Psych vs. EM?

[Bluecheese]

Hi, I am a medical student considering both EM and Psych. Apart from working in, and researching, the fields more, I was hoping the psychiatrists could fill me in on some questions.

1) How much of your work is psycotherapy vs. medication management?
2) Was there anything about the psychiatry that you wish you knew before entering?
3) What do you see as the biggest upsides, and downsides, of the psychiatry?
5) EM and psychiatry appear almost opposite to me (although I think I am multifaceted and will enjoy different fields). One of the things that drew me toward EM initially was that it involves interventions that often give tangible results. Is it easy to perceive the effect you have on your patients? How much satisfaction do you take in your work? I've heard that some find the psychiatry emotionally draining--has that been your experience?
6) How common is it to give patients your personal phone number to call night or day in case of emergency?
7) Do you use telepsychiatry in your practice? How prevalent is telepsychiatry? Can one do telemedicine from abroad? Do you see any problems with telepsychiatry now, and how do you see telepsychiatry changing in the future?

A big thank you!

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[dl2dp2]

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[MacDonaldTriad]

1. How much of your work is psycotherapy vs. medication management?
   You can find psychiatrists who do 99% therapy and almost no med management and some who are 1% vs 99%. If you are worth your salt, it is impossible to do psychiatry without any psychotherapy even if you claim you do not do therapy.
   
   2) Was there anything about the psychiatry that you wish you knew before entering?
   I think that more than any other field in medicine, no one has a clue about what they are getting into until they get into it. Medical school psych rotations are not very representative of the practice of psychiatry.
   
   3) What do you see as the biggest upsides, and downsides, of the psychiatry?
   Easy to get into, high demand, can get a job anywhere you want, don’t like your job, here is a different one. Downsides, ambiguous risk management and fairly bad PR/image issues.
   
   5) EM and psychiatry appear almost opposite to me (although I think I am multifaceted and will enjoy different fields). One of the things that drew me toward EM initially was that it involves interventions that often give tangible results. Is it easy to perceive the effect you have on your patients? How much satisfaction do you take in your work? I've heard that some find the psychiatry emotionally draining--has that been your experience?
   I have never practiced ER medicine, but the word on the street is major burn out. Psychiatry is many things, but seldom monotonous. It has been criticized as ineffectual and never “curing” anyone, but this isn’t true. Making people half better can improve their quality of life 90%, and mood disorders and anxiety disorders are often responsive to treatment. If you want to name fields with poor outcomes, try neurosurgery, oncology, or neurology.
   6) How common is it to give patients your personal phone number to call night or day in case of emergency?
   Personal phone number? Never.
   
   7) Do you use telepsychiatry in your practice? How prevalent is telepsychiatry? Can one do telemedicine from abroad? Do you see any problems with telepsychiatry now, and how do you see telepsychiatry changing in the future?
   Telepsychiatry is growing, but mostly in an effort to provide services to rural underserved areas. I don’t see our field being outsourced oversees to some Indian tech support operation. Patients want to have connection and be with their providers. Rarely, patient will call at their appointment time and say “I just don’t feel like driving to see you, can we just do this by phone”, but this is after they are doing well and have an established relationship. I really don’t think that any patients prefer the technology substitute if they are given a choice. I think you can do telepsychiatry from anywhere as long as you are licensed in the state in which you are sending your services, but I don’t know much about this. Do some rotations and you will figure this out. EM vs psych is like deciding where to live, Hawaii or Alaska both are good and bad and realistic options.

 

[Merovinge]

For the record, I worked in an ED for 2 years and really like the pacing of the ED. This makes me an odd ball compared to most psychiatrists but I love emergency psych, C/L psych, and anything fast paced with a time-limited engagement with patients. I would have taken extra nightfloat or call shifts if it got me out of other rotations .
1) How much of your work is psycotherapy vs. medication management?

- Whatever you want it to be in BOTH residency and practice. I do a lot of psychotherapy now, but some residency programs have this minimized (want the term Biologic emphasized if that is your thing)

2) Was there anything about the psychiatry that you wish you knew before entering?

- Surprisingly not much, I actually felt like 3-4 months I spent in med school was fairly representitive of what happens. Therapy I like more than expected. Residency programs can vary wildly though, so definitely do your research.

3) What do you see as the biggest upsides, and downsides, of the psychiatry?

Upsides - Time requirement is very reasonable compared to almost all areas of medicine, we work about the same number of hours as EM residents but less wonky hours and no butt abcesses! Schedule for your day can be almost anything you want from hectic to chill, complex to routine, therapy to meds, even individual apts, supervising residents, to groups. "Bread and butter" pts remain very interesting to me, no such thing as a boring case of schizophrenia, bipolar, or depression (to me at least).

Downsides - Minor social stigma depending on culture, slightly harder to moonlight than ED, prolly make a smidge less than ED but can be comparable. Very beholden to specific supervisors in residency compared to something like ED med where you vary attendings daily.

5) EM and psychiatry appear almost opposite to me (although I think I am multifaceted and will enjoy different fields). One of the things that drew me toward EM initially was that it involves interventions that often give tangible results. Is it easy to perceive the effect you have on your patients? How much satisfaction do you take in your work? I've heard that some find the psychiatry emotionally draining--has that been your experience?

- This is a big complaint from some but I really disagree this is the case in psych. We see dramatic improvement in the span of a few days/weeks depending on the condition and treatment. Others improve over the span of a months to year/2 years in therapy. ED youll see frequent flyiers all time and I find it rarely rewarding to jam someone up with opioids. Psych also offers you a real chance to be present with someone in their moment of severe suffering. It's often not the cure that gets me excited, it's the day-to-day of people knowing someone is listening to them about the hardest things in their life.

6) How common is it to give patients your personal phone number to call night or day in case of emergency?

- Please no. I do give pager info out but only to be paged from 8-5 M-F. I have had 1 psychotic pt break this pact so far in 2 years.

7) Do you use telepsychiatry in your practice? How prevalent is telepsychiatry? Can one do telemedicine from abroad? Do you see any problems with telepsychiatry now, and how do you see telepsychiatry changing in the future?

- This will likely be a thing, anything that can lower costs is somethingto keep on the radar, but telepsych will never replace the meaning associated with coming into the clinic and walking into the psychiatrist's office in my opinion.

 

[MacDonaldTriad]

we work about the same number of hours as EM residents but less wonky hours and no butt abcesses!

This is a huge upside to psychiatry most of us didn't appreciate.

An ER doc and a psychiatrist walk into a bar.

ER doc: How was your day?

Psychiatrist: OK I guess, I was supervising a resident and he insisted his bulimic borderline patient was just somaticizing, but I was worried so we sent her to the ER. How was your day?

ER doc: I was supervising a resident on a rectal abscess and he missed her history of laxative abuse.

Psychiatrist: We are talking about the same patient aren’t we?

ER doc: Yep, Good job playing real doctor.

Psychiatrist: Good job playing real psychiatrist.

 

[Leo Aquarius]

Hi, I am a medical student considering both EM and Psych. Apart from working in, and researching, the fields more, I was hoping the psychiatrists could fill me in on some questions.

1) How much of your work is psycotherapy vs. medication management?
2) Was there anything about the psychiatry that you wish you knew before entering?
3) What do you see as the biggest upsides, and downsides, of the psychiatry?
5) EM and psychiatry appear almost opposite to me (although I think I am multifaceted and will enjoy different fields). One of the things that drew me toward EM initially was that it involves interventions that often give tangible results. Is it easy to perceive the effect you have on your patients? How much satisfaction do you take in your work? I've heard that some find the psychiatry emotionally draining--has that been your experience?
6) How common is it to give patients your personal phone number to call night or day in case of emergency?
7) Do you use telepsychiatry in your practice? How prevalent is telepsychiatry? Can one do telemedicine from abroad? Do you see any problems with telepsychiatry now, and how do you see telepsychiatry changing in the future?

A big thank you!

1) They go hand in hand. Every patient of mine gets therapy and some form of medication management.

2) No. I knew enough from med school rotations.

3) Biggest plus of psychiatry = therapeutic bonds with patients and the appreciation you get from patients and their families.
Biggest downside = the general population not understanding and appreciating what psychiatry is and does

4) - you omitted -

5) Yes, EM has quick tangible results. But so does Psychiatry. You correct a delirious patient, or treat that agitated or psychotic patient and you REALLY see the difference (along with all the nursing staff and other doctors who think you've performed some miracle). Plus, while you do get tangible results all the time in EM, you rarely get an appreciative 'thank you' from patients. In Psych, you get appreciative patients on a more consistent basis.

6) Not common at all.

7) There are 2 big limitations to telepsychiatry having worked along side a pioneer in telepsychiatry in California. First, when there's an emergency you're screwed. You can't escort the patient to get help. Second, patients don't like it as much. They keep looking at the screen which is not looking into the camera so you can't make really good eye contact. It's harder to get a visceral sense of how your patient is feeling.

Good luck! They are both great careers for the right doctor.

 

[Roxas]

I think that more than any other field in medicine, no one has a clue about what they are getting into until they get into it. Medical school psych rotations are not very representative of the practice of psychiatry.

As a pre-clinical student interested in psych, what would be your recommendation in order to get the most representative psych experience?

 

[J ROD]

I actually had it narrowed down to those 2 as well. I chose Psychiatry because I have always liked the puzzle of how every patient is unique in their own way to some extent in Psychiatry. I found there was more variety. Regular hrs, etc.

The main thing that really attracted me to EM was the "excitement". Well, if you get in the right area in Psychiatry, there is more than enough excitement as well.

So, once I got a look at it all, the choice was very easy for me. I was never that big on doing procedures even though I am good at them. Also, I don't need to carry the hearing aid around......

 

[psych72]

I loved my EM rotation, but I honestly just hate the thought of suturing at 3 AM in the morning when I'm pushing 50. It seems so exhausting.

 

[MacDonaldTriad]

As a pre-clinical student interested in psych, what would be your recommendation in order to get the most representative psych experience?

The vast majority of psychiatrists do outpatient work. Medical school is organized into 6 week blocks in most places. This makes most psych rotations put you in lock inpatient services; consultation and lesion work, or psych ER settings. I’m not saying these settings are bad, just not representative of what the work is like. Building long term relationships and obtaining the trust required to effect change in lives isn’t well demonstrated in a six week block.

My university has been implementing longitudinal experiences that matrix on top of the block system. This was pushed by well-meaning ignorami who are seduced by the idea of allowing medical students to select a particular branch of medicine and have a half day a week seeing ambulatory patients in that field. This was wisely placed with the second disastrous push for centralized didactics so students are away from their block rotations one day out of five. As a result of all of this well thought out and innovative misguided brilliance is a medical school that is incapable of giving medical students anything close to primary responsibility for taking care of patients on their block rotations because one day a week, someone has to do that for them.

Oh, just so I can be a team player, other than the above points, this idea has been an attractive success that will continue to be bragged about and pointed to as a clear sign of educational progress.

 

[psych72]

The vast majority of psychiatrists do outpatient work. Medical school is organized into 6 week blocks in most places. This makes most psych rotations put you in lock inpatient services; consultation and lesion work, or psych ER settings. I’m not saying these settings are bad, just not representative of what the work is like. Building long term relationships and obtaining the trust required to effect change in lives isn’t well demonstrated in a six week block.

My university has been implementing longitudinal experiences that matrix on top of the block system. This was pushed by well-meaning ignorami who are seduced by the idea of allowing medical students to select a particular branch of medicine and have a half day a week seeing ambulatory patients in that field. This was wisely placed with the second disastrous push for centralized didactics so students are away from their block rotations one day out of five. As a result of all of this well thought out and innovative misguided brilliance is a medical school that is incapable of giving medical students anything close to primary responsibility for taking care of patients on their block rotations because one day a week, someone has to do that for them.

Oh, just so I can be a team player, other than the above points, this idea has been an attractive success that will continue to be bragged about and pointed to as a clear sign of educational progress. [/QUOTE

For me it was 2 times a month

Also, can a psychiatrist work at an urgent care for shifts? Assuming one likes the mystery of ER...I mean gp's get to do it all the time. Just for the allure of switching things up once in awhile

 

[smalltownpsych]

1) They go hand in hand. Every patient of mine gets therapy and some form of medication management.

I hope that part of your medication management includes not prescribing. Do you just refer those patients out then? Many of my patients (outpatient) don't get a medication referral.

For OP, I work with the EM docs when I'm on call and they deal with psych cases day in and day out, but tend to get pretty frustrated because most don't have the tools that we do and only see the negative side of mental illness and substance abuse. The nice thing about EM is that you will get a lot of exposure to psychiatric issues and can develop some of those skills. One of our EM docs loves to get pointers from me because she likes to talk to the people and help out with the psychological aspects of what her patients are struggling with. We even have a bit of friendly competition to see who can get the best information and traction with the patient. (Of course, I win most of the time, but she is probably better at my job than I would be at hers!). Most of the other docs just say, "Glad you are here so you can go talk to them."

 

[milesed]

I have to agree with most of what is already posted. I'll just say that if you go into EM, you will be doing psych.

 

[675015]

I have to agree with most of what is already posted. I'll just say that if you go into EM, you will be doing psych.

Not necessarily "doing psych." Though they will SEE psych patients. But there is much bad psychiatry practiced in the ED.

 

[OldPsychDoc]

 

[HappyKitten]

^^hah! I feel like cardiology should be closer to the right tho

 

[MLT2MT2DO]

^^hah! I feel like cardiology should be closer to the right tho

Not to mention pathology....or maybe they actually do love there jobs once they can find one

 

[Doctor Bagel]

Isn't EM a super high burnout specialty? Most that I've worked with have seemed pretty darn miserable. Shift work sounds nice but starts to suck as you age and don't want to work in the middle of the night.

Also, psychiatrists can do pure emergency psychiatry types of work, although you might need to be a bigger city to find it.

 

[Leo Aquarius]

I hope that part of your medication management includes not prescribing. Do you just refer those patients out then? Many of my patients (outpatient) don't get a medication referral.

Yes, it's strictly reviewing and managing any current medications. I try NOT to prescribe meds and always start at "can their problem be solved with therapy and lifestyle changes first."

 

[Leo Aquarius]

Isn't EM a super high burnout specialty? Most that I've worked with have seemed pretty darn miserable. Shift work sounds nice but starts to suck as you age and don't want to work in the middle of the night.

Also, psychiatrists can do pure emergency psychiatry types of work, although you might need to be a bigger city to find it.

I figured out pretty quickly in med school on my EM rotation that trusting somebody's life in my hands at 4am is a most unwise proposition.

 

[Thewonderer]

1) How much of your work is psychotherapy vs. medication management?
You always do some form of psychotherapy even when you do medication management. For example, if the patient is scared of certain medications, you explore their personal and family history and find out where that fear comes from. Say someone says, I know Celexa might work for me because as you correctly said, I share 50% of my gene with my mother who was on Celexa at one time but I refuse to take Celexa because I associate that with my mom being crazy and getting admitted to psych hospital for suicide attempts on multiple occasions! Then you respect that wish and move on to alternatives such as Prozac, Zoloft, etc. You always monitor yourself for counter-transferance even if you only prescribe meds so you can stay professional. Furthermore, if my patients are anxious about meds, I do start explaining why and what the meds are for and I might not end up writing a prescription at the end of that visit. I just put that as exposure therapy. The patients can agree to that med 1 or 2 or 3 visits later. But at least I have some exposure therapy done in that time span. So if you want to be a good psychopharmacologist, you have to be a good therapist too.

2) Was there anything about the psychiatry that you wish you knew before entering?
Nope. It is a fascinating field. The longer you practice, the more you know. I actually underestimated the power of medications during medical school and during residency. When the patient is on the right set of meds, you see vast, rapid improvements. It is amazing. I always cringe when some psychiatrists pretend to be therapists and say that "not everyone may benefit from meds but everyone can always benefit from therapy." It is a marketing tool to suck the patients into forever, once-a-week psychotherapy that last...well...forever. With the severity of the patients we see, pretty much all of them need meds. If they don't need meds, they probably would not have gotten into our doors.

3) What do you see as the biggest upsides, and downsides, of the psychiatry?

Biggest upsides: not a demanding life style (if you don't want it to be. Little to no calls), autonomy, seeing patients improve drastically.

Biggest downsides: the stigma (it is hard to overcome but well, so be it. I don't care too much), income is really not that high (seriously, anesthesiologists and all surgical subspecialties make a lot more. Spending time with patient does not pay. By doing a procedure for 5 minutes only, that pays a load). It is HARD to take vacation. I have very good, excellent colleagues who can cover for me while I go on vacation but my patients almost never utilize them when I am gone. It is tough to go on vacation just because of that.

I don't find the lack of objective diagnostic tools (such as MRI, CT or EEG, etc.) to be a downside because I find it fascinating to solve a puzzle and get collateral info. If psych has those objective diagnostic tools, then we become glorified car mechanics just like any other fields of medicine.

5) EM and psychiatry appear almost opposite to me (although I think I am multifaceted and will enjoy different fields). One of the things that drew me toward EM initially was that it involves interventions that often give tangible results. Is it easy to perceive the effect you have on your patients? How much satisfaction do you take in your work? I've heard that some find the psychiatry emotionally draining--has that been your experience?
Psychiatry involves quite drastic improvements if you get the meds right and there is a good therapeutic alliance. Emotionally draining should not happen if a) you keep your professional boundaries and b) you don't pretend to be patients' mothers/fathers/parents. It irks me when therapists send suicidal patients out and then get so anxious and call me to see if I can see the patients the next day. Then the therapists call the patients every day for the next week to make sure their patients are still alive. So if you are an anxious person, yes psychiatry can be very emotionally draining for you. It has to.

6) How common is it to give patients your personal phone number to call night or day in case of emergency?
Never. Never, ever.

7) Do you use telepsychiatry in your practice? How prevalent is telepsychiatry? Can one do telemedicine from abroad? Do you see any problems with telepsychiatry now, and how do you see telepsychiatry changing in the future?

I don't do telepsychiatry.

 

[Leo Aquarius]

If you like psychiatry and emergency medicine, consider emergency psychiatry. You see all the psych related craziness right off the streets with the benefit of regular hours, no interventional hassles like cutting, suturing, etc, while working in an emergency room. For some it's the best of both worlds. You would need to complete a psych residency at an institution with an active psych ER or do a Psych ER fellowship to position you for employment opportunities.

 

[MacDonaldTriad]

The bad news is that the ABPN decided to put a halt on continuing to expand sub-specialties in psychiatry at emergency psychiatry so there isn’t a board certification in this after fellowship. The good news is that the ABPN decided to put…. This means no test, no $, and no MOC.

 

[Bluecheese]

I appreciate all the replies. Thanks

 

[Still Kickin]

 

[DJspreadsheet]

I'd call your typical internist and surgeon (and dermatologist) many things. Sane isn't one of them.

 

[PreHippocrates]

Warning: Non-sequitur impending. . .

What if you really liked EM, and you really liked child/adolescent psych, but you don't like the adult inpatient psych?
I am an MS3 and have done a bit of EM, and a bit of child psych, and really enjoyed both. I think my personality fit child psych more. But I've just started my psych clerkship and it's all inpatient, with very sick patients. I'm not finding it nearly as gratifying as child psych.
A week ago I was leaning towards child psych, but not I'm not sure if I should reconsider EM based upon my adult inpatient experience.
For those of you who are at least interested in both of these fields -- What do you think? Should I be suspicious of child psych just because adult inpatient isn't suiting my fancy? Should I not be asking this question because most of psych is outpatient, and my only non-glorious experiences have been inpatient?
Thanks!

 

[nitemagi]

Inpatient psych is definitely a poor representation of the field. A better Q you might ask yourself is what kind of work can you see yourself doing and still enjoying in 10 years? 20 years?

 

[st2205]

Inpatient psych is definitely a poor representation of the field. A better Q you might ask yourself is what kind of work can you see yourself doing and still enjoying in 10 years? 20 years?

This is similar to my thoughts. I entertained the though of urology because I liked a bit of surgery and a bit of medicine (OB was out for lifestyle and just not interested in ENT issues). I thought about what I could see myself sitting down and reading on 15 years. I could sit down and read about psychosis. I wasn't sure I could sit down and read about BPH.

 

[TexasPhysician]

I initially hated inpatient as a med student. Now I find it entertaining in short bursts to mix up life.

 

[Gambler 101]

OP, what is it that you like about each field? I wonder how much you value continuity vs procedures vs "traditional medicine"


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[thoffen]

Hi, I am a medical student considering both EM and Psych. Apart from working in, and researching, the fields more, I was hoping the psychiatrists could fill me in on some questions.

1) How much of your work is psycotherapy vs. medication management?
100% med management but 90% of what I care about in my job is relational and placed on a framework from psychotherapeutic training.

2) Was there anything about the psychiatry that you wish you knew before entering?
Wish I knew more about psychotherapy, but I think if I had sought some cognitive understanding of it I would have been turned off, when reality for me now is quite different. Otherwise, I wish I knew a whole lot more about the extreme diversity of the field and the opportunity to do anything you want in it anywhere you want and to change your mind at any time -- even without subspecialty training.

3) What do you see as the biggest upsides, and downsides, of the psychiatry?
The biggest upside to me is the ability to pay more attention to the relationship I have with my patients and to be given the tools to explore that. Otherwise, I was happily surprised by the lifestyle advantages the specialty provides. Biggest downside is systems of care and lack of resources for patients. Many people you might know how to help or what they need but are restricted in being able to provide it. Otherwise, probably that the impact of many of my interventions for many people is absent or small.

5) EM and psychiatry appear almost opposite to me (although I think I am multifaceted and will enjoy different fields). One of the things that drew me toward EM initially was that it involves interventions that often give tangible results. Is it easy to perceive the effect you have on your patients? How much satisfaction do you take in your work? I've heard that some find the psychiatry emotionally draining--has that been your experience?
I don't find psychiatry emotionally draining. It's emotionally stimulating for me, but you can definitely be affected strongly by your patients. I like that, see it as countertransference, and attempt to neutralize it and use it to inform me about patients, but that is not always easy. I think all of medicine will disappoint you when it comes to seeing tangible results. Sometimes psychiatry does (robust antipsychotic or antidepressant response, ECT-response), and that's rewarding.

6) How common is it to give patients your personal phone number to call night or day in case of emergency?
I know some people who have done this. But that's a rare practice.

7) Do you use telepsychiatry in your practice? How prevalent is telepsychiatry? Can one do telemedicine from abroad? Do you see any problems with telepsychiatry now, and how do you see telepsychiatry changing in the future?
I don't and don't know enough about it to answer your questions.

I don't want to bash EM, but I don't particularly think it is a rewarding field for many. There is a big advantage in that it is purely shift-work and leaves you opportunity to compartmentalize your life both in patient care and in free time. That said, I don't think very many people are good at that. The people that do it either seem to be particularly mentally able to handle stress or are particularly good at displacing their emotions instead of holding on to them. The latter might be necessary at times but can be bad -- psych patients and pain patients and low SES patients, for example, often get different care and aren't taken as seriously. The ER has to communicate with many specialties for admissions or consults, and very often it ends up being contentious.

 

[Armadillos]

Also worth considering that the shift work schedules probably look better on paper than they feel in real life. I would much rather work 45 hours 8-5 than 35 hours of alternating shift times.