Psych attending considering Pain vs Anesthesia

[bobeanie95]

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Hi all,

I'm a new psych attending and have struggled with specialty choice all throughout residency. I consistently felt like I was missing procedures, physiology, anatomy, and the more concrete aspects of medicine. I was the intern that enjoyed IM more than inpatient psych and even enjoyed rapids, codes, etc. I waited until PGY-3 to see if outpatient psych would be a better fit based on what my psych attending recommended, but I still felt somewhat understimulated. At that point it made the most sense to finish residency rather than quit more than halfway through.

Now I'm in a relatively chill academic outpatient psych job (4 days/week, lunch breaks, very little/no call) and have plenty of hobbies/interests outside of medicine, but I'm still feeling somewhat unfulfilled by the actual work.

I enjoy patient relationships at times, but I think my biggest issue is that the interventions in psych are mostly medications/therapy. I'm getting trained in TMS, but even that has felt fairly hands-off. I've recently been shadowing in pain and have really enjoyed the MSK/neuro/ortho/anatomy/procedural aspects.

I'm now considering either whether to apply for pain fellowship or repeating residency in anesthesia through a reserved position. I'd be ~34 when starting retraining. Obviously there would a real opportunity cost in terms of missed income including compounding, being an intern again and going back to having call.

For anyone who's practiced in pain/anesthesia or made a major specialty retraining: does this sound like a legitimate specialty mismatch, or am I just romanticizing other fields because I'm bored with psych? Would you personally spend 3 years retraining in anesthesia if you already had a psych residency and could potentially enter pain directly?

Any perspectives and feedback are appreciated!

 

[aneftp]

Psych docs inherently at lazy to start with (sorry not to sugar coat)

Rarely do psych docs go to anesthesia

It’s usually the other way around where anesthesia docs can’t handle the stress pace of surgery that they escape to do psych.

Let’s not sugar coat it. It’s about the Benjamin’s. I hate it when people don’t come out and just say it. Show me the money. And anesthesia is where the money is.

At the end of the day. Do what’s best for you. If you want more cash. Go into anesthesia. Most of my psych friends are all hitting 600k-700k doing very little work.

So why would you switch back into anesthesia if u are making 600-700k no calls no weekends??

 

[bobeanie95]

I don't really understand the “lazy” characterization. I'm considering voluntarily repeating several years of residency after already completing one because I feel like I'm missing the procedural/physiologic side of medicine. Whatever you think of the decision, I don't think that’s particularly consistent with being unwilling to work hard.

Money also isn't my primary motivation. I already have a comfortable job. If maximizing income were the goal, I wouldn't be considering giving up several years of attending income for more training.

I'm mainly trying to figure out whether I'd be more fulfilled doing more procedural/physiologic medicine and if it would be a better fit for me long term.

 

[aneftp]

I don't really understand the “lazy” characterization. I'm considering voluntarily repeating several years of residency after already completing one because I feel like I'm missing the procedural/physiologic side of medicine. Whatever you think of the decision, I don't think that’s particularly consistent with being unwilling to work hard.

Money also isn't my primary motivation. I already have a comfortable job. If maximizing income were the goal, I wouldn't be considering giving up several years of attending income for more training.

I'm mainly trying to figure out whether I'd be more fulfilled doing more procedural/physiologic medicine and if it would be a better fit for me long term.

Markets can change quickly. Would u be happy working q4/5 overnight call solo for 350k in the future with 6-8 weeks off?

Thats what the market was 2012-2020 in most parts of the country.

 

[narcotics999]

Markets can change quickly. Would u be happy working q4/5 overnight call solo for 350k in the future with 6-8 weeks off?

Thats what the market was 2012-2020 in most parts of the country.

This is not going to happen. Otherwise I will just retire. Anesthesiologists shortage again.

 

[dannyboy1]

Psych docs inherently at lazy to start with (sorry not to sugar coat)

Rarely do psych docs go to anesthesia

It’s usually the other way around where anesthesia docs can’t handle the stress pace of surgery that they escape to do psych.

Let’s not sugar coat it. It’s about the Benjamin’s. I hate it when people don’t come out and just say it. Show me the money. And anesthesia is where the money is.

At the end of the day. Do what’s best for you. If you want more cash. Go into anesthesia. Most of my psych friends are all hitting 600k-700k doing very little work.

So why would you switch back into anesthesia if u are making 600-700k no calls no weekends??

Why you hating on the lazy docs? I’m lazy. That’s why I went into anesthesia. It is truly the specialty that works the least.

 

[aneftp]

This is not going to happen. Otherwise I will just retire. Anesthesiologists shortage again.

Markets change. It’s unpredictable. So never say it can’t happen again.

More AAs are graduating. More SRNA are graduating. Contrary to common thinking. Older docs aren’t retiring even in this red hot stock market. Most are still gonna to work into their 60s.

We have had two cycles 1995-2000 and 2012-2020 with anesthesia salaries not keeping up with inflation

 

[aneftp]

Like I said. I have never seen a psych background go back into anesthesia residency. Never

OP would be the first ever case. (That I know of). If you got a spot waiting for you in anesthesia . Go for it.

 

[cittykat]

One of my coresidents switched to psych after CA-1 year. He was a much better than average anesthesia resident who was well liked in our department. He has a thriving child psych practice in western NY (his hometown) now. Does tons of neuropsych evals and makes much more than most anesthesiologists. His reason for swapping was that he couldn’t imagine working in cold windowless rooms for the rest of his life. Something to consider.

 

[aneftp]

One of my coresidents switched to psych after CA-1 year. He was a much better than average anesthesia resident who was well liked in our department. He has a thriving child psych practice in western NY (his hometown) now. Does tons of neuropsych evals and makes much more than most anesthesiologists. His reason for swapping was that he couldn’t imagine working in cold windowless rooms for the rest of his life. Something to consider.

That’s what I’m saying. Lots of anesthesia residents have switched into psych during my lifetime.

I just never see it the other way around.

 

[victor le cube]

We had a resident switch to psych half way through CA-1 year after falling asleep in the OR on more than one occasion (the attending walked in and they were passed out at 3am on a busy call day). It can be exhausting in a work horse program but attending life is a bit better overall, though with much more call than residency (for me at least)

 

[aneftp]

We had a resident switch to psych half way through CA-1 year after falling asleep in the OR on more than one occasion (the attending walked in and they were passed out at 3am on a busy call day). It can be exhausting in a work horse program but attending life is a bit better overall, though with much more call than residency (for me at least)

Again another example of anesthesia to pain!

I have yet to see an example of psych to anesthesia! Can’t say it hasn’t happened. But it’s rare

 

[UscGhost]

We had a resident switch to psych half way through CA-1 year after falling asleep in the OR on more than one occasion (the attending walked in and they were passed out at 3am on a busy call day). It can be exhausting in a work horse program but attending life is a bit better overall, though with much more call than residency (for me at least)

Attending life is vastly better.

10x the pay for 1/2 the hours

 

[Hoya11]

Hi all,

I'm a new psych attending and have struggled with specialty choice all throughout residency. I consistently felt like I was missing procedures, physiology, anatomy, and the more concrete aspects of medicine. I was the intern that enjoyed IM more than inpatient psych and even enjoyed rapids, codes, etc. I waited until PGY-3 to see if outpatient psych would be a better fit based on what my psych attending recommended, but I still felt somewhat understimulated. At that point it made the most sense to finish residency rather than quit more than halfway through.

Now I'm in a relatively chill academic outpatient psych job (4 days/week, lunch breaks, very little/no call) and have plenty of hobbies/interests outside of medicine, but I'm still feeling somewhat unfulfilled by the actual work.

I enjoy patient relationships at times, but I think my biggest issue is that the interventions in psych are mostly medications/therapy. I'm getting trained in TMS, but even that has felt fairly hands-off. I've recently been shadowing in pain and have really enjoyed the MSK/neuro/ortho/anatomy/procedural aspects.

I'm now considering either whether to apply for pain fellowship or repeating residency in anesthesia through a reserved position. I'd be ~34 when starting retraining. Obviously there would a real opportunity cost in terms of missed income including compounding, being an intern again and going back to having call.

For anyone who's practiced in pain/anesthesia or made a major specialty retraining: does this sound like a legitimate specialty mismatch, or am I just romanticizing other fields because I'm bored with psych? Would you personally spend 3 years retraining in anesthesia if you already had a psych residency and could potentially enter pain directly?

Any perspectives and feedback are appreciated!

maybe 2 more years at an IM program

the jump to anesthesia, as others are not so eloquently trying to relay, is a vast vast clinical learning curve

from my medicine year (which i also enjoyed) to anesthesia was a shock to me, for 6 months i wanted to go back to IM

im not sure at 34 that shock would be something i would have motivation to overcome

i think you would find what you are seeking in IM by taking some hospitalists shifts

i had psych residents in my pain fellowship class, upon leaving, their practice of pain management was not apples to apples compared to mine

they were focused more on medication management, addiction, much less so on injections and interventions, so its not like that is an instant path to more hands on clinical time for you, its just a switch of patient populations to the psychology of back pain suffering vs the typical psych practice of depression/anxiety/mood disorder management.

personally i would stick with psych, get a cushy job and do therapy on the side, no weekends, no crazy clinical stuff happening, this need to save lives/be clinical badass will pass and is kind of an immaturity thing that many young physicians including myself went through. you are doing enough as a psych doc

 

[Hot_Sauce]

I think its reasonable to consider gas if that's where your heart lies, and more than reasonable to try for a pain fellowship. I love pain coming from a non-anes/PMR specialty; it is rewarding procedurally, anatomically, and the ability to use your hands. To all the naysayers saying you won't practice, well that depends on you. If you feel rusty, take it on yourself to go to more cadaver workshops and trainings. Looking back, I got the best of all worlds, ability to practice my cognitive specialty a couple days per week (which I do), and practicing pain a couple days per week. I'm a new grad and plan to move to 90%+ pain in due time.

 

[sloh]

One of my coresidents switched to psych after CA-1 year. He was a much better than average anesthesia resident who was well liked in our department. He has a thriving child psych practice in western NY (his hometown) now. Does tons of neuropsych evals and makes much more than most anesthesiologists. His reason for swapping was that he couldn’t imagine working in cold windowless rooms for the rest of his life. Something to consider.

Child psych for cash in a high-cost-of-living location where the worried-well rich families can blow money is the 3D chess move for psych right now. It used to be inpatient psych, but now it's child psych, cash pay.

 

[aneftp]

Child psych for cash in a high-cost-of-living location where the worried-well rich families can blow money is the 3D chess move for psych right now. It used to be inpatient psych, but now it's child psych, cash pay.

50k child psych billing cause lawyers for a few of my friends going through divorce custody battles. It’s insane billing and it’s all BS doesn’t do jack to be honest

So you are right. Do Private child psych and make the cash.

All vodoo analysis child psych gives reports to the courts.

 

[Stumpyman]

Child psych for cash in a high-cost-of-living location where the worried-well rich families can blow money is the 3D chess move for psych right now. It used to be inpatient psych, but now it's child psych, cash pay.

But not every psychiatrist can do that. Takes a certain level of business acumen, marketing, style, and communication skills that are far from universal to all psychiatrists. There's something to be said about the ease and comfort of knowing you can be employed for a high salaried job, have decent job security, and not be massively overworked. Psych is moreso going the way of EM in terms of oversaturation, and while the concerns are there with anesthesia, the market is booming. In my opinion we will see more questions like this thread, if a market is squeezed enough, many people will just eat the lower salaries/more work for private equity in psych but I think more people will start to think about another residency or fellowship.

 

[sloh]

But not every psychiatrist can do that. Takes a certain level of business acumen, marketing, style, and communication skills that are far from universal to all psychiatrists. There's something to be said about the ease and comfort of knowing you can be employed for a high salaried job, have decent job security, and not be massively overworked. Psych is moreso going the way of EM in terms of oversaturation, and while the concerns are there with anesthesia, the market is booming. In my opinion we will see more questions like this thread, if a market is squeezed enough, many people will just eat the lower salaries/more work for private equity in psych but I think more people will start to think about another residency or fellowship.

I agree lot of psychiatrists don't have the business acumen, style, communication skills, etc., to start and run a profitable child psych practice. Plus, you have to do a fellowship for it as well. So, definitely not easy, but like you said, psych is getting saturated. The issue with new grads for psychiatry is that most of them don't feel that these employed jobs offer high enough pay, especially in desirable locations. This is one of the few more lucrative options for psychiatry as it continues to get squeezed.

 

[cittykat]

Child psych for cash in a high-cost-of-living location where the worried-well rich families can blow money is the 3D chess move for psych right now. It used to be inpatient psych, but now it's child psych, cash pay.

Yup. Pay $5-10k for a diagnosis and get your kid test accommodations and public school services for life. Because if you’re rich, you can’t possibly have a dumb kid. They must be smart but have a LD

Wealthy Students More Likely to Get Disability Accommodations, Study Finds

Section 504 plans are one of the most important sources of disability services in schools. Why are well-off families their biggest beneficiaries?

www.the74million.org

 

[bobeanie95]

Money really isn't the main goal, it’s an important factor though. I could easily scale my hours in psych to make more. Child psych can definitely be lucrative as well, but it doesnt solve the issue I’m facing.

The main question that I’m trying to address is whether I’d find the day to day work more engaging and rewarding if I have 30+ years of work ahead. What I struggle with in psych is that majority of the diagnostics, treatment and even the therapeutic effect (willingness to take or continue medications) is predominantly based on just the interview and the patient-doctor relationship. I don’t particularly dislike the relationships. It’s frustrstating to feel that majority of what I have to offer is the psychiatric interview.

I mainly miss having more objective data and imaging to make a diagnosis, hands on procedures/medications to treat a patient in the moment and feeling more immediate feedback on such an intervention, instead of waiting for weeks to see if a medication works. I think pain could be a good solution without starting over, but I wanted to consider both gas and pain.

 

[aneftp]

Money really isn't the main goal, it’s an important factor though. I could easily scale my hours in psych to make more. Child psych can definitely be lucrative as well, but it doesnt solve the issue I’m facing.

The main question that I’m trying to address is whether I’d find the day to day work more engaging and rewarding if I have 30+ years of work ahead. What I struggle with in psych is that majority of the diagnostics, treatment and even the therapeutic effect (willingness to take or continue medications) is predominantly based on just the interview and the patient-doctor relationship. I don’t particularly dislike the relationships. It’s frustrstating to feel that majority of what I have to offer is the psychiatric interview.

I mainly miss having more objective data and imaging to make a diagnosis, hands on procedures/medications to treat a patient in the moment and feeling more immediate feedback on such an intervention, instead of waiting for weeks to see if a medication works. I think pain could be a good solution without starting over, but I wanted to consider both gas and pain.

Do you see yourself waking up at 5-6am every day and being in the or by 630-645am most days?

Do you see yourself on calls and weekends?

Regardless you finished ur psych residency and I assume boarded already so have a fall back option.

So you can potentially will lose 3 years earning potential.

 

[Dantrolene FC]

I don’t have much to add. But I’ll say psych and anesthesia are polar opposites. And I doubt much, if any, of us ever seriously considered psych.

My psych attending in med school literally told me I should try and do a specialty that is more technical 😂

 

[cittykat]

Money really isn't the main goal, it’s an important factor though. I could easily scale my hours in psych to make more. Child psych can definitely be lucrative as well, but it doesnt solve the issue I’m facing.

The main question that I’m trying to address is whether I’d find the day to day work more engaging and rewarding if I have 30+ years of work ahead. What I struggle with in psych is that majority of the diagnostics, treatment and even the therapeutic effect (willingness to take or continue medications) is predominantly based on just the interview and the patient-doctor relationship. I don’t particularly dislike the relationships. It’s frustrstating to feel that majority of what I have to offer is the psychiatric interview.

I mainly miss having more objective data and imaging to make a diagnosis, hands on procedures/medications to treat a patient in the moment and feeling more immediate feedback on such an intervention, instead of waiting for weeks to see if a medication works. I think pain could be a good solution without starting over, but I wanted to consider both gas and pain.

What was your initial draw to psych? Did you consider more technical specialties in medical school? Do you have good hands? Looking at your post history it looks like you went to med school at Penn. That place has a great anesthesia department. Did you do any electives there?

 

[Stumpyman]

Money really isn't the main goal, it’s an important factor though. I could easily scale my hours in psych to make more. Child psych can definitely be lucrative as well, but it doesnt solve the issue I’m facing.

The main question that I’m trying to address is whether I’d find the day to day work more engaging and rewarding if I have 30+ years of work ahead. What I struggle with in psych is that majority of the diagnostics, treatment and even the therapeutic effect (willingness to take or continue medications) is predominantly based on just the interview and the patient-doctor relationship. I don’t particularly dislike the relationships. It’s frustrstating to feel that majority of what I have to offer is the psychiatric interview.

I mainly miss having more objective data and imaging to make a diagnosis, hands on procedures/medications to treat a patient in the moment and feeling more immediate feedback on such an intervention, instead of waiting for weeks to see if a medication works. I think pain could be a good solution without starting over, but I wanted to consider both gas and pain.

Honestly, you're going to have to think about this and come up with your own conclusion, as it seems to be more based on life values and fulfillment than objective measures such as pay and workload. As a psychiatrist feeling the squeeze in the market, I think the objective factors play a role but if you are making loads of money in a job you end up not being able to stand, then it's not worth the extra money. Personally, at this point in my career, I think of medicine as purely a job. I don't know how much extra fulfillment I'd get from another specialty, and I too am not very passionate about psychiatry anymore. But my values changed over time, I want financial freedom and to be with my family more. I do sometimes wish I entered a more in-demand specialty, but it can still work with psychiatry though the opportunities are dwindling.

 

[Ronin1]

If the procedure part is missing just apply directly to pain. You have a decent chance of matching with the current environment.

I would say that everything becomes repetitive after many years anesthesia and pain included.

Financially pain has a very high ceiling if that matters. And there are no nights and weekends. I have a very Cush life compared to a call taking anesthesiologist

 

[2buckchuck]

I wouldn’t try to switch. I think a lot of people struggle with meaning after they finish training and settle into a job. You have been delaying gratification for years, and now that you have “made it” the gratification isn’t what you thought it would be. I think the solution is a little soul searching and un-brainwashing from medical training.

 

[passiveobserver1979]

Honestly, you're going to have to think about this and come up with your own conclusion, as it seems to be more based on life values and fulfillment than objective measures such as pay and workload. As a psychiatrist feeling the squeeze in the market, I think the objective factors play a role but if you are making loads of money in a job you end up not being able to stand, then it's not worth the extra money. Personally, at this point in my career, I think of medicine as purely a job. I don't know how much extra fulfillment I'd get from another specialty, and I too am not very passionate about psychiatry anymore. But my values changed over time, I want financial freedom and to be with my family more. I do sometimes wish I entered a more in-demand specialty, but it can still work with psychiatry though the opportunities are dwindling.

I thought psych was hot right now. What happened ? NPs ?

 

[aneftp]

If the procedure part is missing just apply directly to pain. You have a decent chance of matching with the current environment.

I would say that everything becomes repetitive after many years anesthesia and pain included.

Financially pain has a very high ceiling if that matters. And there are no nights and weekends. I have a very Cush life compared to a call taking anesthesiologist

Pain is not lucrative these days. It’s all about the rvu in pain.

So many different pain hospitals based contracts some base $425k plus rvu after say 15k rvu at $60/rvu so if you do 20k rvu.
That’s $450k plus (5000 rvu (first 15k is the base) $5000 x $60/rvu ($300k)

You gross comes out to $750k only for pain. Not great

Some private places before buy in is strict $32/rvu. So even if you generate 20k rvu. That comes out to only $640k! Horrible

Now if they let you buy in. It’s $60/rvu x 20k after buy in. So 1.2 million sounds better.

So many different pain contracts.

 

[Stumpyman]

Pain is not lucrative these days. It’s all about the rvu in pain.

So many different pain hospitals based contracts some base $425k plus rvu after say 15k rvu at $60/rvu so if you do 20k rvu.
That’s $450k plus (5000 rvu (first 15k is the base) $5000 x $60/rvu ($300k)

You gross comes out to $750k only for pain. Not great

Some private places before buy in is strict $32/rvu. So even if you generate 20k rvu. That comes out to only $640k! Horrible

Now if they let you buy in. It’s $60/rvu x 20k after buy in. So 1.2 million sounds better.

So many different pain contracts.

That's so much better than your average psych contract. And a pain fellowship is one year, easier to get into from psychiatry. Anesthesia residency is already competitive, it's hard to make the case that a psychiatrist purely loves procedures and was meant to be an anesthesiologist. Having to complete a 4 year residency after already being an attending in psych sounds like torture, but a 200+K pay bump for a one yr fellowship doesn't sound bad.

 

[Stumpyman]

I thought psych was hot right now. What happened ? NPs ?

That was the narrative for a few years but private equity has been taking over, coupled with too many new shoddy residency programs churning out grads rapidly. NPs too, they outnumber is and have grown exponentially faster than any other specialty. EM is very similar. Psych is too "easy" to open a new residency program with or become an NP under. I can still get a job anywhere though, just the offers aren't enticing unless it's an undesirable location, and the salaries + workload are much more unfavorable than in the past.

 

[cittykat]

That was the narrative for a few years but private equity has been taking over, coupled with too many new shoddy residency programs churning out grads rapidly. NPs too, they outnumber is and have grown exponentially faster than any other specialty. EM is very similar. Psych is too "easy" to open a new residency program with or become an NP under. I can still get a job anywhere though, just the offers aren't enticing unless it's an undesirable location, and the salaries + workload are much more unfavorable than in the past.

Private equity, shoddy new programs and an influx of midlevels? Sounds familiar. Anesthesia is not neurosurgery, ortho, cardiology, or even radiation oncology.

 

[slowthai]

But not every psychiatrist can do that. Takes a certain level of business acumen, marketing, style, and communication skills that are far from universal to all psychiatrists. There's something to be said about the ease and comfort of knowing you can be employed for a high salaried job, have decent job security, and not be massively overworked. Psych is moreso going the way of EM in terms of oversaturation, and while the concerns are there with anesthesia, the market is booming. In my opinion we will see more questions like this thread, if a market is squeezed enough, many people will just eat the lower salaries/more work for private equity in psych but I think more people will start to think about another residency or fellowship.

Current psych resident here that's been thinking extremely hard about switching to DR. If someone offered me a spot I could see myself taking it, honestly. I truly love psychiatry, but the swift erosion of our leverage is something that I can't countenance.

 

[abolt18]

Do you see yourself waking up at 5-6am every day and being in the or by 630-645am most days?

Do you see yourself on calls and weekends?

Regardless you finished ur psych residency and I assume boarded already so have a fall back option.

So you can potentially will lose 3 years earning potential.

I wake up at 0615-0630 and walk into the hospital at 0655 every then pre-op at 0700. Go set out ETT or LMA and open a syringe or two. Even draw up drugs if I'm feeling crazy. Then I go to the lounge. Nurses call me when they're in the OR with the patient around 0715-0730, I walk in, nurses already put monitors and sometimes are even pre oxygenating.

Now calls and weekends? Woof. Nature of the beast.

 

[aneftp]

I wake up at 0615-0630 and walk into the hospital at 0655 every then pre-op at 0700. Go set out ETT or LMA and open a syringe or two. Even draw up drugs if I'm feeling crazy. Then I go to the lounge. Nurses call me when they're in the OR with the patient around 0715-0730, I walk in, nurses already put monitors and sometimes are even pre oxygenating.

Now calls and weekends? Woof. Nature of the beast.

Well either you live in a smaller town or downtown area of big city. Very few docs here live less than 10 min away. And certainly most docs take 30 min to shower and start driving in.

some of our ORs start at 7am (a few rooms) so we usually there by 640am.
The surgery center starts in room time at 6am so that’s even worst.

 

[cittykat]

The surgery center starts in room time at 6am so that’s even worst.

That’s a no

 

[sloh]

Well either you live in a smaller town or downtown area of big city. Very few docs here live less than 10 min away. And certainly most docs take 30 min to shower and start driving in.

some of our ORs start at 7am (a few rooms) so we usually there by 640am.
The surgery center starts in room time at 6am so that’s even worst.

Yeah, my wife wakes up between 4:30 and 5:00 am. About a 30- to 45-minute commute to work for her. We live in Southern California, a really nice suburb.

 

[sloh]

Private equity, shoddy new programs and an influx of midlevels? Sounds familiar. Anesthesia is not neurosurgery, ortho, cardiology, or even radiation oncology.

I would not put radiation oncology in the same category as neurosurgery, ortho, or cardiology. The radiation oncology job market is quite terrible.

 

[sloh]

Honestly, you're going to have to think about this and come up with your own conclusion, as it seems to be more based on life values and fulfillment than objective measures such as pay and workload. As a psychiatrist feeling the squeeze in the market, I think the objective factors play a role but if you are making loads of money in a job you end up not being able to stand, then it's not worth the extra money. Personally, at this point in my career, I think of medicine as purely a job. I don't know how much extra fulfillment I'd get from another specialty, and I too am not very passionate about psychiatry anymore. But my values changed over time, I want financial freedom and to be with my family more. I do sometimes wish I entered a more in-demand specialty, but it can still work with psychiatry though the opportunities are dwindling.

It's also important to distinguish between a job someone can't tolerate and a job someone can tolerate (although they don't enjoy it very much) but pays very well and has good work-life balance.

job A: work enjoyment 10/10, income 300-400k

Job b: work enjoyment 5-7/10, income 600-800k

I'll take job b

 

[sloh]

Do you see yourself waking up at 5-6am every day and being in the or by 630-645am most days?

Do you see yourself on calls and weekends?

Regardless you finished ur psych residency and I assume boarded already so have a fall back option.

So you can potentially will lose 3 years earning potential.

Yeah, I think a lot of people underestimate the downsides of having to wake up at 5-6 am every day. My wife has really gotten into lifting weights and resistance training, and she wishes she could get a workout in before work.

 

[sloh]

Pain is not lucrative these days. It’s all about the rvu in pain.

So many different pain hospitals based contracts some base $425k plus rvu after say 15k rvu at $60/rvu so if you do 20k rvu.
That’s $450k plus (5000 rvu (first 15k is the base) $5000 x $60/rvu ($300k)

You gross comes out to $750k only for pain. Not great

Some private places before buy in is strict $32/rvu. So even if you generate 20k rvu. That comes out to only $640k! Horrible

Now if they let you buy in. It’s $60/rvu x 20k after buy in. So 1.2 million sounds better.

So many different pain contracts.

I'll say even those gigs you list above that you say are horrible are considered good in Southern California based off the recent grads I've been talking to, lol. I mean, not even recent grads, just grads in the past 5 to 10 years.

 

[cchoukal]

Well either you live in a smaller town or downtown area of big city. Very few docs here live less than 10 min away. And certainly most docs take 30 min to shower and start driving in.

some of our ORs start at 7am (a few rooms) so we usually there by 640am.
The surgery center starts in room time at 6am so that’s even worst.

Seriously, WTF wants to be operating at 0600? If they're crazy enough to do 0600 start times, I'm going to assume there's a bunch of other stupid decisions they're also making. There's a dollar figure that would make me do it, for sure, but it's very high. There's just too much work out there to say yes to venues with such backward values.

 

[Hot_Sauce]

Money really isn't the main goal, it’s an important factor though. I could easily scale my hours in psych to make more. Child psych can definitely be lucrative as well, but it doesnt solve the issue I’m facing.

The main question that I’m trying to address is whether I’d find the day to day work more engaging and rewarding if I have 30+ years of work ahead. What I struggle with in psych is that majority of the diagnostics, treatment and even the therapeutic effect (willingness to take or continue medications) is predominantly based on just the interview and the patient-doctor relationship. I don’t particularly dislike the relationships. It’s frustrstating to feel that majority of what I have to offer is the psychiatric interview.

I mainly miss having more objective data and imaging to make a diagnosis, hands on procedures/medications to treat a patient in the moment and feeling more immediate feedback on such an intervention, instead of waiting for weeks to see if a medication works. I think pain could be a good solution without starting over, but I wanted to consider both gas and pain.

I don’t have much to add. But I’ll say psych and anesthesia are polar opposites. And I doubt much, if any, of us ever seriously considered psych.

My psych attending in med school literally told me I should try and do a specialty that is more technical 😂

That's so much better than your average psych contract. And a pain fellowship is one year, easier to get into from psychiatry. Anesthesia residency is already competitive, it's hard to make the case that a psychiatrist purely loves procedures and was meant to be an anesthesiologist. Having to complete a 4 year residency after already being an attending in psych sounds like torture, but a 200+K pay bump for a one yr fellowship doesn't sound bad.

Doing a pain fellowship does not guarantee you will be able to get a pain job. Many hiring practices/systems only want Anes, several only want PMR for EMGs (and frankly bc they can pay PMR less); several hospital committees have by-laws that state only Anes/PMR/Neuro can take those jobs -- not even EM or DR, let alone psych. Obviously if you hustle and are willing to take ****ty jobs for a couple years and grind and show procedural acumen and your billing numbers, then that could change. But then youre not looking at a 1 year fellowship youre looking at several years of grinding to "prove" yourself.

I was between psych and anesthesia in med school, and in my case most of the gas attendings told me to do psych for a much easier life where I could enjoy patient interactions and relationships meaningfully and be home for dinner everyday.

In terms of practicing pain, I don't think its *that* much better than psychiatry. Physical exams are highly dependent on the performer and the specific day you're seeing the patient. You need a cluster of several exam findings to even have a decent sensitivity/specificity, and if you're going to be doing comprehensive by-the-book exams on every patient to get truly objective data then you will not have a job because that will take an hour per patient assuming they are your usual "neck and back pain" that radiates everywhere. Similarly, imaging at times is very useful and at other times is meaningless noise. It's up to the doctor to put it into context and sell the diagnosis to the patient based on your subjective interpretation of objective findings (very similar to psych). Many practices also refer to rads groups and neuro/pmr groups where they 'over read' and every MRI seems like a war zone and every EMG miraculously has cervical and lumbar radic. Like psych, most pain never goes away and often comes back and gets worse. Honestly, it's really not that different except for the procedural part which can definitely be gratifying; the caveat being that we are paid by procedural numbers so have an incentive to do them and we all know that our bread and butter procedures are salves not solutions. Yeah I can do epidurals for years on somebody and it helps them day-to-day but you're also puncturing their dura many times for unclear/negligible long term benefit, introducing systemic effects of long term steroids, and taking a risk of a bad outcome each time you do it.

For the OP, if you are trying to find a 'third way' by doing Pain, do some shadowing and rotations to see if its really worth it for you. And remember, you can be the most advanced procedural guy in the room doing MILDs and kyphos and BVNAs and SCS, ITDD.... but you will have to work for many years after fellowship to get there as most likely scenario.

 

[cittykat]

I would not put radiation oncology in the same category as neurosurgery, ortho, or cardiology. The radiation oncology job market is quite terrible.

Guess I’m basing that on my n=1. My own doctor who is 20 years younger than me and who I’ve known since he was an intern at the hospital where I practice. He is 7 years out and has a great job money/lifestyle/location.

 

[Stumpyman]

Current psych resident here that's been thinking extremely hard about switching to DR. If someone offered me a spot I could see myself taking it, honestly. I truly love psychiatry, but the swift erosion of our leverage is something that I can't countenance.

Yeah it's really a matter of what your values are and what you want out of life. Sloh had a good example about two job offers. When I was in residency I didn't have a family and didn't really worry about financial independence as I just thought "all doctors make good money." If you really love psych more than anything you can still make it work, it would take being very flexible with location and grinding straight out of residency. I don't mean to be a doomer, the signs just aren't hopeful (and I hope I am wrong but I don't see how anyone can refute the objective numbers of new NPs + residencies).

It was mentioned that anesthesia also has the same problems such as private equity, NPs/CRNAs, and loads of new residencies. I agree those are concerns but from the outside looking in, have they materially impacted the anesthesia job market? I have several anesthesia friends who are quite literally swimming in outstanding job offers. My guess is that anesthesia makes way more money for hospitals than does psych, so the demand is inherently huge. Also, my understanding is that it takes a lot more to train an anesthesiologist than it does a psychiatrist. Not saying you make a "good" psychiatrist this way but if you look up the requirements to open a psych residency, practically any half functioning hospital can do it (and are financially incentivized to do so). With anesthesia, you have procedures and more checks and balances, requiring multiple teaching attendings from different surgical specialties.

 

[abolt18]

Well either you live in a smaller town or downtown area of big city. Very few docs here live less than 10 min away. And certainly most docs take 30 min to shower and start driving in.

some of our ORs start at 7am (a few rooms) so we usually there by 640am.
The surgery center starts in room time at 6am so that’s even worst.

Population almost 300K, metro population just under 500k. I do live 10 minutes away but I hate commuting so choosing to live close was very intentional. And luckily the hospital is on the edge of the city rather than the center.

There is a zero percent chance of me coming in to start a case at 0600 unless someone is paying me a LOT of money for that early morning start.

 

[Ronin1]

Pain is not lucrative these days. It’s all about the rvu in pain.

So many different pain hospitals based contracts some base $425k plus rvu after say 15k rvu at $60/rvu so if you do 20k rvu.
That’s $450k plus (5000 rvu (first 15k is the base) $5000 x $60/rvu ($300k)

You gross comes out to $750k only for pain. Not great

Some private places before buy in is strict $32/rvu. So even if you generate 20k rvu. That comes out to only $640k! Horrible

Now if they let you buy in. It’s $60/rvu x 20k after buy in. So 1.2 million sounds better.

So many different pain contracts.

Obviously it all depends on the details. Anesthesia included. Pain is pretty lucrative imo. I work about 30 hours a week for 850k this year. W2 money but still pretty good

 

[aneftp]

Population almost 300K, metro population just under 500k. I do live 10 minutes away but I hate commuting so choosing to live close was very intentional. And luckily the hospital is on the edge of the city rather than the center.

There is a zero percent chance of me coming in to start a case at 0600 unless someone is paying me a LOT of money for that early morning start.

I’m getting paid A LOT of money to come in at 530am. And it’s not $500/hr. It’s much more. So I’m sure ur chance of coming in at 530 is more than zero percent when that hourly pay is close to $1000/hr.

I’m not gonna to roll out of bed unless I get what I wanted. Some sucker MD is working at the ortho center for $500/hr. He’s desperate for cash I guess.

 

[aneftp]

Obviously it all depends on the details. Anesthesia included. Pain is pretty lucrative imo. I work about 30 hours a week for 850k this year. W2 money but still pretty good

Correct most pain docs I know work 4 days a week. Like I said 750k is the usual pay. So 850k is within limits.

But the issue is how do you get to 1.5 million working 4 days a week. That’s where real money for the work comes into play.

 

[Ronin1]

Correct most pain docs I know work 4 days a week. Like I said 750k is the usual pay. So 850k is within limits.

But the issue is how do you get to 1.5 million working 4 days a week. That’s where real money for the work comes into play.

It takes ownership to crush it in pain.

I don’t need that much money so it’s not worth it to

But the reality most anesthesia docs don’t make 850 or anywhere near that including nights and weekends other than SDN ballers