Practicality of combined practice? (specifically IM-Psych)

[Aylaa]

Hello, I am currently wrapping up my M1 year so this may be a bit early to question, but I would like to know what I'm getting into and make clear goals for myself to stick to.

I have an interest in being certified in both IM and psych. Although it's way early to really think of a specialty that may be suitable before I have even begun rotations, this interest was the result of my love for psychology/psychiatry and my deep interest in being the first contact for patients and foster a strong bond with my patients. Questioning which approach I would want to practice in (essentially, psychiatry vs some type of IM or FM), I was eventually introduced to the idea of combined residency programs. The idea of being double certified in IM-psych is appealing to me. I just don't want to be blinded by naivety and make sure this is a practical route to pursue as medicine continues to change in the future.

Before I begin listing reasons as to why I begin discussing my findings from some articles I found to help formulate my opinion, I want to say that I would appreciate any posts in this thread if you have any personal experience or you are close to a friend that has gone through this process and could tell me what you/your friend think of this route.

I have some questions, but the following write up is just some findings and my interpretations of what I found to give some background on what I am questioning. Feel free to skip below to after the quote to just address the questions if you are well-versed with this topic.

I found this SDN article discussing med-psych written by Guera in 2018. It had a lot of good information that served as a good introduction and overview to med-psych. Very quick recap of that article: currently there are 14 med-psych programs int he US, med-psych is a 5-year training program, most med-psych graduates take on an academic role, and psychiatry (alone) had an increase in applicants in 2016.

According to a 2001 article by Stiebel and Schwartz, a survey with responses of n = 122 showed that 70% of respondents were involved only in the practice of psychiatry and 15% of respondents practiced in some type of combined med-psych setting. To me, this seems like pursuing med-psych would be a complete waste if the majority of certified physicians end up practicing solely psychiatry. However, I question the applicability of this finding because (1) it is an older article and (2) 83% of respondents had done training in separate residencies (93% of 83% initially completed IM training, and then on average 7 yrs later begun their second residency - indicating some type of dissatisfaction in their field perhaps... but the article mentions 2/3 of the 93% subgroup took a second residency out of interest in both fields), which may skew these results and findings to my needs. as that is a different route than what I am planning.

According to a 2011 article by Summergrad, Silberman, and Price, it seems like double certified psychiatrists are more likely to work in consultation or inpatient psych as opposed to outpatient. This is not inherently a problem, but this plays into possible loss of autonomy as a physician as medicine moves more towards business and administrative functioning. Further, concerning the evolution of medicine, a 2019 article by Smith and Jung shows that <40% of dual-boarded physicians practice in both trained specialties and employers/organizations are not necessarily recruiting physicians that acquired niche dual-certification training.

Contrasting from these questions of practice, it seems like the first article linked earlier by Guera and some threads on SDN that I have searched for before have described that some distress or negativity towards the prolonged training time, especially when peers (which will most likely end up practicing almost exactly the same way as the double-certified physicians as evidenced by previously linked articles) complete their training earlier and move on to be able to begin practicing, and also some negativity towards the increased stress and workload that comes with juggling two programs.

Questions I have
1. Does it really seem practical to pursue a med-psych training if the majority of respondents to surveys indicate that they do not practice in both specialties they are trained in?
2. Is getting this training too niche for a job market that does not necessarily value these skills in combination?
3. With 14 programs for med-psych, are these programs at all competitive simply due to the limited spots available? Would having to build a competitive application be worth going through a residency that takes longer to complete than either residency separately if these physicians typically practice in only one field?
4. Do you have any suggestions of how I should proceed in either learning about these combined residencies or making the most of my (in-progress) medical education to be able to figure out if I truly wish to pursue a combined training route when the time to apply comes?
5. Is the stress/workload of essentially two programs worth the double certification?

Thank you so much for reading and thank you in advance for your responses.

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[michaelrack]

Hello, I am currently wrapping up my M1 year so this may be a bit early to question, but I would like to know what I'm getting into and make clear goals for myself to stick to.

I have an interest in being certified in both IM and psych. Although it's way early to really think of a specialty that may be suitable before I have even begun rotations, this interest was the result of my love for psychology/psychiatry and my deep interest in being the first contact for patients and foster a strong bond with my patients. Questioning which approach I would want to practice in (essentially, psychiatry vs some type of IM or FM), I was eventually introduced to the idea of combined residency programs. The idea of being double certified in IM-psych is appealing to me. I just don't want to be blinded by naivety and make sure this is a practical route to pursue as medicine continues to change in the future.

Before I begin listing reasons as to why I begin discussing my findings from some articles I found to help formulate my opinion, I want to say that I would appreciate any posts in this thread if you have any personal experience or you are close to a friend that has gone through this process and could tell me what you/your friend think of this route.

I have some questions, but the following write up is just some findings and my interpretations of what I found to give some background on what I am questioning. Feel free to skip below to after the quote to just address the questions if you are well-versed with this topic.




Questions I have

2. Is getting this training too niche for a job market that does not necessarily value these skills in combination?

There are few non academic med psych jobs. However I have had several non academic psych jobs in which I later was asked to supervise family nurse practitioners doing the medical H and p on the psych patients (and made extra $ this way). I also have a side gig collaborating with an fnp who does a minor medical/weight loss/low T clinic

 

[mdjo]

This isn't specific to IM-Psych but rather my opinion on combined residencies in general: people in these programs have been tricked into giving up YEARS of their life, at the prime of their life, because they were indecisive medical students. Jobs where you truly need and use two separate board certifications are extremely rare and mostly limited to academia. Just because you like two medical specialties is not a good reason to extend your medical training and you will definitely regret it when your peers are starting as attendings and you're still staring down the barrel of an extra year or two as a trainee (especially when you're going to end up in the same hospitalist job as them anyway).

Pick the one you like more and you can take a special interest in the other thing (e.g. being a hospitalist interested in delirium, or a PCP who's great at rashes). Don't do a combined residency!

 

[Aylaa]

Thank you both for your comments. I just noticed there is a combined residency program and now realize I should have posted this thread there. That forum seems a little dead though so I'm not entirely upset haha.

So it seems that with what my intentions are in medicine, doing med-psych would not be the best for me. I suppose for now I will stick to pursuing psychiatry, but I would still be open to a double certification program if I see I can utilize both in my practice in the future, but that just seems unlikely so far.

 

[chessknt]

Dont worry about this until you have done both since your perception of what either actually entails could change drastically. If you are angling for CV building find a research project tangentially related to what you are trying to do so it can be used for either in case you make a more firm decision.

 

[luckrules]

I am in a combined residency. I would say its very impractical and would not recommend it to anyone - except for those who really want to do it. It kind of sucks knowing you are training longer and its tough to switch back and forth. But if you want to do it, then it can be immensely rewarding knowing that you are skilled in both fields and there are certain patients - usually encountered on CL psych, but not exclusively, that give a special kind of satisfaction when you can provide comprehensive care.

I'm not saying that I'd recommend it to anyone. And I'm too early in to say if there is any particular career path that it opens up that you would have no access to from a single residency (although I suspect not). But for the right kind of person who is willing to sacrifice an extra year or two (depending on the direction) and a lot of heartache to do it, it can be a good path. This kind of person is NOT someone who just likes both fields and wants to do both, but usually someone who seems themselves as a sort of integrated practitioner and likes the overlap fields.

Feel free to PM me.

 

[michaelrack]

Now that I am at a real computer rather than typing on my phone, let me expand a little on combined training. For some someone who is more interested in medicine/primary care, I would NOT recommend doing the 2 additional years of training that med/psych (or familypsych) requires (3 vs 5). For someone more interested in psychiatry, it makes a little more sense to do the additional year of combined training (4 vs 5).

Although I primarily practice impatient psych, I do get some benefit from the combined training (internal medicine/psych). I have at times collaborated with FNP's who do the medical H and P's at psych facilities. Family practice/psych training may be a little more useful since many psychiatric facilities have both child and adult patients that are seen by the FNP's.

In addition to some side gigs collaborating with traditional outpatient psych nurse practitioners. I also collaborate with an FNP who does a minor medical/Low T/weight loss clinic.

At some of my inpatient psych jobs, I have gotten extra $ for having the additional medicine certification (sometimes it's built into the base salary, at other times it has come in the form of NP collaboration stipends).

I don't think combined training makes financial sense for outpatient nonacademic practice. A lot of billing and cross-coverage issues come up when trying to do a combined clinic, although I guess it's possible to do successfully.

On a side note, several years ago I was doing rural IP psych at a general hosp in Mississippi. The hospital lost over half of its small IM staff and I was pulled to cover the inpatient med wards for several days (with the assistance of a good FNP and the ER doc doing a good job with initial orders). Doing IP medicine for the first time in over 12 years was an exciting experience, but something I doubt I will repeat.

 

[CCM-MD]

Now that I am at a real computer rather than typing on my phone, let me expand a little on combined training. For some someone who is more interested in medicine/primary care, I would NOT recommend doing the 2 additional years of training that med/psych (or familypsych) requires (3 vs 5). For someone more interested in psychiatry, it makes a little more sense to do the additional year of combined training (4 vs 5).

Although I primarily practice impatient psych, I do get some benefit from the combined training (internal medicine/psych). I have at times collaborated with FNP's who do the medical H and P's at psych facilities. Family practice/psych training may be a little more useful since many psychiatric facilities have both child and adult patients that are seen by the FNP's.

In addition to some side gigs collaborating with traditional outpatient psych nurse practitioners. I also collaborate with an FNP who does a minor medical/Low T/weight loss clinic.

At some of my inpatient psych jobs, I have gotten extra $ for having the additional medicine certification (sometimes it's built into the base salary, at other times it has come in the form of NP collaboration stipends).

I don't think combined training makes financial sense for outpatient nonacademic practice. A lot of billing and cross-coverage issues come up when trying to do a combined clinic, although I guess it's possible to do successfully.

On a side note, several years ago I was doing rural IP psych at a general hosp in Mississippi. The hospital lost over half of its small IM staff and I was pulled to cover the inpatient med wards for several days (with the assistance of a good FNP and the ER doc doing a good job with initial orders). Doing IP medicine for the first time in over 12 years was an exciting experience, but something I doubt I will repeat.

Nice. The benefit of combined residencies? One gets to "collaborate" with FNPs. How amazing. I'm sure you're making a killing. FYI, don't need 2 residencies for that, can do just fine with 1.

"Inpatient medicine after 12 years was an exciting experience" - this is the crux of the problem of combined residencies. I'm sure you were up to date on the most evidence based practices after not practicing it for over a decade. I'm sure you "collaborated" excellently with your FNP. Hopefully you didn't have any "exciting" adverse outcomes.

 

[michaelrack]

I am fully certified and meeting MOC for IM. For several days it was just me and the chair of medicine available/covering. Not an ideal situation, but l was the highest qualified doc available at the time..... more qualified than some of the doctors pulled in NY in late March/ early April to cover Covid wards .
The ICU was closed down and steps were taken to avoid complicated cases (sent to the "big city " by the er). No adverse events. I love rural practice, I only left Panola medical center in batesville Mississippi because it was too far from my Memphis home, and there had been too many changes in ownership and management.... though the chair of medicine is a good guy and has endured through it all

 

[michaelrack]

Nice. The benefit of combined residencies? One gets to "collaborate" with FNPs. How amazing. I'm sure you're making a killing. FYI, don't need 2 residencies for that, can do just fine with 1.

I make a little more than the average psychiatrist but not exactly killing it. Still technically bankrupt from some misadventures in sleep medicine (filed 5 years ago, case still open). Doing a sleep medicine fellowship in addition to combined residency was overkill.
Easy to criticize anonymously

 

[PikminOC]

I make a little more than the average psychiatrist but not exactly killing it. Still technically bankrupt from some misadventures in sleep medicine (filed 5 years ago, case still open). Doing a sleep medicine fellowship in addition to combined residency was overkill.
Easy to criticize anonymously

What happened? I thought sleep med would have low risk

 

[michaelrack]

What happened? I thought sleep med would have low risk

Business failure of the company that owned the sleep labs..... I was cosigner on a lot of business loans... I was then fired by the company that acquired the main sleep lab. No clinical/malpractice issues

 

[PikminOC]

Business failure of the company that owned the sleep labs..... I was cosigner on a lot of business loans... I was then fired by the company that acquired the main sleep lab. No clinical/malpractice issues

Were you an owner? Why did you cosign loans? Why didnt the new company assume the loans or pay off the debt? That wasnt a requirement in the sales agreement?

 

[michaelrack]

1. Yes I had a minority stake 2. Bad decision
3. New company acquired old company in bankruptcy, with my nonfinancial assistance
4. Theoretically the accounts receivable would go to paying debts.... but the bankruptcies for both myself and the old company are still open after more than 5 years.

Forbes magazine ( electronic version) did a write up of a legal argument my attorney raised, Google "Michael Rack and bankruptcy " if you're interested

 

[hocus_bolus]

Can someone who is dually trained work inpatient medicine some days and outpatient psych some other days? This seems pretty appealing to me, someone who is interested in psych but does not want to lose touch with what I would have learned in med school.

Now that I am at a real computer rather than typing on my phone, let me expand a little on combined training. For some someone who is more interested in medicine/primary care, I would NOT recommend doing the 2 additional years of training that med/psych (or familypsych) requires (3 vs 5). For someone more interested in psychiatry, it makes a little more sense to do the additional year of combined training (4 vs 5).

Although I primarily practice impatient psych, I do get some benefit from the combined training (internal medicine/psych). I have at times collaborated with FNP's who do the medical H and P's at psych facilities. Family practice/psych training may be a little more useful since many psychiatric facilities have both child and adult patients that are seen by the FNP's.

In addition to some side gigs collaborating with traditional outpatient psych nurse practitioners. I also collaborate with an FNP who does a minor medical/Low T/weight loss clinic.

At some of my inpatient psych jobs, I have gotten extra $ for having the additional medicine certification (sometimes it's built into the base salary, at other times it has come in the form of NP collaboration stipends).

I don't think combined training makes financial sense for outpatient nonacademic practice. A lot of billing and cross-coverage issues come up when trying to do a combined clinic, although I guess it's possible to do successfully.

On a side note, several years ago I was doing rural IP psych at a general hosp in Mississippi. The hospital lost over half of its small IM staff and I was pulled to cover the inpatient med wards for several days (with the assistance of a good FNP and the ER doc doing a good job with initial orders). Doing IP medicine for the first time in over 12 years was an exciting experience, but something I doubt I will repeat.

 

[CCM-MD]

Can someone who is dually trained work inpatient medicine some days and outpatient psych some other days? This seems pretty appealing to me, someone who is interested in psych but does not want to lose touch with what I would have learned in med school.

Don’t waste your time. Pick one and move on. Most people who do dual residencies end up practicing only one for a variety of reasons.