Neuro vs. Psych Debacle

[zilly]

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I am a 4th year med student and I can't seem to decide between psych or neuro. There are aspects of both that I really like. I was a psychology major in college and I have always found psychiatric disorders very interesting. I also like the opportunity to spend time talking to patients (not always the case in some other areas of medicine). At the same time, I am fascinated by the organic causes for psychiatric and neurologic illness. However, in the realm of neuro, I am more interested in CNS disease (epilepsy, MS), and I am not particularly interested in the PNS or neuromuscular disorders. Also, I hope to have an outpatient-based practice in the future regardless of what field I choose. Thus, I don't think I would enjoy specializing in stroke or other areas that require lots of inpatient hours.

I enjoyed both rotations during medical school, and I have done additional electives in both fields. I know that there are some combined programs out there, but I really would like to choose one. Another consideration I have is that I would like to raise a family someday, so I want to eventually have some flexibility as far as hours and call.

It would be great if I could get opinions from any neurology or psychiatry residents/attendings out there. I would like to know if you enjoy what you do, if you would make the same career choice if you had to do it again, and if you feel that you have enough free time that you can accomplish your endeavors outside of medicine.

Thanks, you have no idea how much I appreciate your help!

 

[Rogue Synapse]

Have you thought about biopsych or behavioral neurology? There are only 9 combined psych/neuro programs out there, but more than 9 fellowships in either biopsych or behavioral neurology. Sorry, I know I'm not exactly the qualified opinion-giver you were looking for.

 

[Boxer1]

To summarize something from Iserson's book, think of choosing your specialty as a choice between multiple good options. It's not like there's one right choice and several wrong ones. You can probably be happy doing any number of things so it's not something to really agonize over.

Now my thoughts. When choosing between two good choices that each have things that appeal to you, look at the whole package. Realistically, how much do you need to make. How much do you want to work? What can you not live without in a specialty? What aspects of each specialty are not appealing to you? Which of the less appealing aspects is more tolerable. You mentioned that you don't like peripheral stuff or much inpatient. What aspects of Psych do you dislike? Depression, Axis II stuff?

Choosing a specialty is a personal thing. Others can give you input and help you look at things from different perspectives but ultimately you're the one that needs to be happy.

 

[BrianUM]

Just curious,

From my understanding Neurologists get trained in certain aspects of Psychiatry and vice versa. How comfortable do neurologists usually feel treating and managing run of the mill depression and anxiety in patients or is this something that you refer to psych and pcp all the time

 

[Boxer1]

How comfortable do neurologists usually feel treating and managing run of the mill depression and anxiety in patients or is this something that you refer to psych and pcp all the time

It's attending specific. In my experience, the ones who see a lot of the Neuro diseases that tend to have psych features (Parkinsons and Dementias with Mood/Psychosis, MS and Pain with mood disturbances) are usually more comfortable managing those themselves. The attendings that deal more with things like stroke/PNS tend to pass on the management of Psych stuff to the PCP or Psych.

These are just trends I have observed.

 

[Nerdoscience]

Honestly, I would pick based on what you don't like in this case. If the thought of having to work up a foot drop turns you off, do Psych. If doing commitment hearings, calling magistrates for holds, and running behavior codes sounds like torture, do Neuro.

 

[neurologist]

Here's how I would look at it:

A very high percentage of neurology patients (particularly in your areas of interest, epilepsy and MS) have comorbid psychiatric issues (depression, anxiety).

The reverse (psych patients having neurologic disease) is not quite as common.

So, my suggestion would be to do neuro, subspecialize in whatever area interests you (MS, epilepsy, etc) but if you are interested in and comfortable dealing with psych issues, you have the option of addressing those issues directly with your patients rather than referring them to a psychiatrist.

The other option, as someone else pointed out, would be a neurobehavioral fellowship.

 

[Vader]

I am currently in my prelim medicine internship year and will be starting a neurology residency in July. I had a very similar decision to make regarding specialty choice. Like you, I am interested in the interface between neurology and psychiatry and many disorders that overlap (Alzheimer's, FTD, autism, etc). I also have a strong academic research interest that will allow investigative overlap, even if I don't end up seeing specific disorders in clinic.

The decision on what specialty to choose resides mainly with what you see yourself doing in the future, particularly if you see yourself in a mainly clinical career. I.e. do you want to take care of patients with Alzheimer's and other dementias or do you want to take of of patients with schizophrenia, depression, autism, etc? Also, do you like doing the neuro exam and localizing lesions or do you like thinking about receptors and pharmacology, doing psychotherapy, etc. The divisions are obviously not nearly so clear-cut nowadays and there is plenty of overlap between specialties.

I would say that if you are interested in the neuro exam, localization and a focus on cognitive/behavioral disorders, behavioral neurology is an excellent sub-specialty to pursue. It provides a nice combination of time for talking to patients, doing a focused neuro exam, thinking about localization, and managing patients with pharmacologic agents. Of course, this means 4 years of internship/residency plus 2 additional years of fellowship, versus just 4 years of psychiatry residency.

I ultimately decided on neurology because I enjoy the neuro exam, the medicine-like qualities of diagnosis and treatment, the strong academic focus, and great support for research. Plus, during my psych rotation I routined got lambasted for mentioning the word "brain" and trying to apply localization principles rather than simply diagnosing by the DSMIV criteria. I felt more "at home" with the neurologists, particularly the behavioral folks. Even the PNS people at least had an appreciation for the CNS because of their training. Of course I did my PhD with a psychiatrist, so had plenty of contact with research-minded psychiatry folks and found them very stimulating!

Tough choice! Good luck! 😉

 

[Amos]

I have BA in psychology and have always had a strong interest in anxiety and psychosis. In addition I spent much of my time in grad school focusing on mechanisms of psychiatric disease.

That being said, while I kept my research interests in mind while choosing a specialty, my highest priority was on what I would enjoy if I was a clinician 100% of the time. I enjoy understanding the mechanisms of organic disease, and felt like a lot of psychiatry was based on empiric evidence without understanding specific lesions in the brain or mechanism at the interface of molecules and neuron excitability.

I also felt like many psych residencies did not have enough of an internal medicine foundation which would help me gain a clinical understanding of how the body functions as a whole. It seems psych is often isolated from other fields in terms of standard medical practice. If a cool brain lesion or degenerative condition is identified as the cause of a patient’s problem they are whisked off to neurology or neurosurgery. I’m sure it depends on the institution, but most psychiatrists don’t spend a lot of time correcting hyponatremia, interpreting MRAs, or performing ABGs in the NICU. After all my time as a scientist and medical student I didn’t want to move away from basic nuts and bolts natural science, anatomy and physiology I have spent so long learning.

In addition a LARGE, LARGE part of clinical psychiatry, at least dealing with inpatients as a resident, is dealing with social issues and axis II disorders. Sometimes it seems like over 50% straight up social work. Given the social challenges those with mental illness often face, even with good ancillary support you are constantly thinking about rehab placement, insurance issues, domestic abuse, child support, law issues, etc. Some people like that sort of thing, but I would rather spend my time managing medical illness.

As others have pointed out you also want to think hard about some of the most common types of patients you will deal with. At my current institution where I am a prelim, most of psych call/consults consists of seeing patients with suicidal ideation or difficult cluster B patients that the primary team doesn't want to manage. The super interesting hallucinations or profound OCD patient is few and far between. Sure neuro has it's tedious aspects as well, but I would much rather see a bunch of headache or neuropathy patients vs. borderline patients or meth addicts.

It is also helpful to consider what specialties are related to neuro and psych. Neuro shares common ground with medicine, neurosurg, and psych (among other specialties). Psych shares major boundaries with social work, clinical psychology, and neuro.

I’ve had a couple close acquaintances from my MD/PhD program make the exact opposite decision and we’ve had many good conversations about it. Whatever you decide just make sure to get input from both sides of the fence. While I will always maintain a strong interest in psychiatric disorders, there have been many days in my first 2 months of residency where I have been glad that I chose neuro vs. psych.