Peds vs Psych dilemma

[flako]

I'm finishing up my 3rd year and getting ready to began planning my 4th year schedule. I have always been interested in pediatrics and I enjoyed my ped oupatient rotation. Howerver, I did not have a good ped inpatient experience. Following this rotation I had my pshych rotation which I enjoyed very much. Now I have began to dout if peds is for me or not. Any help please.

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[masterofmonkeys]

This seems to be a very common dilemma (or at least was in my class, with 1/3 of the 14 who decided on going into psych also seriously considering peds).

The first thing is that yes, inpatient peds sucks, and it likely does so almost anywhere. The fact of the matter is that teaching hospitals take on a disproportionate burden of inpatient pediatrics cases overall due to limited inpatient peds beds in private hospitals, on top of which you are going to of course get the sickest, just as they do on the adult side of things.

Once you're out though, the lifestyle and stresses of a peds hospitalist, outpatient, or mixed practice doctor is much different (and easier). Which is something to keep in mind.

Psych on the other hand, it SEEMS that hours/stress as a resident are not that much different than those an attending faces. Psych residencies in general the hours on inpatient are shorter and are less stressful (if they weren't lying to me on the interview trail lol), and call schedules are less onerous, rarely working over 60hrs--which is rather similar to being an attending. Whereas in peds you are bumping against or over 80hrs on a regular basis and are often q3 on inpatient. I have not met too many peds attendings (including hospitalists or mixed practice docs) who even approach that amount.

It's important to look at your residency versus your career once you're out and reflect on the differences. Many residency lifestyles are considerably worse than that of attendings and this isn't limited to peds (neuro-spine for instance, and to a lesser degree general surg and ob/gyn). Many are more similar and laid back(ER, psych, ophtho, and family come to mind).

As far as scheduling goes, most of my friends who were torn ebtween the two did an early sub-I or representative elective in each (consult or outpatient or something) and went from there. They also reflected on what about peds drew them to it. In several cases, after sitting back and thnking about it, they realized that their attraction to peds lay in talking to the children and their families about the stresses they were going through etc, rather than the treatment of the illness itself.

 

[BobA]

Why not throw your hat in the ring for a triple board program?

For me personally, a sub-I wasn't enough to make me 100% certain that THIS was the field for me. I still had a lot of doubts. I will probably continue to have doubts. I like the idea that there are diverse psych fellowships (peds, psychosomatic, forensics, sleep) that will allow me to be flexible with what I do from here.

I looked strongly at IM/Psych & FM/Psych programs because I couldn't decide what to do. I decided that I was going to pick one or the other eventually and just decided to do it now rather than later. However, I still have thoughts that FM/Psych might have been a good route to afford more career flexibility.

I wish I had at least applied and looked at some FM/Psych programs.

 

[peppy]

I'd suggest trying to do a child psychiatry elective early in 4th year. You might discover that field is a good mix of what you like about peds and psych. Dealing with children who have challenging behaviors might help you decide you DON'T want to dedicate your career to working with children. And if you end up going into peds after all, having some understanding of child psychiatric issues will be useful "background info". 🙂
Good luck with the decision

 

[anesthesiarocks]

I'm finishing up my 3rd year and getting ready to began planning my 4th year schedule. I have always been interested in pediatrics and I enjoyed my ped oupatient rotation. Howerver, I did not have a good ped inpatient experience. Following this rotation I had my pshych rotation which I enjoyed very much. Now I have began to dout if peds is for me or not. Any help please.

what is the dilemna? You've supposedly done a rotation in both and can see what each does. Would you rather be a hands on clinician, admitting a septic 18 month old and doing that full work up, or would you rather be a non-procedural physician and admit refractory schizoaffective pts off their meds? Some like the former, some like the latter.....

 

[anesthesiarocks]

Why not throw your hat in the ring for a triple board program?

For me personally, a sub-I wasn't enough to make me 100% certain that THIS was the field for me. I still had a lot of doubts. I will probably continue to have doubts. I like the idea that there are diverse psych fellowships (peds, psychosomatic, forensics, sleep) that will allow me to be flexible with what I do from here.

I looked strongly at IM/Psych & FM/Psych programs because I couldn't decide what to do. I decided that I was going to pick one or the other eventually and just decided to do it now rather than later. However, I still have thoughts that FM/Psych might have been a good route to afford more career flexibility.

I wish I had at least applied and looked at some FM/Psych programs.

why? Nobody practices im and psych in reality after training....or fm and pysch.........or peds and psych.......you're going to do one or the other. Thats why there is such a low number of spots for these "combined" programs(because the demand is so low)


If I wanted to be an internist and manage CHF and stuff, I'd do that. If I wanted to do peds and tap 2 year olds with the meningoccoccus, I'd do that. but I dont, and anyone who wants to actually practice psych after training wont be doing that either if they do a combined program.....

 

[diosa428]

why? Nobody practices im and psych in reality after training....or fm and pysch.........or peds and psych.......you're going to do one or the other. Thats why there is such a low number of spots for these "combined" programs(because the demand is so low)


If I wanted to be an internist and manage CHF and stuff, I'd do that. If I wanted to do peds and tap 2 year olds with the meningoccoccus, I'd do that. but I dont, and anyone who wants to actually practice psych after training wont be doing that either if they do a combined program.....

Actually, Duke has an psych/medicine inpatient team that deals with inpatient medical admissions who have psychiatric comorbidities. So, yes, there are people out there who continue to be boarded in both and practice both. Additionally, my FP doc was treating quite a few pts for depression and also had a schizophrenic patient who was hearing voices that were telling her to kill herself, but since we were in rural NC, there weren't any psychiatrists that were easily accessible that accepted her medicaid, so he was trying to manage her condiiton while she waited 2 weeks for her appointment at the local health department. He was completely uncomfortable with it. I would imagine that having training in psych would be helpful for other FPs in similar rural areas where there is not a lot of psych care available and they are left managing psych issues. Not everyone spends the rest of their life working at an academic center in a big city.

 

[diosa428]

what is the dilemna? You've supposedly done a rotation in both and can see what each does. Would you rather be a hands on clinician, admitting a septic 18 month old and doing that full work up, or would you rather be a non-procedural physician and admit refractory schizoaffective pts off their meds? Some like the former, some like the latter.....

Really? Did you not meet anyone who was deciding between two specialties in your medical school class? Your posts assaulting anyone who isn't able to decide what they want to do for the rest of their life based on a 4-8 week, highly subjective experience is kind of ridiculous. It's not impossible for people to like more than one thing.

 

[BobA]

why? Nobody practices im and psych in reality after training....or fm and pysch.........or peds and psych.......you're going to do one or the other. Thats why there is such a low number of spots for these "combined" programs(because the demand is so low)


If I wanted to be an internist and manage CHF and stuff, I'd do that. If I wanted to do peds and tap 2 year olds with the meningoccoccus, I'd do that. but I dont, and anyone who wants to actually practice psych after training wont be doing that either if they do a combined program.....

I know what you mean. I didn't end up applying to any IM/Psych or FM/Psych programs. However, I kinda wish I had just gone and taken a look and seen what they were like.

Triple board programs are only 5 years. A tough 5 years. But they afford tremendous career flexibility. I'm just suggesting that applying and taking a look could be helpful. I wish I had at least interviewed at a few (probably FM/Psych).

 

[masterofmonkeys]

I know what you mean. I didn't end up applying to any IM/Psych or FM/Psych programs. However, I kinda wish I had just gone and taken a look and seen what they were like.

Triple board programs are only 5 years. A tough 5 years. But they afford tremendous career flexibility. I'm just suggesting that applying and taking a look could be helpful. I wish I had at least interviewed at a few (probably FM/Psych).

Yeah, I find myself in that same camp of wishing I'd at least interviewed in med/psych or fm/psych. I wish even more that a pm&r/psych program existed. Or that sports med fellowships were open to psych. But meh.

I find nothing odd at all about finding yourself drawn to two different areas of medicine, especially if one of them is psych and the other general (adult, peds, both). Most people don't go into medical school having no interest in somatic medicine. So it seems perfectly natural that if you have a strong enough interest in general medicine, you'd continue to be torn between med and psych, or peds and psych, or family and psych.

 

[nancysinatra]

Ok, since we are making up our dream combined programs, here's mine: trauma surgery/psych. (And I might add anesthesia to the mix, even, if it weren't going to add so many extra years. I am DYING to know how to intubate in every weird situation.) You scoff, but hear me out. With this combined program I will treat all the antisocial PD types who get into gun fights, gang violence, etc, the substance abusers who come in after falls, accidents and fights, perpetrators and victims of road rage--you name it. I will provide ALL their treatment! Seriously it is an unidentified common ground patient population between surgery and psychiatry.

EDIT: when I say I would "add anesthesia to the mix," I don't mean that literally. For as long a road as that combined program would be, and as burnt out as I'm sure it would make me, I would want to try to stay awake for it. I would actually like to learn how to do the anesthesia for the patients as well. But that's just too many years of training!

 

[rpkall]

Re:
peds vs.
psych -> child psych
vs. tripleboard
vs. peds -> developmental/behavioral peds

i.e., twenty ways to accomplish similar career goals...

-------------------

I struggled with this decision in the past 2 months leading up to ROLs being due. I loved the physical diagnosis and outpatient "doctoring" that pediatricians do--but I also was passionate about behavioral neurobiology in the pediatric population (what's really happening in the brains of autistic kids, kids with complex childhood trauma, etc).

In the end, I chose to pursue child psychiatry (via psych residency) for the following reasons:

- Child psych is remarkably underserved, and that won't change--there are simply too many kids in need of services (from kids with neurodevelopmental disabilities, autism, trauma, and genuine burgeoning psychiatric disorders). I felt that my contribution to a community in need would really matter. (in contrast, peds is not underserved at all, even in the subspecialties)

- Even if you choose to work in public service child psych (state funded programs, residential treatment centers, foster care services) the money is better in child psychiatry than peds--because you can have a part time private practice to supplement income.

- Psychiatry residency is generally more lifestyle compatable than peds (even through all 5 years, including 3 for general and 2 for child fellowship) -- and depending on your personality/temperament, you might enjoy it more (therapy is actually fun to learn and practice, and contrary to popular opinion, in psychiatry you get to see your patients really do better, both in the severity of symptoms and in general functionality). Lifestyle is very much better than triple board programs, at most places.

- I was always most interested in the behavioral issues kids and teens were having--dysregulation, run-ins with the legal system, anxiety, depression, substance abuse, grappling with past traumas, etc. These are generally very interesting for pediatricians too, but you just get more time and more exposure to these things in psychiatry--and for your career, you get to focus on them, you get time with these patients and their families, and you get to really find out what their lives are like in more detail.

- I wanted a chance to advocate for the ethical practice of psychiatry with kids, including holding more educated positions on psychotropic use and the integration of family therapy into treatment plans. Many child psychiatrists spend more time taking kids OFF psychotropic meds and refining diagnoses rather than just throwing meds at problems (because they have more than 15 minutes to evaluate kids, and they get to develop relationships that can be therapeutic, as well as do family therapy, etc).

- Relationships. I think developing therapeutic relationships with kids and their families who are in significant distress, with significant family psychopathology, is the ultimate challenge. Relationships with kids and families are relatively "easier" to navigate when everyone is happy and healthy or when all discussions focus only on medical issues.

- I wanted to practice something that wasn't "cookie-cutter," so to speak. Meaning just that most of medicine and pediatrics is practiced nowadays by defining a problem and proceeding through a pre-orchestrated set of questions and answers (the "flow chart" diagram) that ultimately gets you to a diagnosis and treatment regimen. This kind of medicine wouldn't have been fulfilling for me--because I would know that the guy sitting behind me in grand rounds would have made the same decisions I did, done the same workup, and gotten the same results. I'd feel a little like one of the cogs in a very large machine. Psychiatry actually isn't like that. Much of what's done in therapy in the outpatient arena depends a lot on the individual skills and characteristics of the therapist (compassion, ethics, verbal and nonverbal communication abilities, passion for the work, etc).

- At some point I realized that part of what compelled me to do peds was a need to "legitimize" my love for psych by adding something more "medical" in my credentials. Most of my in-laws don't really respect psychiatry, as compared to surgery, cardiology, peds, even OB--and it might have been easier for me to just do a triple board so I didn't have to face their criticism. But honestly, I didn't *love* practicing any of those specialties (even as an MS4 when the pressure was off and people were letting me get more hands-on experience). But I actually love doing what psychiatrists do on a daily basis. Whether my family thinks it's "medicine" or "pseudoscience" is their issue. At least I know I'll be happy going to work in the morning.

Anyway, I hope some of that is helpful.


🙂

 

[OldPsychDoc]

Ok, since we are making up our dream combined programs, here's mine: trauma surgery/psych. (And I might add anesthesia to the mix, even, if it weren't going to add so many extra years. I am DYING to know how to intubate in every weird situation.) You scoff, but hear me out. With this combined program I will treat all the antisocial PD types who get into gun fights, gang violence, etc, the substance abusers who come in after falls, accidents and fights, perpetrators and victims of road rage--you name it. I will provide ALL their treatment! Seriously it is an unidentified common ground patient population between surgery and psychiatry.

Not unidentified at all. About 2/3 of my transfers from the "real hospital" 🙄 are overdoses, the other 1/3 are mostly jumpers, cutters, stabbers, etc. Had to send a nice self-stabber back today b/c of a wound infection. Do a hand surgery/plastics fellowship for all those tendon repairs and patients will be dying to become your patient! 😉

 

[BobA]

Ok, since we are making up our dream combined programs, here's mine: trauma surgery/psych. (And I might add anesthesia to the mix, even, if it weren't going to add so many extra years. I am DYING to know how to intubate in every weird situation.) You scoff, but hear me out. With this combined program I will treat all the antisocial PD types who get into gun fights, gang violence, etc, the substance abusers who come in after falls, accidents and fights, perpetrators and victims of road rage--you name it. I will provide ALL their treatment! Seriously it is an unidentified common ground patient population between surgery and psychiatry.

EDIT: when I say I would "add anesthesia to the mix," I don't mean that literally. For as long a road as that combined program would be, and as burnt out as I'm sure it would make me, I would want to try to stay awake for it. I would actually like to learn how to do the anesthesia for the patients as well. But that's just too many years of training!

One of the ED attendings here has made her research career out of studying alcohol abuse among college students. Specifically, she's studied how energy drinks + alcohol leads to increased alcohol consumption and increased risk of trauma.

Unfortunately, when I told this attending I was going into psych she said "I could never do that because people don't get better." She then proceeded to supervise an intern who was placing a central line in a brain-dead, dialysis dependent septic patient who had presented from a skilled nursing facility.

 

[anesthesiarocks]

I know what you mean. I didn't end up applying to any IM/Psych or FM/Psych programs. However, I kinda wish I had just gone and taken a look and seen what they were like.

Triple board programs are only 5 years. A tough 5 years. But they afford tremendous career flexibility. I'm just suggesting that applying and taking a look could be helpful. I wish I had at least interviewed at a few (probably FM/Psych).

the problem I have with triple board programs:

1) youre not spending as much time(not nearly as much) training in one field as someone who just does a psych residency(or a peds residency). People who do general psych spend the better part of four years(3 years 8 months on psych and neuro than 4 "other" months) doing psych and nothing but psych. People doing a "triple boarded" 5 year program in three different fields arent spending nearly that long. And people who do 3 years of pure peds can say the same thing about people doing far less than that.

2) it's very costly to sit for three boards, keep up certification in three areas, etc......

If I want to go to a psychiatrist I want someone who trained in psychiatry, not freaking pediatrics x% of the time. if I want an pediatrician for my kid I dont want someone who spend significant time doing adult psych. If I want a psychiatrist for my kid I'll take them to a special needs pediatrician or a child psychiatrist(depending on what sort of issues they have)..........

 

[BobA]

the problem I have with triple board programs:

1) youre not spending as much time(not nearly as much) training in one field as someone who just does a psych residency(or a peds residency). People who do general psych spend the better part of four years(3 years 8 months on psych and neuro than 4 "other" months) doing psych and nothing but psych. People doing a "triple boarded" 5 year program in three different fields arent spending nearly that long. And people who do 3 years of pure peds can say the same thing about people doing far less than that.

2) it's very costly to sit for three boards, keep up certification in three areas, etc......

If I want to go to a psychiatrist I want someone who trained in psychiatry, not freaking pediatrics x% of the time. if I want an pediatrician for my kid I dont want someone who spend significant time doing adult psych. If I want a psychiatrist for my kid I'll take them to a special needs pediatrician or a child psychiatrist(depending on what sort of issues they have)..........

The people who do triple boards tend to be pretty smart. I trust they can handle it.

Also, they have career flexibility. If career flexibility is desirable to you, you might like a triple board program. If it's not, then it's not.

Either way, the OP is likely to learn more about triple boards by going and interviewing than they are from this msg board.

 

[diosa428]

the problem I have with triple board programs:

1) youre not spending as much time(not nearly as much) training in one field as someone who just does a psych residency(or a peds residency). People who do general psych spend the better part of four years(3 years 8 months on psych and neuro than 4 "other" months) doing psych and nothing but psych. People doing a "triple boarded" 5 year program in three different fields arent spending nearly that long. And people who do 3 years of pure peds can say the same thing about people doing far less than that.

2) it's very costly to sit for three boards, keep up certification in three areas, etc......

If I want to go to a psychiatrist I want someone who trained in psychiatry, not freaking pediatrics x% of the time. if I want an pediatrician for my kid I dont want someone who spend significant time doing adult psych. If I want a psychiatrist for my kid I'll take them to a special needs pediatrician or a child psychiatrist(depending on what sort of issues they have)..........

I bet if you lived in a rural area of the US, you would thank your lucky stars that someone could treat your kid's medical AND psychiatric problems, rather than faulting them for their lack of appropriate adult psych training.

 

[nancysinatra]

Not unidentified at all. About 2/3 of my transfers from the "real hospital" 🙄 are overdoses, the other 1/3 are mostly jumpers, cutters, stabbers, etc. Had to send a nice self-stabber back today b/c of a wound infection. Do a hand surgery/plastics fellowship for all those tendon repairs and patients will be dying to become your patient! 😉

Excellent! I never thought about the overlap with cutters (penetrating trauma) or jumpers (blunt trauma). Also, there is sadly the risk of esophageal perforation with bulimic patients. And the bariatric patients must be screened too, so I could do that and then proceed to operate, although I realize that's a specialty surgery. Still I am all for all-in-one treatment. By doing anesthesia as well I could design a trach that people could speak through and then they could have psychotherapy done right there in the ICU. I never want to leave the hospital!

I am not saying this to sound uncaring or mean but I do not understand anyone's love for peds or medicine. They bored me to tears. But with surgery you see crazy things. Painful, disgusting necrotizing fasciitis left untended for days or weeks! GSWs! Unbelievable lacerations! Where else do you see that? Hmmmm.... Psych. Gotta love it. Now medicine, it's all about renal failure and anemia. If it were toxic shock or shellfish poisoning every day or interesting neurological conditions I'd be up for it, but it's rarely about that. And peds, I swear, the most exciting thing that comes along in a given month is R/O Kawasaki and the rest is all "q4h albuterol nebs wean to q6h as tolerated."

That's just my take on it. I suppose people do have their reasons.

 

[anesthesiarocks]

I bet if you lived in a rural area of the US, you would thank your lucky stars that someone could treat your kid's medical AND psychiatric problems, rather than faulting them for their lack of appropriate adult psych training.

you dont get it....the fact that they wasted any time on "adult" psych training in that scenario would be less time they have to spend on the training Im actually bringing my kid if for them to see.

Plus, from a providers standpoint(after are or all we are all going to be providers) in a small town it would be a nightmare trying to find office staff to code and bill for two very different fields......the whole thing is just silly.

 

[anesthesiarocks]

The people who do triple boards tend to be pretty smart. I trust they can handle it.

Also, they have career flexibility. If career flexibility is desirable to you, you might like a triple board program. If it's not, then it's not.

Either way, the OP is likely to learn more about triple boards by going and interviewing than they are from this msg board.

1) not all of them are that smart. don't mistake the limited number of spots for "competitiveness". There is a reason there are only something like 11 or 13 or whatever combined psych/peds programs(and thats only the dual one)- because the whole idea is silly and not that many people want to do it. Hell there are only about 100 or so meds/peds programs total.

2) Career flexibility is overrated. At some point you have to **** or get off the pot. Most of us entering training are in are mid to late 20s or even 30+ in some cases. We'll be even older by the time we finish residency. I understand someone picking IM over family medicine if they are split on the issue because they may decide to do cards or gi or something later and so they pick IM because it gives them that flexibility, but thats a completely different issue.

3) I want to actually use the training I recieve. Thats a fairly simple goal, but people who do these triple board programs don't to a large degree. And thus they get less training in the thing they actually end up doing. I want to do adult psych, and the idea that someone could spend 16-18(?) months doing adult psych in these silly triple board programs and have the same board eligibility I do in adult psychiatry when I have spent 2.5x the training they have is absurd. I'm not from a small city(> 500,000 people) and I don't know of a SINGLE person who would treat both rsv bronchiolitis in a 12 month in between seeing pure peds psych cases..........it just doesnt happen.

 

[BobA]

1) not all of them are that smart. don't mistake the limited number of spots for "competitiveness". There is a reason there are only something like 11 or 13 or whatever combined psych/peds programs(and thats only the dual one)- because the whole idea is silly and not that many people want to do it. Hell there are only about 100 or so meds/peds programs total.

2) Career flexibility is overrated. At some point you have to **** or get off the pot. Most of us entering training are in are mid to late 20s or even 30+ in some cases. We'll be even older by the time we finish residency. I understand someone picking IM over family medicine if they are split on the issue because they may decide to do cards or gi or something later and so they pick IM because it gives them that flexibility, but thats a completely different issue.

3) I want to actually use the training I recieve. Thats a fairly simple goal, but people who do these triple board programs don't to a large degree. And thus they get less training in the thing they actually end up doing. I want to do adult psych, and the idea that someone could spend 16-18(?) months doing adult psych in these silly triple board programs and have the same board eligibility I do in adult psychiatry when I have spent 2.5x the training they have is absurd. I'm not from a small city(> 500,000 people) and I don't know of a SINGLE person who would treat both rsv bronchiolitis in a 12 month in between seeing pure peds psych cases..........it just doesnt happen.

Then I guess it's good you didn't apply to triple board programs.