psych vs surgery--last minute waffling

[nancysinatra]

Hey, has anyone else around here had the problem of having a hard time deciding between psychiatry and surgery? I've made it through almost all of 3rd year, and this entire time I have been positive I'll head for a psych residency. I've loved psychiatry all along. I liked medicine and peds too, but I never got that excited about them. My feelings about Ob/gyn are posted elsewhere. Family practice sounds cool, but what I like about it, I think psychiatry addresses more straight on. So... I thought I was clear! Then I started my surgery rotation, and I am loving it! Especially trauma. When I first came to medical school, that is what I saw myself doing. Then I got caught up in all the medicine we had to learn, and wasn't too thrilled with the rounding, the differential diagnoses in medicine, the endless "feedback mechanisms," and just the general style of thinking and relating to patients. I figured surgery would be more of the same. But actually, I am finding that I really enjoy the cases and the way of thinking about them, and of course, the operations and procedures.

I've signed up for a trauma surgery elective, and a couple weeks of emergency medicine. Those are skills I really want to have. I'm afraid I may miss this part of medicine dearly once I've branched off into psychiatry in a year or so. I'm realizing I would really miss having the skills to handle an emergency, and having the chance to use them.

There was a thread a while ago started by someone who was worried they'd miss the physical exam side of medicine in psych--has anyone had a similar concern relating to surgery vs psych? If so, how did you come to a decision?

Also, is there a way to sort of specialize in surgical cases, within C/L psychiatry? Right now, on our unit, is a patient with necrotizing fasciitis, who, if she saw what we can see when we look at her wound, I'm not sure she would ever recover from the sight. Half of her upper body is GONE. She also thinks she should be at home right now, just living her normal life. The aspect of denial is very interesting. Well, anyway, it's a tangent, but I really find this case fascinating.

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[sunlioness]

There's an attending on our C/L service who does a lot of work with transplant patients. I don't know if it's possible to build a career around such things, but I think it's definitely possible to carve out your own niche in an area of interest. But if it's doing surgery that you actually like, would working with the psychiatric issues of surgical patients necessarily fill that need?

It's a tough decision, but I think you're doing the right thing by taking more electives. Good luck!

 

[Doc Samson]

Yes, it's entirely possible to subspecialize in CL. I am a resolute CL generalist, but have colleagues that specialize in:

Trauma
Burns
Transplant (and even then sub-subspecialized based on organ)
OBGYN/Women's mental health
Peds (folks with CL and Child training)
AIDS
CF
Epilepsy
Geriatrics

And I'm sure I'm forgetting a few.

 

[strangeglove]

You'd be surprised how many psychiatrists at one point toyed with the idea of surgery and vice-versa. They are both very invasive, requiring you to look beneath the surface at the cost of some pain. They both also require you to think very quickly. Most people think of change happening very slowly in psychiatry, but try to think slowly when a patient starts crying in front of you or, better yet, when he threatens to kill himself. It's not so different from dealing with a ruptured AAA - apart from all of that surgical stuff. The hours are better in psychiatry, too.

 

[Faebinder]

I am almost done with 1 year of surgery. Frankly, I am glad I am switching this June.

The OR is a very malignant place. The personalities of many surgeons get twisted by the career requirement. Many feel that to advance themselves, they need to look better than others, rather than take an honest look at themselves. They dont value their time and they sacrifice family for career at so many levels. Worst of all, they dont find a fault in the mentality and will call any attempt of improvement a sabbotage of a "good" part of the field.

Many get burnt out and eventually switch to something like psychiatry. You wont see someone burnt in psychiatry switching to surgery... that's extremely rare.

 

[espaceLumiere]

There was a thread a while ago started by someone who was worried they'd miss the physical exam side of medicine in psych--has anyone had a similar concern relating to surgery vs psych? If so, how did you come to a decision?

There are combined neuro/psych and medicine/psych residency programs from what a psych attending told me. Emergency psych, from my 3rd year rotation, seems to be have a stronger focus on medicine.

I don't think you'd totally miss out on the physical exam side- if you're going to be working inpatient, you're going to need to admit patients and you're going to have to do a basic physical.

 

[sunlioness]

I don't really know of anyone who did a combined program who in the end didn't end up exclusively practicing one specialty or the other. And yes, I have done physical exams as a psychiatrist on my inpatient rotations and on call, but what we do is very abbreviated compared to what I did as a medicine intern. After my intern year in internal medicine, I was very comfortable ruling out MI and managing my patients blood sugars/hypertension/coumadin/whatever on my own without medicine consults. A few years later and I am nowhere near as comfortable with these things as I was then. I don't think someone who really needs the hands on physical diagnosis piece or procedures to be happy can reasonably expect to find that in psychiatry. Whether that's a deal breaker or not though is entirely personal.

 

[michaelrack]

I don't really know of anyone who did a combined program who in the end didn't end up exclusively practicing one specialty or the other.

I know one person, but she's director of a med-psych residency program, so maybe she doesn't count.

 

[RaistlinMajere]

I am right there with you, Nancy. Only my revelation happened the reverse of yours. I had surgery first and was surprised by how much I enjoyed it. I toyed with the idea of being a surgeon until I did my psych rotation and loved it even more.

I do see similarities between the two fields. Clearly surgery is action-oriented with patients needed a specific repair of something. While there may be less of an obvious "fix" in psych, I found it to be similar in that there usually is 1-2 active problems that have landed a pt in the hospital. This contrasts with medicine where pts typically have multiple medical problems. Plus, I'm not a huge fan of rounding for hours--unless we're talking about psychiatric problems, then I found I was captivated.

Regarding lifestyle, it can be deceptive. It is not just how many hours per week you're working, but how satisfied you are during those hours.

For me, the decision came down to the fact that I knew longer term I would be more stimulated and excited about dealing with the complexities of the psych patient versus surgery. It seems like most of the time the surgeries become routine for the surgeons. In a way, by definition it has to for them to be an expert. With psych everything is exciting and I know I'll never be bored because everyone's story is unique. I think how the brain affects behavior and psychopharm to be fascinating, and preferred being an expert in these areas over anything surgical. Basically, once I experienced psychiatry the more physical aspects of surgery just seemed to pale in comparison. It sounds like you might be feeling the opposite.

Surgery vs. psych is a tough decision. Both fields are great and absolutely necessary. Try to think what will make you happier in the long run.

To thine own self be true.

 

[pillion]

I was between anesthesia and psych, not because they were similar but because they appealed to two different aspects of medicine, one more narrow and procedural, and the other more broad and interpersonal. In the end, it came down to a question of which was better suited to my own personal strengths and interests. As for surgery, I've heard the glamor of it disappears after a while, but maybe that's just the view of surgeons who were not meant to be surgeons.

 

[diosa428]

Yeah I can't decide between psych and ophtho. What appeals to me about ophtho is that there is some OR time, but the surgeries are shorter and there's also a fair bit more clinic time than in gen surg (not to mention less hours spent at the hospital in total). I think part of the problem deciding between the two stems from the fact that, if you choose psych, you basically will never do procedures again. As a med student, I have a hard time knowing whether or not I'll care about this in a few years, but right now I like working with my hands AND my brain.

 

[michaelrack]

Have you considered neurosurgery? You could specialize in psychosurgery.

 

[billypilgrim37]

Most people I know who go into surgery agree with the statement, "You shouldn't go into surgery unless that's the only thing that could make you happy."

I don't know if that's the wisest advice, but I've heard it from enough people.

I don't think the same thing is applicable to psych. I think a lot of us would be happy doing a lot of other things, even if we'd be happiest as psychiatrists.

 

[sunlioness]

That's an interesting way of looking at it. I actually COULD say that about psych, I think. At least within medicine. I think I could have been happy going to grad school for psychology, though I don't regret becoming a physician. And to me, "no procedures" is a huge huge bonus. If I'd stayed in internal medicine, I probably would have done palliative care. I really liked it, but then I realized the reason I liked it was the huge counseling/spirituality component. In psychiatry I can still have that and with people who (hopefully) aren't dying.

 

[2tall]

Glad to see I'm not alone! Going into fourth year and planning electives and aways with no certainty has me a little stressed.

It would be so much easier if during each rotation the heavens opened up and God appeared saying "Yes, my child," or "No. Not this one."

I could honestly be happy doing Surgery, Medicine or Psych. Maybe I'd have to tweak my definition of happiness a little bit with surgery though.

 

[Wednesday]

Hey Nancy,

I would advise you to take some electives and have some serious, no BS conversations with the attendings you encounter and what their lives are like. I switched from ob/gyn to psych this year (from your post I am imagining that you hated ob, but it is a surgical specialty, so take this post from that standpoint) and although I LOVED ob, I realized that if I stayed in it, it would have been very difficult to have the life I want for myself and specifically for my family.

A few things to think about:
1. If you truly love surgical procedures, I actually don't think they lose their appeal (people will say this, but I didn't really observe that in the older attendings I was with). You will probably miss them (I do) but there are aspects of psychiatry that I would miss if I went back to ob.
2. If you are a surgeon, your hands are what they need from you. This means that even when you are 50 years old, if your services are needed, your physical presence is needed. Seems okay as a 20 or 30 something, but this can get very old. This is not true in psychiatry. In fact, there are psych jobs with no call. Imagine that.
3. Relationships with patients are much different in psych vs surgical fields. Much, much different.
4. Realistically think about what you want from your life and see if it fits with a surgeon's lifestyle. When I finally defined who I wanted to be as a member of my family, I realized that it absolutely did not fit with ob/gyn. Others had very different experiences (and did not understand why I would quit given how much I loved what I was doing.)

Although I do miss my previous field, I really could not imagine a different course than I have taken.

Good luck with your decision. Remember you can always switch to psych if you choose surgery and realize that you shouldn't have.

 

[nancysinatra]

Thanks everyone for these responses! They are very helpful. I got tied up with my rotation and it's taken me awhile to respond, but the replies have helped me think about this question in ways I hadn't thought of myself.

It's especially helpful to hear from residents who have done a year in a surgical field. I do worry about getting swallowed up into a malignant environment. I might not mind the surgery lifestyle itself, but if there's a rat race mentality behind it, I know I would HATE that. That seems more common in surgery than in psychiatry. Yet I loved my first month of surgery and was impressed with how pleasant an experience it was...

I like procedures, but don't feel a need to do them every day. I think my concern is more about losing the basic knowledge of what to do for people in a traumatic situation. I hate to admit this, but I watched a lot of "ER" before coming to med school. I totally saw myself rushing around and rescuing people from the brink of death every day, and then wiping my brow at the end, in this dramatic, made-for-tv kind of way. Ok, I know it's loony, but oh-how-sad not to be able to do that... And I do genuinely love the excitement of trauma surgery, so it's a true sadness. Does anyone else feel a little disillusioned that way? Like what you are as you leave med school is not what you thought you'd become when you started?

But on the other hand, I know that in surgery I would miss the patients and the interesting problems that psychiatry deals with.

I've got a great line up of psychiatry and trauma surgery electives starting this summer, so regardless, my year should be great!

 

[smq123]

I like procedures, but don't feel a need to do them every day. I think my concern is more about losing the basic knowledge of what to do for people in a traumatic situation. I hate to admit this, but I watched a lot of "ER" before coming to med school. I totally saw myself rushing around and rescuing people from the brink of death every day, and then wiping my brow at the end, in this dramatic, made-for-tv kind of way. Ok, I know it's loony, but oh-how-sad not to be able to do that... And I do genuinely love the excitement of trauma surgery, so it's a true sadness. Does anyone else feel a little disillusioned that way? Like what you are as you leave med school is not what you thought you'd become when you started?

I was also trying to decide between surgery and another field. I realized, though, that as much as I liked surgery, I didn't really want to be a resident in ALL surgical fields. I wasn't crazy about general (appy, appy, chole, chole, chole, biopsy, chole, etc.). CT was fun for a while, but the patients are REALLY sick. Plastics was fun for a couple of weeks...but got kind of old fast. And, unlike you, I hated trauma.

Will you like being a SURGICAL resident...and not just a temporary TRAUMA surgery resident? Would you mind rotating through vascular, endocrine (necks, necks, and more necks!), CT, breast, colorectal, etc.? These are all fields that you will need to rotate through....and many of them don't have anything nearly as exciting as a GSW or stabbing victim.

Is there any kind of subspecialty in psych that deals mainly with high-acuity patients? Maybe someone who works in a crisis center? (I never looked seriously at psych as a career, so I can't say - sorry if I sound really stupid!)

 

[RRoguish]

Hey, has anyone else around here had the problem of having a hard time deciding between psychiatry and surgery? I've made it through almost all of 3rd year, and this entire time I have been positive I'll head for a psych residency. I've loved psychiatry all along...

... has anyone had a similar concern relating to surgery vs psych? If so, how did you come to a decision?

Psychology was my major in college. Orthopedic surgery was my first love in medical school, I devoted all my electives and even recreational activities to building a career in Sports Med/Ortho. It was cool, they got to play with drills and screws and carried a huge tool box going into surgery, it was what-you-see-is-what-you-get. Then during the one year hiatus I took after med school, I realized I was just attracted to the "glamour" side of it. I also realized that my personality and skills was more suited for Psychiatry -- I figured I would be a mediocre orthopedic surgeon at best, but potentially could be a really good psychiatrist. Cliche as it sounds, at that point I felt it was my calling. Add to that the hours and lifestyle differences, and I knew it was Psych for me.

 

[strangeglove]

Is there any kind of subspecialty in psych that deals mainly with high-acuity patients? Maybe someone who works in a crisis center? (I never looked seriously at psych as a career, so I can't say - sorry if I sound really stupid!)

Emergency Psychiatry deals with a lot of acute stuff like suicidality, drug intoxication, psychosis and mania. It also has the benefit of being like Emergency Medicine in that it's basically shift work with a very flexible schedule. The downside is a lot of frustrating social work issues surrounding homelessness.

 

[Kazema]

It's funny, I have the same dilemma - going into my surgery rotation (my last of 3rd year) I was 100% set on psych because I figured there was no way I'd want to do surgery. I found inpatient surgery quite benign. I really enjoy the OR; the procedures made a lot of sense and I found that I enjoyed getting caught up in the flow of each operation. My "outpatient" rotation was vascular surgery, and shockingly, I LOVE it. I even like the clinic - I hated OB/Gyn clinic and medicine clinic more than anything else I did all year. I just love how vascular surgery combines the OR, endovascular stuff, and a pretty straightforward clinic experience into one specialty.

I have found that a lot of surgery residents and several attendings have commented that they had been considering psychiatry at one point or another. I think part of it is that in both specialities you are personally addressing your patient's problem, and not (completely) relying on medications or other specialists to solve the problem. Surgeons and psychiatrists are alike in having a crucial impact in their patients' recovery.

I still have my decision to make, I think in the end lifestyle will decide things...