Psychiatrist First, Physician Second?

[Bezii]

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Hello,

I am a perspective med student with an interest in both psychiatry and clinical psychology. I have read numerous posts concerning the pros and cons of each career path and only one post discussing dual degrees. There is compelling advice in each thread, but it seems to revolve around the idea that psychiatry and psychology do not mix. Specifically, many members maintain that a psychiatrist is a "physician first and a psychiatrist second."

I want to be a psychiatrist first. The fact is, I have virtually no interest in medicine outside of psychiatry and neurology (at least, in terms of a career path - I do find medicine interesting enough to remain sufficiently engaged throughout med school and any required CME). I firmly believe that psychotherapy and psychological testing can be hugely important to psychiatry, and I would like to further explore this connection in future practice.

Is it really that taboo to practice both psychology and psychiatry? Granted, I realize that most psychiatrists work in conjunction with psychologists and/or social workers, but I am personally interested in working at the intersection of psychology, psychiatry, and neurology. They are all hopelessly intertwined, and I personally believe that the best methods of diagnosis and treatment involve all three fields. After all, any physician knows that a positive patient is more likely to recover than a hopeless patient, which shows that even physical conditions have a psychological component. I imagine the psychological component would be tenfold in any mental illness.

To clarify, I would rather not become just a clinical psychologist or a physician-scientist (since I do not want to focus primarily on research). I may love psychology, but psychiatrists can prescribe medications - not to mention the additional money and job stability.


Should I pursue an MD, a dual MD/PhD, a dual MD/MA?

Is there anything that a clinical psychologist is licensed to do that a psychiatrist is not allowed to do? Can psychiatrists train to administer psychological tests and psychotherapy? What would this additional training entail?

Would I find a niche as a psychiatrist/psychologist? Is this a path that is commonly taken, or would I be the odd one out?


Thank you in advance! The premed forums are wonderful, but I desperately need advice from a licensed psychiatrist...

 

[IAmAUser]

.

 

[Bezii]

Yes, that was quite helpful. I wouldn't say, however, that I am not interested in medicine. I actually enjoy a variety of subjects ranging from those in the natural sciences to those more in the philosophical spectrum. I was more trying to make the point that I do not want to be a practicing physician. There is some chance that this could change in the future (I've seriously considered medicine in the past), but my current passion is mental health.

I am very glad to hear that psychiatrists are trained to give psychotherapy. It is very important to me to have the option to have a more in-depth relationship with patients than many psychiatrists have. Then again, I suppose that is directly related to the doctor's case load...

🙄

 

[235750]

The fact is, I have virtually no interest in medicine outside of psychiatry and neurology

If this is really true, I would advise against medical school. You'll be miserable.

I was basically in the same boat as you Bezii, and I will have completed my first year of medical school this Friday (!!!!!)

I agree with IamAUser that you will be miserable. I know I am. But you have to ask yourself: how happy are you now and how sure are you about psychiatry? I was miserable before med school, working in the most boring profession in existence (biostatistics), so I thought, what's an extra 5 years (med school + intern year) to do what I really enjoy?

Every situation is different. For me being a psychiatrist is just that alluring that I am willing to put up with this much unhappiness. I have to threaten myself mentally with failure in order to study most days, and it's taxing.

The frustrating thing I find about medical school is the disconnect between what we learn and what I perceive to be useful, practical medicine. Do I care about all 20 intermediates in the kreb cycle? Hell no, what's the point of memorizing all of them?! In 4 days I'll forget it all anyway. And don't even get me started about all the rare conditions you'll never see in practice, but you have to memorize because "step 1 loves it". Bah!

I've had plenty of job experience in mental health so I knew this was the career for me. The only way I'd reccomend you apply to med school is if you've 100% sure that psychiatry is for you. Because once you start, there is no turning back. It's indentured servitude if you graduate with $230k debt and hate your job

I'm nervous sometimes that I made the wrong decision, but I know others on this forum (like Whopper) are like minded, and they turned out ok. It gives me hope!

Sorry for the rant. Also if you do not enjoy research, there is no reason for a joint degree.

Good luck

 

[billypilgrim37]

I was more trying to make the point that I do not want to be a practicing physician.

Then you do not want to be a psychiatrist.

 

[Evidence Based]

Is there anything that a clinical psychologist is licensed to do that a psychiatrist is not allowed to do? Can psychiatrists train to administer psychological tests and psychotherapy? What would this additional training entail?

Yes, actually. From what I understand, psychological testing is the sole province of licensed clinical psychologists. So while you will certainly have access to providers of testing, don't expect to be licensed to interpret the MMPI or WAIS as a psychiatrist.

 

[whopper]

As a psychiatrist, in several possible scenarios such as ER and inpatient, you will occasionally have patients who are medically compromised and you will have liability if you overlook their medical problems.

About once a week in ER psychiatry, I had a patient that was medically unstable and the ER doctor missed it (e.g. a broken leg, a punctured lung, in significant danger of stroking). I had to catch it.

If you have no interest in the medical problems outside of psychiatry, forget consult liason psychiatry.

Psychiatric patients are also much more likely to have medical problems vs. someone in the general population, and not have them treated. I have several patietns with no primary care doctor with several medical problems. I have to at least notice them and try to do what I can with them such as at least offering a referral and tell them why they need a PCP.

Many medical problems are very much connected with the mental health problem. E.g. obesity can cause obstructive sleep apnea. If your patient can't sleep, you likely might not want to give them a sleep medication. How will you be able to discern these without medical knowledge? Another example, depression caused by hypothyroidism vs. pure primary depression. Again, you have to have medical training.

The fact is, I have virtually no interest in medicine outside of psychiatry and neurology

If you go to medical school, prepare to have over 90% of your very difficult curriculm have no basis whatsoever in mental health, and then as a psychiatry resident having to do months of internal medicine. I'm talking about 70-100 hrs a week studying in a medical curriculum for years.

From what I understand, psychological testing is the sole province of licensed clinical psychologists.

Not necessarily, though in general this is true for many psychological tests. The MMPI in many states must be given by a licensed psychologist. There are some tests psychiatrists can give, there are other tests that we are qualified to give, but cannot because of guild concerns (e.g. the author of the exam who was a psychologist specifically made rules that only a psychologist can given them to earn more money for his profession.)

The MMPI IMHO is justified in keeping it to psychologists only. Why? You have to have some very intense training to be able to administer it and interpret it. This is training we psychiatrists don't have in our curriculum.

(Though IMHO, some counseling curriculums do offer just as much training vs the psychologists in the MMPI, then the counselors still can't administer it because they're not techinically psychologists....)

That is not meant as a specific attack on psychologists because all fields do that. I'm just pointing out the psychologists above because the specific question was psychological testing. You'll see the same no matter what the field.

 

[DD214_DOC]

I went to medical school firmly decided on psychiatry. I was a psychology undergrad and went as far as to enter a PhD program in psychology but found that I didn't really care that much for the research focus (it was in general psych, not clinical). I really had no opinion on other areas of medicine. I guess I thought they were a little interesting but otherwise never put much thought into it.

I ended up liking quite a bit of the other stuff, particularly physiology. I thoroughly enjoyed the basic science years. Of course, I still enjoyed the psych and neuro courses the most.

Once I hit clinicals I found that I also liked other areas of medicine and ultimately had to decide between psychiatry and a few other fields. I ended up choosing psychiatry due to a combination of intellectual interest, lifestyle, and exposure.

My point is that you may surprise yourself and end up liking the other stuff -- or you may not. I absolutely HATED musculoskeletal stuff and dermatology. You just drudge through it all like everyone else.

 

[Therapist4Chnge]

All psychiatrists are trained in core psychotherapies as part of their residency training (cbt, psychodynamic, and suportive, with additional exposure to family, group, and couples).

I think this is over-stated, as most psychiatrists would agree there are a handful of residencies that provide thorough and in-depth talk therapy training, and most do a fraction of that training.

Psychiatrists in general do not administer detailed neuropsychological testing, not because they aren't "licensed" to, but because, to me at least, these tests are long (many hours) and tedious and psychologists are better trained to administer them anyway.

I'd think ethics has something to do with it.....

....I do not want to be a practicing physician.

Then you will most likely be miserable. I was in your position, and I shadowed some physicians and realized that even if I completed a Ph.D. / M.D. (my original goal), I'd still have to trudge through OB/GYN and a host of other rotations that were of no interest to me. Physician first...then psychiatrist.

 

[whopper]

I think this is over-stated, as most psychiatrists would agree there are a handful of residencies that provide thorough and in-depth talk therapy training, and most do a fraction of that training.

The current ACGME guidelines require psychotherapy training although it's minimum standards leave a lot of leeway for programs. A program could give very minimal training in this area and get away with it.

I'm not sure of what the minimal standards are in a psychology graduate program.

 

[getunconcsious]

Hello,


I want to be a psychiatrist first. The fact is, I have virtually no interest in medicine outside of psychiatry and neurology (at least, in terms of a career path - I do find medicine interesting enough to remain sufficiently engaged throughout med school and any required CME). I firmly believe that psychotherapy and psychological testing can be hugely important to psychiatry, and I would like to further explore this connection in future practice.


Thank you in advance! The premed forums are wonderful, but I desperately need advice from a licensed psychiatrist...

To be honest, most of this post makes it sound like you'd be happier as a clinical psychologist. There are a LOT of non-mental health related things you have to do on this path that you might not like much at all, including:
(Pre-clinical years)
--Dissect a cadaver
--Spend literally hundreds of hours of your life learning about all sorts of weird diseases and medical/surgical treatments for them.
(Clinical years)
--Deliver a baby, or 2 or more.
--Disimpact a burdensomely constipated person
--See patients die on the medicine wards
--See patients with stroke/some other neurologic condition that can't be ameliorated.
--"Prognosis consults" where neurology is consulted to basically give permission to pull the plug is also not uncommon
--See and manage bronchiolitis on peds wards, while contracting it yourself
--Scrub into surgery
--Hold retractors for 10 hours
--Get yelled at and generally harassed by surgeons b/c you're the med student
(Internship)
--Q4, for at least 3-4 months out of the year
--Get paged by nurses for diet order changes or tylenol at 2 AM (annoying)
--Get paged by nurses b/c your medicine patient has a new fever of 102 in th middle of the night (don't panic, just get cultures and start broad-spec abx)
--Get paged to a rapid response/code in the middle of the night on medicine (Ok, NOW you can panic).

I think the main reason to be a psychiatrist is if you're very interested in the psychopharm/medicine aspects of psychiatry a lot. Can you have a cash-based therapy practice? It can probably be done, but I don't see a great reason to put yourself through all of this. If you know now that your primary interests are psychotherapy and psychological assessment, I honestly think you're probably farther ahead to go to grad school in psychology. Psychologists are highly respected trained professionals who have WAY more therapy training than most of us MD types will ever have. Good luck, whatever you decide

 

[Daftrage]

I was also in your boat several years ago (now finishing up 3rd year). Although at the time i really thought I would be doing psychiatry or psychology, I still really like science and was interested in other fields of medicine. That ended being my saving grace to get me this far because it is a daunting task. (I am currently on Gyn Onc and working from 4am to 6pm largely doing surgeries which I don't enjoy)

If you don't enjoy science then you are going to be miserable for your first two years especially, and probably beyond too. You may also be surprised to find that you may like another field as well or better. After doing IM I changed my mind on career path for a while but then got set back on the righteous path after doing my psych rotation.

 

[masterofmonkeys]

I'm a huge proponent of psychotherapy and chose my residency programs based in large part on their ability to offer solid training in it.

But if you do not want to be a physician, don't become a psychiatrist. Beyond all the reasons Whopper listed, there is the simple fact that one of the more poorly understood areas of psych is that mental illness does in fact affect other parts of the body, not to mention that our medications do as well.

Psychoendocrinology and psychoimmunology are fields that will only continue to grow. And more and more specialties are paying attention to the role of psych in a myriad of 'somatic' disorders, from SVT to HTN to fibromyalgia to cancer to problems with pregnancy.

Mentally ill patients get sick. And sometimes 'sick' patients are actually just mentally ill. In some series, up to 40% of panic disorder patients actually have secondary panic in response to an arrythmia. Your ability to read an EKG can save a patient a lifetime of pain. And SIADH and primary polydypsia are not infrequently seen. And I swear hypertensive urgencies are far more common on the psych ward than the medicine ward, so it's important to know that hydralazine, while perfectly appropriate in an asymptomatic patient is the worst choice to make in someone who has associated CNS symptoms.

Chronic Daily Headache, fibromyalgia, IBS, intractable abdominal and pelvic pain, well those are at least as much psych as they are somatic. Stepping in to offer adequate psychiatric and psychosocial treatments can save these patients from invasive tests and procedures and dramatically improve their quality of life. As much as I get when non-psychiatrists fail to recognize the role of psych in a patient's presentation, I get far more annoyed when a psychiatrist sends a patient back to the other doc saying 'Well, I think this might be real', simply because they lack the confidence in understanding that body system to say 'this doesn't make sense'.

Having the medical knowledge to be able to tell psych from non-psych, and appropriately understand the contribution of each is all too often an overlooked skill.

The brain is a fully integrated part of the body, and thus problems with the body can manifest in the brain, and problems with the brain can manifest in the body.

 

[Suenya]

I was in a similar position. I'll let those that know from experience give you better answers, but I just wanted to address the dual-degree option. I think there is very little reason a dual degree would be beneficial to you as someone interested in psych without a strong interest in research.

 

[peppy]

I think the main reason to be a psychiatrist is if you're very interested in the psychopharm/medicine aspects of psychiatry a lot. Can you have a cash-based therapy practice? It can probably be done, but I don't see a great reason to put yourself through all of this. If you know now that your primary interests are psychotherapy and psychological assessment, I honestly think you're probably farther ahead to go to grad school in psychology. Psychologists are highly respected trained professionals who have WAY more therapy training than most of us MD types will ever have. Good luck, whatever you decide

I agree with this sentiment. There are reasons why most psychiatrists don't do a lot of therapy. In most practice settings your ability to choose treatments will be dictated by outside forces and financial practicality. Psychology sounds like a better fit for what you want to do. I *like* general medicine but even I sometimes wish I had just pursued psychology instead.

 

[Manicsleep]

I think the main reason to be a psychiatrist is if you're very interested in the psychopharm/medicine aspects of psychiatry a lot. Can you have a cash-based therapy practice? It can probably be done, but I don't see a great reason to put yourself through all of this. If you know now that your primary interests are psychotherapy and psychological assessment, I honestly think you're probably farther ahead to go to grad school in psychology. Psychologists are highly respected trained professionals who have WAY more therapy training than most of us MD types will ever have. Good luck, whatever you decide

I disagree.
1) There are MANY psychiatry programs that provide significant exposure to psychotherapy and even provide psychotherpy to you if you want the exposure. Mine did.
2) There are plenty of psychology doctorate programs that are just god awful and I happen to work with a lot of psychologists who know almost nothing about psychotherapy beyond the basics and I can run rings around them in testing.
3) The biggest hurdle in this decision is if you want the full exposure of psychology, neurology and the rest of medicine which is psychiatry. You must understand and be willing to embrace that psychiatry is bio-psycho-social. You can do psychodynamic therapy in the morning and be reading an EEG at noon and then visit an ICU in the afternoon to treat a post-op delirium. (What I did yesterday..oh and be willing to take call).

 

[whopper]

Forgive the sarcasm, but there is some point to it.....

IMHO a psychiatrist not wanting to know psychotherapy is like a primary care physician who doesn't want to know the value of a healthy lifestyle (exercise, sleep, diet).

Oops, I forgot. The old idea of a doctor taking the time to educate the patient on a disorder, teach them how to live with it, and how to get the maximum benefits of treatment by utilizing all aspects of therapy including elements aside from and including medication are no longer what we're supposed to do these days!

You got high cholesterol? Forget exercise and diet, here's your statin.

We're going to crack open your chest and do open-heart surgery tomorrow on you. Oh? You don't like that idea? I'm going to order a psychiatry consult because you obviously don't have the capacity to decide. After all you just disagreed with ME---YOUR DOCTOR even though I didn't even explain why I think I we need to do this surgery on you that has a chance of killing you.

You got pain, here's your Percocet, you got anxiety, here's your Xanax, your dad raped you? Here's some Prozac. You want to have sex with some little kids? Here's some finasteride..... Next!

Oh, and by the way, getting back to reality, all the above? I've seen it happen for real. Last time my wife saw her doctor, she sat in an office alone for about fifteen minutes, a doctor walked in, gave her a script, and told her the meeting was over.

 

[OldPsychDoc]

...
3) The biggest hurdle in this decision is if you want the full exposure of psychology, neurology and the rest of medicine which is psychiatry. You must understand and be willing to embrace that psychiatry is bio-psycho-social. You can do psychodynamic therapy in the morning and be reading an EEG at noon and then visit an ICU in the afternoon to treat a post-op delirium. (What I did yesterday..oh and be willing to take call).

I was really glad I'm a physician today. In addition to the usual needing to be comfortable with my geriatric patients' discharge meds (coumadin? digoxin?), I had a depressed outpatient with adrenoleukodystrophy who's getting bounced between neurology, endocrinology, and rehab without anyone talking to the frantic husband about why his wife isn't walking. And then, because it's "my week", I'm fielding calls all day from the rest of the medical group--like from nurses who can't pronounce ven-la-fax-ine, let alone know what it is 🙄 , and from internists being told that their 7 mo pregnant patient MUST be taken off their (4 years stable) dose of 150 mg bupropion, without anyone giving a compelling reason other than "She's pregnant." [six more days and counting...oh well, at least "call" is only once a quarter, and I sleep in my own bed...]

 

[Therapist4Chnge]

I disagree.
1) There are MANY psychiatry programs that provide significant exposure to psychotherapy and even provide psychotherpy to you if you want the exposure. Mine did.
2) There are plenty of psychology doctorate programs that are just god awful and I happen to work with a lot of psychologists who know almost nothing about psychotherapy beyond the basics and I can run rings around them in testing.

Just a word of caution about anecdotal evidence...everyone has it. A few weeks ago I had a PCP ask me (not a physician nor prescriber) what anti-depressant he should give a patient I referred to him. While I appreciated his willingness to ask for input, I was a bit taken back that he had NO IDEA about a common SSRI (he googled it while we were talking). To fix the problem I put in a consult to someone I trusted over in out-patient psychiatry and told the patient that the physician was tied up but I could get him in to see someone else. Since then I have avoided making any psych-related consults to that provider.

 

[getunconcsious]

Forgive the sarcasm, but there is some point to it.....

IMHO a psychiatrist not wanting to know psychotherapy is like a primary care physician who doesn't want to know the value of a healthy lifestyle (exercise, sleep, diet).

Oops, I forgot. The old idea of a doctor taking the time to educate the patient on a disorder, teach them how to live with it, and how to get the maximum benefits of treatment by utilizing all aspects of therapy including elements aside from and including medication are no longer what we're supposed to do these days!

You got high cholesterol? Forget exercise and diet, here's your statin.

We're going to crack open your chest and do open-heart surgery tomorrow on you. Oh? You don't like that idea? I'm going to order a psychiatry consult because you obviously don't have the capacity to decide. After all you just disagreed with ME---YOUR DOCTOR even though I didn't even explain why I think I we need to do this surgery on you that has a chance of killing you.

You got pain, here's your Percocet, you got anxiety, here's your Xanax, your dad raped you? Here's some Prozac. You want to have sex with some little kids? Here's some finasteride..... Next!

Oh, and by the way, getting back to reality, all the above? I've seen it happen for real. Last time my wife saw her doctor, she sat in an office alone for about fifteen minutes, a doctor walked in, gave her a script, and told her the meeting was over.

K, so I got the super beat-down on this one. Forgive me after my months of
q4 winter peds rotations?

I certainly never said that psychiatrists should not be trained in therapy. Only that if psychotherapy is your main interest in life and you don't want to do the meds, it makes more sense to be a psychologist. I stand by that sentiment. If you want to do both then be a psychiatrist. Only don't be stupid enough to do triple board and end up q4 in the NICU and on wards in bronchiolitis season. that is all.

 

[getunconcsious]

And also, are we not de-valuing psychologists/social workers/other mental health professionals with this idea that only WE can deal with these issues? I mean come on folks, delegate a bit! Otherwise you'll never get under the 80 hour limit!

 

[peppy]

Forgive the sarcasm, but there is some point to it.....
IMHO a psychiatrist not wanting to know psychotherapy is like a primary care physician who doesn't want to know the value of a healthy lifestyle (exercise, sleep, diet).

I think we can all agree that psychotherapy has its place and that psychiatrists should make appropriate recommendations/referrals if they don't do psychotherapy. I think some of us are just saying that psychiatrists may not need to be the ones who are personally performing therapy. PM&R docs know a lot about physical therapy and its indications, but the vast majority of them let physical therapists actually carry out the therapy.

 

[Manicsleep]

Just a word of caution about anecdotal evidence...everyone has it. A few weeks ago I had a PCP ask me (not a physician nor prescriber) what anti-depressant he should give a patient I referred to him. While I appreciated his willingness to ask for input, I was a bit taken back that he had NO IDEA about a common SSRI (he googled it while we were talking). To fix the problem I put in a consult to someone I trusted over in out-patient psychiatry and told the patient that the physician was tied up but I could get him in to see someone else. Since then I have avoided making any psych-related consults to that provider.

Did this person say they have NO IDEA or were they talking about efficacy/effectiveness?
Also, did they confuse you for a psychiatrist? Did you explain to them that you, in fact, probably had LESS OF AN IDEA than he did.
My question to you:
Did you ask the relevant questions?
Even if you did all of the above, what is your point? If you are saying that there was a physician who was lazy or didn't know what they were doing, well thats just human nature. If its something else, clarify.

 

[Therapist4Chnge]

Did this person say they have NO IDEA or were they talking about efficacy/effectiveness?
Also, did they confuse you for a psychiatrist? Did you explain to them that you, in fact, probably had LESS OF AN IDEA than he did.
My question to you:
Did you ask the relevant questions?
Even if you did all of the above, what is your point? If you are saying that there was a physician who was lazy or didn't know what they were doing, well thats just human nature. If its something else, clarify.

My point was that your anectdotal example is as useful/useless as mine, and taking a swipe at psychology b/c you encountered a poorly trained clinician is not relevant to this conversation.

 

[Manicsleep]

My point was that your anectdotal example is as useful/useless as mine, and taking a swipe at psychology b/c you encountered a poorly trained clinician is not relevant to this conversation.

Ahh I see. You thought I took a swipe at psychology so you took one at medicine. Got it.

FYI, i was correcting a post that stated that all psychiatrists do is psychopharm and that psychologists are WAY better in therapy.

 

[whopper]

K, so I got the super beat-down on this one. Forgive me after my months of
q4 winter peds rotations?

Okay, sorry, I wasn't trying to beat down on you. The sarcasm would've been better if we were in person because then you would've seen on my end that I didn't mean any offense or beat-down.

(And I was just mentioning how sarcasm doesn't work well in message boards a few weeks ago....sorry).

Some of the angst and animus of that last post wasn't in any way directed at you, but at the situations I mentioned where I witnessed them actually happening.

I don't think there's a problem delegating psychotherapy to others, but even if we do that, we still need to be on top of psychotherapy. Our skills to detect if the person is in need of psychotherapy, our ability to communicate with psychotherapists, and our limited opportunities to throw some psychotherapy in the mix even if we are doing med-checks only will be sharpened if we keep on top of that skill.

E.g. if you don't know how DBT works and you delegate it to someone else, you won't know what they're talking about when they mention the person has a problem with radical acceptance or mindfullness. Only by knowing at least how DBT works, will you be on the same page when the person giving the psychotherapy addresses these issues with you.

I hate saying it, but if we want cost-effective medicine, we have to start delegating some of the things we could do to others who will not charge as much money.

As for psychologists, their skills and training don't necessarily always make them good psychotherapists either. Just as we are trained in a medical model and may overly rely on it, I've seen several psychologists overly relying on statistics from a population standpoint and not being able to detect what's going on with the individual patient.

 

[phantomflair]

Hmm, probably inevitable that this thread would get into a debate of psychiatry vs psychology.

I would just add that one of my fellow residents in my residency program was actually a practicing clinical psychologist for 10+ years before deciding to go to medical school and going the psychiatrist route. All I can say is that her skills in psychotherapy very much exceeds the rest of us and that from a recruitment perspective she is in demand because of her strength in that skill set. Which is not to say that if you wanted to focus on psychotherapy that you couldn't do that as a psychiatrist; but I find generally that very few psychiatrists are interested in going hard core down that route.

 

[whopper]

I have a bachelor's in psychology and I've learned things in that curriculum that aren't taught in a psychiatry residency which have been very useful in psychiatry.

Both fields are really compartmentalizations of a broader field that should have the same end.

I hope you didn't interpret my comments as anti-psychology. If you look in several other threads, I've argued quite a bit that psychologists are our colleagues and in some way are better than us psychiatrists in a few areas.

 

[Manicsleep]

Hmm, probably inevitable that this thread would get into a debate of psychiatry vs psychology.

I would just add that one of my fellow residents in my residency program was actually a practicing clinical psychologist for 10+ years before deciding to go to medical school and going the psychiatrist route. All I can say is that her skills in psychotherapy very much exceeds the rest of us and that from a recruitment perspective she is in demand because of her strength in that skill set. Which is not to say that if you wanted to focus on psychotherapy that you couldn't do that as a psychiatrist; but I find generally that very few psychiatrists are interested in going hard core down that route.

That makes sense though. she has 10 years in psychology plus clinical rotations in medical school where she was using her skills consciously and subconsciously. That gives a huge advantage but by the time you are a few years into practice (if you do psychotherapy) you will have practically the same skillset.
You are right though, psychotherapy is hard to practice in todays climate, so that may never actually happen for many psychiatrists and most only do it on a partial basis. However, I think that if you have the mindset, you end up doing some even in the 20 minute sessions.

However, I agree with Whopper, I don't see those comments as anti-psychology. I think the clinical climate is changing and that sometimes its for the better and sometimes not so much.
I think we need to fight against the misconceptions that certain people have or would like to promote. One of them is that psychologists are better therapists. This is simply not true.
Not being able to do therapy as much as we would like or because of being out of practice is one thing, not being able to because of a lack of training is a pure falsehood. If your program is not teaching it to you, you need to report them when the ACGME rolls around next. They come about every 1-5 years depending on how good they think your program is teaching residents (and you are encouraged to complain).

 

[phantomflair]

I disagree.
1) There are MANY psychiatry programs that provide significant exposure to psychotherapy and even provide psychotherpy to you if you want the exposure. Mine did.
2) There are plenty of psychology doctorate programs that are just god awful and I happen to work with a lot of psychologists who know almost nothing about psychotherapy beyond the basics and I can run rings around them in testing.
3) The biggest hurdle in this decision is if you want the full exposure of psychology, neurology and the rest of medicine which is psychiatry. You must understand and be willing to embrace that psychiatry is bio-psycho-social. You can do psychodynamic therapy in the morning and be reading an EEG at noon and then visit an ICU in the afternoon to treat a post-op delirium. (What I did yesterday..oh and be willing to take call).

I just want to emphasize this last part -- having to take call -- as a HUGE difference b/w psychiatry and psychology. While I definitely do think that psychologists have their own strengths, the fact of the matter is that they see way less acuity and psychopathology in their training. Even how one goes about managing the suicidal patient is vastly different if all you've seen is the suicidal outpatient vs seeing 6 of them in a row in emerg (often brought in by police) on a busy night of call.

On this topic of psychotherapy from a psychologist vs psychiatrist... I guess my experience in my own training program has been that a GOOD (that being the operative word) psychologist can do a better job of it. Generally, I've found psychologists make better psychotherapy supervisors than psychiatrists. A big difficulty is that lots of psychiatrists would describe their approach to psychotherapy as "eclectic" which becomes problematic when you're really wanting to learn a solid system particularly with manualized forms of therapy. I find that psychologists are better able to list the evidence behind the efficacy of a psychotherapy (which you'd have to know well when that's the only treatment you can offer) and take less of a mish-mash approach to therapy, making for more consistent teaching and supervision.

 

[futureapppsy2]

(Though IMHO, some counseling curriculums do offer just as much training vs the psychologists in the MMPI, then the counselors still can't administer it because they're not techinically psychologists....)

Links? I have yet to see a Counseling MA/MS program that offers a comparable, experiential course in psychological testing/assessment (i.e., one that involves multiple observed/reviewed administration, scoring, and write-up sessions), though I've seen a lot of programs that have more broad, general "testing" courses that don't cover the instruments in comparable depth, or, even if they might, don't provide the actual hands-on training and supervision a PhD/PsyD course would. *curious*

 

[Manicsleep]

On this topic of psychotherapy from a psychologist vs psychiatrist... I guess my experience in my own training program has been that a GOOD (that being the operative word) psychologist can do a better job of it. Generally, I've found psychologists make better psychotherapy supervisors than psychiatrists. A big difficulty is that lots of psychiatrists would describe their approach to psychotherapy as "eclectic" which becomes problematic when you're really wanting to learn a solid system particularly with manualized forms of therapy. I find that psychologists are better able to list the evidence behind the efficacy of a psychotherapy (which you'd have to know well when that's the only treatment you can offer) and take less of a mish-mash approach to therapy, making for more consistent teaching and supervision.

Its unfortunate that you are in a program where there are no supervisors that do specific types of therapy. For example I do the "eclectic mix" but I also do CBT, IPT and psychodynamic (Plus I run various types of groups).
Our program had psychiatrists that did everything. And if the patient you had was on medication, your supervisor was a psychiatrist. Luckily we had plenty.

A lot also has to do with how people view themselves. When I joined my current practice, nobody did therapy. Not even the ecletic mix. Now we have everyone doing CBT and running groups because its cost efficient. Also myself, a psychologist and an area psychiatrist are re-training the other psychiatrists in psychodynamic therapy this summer to increase the number of fee for service patients.

I will say though that the eclectic mix as you call it is really the best therapy approach as long as you dont get careless. I started out compartmentalizing everything and have been moving to mix things as needed because patients are not "manualized" so its important to learn the integration of techniques as early as you can. Just be able to say, that part is supportive, that part CBT or DBT etc.

I have yet to see a Counseling MA/MS program that offers a comparable, experiential course in psychological testing/assessment (i.e., one that involves multiple observed/reviewed administration, scoring, and write-up sessions), though I've seen a lot of programs that have more broad, general "testing" courses that don't cover the instruments in comparable depth, or, even if they might, don't provide the actual hands-on training and supervision a PhD/PsyD course would. *curious*

Masters levels programs generally offer only broad courses. However, there are plenty of psychologists graduating these days that dont have significant testing experience. The same goes for psychiatrists. People in our program were given a general course and then the choice of taking it up a notch. Some did, some decided to do something else instead.

 

[Therapist4Chnge]

Links? I have yet to see a Counseling MA/MS program that offers a comparable, experiential course in psychological testing/assessment (i.e., one that involves multiple observed/reviewed administration, scoring, and write-up sessions), though I've seen a lot of programs that have more broad, general "testing" courses that don't cover the instruments in comparable depth, or, even if they might, don't provide the actual hands-on training and supervision a PhD/PsyD course would. *curious*

I've guest lectured in MA/MS assessment courses, and they are nothing like the doctoral version. The depth and breadth are much different. Almost none of the supporting stats were covered, which is a big consideration in test selection and interpreting. The course is basically, "here are some common personality assessments. Here are some IQ measures, etc." Most of the common psych assessments are not difficult to administer, but the interpetation and integration of the data is another matter.

 

[whopper]

My own psychotherapeutic approach begins with supportive psychotherapy, but based on what I see or hear, I will consider adding elements of other therapies.

IMHO, unless you truly read up on psychotherapy, you cannot truly master it. My wife is reading Linehan's books, and teaching me how to do DBT, and, well let's just say at least for me, if you read it for real, it's as mind-blowing and opening as learning about the theory of evolution, or genetics. I haven't even thought of some of the approaches in the Linehan books until reading about them, and if you understand it, it makes sense. I've also had far more success with borderline PD patients than I've had before.

I still don't think I'm good enough to do the DBT myself. I'd place myself at the Luke Skywalker at Ep IV. I realize how great it can be, I've done a little of it, but I still have a long way to go.

 

[sunlioness]

As for psychologists, their skills and training don't necessarily always make them good psychotherapists either. Just as we are trained in a medical model and may overly rely on it, I've seen several psychologists overly relying on statistics from a population standpoint and not being able to detect what's going on with the individual patient.

Yeah, I have noticed this as well. In my totally anecdotal, non-scientific not-designed to offend anyone experience, the psychotherapy I've been most impressed with has often been provided by LCSWs. Don't know why this would be, if it's a local thing or a me thing or what, but I've found it interesting.

So I've wondered about that. If maybe psychiatrists just are the best at medications and patients with complex medical issues and psychologists at testing and assessment, while the best actual psychotherapists are masters levels. Which I kind of don't want to be the case, but I've seen enough to wonder about it. 🙂

 

[Manicsleep]

Yeah, I have noticed this as well. In my totally anecdotal, non-scientific not-designed to offend anyone experience, the psychotherapy I've been most impressed with has often been provided by LCSWs. Don't know why this would be, if it's a local thing or a me thing or what, but I've found it interesting.

So I've wondered about that. If maybe psychiatrists just are the best at medications and patients with complex medical issues and psychologists at testing and assessment, while the best actual psychotherapists are masters levels. Which I kind of don't want to be the case, but I've seen enough to wonder about it. 🙂

Maybe its a local practice issue? Maybe they just do more therapy.
I have noticed that in the local groups here psychologists have been replaced by LCSWs, MFTs and even psych techs (inpatient) in order to save money. I was initially against it but there have not been any actual problems. I am still not sold but it is the wave of the future.

The best therapists I have seen were all psychiatrists or psychologists. Hard to argue one over another because style has so much to do with it. If the patient was otherwise healthy and didnt need meds, I think the psychologist is always the way to go because of cost and vice versa with complicated patients going to psychiatrists, even for psychotherapy.

I have worked with some good psych techs and LCSWs in groups but its not the same. I do my own psychotherapy a lot of the times and until recently had psychologists working in our group who did therapy. The LCSWs are ok but by no means superior.

 

[sunlioness]

I was thinking about this more after I posted and I think it's probably because the LCSWs I know have been in practice longer than the psychologists I know. So it's probably mostly a question of years of experience.

 

[whopper]

Maybe its a local practice issue? Maybe they just do more therapy.

I think it's a combination of factors.

Medical doctors get so much hammering of biological therapies. Several non-psychiatrists have been critical of psychiatrists for using non-biological treatments even though the data clearly supports that multimodal treatments are more effective than just medication alone.

(And of course the non-psychiatrists who fit my demographic usually don't even know what the #uck they're talking about. It's not like they have data pointing to their opinion as right. It's clearly a case of egocentricism and narcissism. They think their way has to apply to every field, nor do these doctors appreciate that psychotherapy is an important element of even non-psychiatric medical practice.)

As for psychologists, there's so much emphasis on statistics. Remember, psychology is the study of the human mind in general, not just treating people.

There's so much data, one could establish a niche within a specific area while losing sight of the whole picture. Take a look at House for example. He's an expert at what he does, but he has no bedside manner, and that too is an important element in treating the patient.

And maybe that's why some people get so good at one specific niche....The human mind can only know so much.

As for LCSWs, I know little of their training in psychotherapy, nor do I know much of them in general. I've only worked with 1 who did psychotherapy and I wasn't impressed. I had one of her patients come into my unit who had severe borderline PD. The LCSW did psychotherapy on this patient for 3 years. I asked her to come to the treatment team meeting because I wanted to touch base and figure out how far the patient progressed in her psychotherapy. I had some strong concerns about why a patient who had undergone 3 years of psychotherapy was now extreme in her mental illness to have to be hospitalized in a long-term facility despite not having a history of being to this extreme.

Turned out the patient and the LCSW said there pretty much was no improvement at all after 3 years. The LCSW didn't even know what DBT was, and wasn't focused on reducing the patient's self-destructive behaviors. The LCSW couldn't identify that the patient had borderline PD, after 3 years of seeing the person. I came to a conclusion that the psychotherapy was more of the LCSW hand-holding the borderline in a possibly destructive manner...e.g. the LCSW gave positive emotional support anytime the borderline pt acted out, thus reinforcing the borderline's acting out (she gets emotional reward anytime she makes a suicidal threat).

No rub against you Sunlioness...that's just been my experience on just 1 LCSW.

 

[billypilgrim37]

So, in summary

a) there are a variety of people who suck at psychotherapy
b) there are a variety of people who rock at psychotherapy
c) the letters after your name account poorly for therapist quality
d) psychiatrists aren't allowed to say anything bad about psychologists no matter what

 

[Manicsleep]

So, in summary

a) there are a variety of people who suck at psychotherapy
b) there are a variety of people who rock at psychotherapy
c) the letters after your name account poorly for therapist quality
d) psychiatrists aren't allowed to say anything bad about psychologists no matter what

I know I know...D!!!

Did I get it right?

 

[whopper]

Say what you want against psychologists so long as its fair and true IMHO. Problem with our board is with the occasional psychologist-prescription debate, some psychiatrists take it a step further and try to demean their entire profession (remember the majority of psychologists don't even want to prescribe).

I think the 2 main variables that correlate with good psychotherapy are 1) if the therapist actually knows how to do the right type of psychotherapy for the disorder and 2) if the therapist actually cares to do a good job (which logically leads to other things such as being a good listener). This is with the strong emphasis that the "caring" has to be within professional boundaries.

For several disorders such as depression, the type of psychotherapy often does not matter, nor does the level of training, and that is verified in studies. In those cases, the therapist has to care about the patient. For others, such as borderline PD, the type of psychotherapy does matter, and you have to know how to do it. Further you actually have to care about what you're doing. This is not easy because it could emotionally taxing.

Anyone can conduct psychotherapy like that quack from There's Something About Mary. That's where I noticed where several psychotherapists fail. As for the training, IMHO, based on the level of training I've seen in several programs, psychiatry or otherwise, that is just the beginning. You really have to make it a lifelong learning process. Maybe after a few years you might be decent. IMHO a psychiatrist who only gives meds, and only cares on that level certainly won't reach the "decent" status.

I think several therapists confuse giving a damn about their patient with countertransference, and equate all countertransference as bad. So in effect, they believe they shouldn't care about their patient--at all, except to fulfill the minimal obligations of their job. I think we have to put some passion into the job, feel proud when we get patients better, and if we aren't making progress, allow it to stir some emotional desire to want to dig deeper and figure out what's not working. This is very different from trying to be their friend, or becoming close to the patient in a manner that violates professional boundaries.

a) there are a variety of people who suck at psychotherapy
b) there are a variety of people who rock at psychotherapy
c) the letters after your name account poorly for therapist quality

Exactly.

 

[Cinnameg]

I agree with IamAUser that you will be miserable. I know I am. But you have to ask yourself: how happy are you now and how sure are you about psychiatry? I was miserable before med school, working in the most boring profession in existence (biostatistics), so I thought, what's an extra 5 years (med school + intern year) to do what I really enjoy?

Every situation is different. For me being a psychiatrist is just that alluring that I am willing to put up with this much unhappiness. I have to threaten myself mentally with failure in order to study most days, and it's taxing.

Amen to that. I went to medical school to be either a psychiatrist or a neurologist -- nothing else -- and now I'm almost done. It's been a chore the whole way. Worse, both psychiatry and neurology are somewhat marginalized medical fields, and telling people (only when asked, but replying honestly) during my 3rd year rotations that I was trying to choose between the two led to a lot of shrugs and some snarky comments. The first two years were the hardest because I was bored in almost all of the classes, with the notable exception of "neuroscience & behavior." I really like knowing everything I know now about human physiology and pathology, but learning it was no fun, and because of my low interest I did not learn it as well as my classmates and am not very high-up in my class. Third year was better because there were patients with psych or neuro problems in most other specialties, and residents who knew my interests would assign me these patients. But overall, knowing what I know now about medical school, I'm not sure I would do it again. After I am in residency and working with the diseases I love every day, I may say that medical school was worth it, but right now, contemplating yet another year (MS4) of not quite doing what I want to do, it's hard to make the case. Realize that if your passion is mental health, the medical school route will be an exercise in patience and extremely delayed gratification.

 

[Daftrage]

Another point is that you may get to medical school and realize just how much you do like other aspects of the field. I came thinking pysch and ultimately have come back to deciding that as a career. But along the way I really enjoyed several fields of medicine (just not Surgery or OB/GYN). That isn't to say that the work is not daunting and will consume you at times, but overall I am grateful that I have had the experience to learn all these other fields if for no other reason I can provide an added level of support and education to my family members in almost all aspects of medical care.

 

[cyneuron]

another point is that you may get to medical school and realize just how much you do like other aspects of the field. I came thinking pysch and ultimately have come back to deciding that as a career. But along the way i really enjoyed several fields of medicine (just not surgery or ob/gyn). That isn't to say that the work is not daunting and will consume you at times, but overall i am grateful that i have had the experience to learn all these other fields if for no other reason i can provide an added level of support and education to my family members in almost all aspects of medical care.

+1

 

[whopper]

the medical school route will be an exercise in patience and extremely delayed gratification.

The delayed gratification is on the order of years. IMHO, the most anyone should hold themself to is months unless you can enjoy the journey.

I hated medical school, and I took a year off. Hating medical school was a large factor in my time off. I needed time to just feel decent again. Several interviewers did not like that, though IMHO, it shouldn't have made a difference.

 

[AcronymAllergy]

I was thinking about this more after I posted and I think it's probably because the LCSWs I know have been in practice longer than the psychologists I know. So it's probably mostly a question of years of experience.

I'd imagine that you're largely correct, and that in many instances, it might be attributable to both experience and desire/interest. Nowadays, it seems as though a good number of people entering LCSW programs are specifically wanting training in psychotherapy. The same can not always be said about clinical psych programs.

As someone else mentioned in another post, psychology--even clinical psychology--is still prevailingly a research-oriented profession as far as many people are concerned. Thus, even in my program, a good proportion of the individuals around me have no, or very limited, interest in pursuing clinical practice after graduation.

 

[sunlioness]

No rub against you Sunlioness...that's just been my experience on just 1 LCSW.

No rub taken. That one you know sounds awful. And I know very little about how they are trained as well.

 

[Therapist4Chnge]

I'd imagine that you're largely correct, and that in many instances, it might be attributable to both experience and desire/interest. Nowadays, it seems as though a good number of people entering LCSW programs are specifically wanting training in psychotherapy. The same can not always be said about clinical psych programs.

As someone else mentioned in another post, psychology--even clinical psychology--is still prevailingly a research-oriented profession as far as many people are concerned. Thus, even in my program, a good proportion of the individuals around me have no, or very limited, interest in pursuing clinical practice after graduation.

The majority of Ph.Ds go on to conduct therapy, not research. However, I think with insurance companies looking towards lower-cost providers/reimbursements, it is a less viable option now, and it will continue to be a poor option.

 

[Manicsleep]

Amen to that. I went to medical school to be either a psychiatrist or a neurologist -- nothing else -- and now I'm almost done. It's been a chore the whole way. Worse, both psychiatry and neurology are somewhat marginalized medical fields, and telling people (only when asked, but replying honestly) during my 3rd year rotations that I was trying to choose between the two led to a lot of shrugs and some snarky comments. The first two years were the hardest because I was bored in almost all of the classes, with the notable exception of "neuroscience & behavior." I really like knowing everything I know now about human physiology and pathology, but learning it was no fun, and because of my low interest I did not learn it as well as my classmates and am not very high-up in my class. Third year was better because there were patients with psych or neuro problems in most other specialties, and residents who knew my interests would assign me these patients. But overall, knowing what I know now about medical school, I'm not sure I would do it again. After I am in residency and working with the diseases I love every day, I may say that medical school was worth it, but right now, contemplating yet another year (MS4) of not quite doing what I want to do, it's hard to make the case. Realize that if your passion is mental health, the medical school route will be an exercise in patience and extremely delayed gratification.

The "marginalizing" of psychiatry is decreasing significantly. The program where I trained has had 1-2 AOA people 6 out of the last 8 years.
I think if you choose psychiatry residency, you may want to choose a program that is well respected regionally (its often better to be the best regionally than be top tier nationally), has a strong research program and a strong psychotherapy program.
Also, picking a program with a lot of fellowships and a combined residency can go a long ways because that means you have a lot of experts plus some people who train in multiple fields and do some education in the other fields.

However, don't be afraid of the stigma. This is going to be an exciting decade to train in psychiatry, I think we are about to move into the next level and make that mind-brain interface tangible.

 

[urnextshrink]

My experience as a mental health underling (outpatient case manager) is what has led me to want to go to med school to train as a psychiatrist and NOT get a Ph.D. in psych., Psy. D., or MSW, even though if I had to choose I'm probably more into therapeutic philosophies/techniques than psychopharmacology, let alone the many other somatic matters I'll hopefully be forced to learn in med school.

For me it's a mix of ego and the desire to be as relevant to a patient's care as possible if I'm going to be in this field. In in-patient units the psychiatrists run the show, full stop. Just last week I was in a treatment planning meeting at the local state hospital, when it was decision time for diagnosis and discharge date, everybody, including the psychologist, shut their mouths and turned to the psychiatrist to see what decisions she would make. Yes that's anecdotal but I encounter this sort of thing weekly, and I'm only in units for 1-2 hours each week.

It's not quite like that in the out-patient community mental health clinic where I work but that's because the docs are not employees but contractors, so sure they do what their told by the clinical director (a veteran LCSW) but they are only there 10-20 hours a week, are never on call, and are immensely respected in the workplace. The only way you could get fired is medicaid fraud.

The psychologist at my clinic has changed positions three times in the past 3-4 years because they like her and they keep having to attempt new and creative ways to pay her salary.

A lot of this probably has to do with medicaid reimburement rates so I can see some variations occurring in place otherwise funded, but bottom line for me is that if I'm going to go into a field like mental health I want to be the person who needs to be in the room for the important decisions to be made.