Practice options in psych

[Eye-eye]

Hello all,

I'm an MS4 who was hoping to go into ophtho until our match kicked me on my ass this week and it was suggested to me that I consider another field. I enjoyed my psych clerkship a lot, and have found myself thinking about pursuing it as a career. The thing is, I don't actually know what the options typically look like after graduating from psych residency, as my only exposures have been an inpatient acute psych unit and a psych ED.

I typically prefer outpatient to inpatient, and imagine there are a lot of pp jobs out there for psych, but I have no idea what these look like. How much do you do med management and overseeing midlevels/psychologists/counselors vs actual therapy? Can you choose to do mostly just one or the other if that's where your interests lie? How much of this is feasible if you'd want to start your own practice or in a rural setting (I'm not a big city person), and how would such a setting impact decisions like cash pay vs insurance? One thing I liked about ophtho is that it's still possible to go hang your own shingle and avoid a lot of the bureaucracy inherent to employed gigs, and it sounds like this is feasible in psych as well, but I'm unsure as to the implications of making such a choice.

I also wouldn't be opposed to thinking about less traditional models of practice, and it sounds like there could be some interesting opportunities in locums work or some other options I'm less familiar with like IMEs (still not entirely sure what that really entails of, to be honest).

I know this is an extremely broad question, but if anyone can speak to the day to day pros and cons, the lifestyle (hours, pay), and such, I would greatly appreciate it! Unfortunately there's limited time before the SOAP, so I'm trying to gather as much information as I can as quickly as I can.

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[Sushirolls]

If you can see yourself being a Psychiatrist. Even from just your taste of inpatient psychiatry, then do it.
There is a massively wide arena of how a Psychiatrist can practice, the setting they do it, and the flexibility of hours, pay, etc.
You can do rural, don't worry about that.

The answer is yes to basically everything you questioned... but can you stand Psychiatry and not want to run away into another field?

 

[Ole_Toe]

I think all of your questions have been answered elsewhere, but you would just need to put in the work to search around and research. Perhaps one of the practicing physicians here will be generous enough to take a stab at your questions. Sorry about match! I'm sure you're a great candidate; I've heard how competitive life is for ophtho

 

[PikminOC]

Do you have the scores to match in psych? I think it is more competitive now.

 

[Eye-eye]

If you can see yourself being a Psychiatrist. Even from just your taste of inpatient psychiatry, then do it.
There is a massively wide arena of how a Psychiatrist can practice, the setting they do it, and the flexibility of hours, pay, etc.
You can do rural, don't worry about that.

The answer is yes to basically everything you questioned... but can you stand Psychiatry and not want to run away into another field?

Wow, this is the first time I've ever heard someone say "if you can see yourself doing it, do it." Usually it's "if you can imagine doing anything else, do that other thing," so that's a good sign. : )

Perhaps I just don't know enough about the downsides, but I don't think I'd want to run away... honestly it seems like a good gig. Some of the patients can be... interesting, but seeing people improve as dramatically as they did with meds was freaking awesome. Now, if you said I can only see people with borderline, that might be different. But I enjoy the ability to spend more time with your patients, to talk to them about the important stuff; and also to be able to really help sometimes with stuff that no one else has, because they've never tried that SSRI or antipsychotic.

I guess my question back to you would be, what are those downsides that make some people want to run away from psych? What things might I not have considered enough and should really think about before signing up?

Thanks for taking the time to answer!

 

[Eye-eye]

I think all of your questions have been answered elsewhere, but you would just need to put in the work to search around and research. Perhaps one of the practicing physicians here will be generous enough to take a stab at your questions. Sorry about match! I'm sure you're a great candidate; I've heard how competitive life is for ophtho

Some of them certainly have, and I apologize for asking things that have already been answered. Just trying to get a better gestalt and make sure I'm not missing anything too major before jumping in, and like I said, there's not a ton of time to get all the wheels rolling.

Thanks for the condolences. It was not a fun experience, and continues not to be, but that's the risk you run when you apply to something as competitive as ophtho (and this year was a particularly brutal one, as it turned out)

Do you have the scores to match in psych? I think it is more competitive now.

Yes, but I appreciate you bringing it up. Avg scores and such are more competitive than I expected, to be honest, but still nowhere near ophtho, from what I can tell.

 

[Stagg737]

Perhaps I just don't know enough about the downsides, but I don't think I'd want to run away... honestly it seems like a good gig. Some of the patients can be... interesting, but seeing people improve as dramatically as they did with meds was freaking awesome. Now, if you said I can only see people with borderline, that might be different. But I enjoy the ability to spend more time with your patients, to talk to them about the important stuff; and also to be able to really help sometimes with stuff that no one else has, because they've never tried that SSRI or antipsychotic.

I guess my question back to you would be, what are those downsides that make some people want to run away from psych? What things might I not have considered enough and should really think about before signing up?

The bolded is what initially sparked my interest in the field, especially with antipsychotics. You'll have to treat personality disorders at times, but the field is very flexible, relatively easy to start PP, and if you're in PP you can vet the patients to take only ones you're interested in. Here's a few other threads to check out which you might find very helpful:

Private Practice in Progress

Building a private practice, N of 1. Enjoy. Month zero: Grand plan was to use money from inpatient gig where independent contractor doing own billings to expedite insurance paneling, so all I had to do was switch over the practice address once opened. Long story short, not a quality place I...

forums.studentdoctor.net

Could what happened to EM happen to psychiatry?

Just wondered to the EM forum it’s pretty frightening. The Derm page also is frightening. I can’t imagine graduating from residency and not finding a job. Could this happen to psych— and if so how do we stop it?

forums.studentdoctor.net

Would you take your dream job for less salary?

I was recently offered an incredible job in a town I really want to live in. The catch? The salary is very low. It's an academic position and I will get a patient population I like. A lot of my time will be protected for a specific area of research I'm interested in and for resident education...

forums.studentdoctor.net

The above may give you an idea of what different jobs may look like, pay, settings, etc. If you want more specifics about what is a "good" job in psych, just search for any of the many "thoughts on this job offer" threads. There's at least 4 of them on the first two pages of this sub-forum.

 

[Attending1985]

Wow, this is the first time I've ever heard someone say "if you can see yourself doing it, do it." Usually it's "if you can imagine doing anything else, do that other thing," so that's a good sign. : )

Perhaps I just don't know enough about the downsides, but I don't think I'd want to run away... honestly it seems like a good gig. Some of the patients can be... interesting, but seeing people improve as dramatically as they did with meds was freaking awesome. Now, if you said I can only see people with borderline, that might be different. But I enjoy the ability to spend more time with your patients, to talk to them about the important stuff; and also to be able to really help sometimes with stuff that no one else has, because they've never tried that SSRI or antipsychotic.

I guess my question back to you would be, what are those downsides that make some people want to run away from psych? What things might I not have considered enough and should really think about before signing up?

Thanks for taking the time to answer!

Some downsides are there are a lot of jobs everywhere but a lot of them are crappy. Quantity of patients seen is emphasized over quality of work.
Can be emotionally exhausting. Hear a lot of sad stories. People not taking responsibility for their lives. Negativity, ect.
Some meds we use have really bad side effects. It’s always difficult to balance risk and benefit and try to protect people’s physical health. This weighs on me at times.

 

[Eye-eye]

The bolded is what initially sparked my interest in the field, especially with antipsychotics. You'll have to treat personality disorders at times, but the field is very flexible, relatively easy to start PP, and if you're in PP you can vet the patients to take only ones you're interested in. Here's a few other threads to check out which you might find very helpful:

Private Practice in Progress

Building a private practice, N of 1. Enjoy. Month zero: Grand plan was to use money from inpatient gig where independent contractor doing own billings to expedite insurance paneling, so all I had to do was switch over the practice address once opened. Long story short, not a quality place I...

forums.studentdoctor.net

Could what happened to EM happen to psychiatry?

Just wondered to the EM forum it’s pretty frightening. The Derm page also is frightening. I can’t imagine graduating from residency and not finding a job. Could this happen to psych— and if so how do we stop it?

forums.studentdoctor.net

Would you take your dream job for less salary?

I was recently offered an incredible job in a town I really want to live in. The catch? The salary is very low. It's an academic position and I will get a patient population I like. A lot of my time will be protected for a specific area of research I'm interested in and for resident education...

forums.studentdoctor.net

The above may give you an idea of what different jobs may look like, pay, settings, etc. If you want more specifics about what is a "good" job in psych, just search for any of the many "thoughts on this job offer" threads. There's at least 4 of them on the first two pages of this sub-forum.

Thank you so much! I'll look through these

 

[Eye-eye]

Some downsides are there are a lot of jobs everywhere but a lot of them are crappy. Quantity of patients seen is emphasized over quality of work.
Can be emotionally exhausting. Hear a lot of sad stories. People not taking responsibility for their lives. Negativity, ect.
Some meds we use have really bad side effects. It’s always difficult to balance risk and benefit and try to protect people’s physical health. This weighs on me at times.

The emotional toll is something I've certainly thought about before as a negative. On the flipside, though, I wonder if it would also help me in my journey toward being a better person - to be more grateful, and more compassionate. These are both things I have always tried to make important, and I think that it is easy to become more cynical and less compassionate in many areas of medicine - likely simply because of burnout. Certainly psych isn't immune from these pressures, but I wonder if the nature of the work would also somewhat inherently help in being mindful about such things and working to not let them control you.

Sorry, I think I'm just rambling for my own sake. Very much appreciate your thoughts.

 

[rjs2131]

The emotional toll is something I've certainly thought about before as a negative. On the flipside, though, I wonder if it would also help me in my journey toward being a better person - to be more grateful, and more compassionate. These are both things I have always tried to make important, and I think that it is easy to become more cynical and less compassionate in many areas of medicine - likely simply because of burnout. Certainly psych isn't immune from these pressures, but I wonder if the nature of the work would also somewhat inherently help in being mindful about such things and working to not let them control you.

Sorry, I think I'm just rambling for my own sake. Very much appreciate your thoughts.

I'm finishing up training in a few months and I've definitely found the above to be true - it's different for everyone, but being exposed to people at their most vulnerable and being able to help (even if it's just by giving someone time and a space to talk/process) has very much helped with my understanding of what is important to me in life and what I value in relationships. I can't speak to the training in any other field but there are certain non-tangible things you have to learn as a psychiatrist (setting boundaries, for example) that serve you in all other aspects of life.

To answer your original question - I have several friends in other specialties and it seems like psychiatry can be a luxury in terms of how many different settings/types of work you can do. Inpatient, outpatient, C/L, ED are the basics, but there are also things like forensic work, working at a school (child psych), working with a college/university, etc. Also many subspecialties within psych that you can pursue. As others have said, if you enjoy this work and find it meaningful, I can't think another specialty/job that offers the flexibility and diversity that psychiatry does.

 

[psyguru]

I work part-time in the following settings: private forensic expert witness practice, psychiatric treatment at a neuro-rehab (outpatient; TBI, SCI, stroke), FQHC, med director of a telepsychiatry practice (I don't see patients there). Its good to have variety. I am really enjoying my private forensic work. Lots of variety that I won't see in a clinical setting.

 

[romanticscience]

All solo private practice here. Mostly clinical, offering combined therapy and meds, depending on the situation. I also do some consultation (expert witnessing/IMEs) work on the side.

I’m a simple guy who is OK working alone. I hated the medical training process but glad I stuck it out. Most of my med-school classmates would probably think my day-to-day is boring. However, I don’t think I could find a better combination of money, autonomy, cognitive novelty, and meaningful patient relationships.

 

[Matthew9Thirtyfive]

I work part-time in the following settings: private forensic expert witness practice, psychiatric treatment at a neuro-rehab (outpatient; TBI, SCI, stroke), FQHC, med director of a telepsychiatry practice (I don't see patients there). Its good to have variety. I am really enjoying my private forensic work. Lots of variety that I won't see in a clinical setting.

Did you do a forensics fellowship?

 

[psyguru]

Did you do a forensics fellowship?

Yes. However, I have seen psychiatrists do forensic work or basic IMEs without the fellowship. I don't believe they have the same level of cases I would such as Capital Mitigation/ Homicide, Multi-Plaintiff Multi-District, etc. Also, the fellowship probably may impact your fees. It allows me to do cases I may not have gotten without the fellowship. For example, many of the will-contests are done either by forensic psychiatrists (I happen to be BIM board-certified as weel and NCD is common in TBI) or geriatric psychiatrists. I have seen Addiction boarded psychiatrists do big-tobacco cases. So it is possible to develop a niche. As a forensic psychiatrist, I may not have some niche expertise in a certain relevant field (i.e. geriatrics) but I think my background is useful as the skills learned in an NGRI exam translate to other types of cases such as will contests. I strive for a large variety of cases and that has served me well as in fellowship you may not have the best variety. In many states, it is required to be forensic boarded for certain criminal evaluations or have the required CME. Anyhow, there is nothing stopping general psychiatrists from doing basic occupational IMEs. Some of them I would decline as they are capped at below 2k an IME or the rate is well below my rate. It is worth noting other specialists do IMEs and there is no other field without forensic training other than forensic pathology and forensic dentistry. Anyhow, if you did obtain another board-certification or some other way to demonstrate rare niche expertise (i.e. eating disorders), you could become a national expert. I have developed a nice niche with my BIM board-certification and experience working in a neuro-rehab. TBI is heavily litigated both in civil and felony criminal cases (particularly capital mitigation).