MS4 Having Second Thoughts about Psych

[New Memnber]

Hello everyone,

I originally poster this under the medical MD forums but it's probably more fitting here.

I created a new profile for this question to remain anonymous. I'm an MS4 currently interviewing at Psych Programs. However, I'm having doubts about my choice. I miss some parts of medicine. And am not too thrilled about a lot of medication management that goes on in psychiatry. I do have an interest in psychology and neuroscience and non medication ways of managing mental illness. I've been doing some google searches on more wholistic or integrative practices and came across an good article on the topic (google search "the new psychiatry" and read the article by henry emmons; SDN won't let me post of link yet since I'm a new member)

Just wondering what you all think of it. Basically, I understand how medications are super important for psychiatry especially for the acutely ill manic or psychotic patient. And it's exciting to see a pt get better with medications and the transformation that takes place in an inpatient psych unit.

However, if I do outpatient work, I don't want my practice to just become medication check ups mixed with a little bit of psychotherapy. I am interested in non medication ways to manage depression and anxiety. I actually have some reservations about prescribing an antidepressant right away if a pt presents with depression or anxiety. But I totally understand how many pts find this beneficial and have some close friends on an antidepressant. Just wondering what you all think. I think I could tolerate all the medication management that is done in residency and then craft my own practice similar to the one described in the article and be very happy. And of course, prescribe medications when I think they are necessary. I guess I got a little discouraged during my consult liason rotation a month ago and started to miss some aspects of medicine. But I still love parts of psych. And could be fine without medicine.

Sorry for the long post. Let me know what you all think and if you experience similar thoughts about medications.

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[Stagg737]

I'll admit, there were times on my IM rotations in residency where I thought "I'm going to miss this", but I always reminded myself that I'll never have to deal with DM and CHF check-ups as an outpt doc again. After residency I'll never have to take a single night of call if I don't want to and I can focus on pathologies that I legitimately find interesting. I think your concerns are valid, I had a few of them myself (like missing "real" medicine). I just remind myself of why I'm going into the field though and that my lifestyle is almost guaranteed to be way better than it ever would have been as an internist unless I want to work myself to the bone.

I'm more pro-medication than you, although I certainly do think therapy is under-utilized. The problem is that many insurance companies won't reimburse you for therapy and medicare reimburses for it very poorly. So you almost need to go cash only if you want to actually make money doing significant amounts of therapy. There's always an opportunity to do therapy with your patients though, even if it's just a med management appt.

The more experience individuals here can comment further, but just wanted to say I think your concerns are valid and that many of us had them at some point along the way.

 

[Psych Person]

Hello everyone,

I originally poster this under the medical MD forums but it's probably more fitting here.

I created a new profile for this question to remain anonymous. I'm an MS4 currently interviewing at Psych Programs. However, I'm having doubts about my choice. I miss some parts of medicine. And am not too thrilled about a lot of medication management that goes on in psychiatry. I do have an interest in psychology and neuroscience and non medication ways of managing mental illness. I've been doing some google searches on more wholistic or integrative practices and came across an good article on the topic (google search "the new psychiatry" and read the article by henry emmons; SDN won't let me post of link yet since I'm a new member)

Just wondering what you all think of it. Basically, I understand how medications are super important for psychiatry especially for the acutely ill manic or psychotic patient. And it's exciting to see a pt get better with medications and the transformation that takes place in an inpatient psych unit.

However, if I do outpatient work, I don't want my practice to just become medication check ups mixed with a little bit of psychotherapy. I am interested in non medication ways to manage depression and anxiety. I actually have some reservations about prescribing an antidepressant right away if a pt presents with depression or anxiety. But I totally understand how many pts find this beneficial and have some close friends on an antidepressant. Just wondering what you all think. I think I could tolerate all the medication management that is done in residency and then craft my own practice similar to the one described in the article and be very happy. And of course, prescribe medications when I think they are necessary. I guess I got a little discouraged during my consult liason rotation a month ago and started to miss some aspects of medicine. But I still love parts of psych. And could be fine without medicine.

Sorry for the long post. Let me know what you all think and if you experience similar thoughts about medications.

You can be the type of psychiatrist you described wishing to become in your post. Plenty of folks have felt what you feel.


A lot of psychiatric practice is lazy practice. Don’t let the attendings and residents you worked under, who may be the types of people who do the bare minimum, create the illusion for you that you’d have to be the same way. I feel disgusted when I come across practicing attendings and residents who don’t think outside the box, i.e. they don’t tap into or keep sufficiently up to date their extensive MEDICAL training roots or don’t have a love and appreciation for integrating different disciplines. Don’t for one second think you have to be exactly like those purely “biological” psychiatrists. In my opinion, those kinds of folks are cynical and devoid of a kind of depth that is important for developing meaningful relationships and finding satisfaction. Psychiatry is a fluid art that utilizes the biological, but psychiatry will never be like the other fields of medicine in how much “medicine” is relied upon. Don’t try to fit into the medical field so much that you think you have to castrate your other passions. Also, please try to avoid becoming or being misperceived as the obnoxious, overly sensitive, feelz, social justice warrior type that is on the rise in psychiatry. Critical thinking, a psychological aptitude and a strong sense of self are must-haves.

When it comes to interviewing for residency, programs that sincerely champion the “biopsychosocial” model are the ones which tend to be more open-minded and balanced in the ways you hope for. Many programs will say they take this approach, but you’ll want to inquire more deeply into how the faculty and residents actually think and practice. On the interview trail, I can recall meeting many residents and faculty that weren’t shy about their strong lack of appreciation for therapy and resentment towards their required training in it. I would say that the majority of people training in psychiatry have wanted nothing to do with psychotherapy for a while now. Places that value integrative medicine, psychotherapy and psychopharmacology do exist still and are fun places to train. California programs (especially LA), places located around psychoanalytic institutes, many of those Northeast programs and plenty of community-focused programs are examples of the programs that still embody an appreciation for the psychological and integrative.

 

[futuredo32]

I am a psychiatrist and I DO miss medicine. So much so that I am applying for a second residency in FP next year There is a lot of psych in primary care.
I have a small private practice and do get reimbursed for therapy, but not tons.
Good luck with your decision.

 

[New Memnber]

thank you all for your comments. I do like psychiatry a lot and am trying to find a residency that emphasizes psychotherapy and more of an integrated model. Or at least allows me time to pursue these interests of mine. And no I am not one of those obnoxious, overly sensitive, social justice warrior ppl. I just really like psychology and integrative therapies and think more psych patients with depression, anxiety, or addiction could use less biological therapies in some cases. It just gets a little discouraging when the most I've seen as medical student is medication management which is an important part of psych, just not something that really thrills me.

 

[futuredo32]

thank you all for your comments. I do like psychiatry a lot and am trying to find a residency that emphasizes psychotherapy and more of an integrated model. Or at least allows me time to pursue these interests of mine. And no I am not one of those obnoxious, overly sensitive, social justice warrior ppl. I just really like psychology and integrative therapies and think more psych patients with depression, anxiety, or addiction could use less biological therapies in some cases. It just gets a little discouraging when the most I've seen as medical student is medication management which is an important part of psych, just not something that really thrills me.

Med management reimburses better, much better.

 

[clausewitz2]

thank you all for your comments. I do like psychiatry a lot and am trying to find a residency that emphasizes psychotherapy and more of an integrated model. Or at least allows me time to pursue these interests of mine. And no I am not one of those obnoxious, overly sensitive, social justice warrior ppl. I just really like psychology and integrative therapies and think more psych patients with depression, anxiety, or addiction could use less biological therapies in some cases. It just gets a little discouraging when the most I've seen as medical student is medication management which is an important part of psych, just not something that really thrills me.

Just keep in mind that no residency program is going to give you enough therapy training to actually be a fully competent therapist in any modality operating without supervision. You will have to seek out significant post-graduation training to be on the level of a clinical psychologist, or even a competent LCSW.

Medicine's culture is all about "see one, do one, teach one." This does not work very well for practicing psychotherapy.

 

[Crayola227]

I grappled with this myself, and ultimately went into a generalist field. PCPs are ground zero for most non-psychotic/violent/in the ED with SI mental illness. That is, depression and anxiety. Frankly, most PCPs are the ones managing that with a few med trials, and hopefully, mostly a lot of lifestyle intervention. If you want to be involved if not the expert and sole provider for a TON of mental illness as a PCP, you can.

PCPs get to do a lot with mental illness, and beyond. No, they're not masters, but that's what you get for getting to be a jack of all trades.

In fact, I think if you are going to be in a primary care field and don't have a passion for mental health, preventative medicine and lifestyle intervention, good luck to you and your patients.

Ground zero of managing anxiety/MDD, to me, is going to be lifestyle, referral to counseling, and some basic psych meds. The sicker patients, the more complicated ones, the ones failing pills I feel comfortable prescribing, go to psych.

Here's the thing for both primary care and psych: we are the perfect cohort of providers to get people in counseling, 12 Step, yoga, meditation, whatever hoo-ha will to help us get people to stop destroying themselves: psychiatrists are in just as good (or not) position to get people to quit drinking, smoking, eating, and sitting around-ing themselves to death. Not actively killing yourself with exogenous substances is a great way to support mental health.

I've worked with psychiatrists that got people into a ton of non-medication based interventions for mental health and overall well-being. But a lot of them don't do the actual psychotherapy. Most MD/DOs don't, in fact. I don't think it's really necessary, and I don't know that it's super high yield for us to do so.

Am I saying the person who Rx's PT, does more than the physical therapist? Hardly. But I'm OK with coordinating and being the one to identify where referral to PT, counseling, nicotine cessation, exercise classes, etc etc as needed, and giving patients the tools to heal themselves. I don't have to carry out each intervention personally. I get satisfaction throwing the right things at problems, seeing what sticks for the patients, and how far they get.

No one is saying that you can't have a practice that tries to provide the pathways to as many non-medication tools as possible for supporting mental health. However, medications are a huge and very complex tool in all of this, and it does have a role in some cases that nothing else can provide. Someone needs to be *the* expert in the diagnosis of complex mental illness, and the use of those medication tools. If not psychiatrists, than who?

For any type of specialty you go into, you need to be realistic about what your role is. Some psychs have very psychotherapy based practices, and that's great. But your training will prepare you to play a very specific role in the health care team, as it should.

If it makes you sleep better at night, you can spend more time on the medical aspects of your patients, you can make referrals where appropriate. Some people see their psychiatrist and no PCP. You can still use the USPTF stuff and get these people baseline labs, lipids a lot of the time, you can counsel for weight loss and screen for DM, etc etc. You need to follow up those labs and know what to do with abnormal results and refer where appropriate. At any point where you talking about something, from an upset tummy to sex life, you can ask if people are getting their colonoscopies, eating right, and have their Pap/STD testing.

Nothing is an either/or proposition in this, it's more about what baseline responsibilities/competencies are, not overstepping, and then just how to skew within what is appropriate for you to do.

 

[Crayola227]

Lastly, some of what I talk about above, depending on the relationship with a psychiatrist, a PCP might not get someone into counseling, treating substance abuse, losing weight, etc etc, but sometimes just hearing the same thing from their trusted loving shrink, then people will actually run out and do it.

 

[Stagg737]

I would say that the majority of people training in psychiatry have wanted nothing to do with psychotherapy for a while now. Places that value integrative medicine, psychotherapy and psychopharmacology do exist still and are fun places to train.

Idk about the about that. I think plenty of us would love to practice more therapy, but I'd also like to actually get paid. Which oftentimes doesn't happen if you're heavily practicing therapy and doing minimal prescribing.

I'd also be careful about "integrative medicine". While I do think there is some value in it (especially if you're referring to therapy), there are A LOT of people practicing treatment modalities which are completely inappropriate and some which are flat out insane. I'm referring to multiple aspects of integrative medicine including forms of therapy (go to the psychology forum and look at some of the stuff they've seen/heard their colleagues doing), treatment plans (had one patient who was told they had a systemic fungal infection making them depressed and the patient bought a new house at the recommendation of their integrative medicine doc), or just other "treatments" (reiki, acupuncture for anxiety, essential oils, etc). Some people in the field are fantastic. Others...not so much...

 

[uname943]

Lifestyle and nonpharm interventions are important and should always be considered. But if a patient gets better without meds, then they shouldn't have been seeing a psychiatrist in the first place. It's not an efficient allocation of resources.

FM or general IM may be a better fit for you. Most psychiatrists do little medicine. In primary care, you will have plenty of patients whose psychiatric needs would be adequately treated without meds.

 

[mymembernames]

I am a psychiatrist and I DO miss medicine. So much so that I am applying for a second residency in FP next year There is a lot of psych in primary care.
I have a small private practice and do get reimbursed for therapy, but not tons.
Good luck with your decision.

Interesting... I have met plenty of folks switch to psych, but not that many going from psych to something else!

 

[Attending1985]

With these reservations don’t do psych. You’re smart to be realizing this now and not later when you’re more entrenched like some of us. Read Nassir Ghaemi’s letter on choosing a medical specialty on medscape I think it will be helpful.

 

[FlowRate]

Just keep in mind that no residency program is going to give you enough therapy training to actually be a fully competent therapist in any modality operating without supervision. You will have to seek out significant post-graduation training to be on the level of a clinical psychologist, or even a competent LCSW.

Medicine's culture is all about "see one, do one, teach one." This does not work very well for practicing psychotherapy.

How much more training do they typically get? I was looking at a sample curriculum for a random clinical psych PhD program and as far as clinical/therapy exposure they get:
Year 1: Observing 2-3 patient interviews/assessment tests/therapy sessions per week. (?150 hours)
Year 2: Performing 2-3 tests per week (?150 hours, not really therapy.)
Year 3: 2-3 "Evidence based" therapy patients per week and 2-3 "other/alternative" therapy patients per week (300 hours)
Year 4: 12-16 hours per week of externship (wide variety in experiences from DBT to neuropsychology.) (750 hours)
Year 5: No clinical work
Intern year: Full time (wide variety) (2000 hours)

We have PhD candidates and interns rotate at some of our sites. I'd say maybe 25% of their time is spent doing therapy but this is obviously highly variable with the rotation/internship site. Their role on the inpatient unit is pretty much the same as ours but without having to also deal with med management and the added burden of medical documentation (including we're always the ones to write the discharge summary including clinical formulation.)

It seems to me the major difference between psychology programs and psychiatry residency might be is the degree to which therapy and therapy supervision are the focus/included in daily work. A more therapy heavy residency program with a lot of therapy supervision (or at least faculty who practice psychotherapy on a regular basis) should probably rival this amount of preparation, maybe with the exception of the intern year, although that definitely does NOT include most psychiatry residency programs. What do you think?

 

[New Memnber]

thanks guys for all the comments and I really enjoyed that Nassir Ghaemi article. for some reason I felt called to psychiatry or even family medicine and I'm still not sure why. I actually didn't enjoy family medicine that much (too much clinic). I'm just still trying to figure out why I feel called to those fields. Maybe it's because I feel sad for those with mental illness and sometimes it's nice to try to talk to them and be there for them. But I feel that you can talk and be kind to people in most areas of medicine where there is patient interaction. And I'm learning that the actual work of psychiatry involving medications may not be that appealing to me. I still haven't completely given up on psych and I'm still learning about some things. Might apply to a few transition/prelim years since its getting late.

 

[Crayola227]

IM *might* be a better fit

I say that hesitatingly because it's one of the most marrow-sucking, and for the ambiguous student may not be the answer

keys here are you do a lot of medicine, there is plenty of heavy mental illness and hard issues, there is a role for being there in that way to patients and their families whether inpt or outpt, and it's not difficult to escape the outpt world and stay inpt

IM scratches a lot of FM itches, at the end of the day the FM and IM practitioner alike can build a practice that looks quite similar to one another, but there are still some significant differences. I've written on this extensively in past posts.

IIRC some prelims/transitional years can count for IM and some places you could stay on if you wished, but it's all quite variable.
I know one barrier is that typically prelims/transitionals don't have the outpt IM clinic requirement built into their year, and I'm not sure how that's "made up" if you switch into categorical.

I'm not sure that they could include you in continuity clinic for that year on the off chance you stay in IM, if you're not already committed to categorical.

 

[Attending1985]

Applying to transitional year is a really good idea. It sounds like you need more time and that’s ok. I personally think they should bring back the rotating internship. Medical school is nothing like residency and IMO a poor way for medical students to base specialty choice.

 

[Shufflin]

If you don't have mental illness going into IM residency, you will when you're done.

 

[Crayola227]

If you don't have mental illness going into IM residency, you will when you're done.

One might even say that going into IM *is* a sign of mental illness. That mental illness is a prerequisite to someone choosing to go into IM. I joke that you must enjoy your own suffering and the taste of your own tears.

 

[FlowRate]

If you don't have mental illness going into IM residency, you will when you're done.

(It's prerequisite for psych and surgery. And, judging by the actuarial conclusions, substance abuse for Gas/EM.)

 

[New Memnber]

IM *might* be a better fit

I say that hesitatingly because it's one of the most marrow-sucking, and for the ambiguous student may not be the answer

keys here are you do a lot of medicine, there is plenty of heavy mental illness and hard issues, there is a role for being there in that way to patients and their families whether inpt or outpt, and it's not difficult to escape the outpt world and stay inpt

IM scratches a lot of FM itches, at the end of the day the FM and IM practitioner alike can build a practice that looks quite similar to one another, but there are still some significant differences. I've written on this extensively in past posts.

IIRC some prelims/transitional years can count for IM and some places you could stay on if you wished, but it's all quite variable.
I know one barrier is that typically prelims/transitionals don't have the outpt IM clinic requirement built into their year, and I'm not sure how that's "made up" if you switch into categorical.

I'm not sure that they could include you in continuity clinic for that year on the off chance you stay in IM, if you're not already committed to categorical.

What's your opinion of combined Med Psych programs?

 

[clausewitz2]

How much more training do they typically get? I was looking at a sample curriculum for a random clinical psych PhD program and as far as clinical/therapy exposure they get:
Year 1: Observing 2-3 patient interviews/assessment tests/therapy sessions per week. (?150 hours)
Year 2: Performing 2-3 tests per week (?150 hours, not really therapy.)
Year 3: 2-3 "Evidence based" therapy patients per week and 2-3 "other/alternative" therapy patients per week (300 hours)
Year 4: 12-16 hours per week of externship (wide variety in experiences from DBT to neuropsychology.) (750 hours)
Year 5: No clinical work
Intern year: Full time (wide variety) (2000 hours)

We have PhD candidates and interns rotate at some of our sites. I'd say maybe 25% of their time is spent doing therapy but this is obviously highly variable with the rotation/internship site. Their role on the inpatient unit is pretty much the same as ours but without having to also deal with med management and the added burden of medical documentation (including we're always the ones to write the discharge summary including clinical formulation.)

It seems to me the major difference between psychology programs and psychiatry residency might be is the degree to which therapy and therapy supervision are the focus/included in daily work. A more therapy heavy residency program with a lot of therapy supervision (or at least faculty who practice psychotherapy on a regular basis) should probably rival this amount of preparation, maybe with the exception of the intern year, although that definitely does NOT include most psychiatry residency programs. What do you think?

First, I am glad you included the caveat about most psych residency programs; we are talking here about what is possible while pursuing psych residency training, not what is likely. A significant proportion of programs will let you graduate with having had three therapy patients ever (one for each of those modalities, don't y'know), which is laughable. If you are only experienced with 3-5 patients you have not learned how to do therapy, you have learned to therapy for those particular people.

Year 3 above, if you are seeing clients weekly to get to 300 hours, is obviously equivalent to having about six long-term therapy cases. This is highly unusual in a psych residency, and I don't think you could feasibly do that before third year in most programs (2nd I guess in the programs that do OP 2nd year and IP 3rd year).

The intern year is also an enormous difference; it is not something that is optional for clinical psychologists, even if it comes after the formal degree.

Based on even the schedule you've provided above, we are talking about an order of magnitude difference in number of cases you will see and clients you will work with; if you are running time-limited evidence-based protocols, multiply the number of different people you will do therapy with even further. There also seems to be a greater possibility of continuity as well but I imagine this is very variable.

To be clear, I am not saying a newly-minted psychiatrist can't become competent to do therapy, but you are going to have to do something more like what LCSWs/LPCs do, i.e. do therapy more or less full-time for a couple of years with weekly supervision before being really ready to practice independently.

 

[hallowmann]

Lifestyle and nonpharm interventions are important and should always be considered. But if a patient gets better without meds, then they shouldn't have been seeing a psychiatrist in the first place. It's not an efficient allocation of resources.

FM or general IM may be a better fit for you. Most psychiatrists do little medicine. In primary care, you will have plenty of patients whose psychiatric needs would be adequately treated without meds.

You will not have much time to adequately treat patient's with psychiatric needs without meds in primary care. When you are expected to see 20 pts a day, you're not getting a ton of one-on-one time with patients.

What's your opinion of combined Med Psych programs?

I wouldn't do Med-Psych if your goal is not to focus on medication, nor would I suggest it if you are simply "torn" between two fields. To be completely honest, Psychiatry still seems like the right choice for you based on your posts, especially at a program that is less biologically focused and has a greater emphasis on psychotherapy.

What you hope to do and how you hope to spend time with patients is something that you would more likely be able to do in Psychiatry than a general medical field.