Psych backup plan: Family Med to Addiction Med?

[Questionarius]

Ok, so let's say I don't match into psych this cycle. Would it be feasible for me to match into family medicine, do a fellowship in addiction medicine, and essentially do the same thing as an addiction psychiatrist after fellowship? Does this sound reasonable? Is the practice of an addiction medicine specialist essentially the same as that of an addiction psychiatrist?

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[WisNeuro]

Limited experience here, I've worked with 3 family med to addiction people, so my n here is fairly low and limited to one healthcare system. But, I haven't been impressed much at all with their knowledge and treatment planning when it comes to the psych side of things. Some of the diagnostic knowledge was shockingly inadequate, and I've had some weird questions asked of me. Such as if I would addend my report to say that the patient had ADHD to justify stims, with the provider's argument that the patient's PTSD had successfully masked her ADHD in childhood.

Not sure if this is others' experience, but I'm a little wary of this specialty given my limited knowledge.

 

[VA Hopeful Dr]

Limited experience here, I've worked with 3 family med to addiction people, so my n here is fairly low and limited to one healthcare system. But, I haven't been impressed much at all with their knowledge and treatment planning when it comes to the psych side of things. Some of the diagnostic knowledge was shockingly inadequate, and I've had some weird questions asked of me. Such as if I would addend my report to say that the patient had ADHD to justify stims, with the provider's argument that the patient's PTSD had successfully masked her ADHD in childhood.

Not sure if this is others' experience, but I'm a little wary of this specialty given my limited knowledge.

As an FP I would mostly agree with this.

My experience has been that the addiction med part is more about treating the medical part (how to dose Suboxone, treating various other withdrawal symptoms, stuff like that). There is some psych there but we don't have the foundation of general psych training for that to build upon.

 

[WisNeuro]

My experience has been that the addiction med part is more about treating the medical part (how to dose Suboxone, treating various other withdrawal symptoms, stuff like that). There is some psych there but we don't have the foundation of general psych training for that to build upon.

So, it's possible that these people were practicing a little out of their scope? They were definitely managing psychiatric meds along with suboxone.

 

[VA Hopeful Dr]

So, it's possible that these people were practicing a little out of their scope? They were definitely managing psychiatric meds along with suboxone.

Hardly. I'm a bread and butter FP and I prescribe psych meds frequently.

We get almost no training in non-pharmacologic management of psychiatric pathology though. So any Axis 2 disorders along with the substance abuse are going to be better served by someone with more psych training either in conjunction with the addiction med person or in place of.

 

[OldPsychDoc]

So based on the replies so far, one should consider it feasible, though not necessarily desirable.
Nevertheless--you'll be a doc with a job, not an unmatched medical student.

 

[WisNeuro]

Hardly. I'm a bread and butter FP and I prescribe psych meds frequently.

We get almost no training in non-pharmacologic management of psychiatric pathology though. So any Axis 2 disorders along with the substance abuse are going to be better served by someone with more psych training either in conjunction with the addiction med person or in place of.

I guess I should have clarified. My wife is also FP and commonly many of her patients with things such as longstanding depression and the like. But, for more severe, longstanding issues, such as Bipolar with history of hospitalizations in manic episodes, or certain psychotic disorders, she'll refer out to psychiatry for management. With the caveat of someone who has been stable on a medication regimen for a good amount of time. I was more referring to the issue of the family to addictions people being the sole prescriber for fairly complex psych stuff (Bipolar with non compliance, raging Cluster B, etc). That's more where I saw the lack of psych background having a discernible impact.

 

[VA Hopeful Dr]

I guess I should have clarified. My wife is also FP and commonly many of her patients with things such as longstanding depression and the like. But, for more severe, longstanding issues, such as Bipolar with history of hospitalizations in manic episodes, or certain psychotic disorders, she'll refer out to psychiatry for management. With the caveat of someone who has been stable on a medication regimen for a good amount of time. I was more referring to the issue of the family to addictions people being the sole prescriber for fairly complex psych stuff (Bipolar with non compliance, raging Cluster B, etc). That's more where I saw the lack of psych background having a discernible impact.

Ah. Yes, that's exactly how I practice as well and agree with your thoughts on the matter.

 

[whopper]

Addiction psychiatry, even if you become a great addiction physician, is only a very small segment of psychiatry that also includes psychotic, anxiety, OCD, and mood disorders.

So to think that if you master addiction medicine even the psychiatric aspects of it and equate it to addiction psychiatry is a leap.

An addiction psychiatrist also has a strong foundation in other disorders and should be expected to treat those disorders with competence even when they are severe. I wouldn't expect the same of an addiction trained FP physician despite that I'm sure dual diagnosis is part of the FP-addiction training. You could, however, be an exception but it'd have to be through training and experience outside of your field that will be very difficult to obtain without doing another residency.

Adding to the confusion you might work with a partner psychiatrist, who if not a very good one (and this is quite common) you might find yourself doing a better job than this other person which could add to your frustration if your interest in psychiatry is better than his or hers.

 

[psyguru]

Ok, so let's say I don't match into psych this cycle. Would it be feasible for me to match into family medicine, do a fellowship in addiction medicine, and essentially do the same thing as an addiction psychiatrist after fellowship? Does this sound reasonable? Is the practice of an addiction medicine specialist essentially the same as that of an addiction psychiatrist?

Other back up options
Neurology with fellowship in behavioral neurology/ neuropsychiatry...there maybe other possibilities like neurodevelopmental (idd)...some neuro subspecialties are under another board and not approved by abms.

Pmr or neuro with brain injury medicine

Family with fellowship in mental health...I think there are some 2 year fellowships in it...probably more out patient based

Of course addictions is good

Just remember none of the above options will probably not give you much exposure to inpatient psych. You will not get the full spectrum of exposure. (I got much broader exposure as I transferred after intern year and also did a forensics fellowship). Your attendings may have less in depth psych knowledge than a pgy4.

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[dl2dp2]

This is an interesting question, esp. since demand is such that addictionologists as a facility job is now paying FM+AM more than any regular FM job. Psych jobs pay even more, mostly because of the add on codes.

My opinion is that Psych is a better specialty than FM+AM, but it's not competitive enough to dually apply. The reason that psych jobs pay more is that these jobs are only open to people with psych board. It has little to do with day to day practice/content, which is one and the same. I would avoid that strategy and focus on psych. Facilities prefer a addiction psych not because they are better at addiction medicine necessarily, but because they are better to plug a hole in the psych needs if such a need arise, which is very often. OTOH, FM needs are not nearly as acute. Also, substance issues just come up way more in a general psych clinic than a general medicine clinic (except in the hot spots). It's much easier to set up a system where you deal with the former, and hence it drives practice growth/referral faster.