen half asleep and make the most ungodly combinations of fats and sugars that I would have never considered eating in the daytime. I'd sometimes fall asleep mid-bite of food. Water was not what my brain wanted. And if I powered through and went to sleep without eating, I would wake up from the grog and my body would find its way to the kitchen. Terrible stuff—in my experience. Two cups of water would just add to the risk of aspirating reflux from overeating right before sleep (in my case eating as falling asleep).

I have read many of your posts over the years and I am sorry that you have not been satisfied with your psychiatric treatment. I'm not sure exactly what you are looking for here, but to remind you, this forum is targeted towards aspiring and learning healthcare professionals. While patient narratives can be enlightening, I hope no one here is going to change their practice based upon the anecdotes of one patient's experience reported on the internet. Please know that your comments may not be helpful to the intended audience, and may in fact be confusing to forum users who are not aware that you are a patient and not a healthcare professional. I would suggest limiting your activity here to reading, and only contributing if a thread specifically asks for patient experiences.
 
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I have read many of your posts over the years and I am sorry that you have not been satisfied with your psychiatric treatment. I'm not sure exactly what you are looking for here, but to remind you, this forum is targeted towards aspiring and learning healthcare professionals. While patient narratives can be enlightening, I hope no one here is going to change their practice based upon the anecdotes of one patient's experience reported on the internet. Please know that your comments may not be helpful to the intended audience, and may in fact be confusing to forum users who are not aware that you are a patient and not a healthcare professional. I would suggest limiting your activity here to reading, and only contributing if a thread specifically asks for patient experiences.
Are you a moderator? I welcome this individuals posts and don’t agree with you telling him or her to essentially shut up on behalf of Sdn.
 
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Are you a moderator? I welcome this individuals posts and don’t agree with you telling him or her to essentially shut up on behalf of Sdn.
No, if I was I would prevent patients from participating here. I tried to be diplomatic and I don't think that offering my opinion on the relevance and helpfulness of someone's posts is the same as telling them to "essentially shut up."
 
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Eh, there's other problems with it beyond access. At our place, it's a 30-session treatment course occurring in 6-10 weeks. So unless you can come in for several hours at least 3 times per week, it's not realistic. Some other problems I've seen is that some patients can't handle the treatment itself d/t paresthesias or discomfort, some have to have lower frequencies or shorter sessions which can impact efficacy, sometimes we find that the wrong spot was initially identified and location has to be adjusted after a few sessions. The biggest issue is the practicality of it. It may be a good option for some patients with severe depression who have open schedules and means to pay, but for most of the patients I talk about it with they just can't logistically do it.

It's not totally benign either. Some patients develop headaches from it which can occasionally be fairly significant, jaw or head pain (separate from headaches) can occur, dizziness/lightheadedness can happen, and ear pain or hearing problems can occur. Patients can also rarely have seizures (fortunately I have not seen this) or rarely (hypo)mania. It's certainly an option, but I only bring it up when patients have failed multiple other therapies and typically talk about ECT or ketamine first if we're going to consider procedures for depression.
It's harder to get esketamine covered around here, and usually ECT/TMS/esketamine are reserved for our refractory patients where they are disabled due to depression so timing isn't an issue. Mismapping doesn't happen almost ever (we use a Neurostar which is pretty good overall with its mapping procedures) in our clinic, and TMS us often chosen because it's more affordable and easier to get approved than esketamime (we don't use ketamine) and is generally picked as an option by our patients that are ECT shy either due to stigma or anesthesia fears. Generally doesn't seem to be a effective as ECT or esketamine though
 
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