Psychiatry as a second residency?

[jankymutt]

I'm a burned out ER physician looking for a new career path. I was exhausted before covid, but even as we round the corner from the pandemic I am still feeling lost and disinterested in my job. For the past year I have been working part-time in addiction medicine and have really enjoyed this work. I find the work fascinating and rewarding. I have been able to get a few part time jobs with my credentials, but most full time jobs want a board certified psychiatrist so I am considering going back to do a psych residency.

My hesitancy lies in that I am 40 years old with a wife and baby on the way. My wife is also a full time physician, but planning on becoming per diem after the baby. Going from my attending salary to a residents salary (especially if I can't moonlight for a year or two) would be financially difficult, but not impossible. My psychiatrists friends are telling me I'm crazy for considering this and are encouraging me to look at addiction medicine fellowships or the clinical pathways (before they close) for board certification in addiction medicine.

Does anyone have any experience or insights on going back to do a second residency? I am wondering if I could get any credit for the PGY1 year from my 4 year ER residency (a lot of the rotations are the same)? Is losing 3-4 years of attending pay in my 40's crazy? Is the addiction fellowship/board certification enough to land me a full time addiction medicine job? Thanks in advance for any help, suggestions, insight!

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[Ole_Toe]

Can you share any insight into why you are burned out by ED work? Residency is rarely the answer to burnout as I’m sure you’ve already considered. Also the patient and social issues that can cause a lot of docs to get burned out in the ED are foundational to much of psychiatry, at least at the resident level.

If I’m understanding you correctly, you would go back for 4 years of psychiatry residency and then an additional year of fellowship?

No one is ever going to recommend this for obvious reasons, especially when you have a family. The practice pathway sounds promising for you. Have you thought about academics? Financially you could moonlight or do UC 3 days a month and end up ahead.

Hope you find a cure for burnout whatever it may be. I would just be nervous about digging myself into a deeper hole in that regard

 

[jankymutt]

Can you share any insight into why you are burned out by ED work? Residency is rarely the answer to burnout as I’m sure you’ve already considered. Also the patient and social issues that can cause a lot of docs to get burned out in the ED are foundational to much of psychiatry, at least at the resident level.

If I’m understanding you correctly, you would go back for 4 years of psychiatry residency and then an additional year of fellowship?

No one is ever going to recommend this for obvious reasons, especially when you have a family. The practice pathway sounds promising for you. Have you thought about academics? Financially you could moonlight or do UC 3 days a month and end up ahead.

Hope you find a cure for burnout whatever it may be. I would just be nervous about digging myself into a deeper hole in that regard

Great questions!

When I got into EM 10 years ago the field was completely different. After residency I worked and then ran a private ER group. It was tough work, but rewarding because emotionally and financially. Like any private practice, our income was directly correlated with our billing. Fast forward 10 years and finding a job in a private ER group is difficult and sometimes impossible depending on geographic location. Also, as I get older it is getting more and more difficult to do multiple night shifts. Missing family time by working nights/holidays/weekends is also less appealing.

Working for corporate groups where shareholder profit at the expense of the physicians is unacceptable to me. These groups are hiring a few docs that have to supervise multiple mid-level clinicians. The patient care is atrocious. The med-mal liability is high and the pay is low. Working for a hospital group is better, but still a mediocre hourly rate with little autonomy in my daily practice. I have not considered pure academic medicine, but if you look at academic emergency medicine the daily life is tough. ER docs at academic institutions still work nights/holidays/weekends and put in a lot of teaching hours that are not well compensated, if at all.

During my 10 year career I have found myself really enjoying caring for the mental health patients, especially the Axis I and II patients. Every ER seems to have a plethora of mental health patients with few mental health resources.

Your point about the financial issues is well understood. The concern I have with trying to do more addiction/mental health medicine without a fellowship is that more and more jobs seem to be migrating towards mid-levels (in all fields).

 

[dl2dp2]

1. addiction medicine fellowship is your quickest way out. I know and have worked with several ER docs who transitioned this way. Best jobs bet after would be an inpatient detox/rehab facility, as demands for psychotherapy and psychiatric co-morbidity is low in these settings (more severe psychiatric conditions get sent out to dual diagnosis units).

Some outpatient jobs also staff addiction medicine physicians (suboxone/methadone groups, etc). Best outpatient addiction jobs are typically psychiatry focused as there's often a psychotherapy/comorbidity component. It is also much easier to set up a solo/small group practice with psychiatry training. But either way I think getting an addiction job is not a huge concern. Keep in mind though that the facility-based addiction jobs typically have a salary ceiling ~ 300k in major metros.

2. psych residency itself is not terrible from an income perspective. You can probably get out of most of 1st year, so you are left with year 2 and 3. Year 3 is typically fairly light mostly outpatient work with some call. From year 3+ you can moonlight, potentially bumping your income to 100k range. You can of course moonlight as an ER doc.

This is not uncommon as there are plenty of older psych residents floating around. Main issue is matching, etc. but if you live in a big metro there are often some open spots at community hospitals to match as PGY2. I don't think it's crazy to transition to psych in your 40s because psychiatrists typically have a VERY long work span vis-a-vis other medical careers, and you can work as a physician well into your late 60s/70s, and part-time work is also plentiful. The alternative, in general, in my experience, is the ER doctor works till 50 and completely retire (from medicine--maybe do something else on the side). I think these are the choices you are looking at.

 

[Sushirolls]

Option 3:
Go open your own private practice now, cash only, and emphasize psychiatry interest.
Open a practice, do what you want with it, make it yours, keep your overhead very low to start with an executive suite or something similar and see what happens.
Get liability insurance as a GP?

This cow is already in the pasture you are thinking of grazing in, and I'm eyeballing an exodus from medicine to be a full time rancher/farmer.

Good luck in whatever you decide.

 

[FlowRate]

I guess I'm still a little unclear as to what outcome you want or your priorities there. I get that you dislike EM work right now from multiple angles--corporatization/VC/PE takeover, downsides of 24/7 ED coverage, etc. Are you just wanting to work days? Better pay? Not cover midlevels? Do you "like" body medicine? Mind medicine is very fuzzy in comparison.

 

[Sushirolls]

To piggy back off that, what are the long term goals:
Practice till you die or medical license yanked?
Retire early?
Work until normal retirement?
Trying to live in specific geographic area?

 

[SubzDoc]

One of my mentors, and my first employer after residency, was an ED doc who burned out and transitioned to an addiction job. Knew a lot about psych and one of the best physicians I ever met. He was not addiction boarded but had done that same job for many years. In that location (small city, not a competitive market), there were any number of doctors from other specialties (EM, OB, FM) doing addiction work, with our without an addiction board cert.

Now I live/work in a larger city, more competitive market. And I'm responsible for some of the hiring for addictions. I briefly looked into hiring an FM doc who wanted an addiction job and was told we can't, all addiction jobs are under the umbrella of the mental health department and we can only hire psychiatrists. I believe this can also be the case in some other large systems, they would want to be hiring a psychiatrist for many addiction positions and, in some cases, would want an addiction board cert as well (through ABPN or ABPM).

The bottom line is I think this is somewhat dependent on your market and what kind of job you are looking to do, as suggested above. You are early in your career and, in the future, I think more and more employers are going to want addiction certification. But depending on your circumstances there can still be room to carve a niche for yourself. Doing another residency isn't just crazy talk but it's a lot more training for someone who is already a board-certified physician. You sincerely have my best wishes.

 

[Sushirolls]

I wonder if OP could actually get a job with the Psych ED that are embedded in the larger metros?
Admit / Observation / Discharge are the only observations.
ED docs are already doing Admit / Discharge for acute psych issues anyways in many EDs. Not exactly out of practice scope?
This might be the least painful way to get out of ED and into Psych?

 

[Celexa]

I'm a burned out ER physician looking for a new career path. I was exhausted before covid, but even as we round the corner from the pandemic I am still feeling lost and disinterested in my job. For the past year I have been working part-time in addiction medicine and have really enjoyed this work. I find the work fascinating and rewarding. I have been able to get a few part time jobs with my credentials, but most full time jobs want a board certified psychiatrist so I am considering going back to do a psych residency.

My hesitancy lies in that I am 40 years old with a wife and baby on the way. My wife is also a full time physician, but planning on becoming per diem after the baby. Going from my attending salary to a residents salary (especially if I can't moonlight for a year or two) would be financially difficult, but not impossible. My psychiatrists friends are telling me I'm crazy for considering this and are encouraging me to look at addiction medicine fellowships or the clinical pathways (before they close) for board certification in addiction medicine.

Does anyone have any experience or insights on going back to do a second residency? I am wondering if I could get any credit for the PGY1 year from my 4 year ER residency (a lot of the rotations are the same)? Is losing 3-4 years of attending pay in my 40's crazy? Is the addiction fellowship/board certification enough to land me a full time addiction medicine job? Thanks in advance for any help, suggestions, insight!

What about palliative care? Shorter time, drastic change of pace from the emergency room.

I think you could probably find a psych residency to take you--I've known several late career switchers--but as you say it's not a trivial amount of time.

I don't think it's crazy to think about it, though. Psych job market is vastly better than EM, and much less physically demanding so potentially prolongs your earning years if you're happier working and retire later. I'm happy with my specialty choice.

 

[hallowmann]

If your main reason of doing psychiatry is to get an Addiction Med job, I don't think you should do it. Either do a 1 yr AM fellowship (during which you can often moonlight) or build up the hours for practice pathway (but do it now). If after that you still feel you are missing something, then you can always go back then for a second residency. At least then you'll achieve some balance/stability with the new baby and wife's reduction in compensation, and you could more realistically approach this decision.

 

[liquidshadow22]

Definitely not worth it. Become a psych NP prob takes less time haha.

 

[Monocles]

I would strongly against ANYONE from doing a second residency, especially for one who burnout is a huge factor.

Is losing 3-4 years of attending pay in my 40's crazy?

Yes 100%. Go for some sort of a 1 year addictions medicine fellowship at most.

 

[comp1]

There's no need at all to do another residency. Your skills would easily transition to working in a wide variety of substance abuse related settings. Honestly, call up your local methadone clinic and I'm betting you'd have a job before you got off the phone.

 

[jankymutt]

Option 3:
Go open your own private practice now, cash only, and emphasize psychiatry interest.
Open a practice, do what you want with it, make it yours, keep your overhead very low to start with an executive suite or something similar and see what happens.
Get liability insurance as a GP?

This cow is already in the pasture you are thinking of grazing in, and I'm eyeballing an exodus from medicine to be a full time rancher/farmer.

Good luck in whatever you decide.

This is a great idea and something I have thought about, but it is scary and an endeavor I need to research more.

I guess I'm still a little unclear as to what outcome you want or your priorities there. I get that you dislike EM work right now from multiple angles--corporatization/VC/PE takeover, downsides of 24/7 ED coverage, etc. Are you just wanting to work days? Better pay? Not cover midlevels? Do you "like" body medicine? Mind medicine is very fuzzy in comparison.

Great questions. At it's core, I enjoy emergency medicine, but currently the medicine is just peripheral. Instead, I am worried about seeing enough patients to meet metrics, seeing patient's fast enough, having to sign MLP charts without actually seeing their patients (literally impossible with how busy these departments are), getting reprimanded because of a bad patient satisfaction review, etc..etc.. Part of the problem is my location. I work in a busy metro area. If I practiced in rural part of the country I probably wouldn't have to worry about the above mentioned issues. I likely could spend more time with my patients and actually be able to spend 10 minutes figuring out their diagnosis instead of shotgunning a dozen tests blindly.

e the long term goals:
Practice till you die or medical license yanked?
Retire early?
Work until normal retirement?
Trying to live in specific geographic area?

Unfortunately, with family, moving is not an option right now. So I'm trying to find a career in medicine that I can enjoy and provide me longevity in my busy New England metro area. If someone handed me $50 million tomorrow I would not be pursuing addiction medicine or psychiatry. It's just a niche of medicine that I have come to enjoy and think I'd be happy working in that field for years. I don't have a desire to retire early, but don't want to work till I'm 90. I think a normal retirement age would be satisfactory.

 

[jankymutt]

Definitely not worth it. Become a psych NP prob takes less time haha.

This hurts my soul, but is likely accurate!

 

[jankymutt]

I wonder if OP could actually get a job with the Psych ED that are embedded in the larger metros?
Admit / Observation / Discharge are the only observations.
ED docs are already doing Admit / Discharge for acute psych issues anyways in many EDs. Not exactly out of practice scope?
This might be the least painful way to get out of ED and into Psych?

I did not think of this but will definitely investigate!

 

[ObsequiousAplomb]

You could also do something much less stressful, like be the internist at a state psychiatric hospital. I know a few who are emergency medicine trained that do it. Pay isn't great, but the work is nowhere near as much of a grind. Same thing with working for a department of corrections.

 

[MacDonaldTriad]

We have had one ER Medicine attending who did ER medicine for about 10 years and then did 4 years of psychiatry training to change specialties. He seemed happy and wrote a book about his psychiatry training. It was about his former training and how it gave him a special perspective in psychiatry. I have no doubt this is true. It seems to me that 4 years of returning to training is hard to shallow and you have to be sure. None the less, there have been people who are happy to have done it. Within my own family, I have example of a doctor who completely changed specialties. It was painful, but it was also motivated by external forces that mandated a change and a need to move on in a direction that was new.

 

[Candidate2017]

Why do a psych residency?

Just open a psych clinic and hire new grad psychiatrists and NPs to labor away for you. There are lots of social workers who do this. Even patients can get into the psych business. The Cerebral online psych startup, which raised billions of dollars, was founded by a patient. Given your flexible schedules, there's no reason why an EM physician or group of EM physicians can't pool their time and money to start a psych clinic. At the very least, you guys know what a psychiatric emergency looks like.

 

[nexus73]

Palliative care seems like a low burnout job, potentially. You may or may not need the 1 year fellowship to get a job. My guess is a lot of hospices in smaller and mid size towns can't get a fellowship trained palliative care doc and your work as an ED doc, plus some reading/conferences, would get you up to speed to get a hospice job.