Having a hard time deciding between the two. Any advice from people who may have had a similar problem?
Psychiatry VS EM
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I haven't known many people torn between the two. They are so diametrically different. I've known one to be exact that he was a psych resident trying to switch to EM (unsuccessful). Analyze what attracts you to each field. Psych does pretty well these days I believe. Huge need, salaries are good, lower stress than EM. (Assuming you can tolerate psychiatry.)
One of my psych attendings in med school was an ex surgeon who had gone back after a few years and completed a psych residency. When I asked him about it, he said he gets paid almost as well, has much lower stress and much better quality of life. For him, he didn't miss the surgery but that seems like an extreme career change to me. He was a very cool dude.
You might have better luck asking on the psych forum.
One of my psych attendings in med school was an ex surgeon who had gone back after a few years and completed a psych residency. When I asked him about it, he said he gets paid almost as well, has much lower stress and much better quality of life. For him, he didn't miss the surgery but that seems like an extreme career change to me. He was a very cool dude.
You might have better luck asking on the psych forum.
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psych
pros: lifestyle, salary
cons: you have to practice psychiatry
pros: lifestyle, salary
cons: you have to practice psychiatry
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You have to deal with a tremendous amount of psychopathology in EM. As much as you think you can side step it and be problem focused, you still spend much of your time "focusing" while trudging through strong & messy headwinds of psychopathology. Yes, the specialties are different, but I don't think they're nearly as different as the uninitiated think they are.
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deleted859535
Once heard someone quote a study where allegedly, some 30% of ED cases directly or indirectly involve psychiatric issues.
Some days that sounds too low.
Some days that sounds too low.
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This isn't even the first thread on SDN EM asking this. To diametrically oppose my colleague, above, psych and EM are very close, due to very many of the patients being, of some sort, psych.
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Yet psychiatrists, completely unbound by EMTALA, get to pick and choose which cash paying, upper middle class patients they want to see and decline seeing the rest, which inevitably filter through the ED at some point, with their festering psychopathological baggage in tow.
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I mean... yes we see a lot of psych but that doesn’t make us psychiatrists. The medicine is totally different. One specialty has tons of procedures. The other...what..ECT? The inpatient management is totally different and outpatient...we don’t even have outpatients. I think our exposure and management of psychiatric dz in the ED adds a false perception that we do a lot of “psychiatry” when in reality I don’t consider any of what we do to overlap with what I remember from med school psychiatry rotation.
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Psych: continuity of care with the pros/cons of that, you can slowly help people make good changes in their lives, more even keeled daily life, no procedures, great lifestyle, can have near total control over your practice environment with the pros/cons of having your own practice
EM: you can be free of any patient once you discharge or admit them, you can quickly make a dramatic save (for a select few of your patients) which can yield substantial satisfaction, there are also big lows as you will see the raw underbelly of humanity in a way few others will, cool procedures, you will have little control over your practice environment with the silver lining being that when your shift ends you can turn your brain off about work until the next shift. Also, you'll be the man/woman when the zombie apocalypse cometh.
EM: you can be free of any patient once you discharge or admit them, you can quickly make a dramatic save (for a select few of your patients) which can yield substantial satisfaction, there are also big lows as you will see the raw underbelly of humanity in a way few others will, cool procedures, you will have little control over your practice environment with the silver lining being that when your shift ends you can turn your brain off about work until the next shift. Also, you'll be the man/woman when the zombie apocalypse cometh.
I don't think anyone is implying that we practice psychiatry or anything of the sort, just that we deal with a lot of psychiatric patients, even if their chief complaint isn't psychiatry-related that day. In that way we get a lot of the cons of psychiatry (the patients' psychopathology) without any of the pros.
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You've been a member since 2006
have over 1,500 posts
and you are still deciding between the two?
Are you in the 10 year medical school program?
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Perhaps you would get somewhat more useful responses if you went into more detail about what you like about each specialty and what your exposure to them have been.
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I personally was very drawn to inpatient psych for the bursts of acuity and watching the effect of interventions. Ultimately I went EM because I liked having the more varied toolbox of skills and like using my hands.
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Yes, there is a difference between "doing" psychiatry, which consists of treating a never ending stream of psychopathology, then watching & waiting for improvement, and "seeing" psych in the ED, which consists of being subjected to the effects of a never ending stream of psychopathology, without the hope or expectation of ever being able to treat it. Which is better, I suppose, is a matter of personal taste.
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Silver lining: For those in the business of "doing" or "seeing" psychopathology, business has never been as good as it is now, in this Golden Age of psychopathology.
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Things in common between EM and psych:
Pros:
- great pay
- great lifestyle
- fulfilling work
Cons:
- both get **** on by other specialities quite frequently
EM specific pros:
- you get the whole spectrum of medicine
- you work with your hands
- instant gratification for a lot of diseases
- shift work, don’t have to deal with stuff outside of the hospital.
Cons:
- burnout is high
- not many docs practicing in their late 50s
- the constant sleep flip flop can be quite miserable from why I hear
- you don’t really have a private practice in the same sense other docs do, but you can open and own UCs if you want
- you deal with a lot of BS patients (comes to the ED bc his chiropractor took his BP and it was 140/90, suture removal, drug seekers).
- you aren’t really a specialist (I know some EM people will disagree with me on this). I think EM are specialists in acute care situations, but they aren’t really specialists in the sense that they “own” an organ system.
Psych pros:
- lots of opportunity and growing due to shortage
- you don’t work with your hands (if you like this)
- you can open up PP, you can do shift work, you can do cash practice. A bit more variety in kind of work vs EM in my opinion.
- the option to do telepsyhiatry from home
- low burnout rate
- lots of psychiatrists practice at much older ages.
- you are a specialist.
Cons:
- insurance reimbursement is lower, they give you a much harder time.
- though not as physically exhausting, definitely can be very emotionally draining.
- you don’t deal with organic disease as much. Granted lots of organic stuff can cause mental health issues, but you’re not gonna be prescribing antibiotics for the UTI anymore.
- lack of instant gratification in a lot disease states
- public confusion about what you are (psychologist? So are you a doctor? So you’re a therapist? Oh you went to med school?)
- stigmatized
Overall though, if you like mental health... consider psych, if you don’t like psychopathology then honestly you’ll be pretty miserable.
Good luck!
Sent from my iPhone using SDN mobile
Pros:
- great pay
- great lifestyle
- fulfilling work
Cons:
- both get **** on by other specialities quite frequently
EM specific pros:
- you get the whole spectrum of medicine
- you work with your hands
- instant gratification for a lot of diseases
- shift work, don’t have to deal with stuff outside of the hospital.
Cons:
- burnout is high
- not many docs practicing in their late 50s
- the constant sleep flip flop can be quite miserable from why I hear
- you don’t really have a private practice in the same sense other docs do, but you can open and own UCs if you want
- you deal with a lot of BS patients (comes to the ED bc his chiropractor took his BP and it was 140/90, suture removal, drug seekers).
- you aren’t really a specialist (I know some EM people will disagree with me on this). I think EM are specialists in acute care situations, but they aren’t really specialists in the sense that they “own” an organ system.
Psych pros:
- lots of opportunity and growing due to shortage
- you don’t work with your hands (if you like this)
- you can open up PP, you can do shift work, you can do cash practice. A bit more variety in kind of work vs EM in my opinion.
- the option to do telepsyhiatry from home
- low burnout rate
- lots of psychiatrists practice at much older ages.
- you are a specialist.
Cons:
- insurance reimbursement is lower, they give you a much harder time.
- though not as physically exhausting, definitely can be very emotionally draining.
- you don’t deal with organic disease as much. Granted lots of organic stuff can cause mental health issues, but you’re not gonna be prescribing antibiotics for the UTI anymore.
- lack of instant gratification in a lot disease states
- public confusion about what you are (psychologist? So are you a doctor? So you’re a therapist? Oh you went to med school?)
- stigmatized
Overall though, if you like mental health... consider psych, if you don’t like psychopathology then honestly you’ll be pretty miserable.
Good luck!
Sent from my iPhone using SDN mobile
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deleted109597
Other alternative was signing up as a freshman in high school, or doing a MD/PhD.
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Life has never been better for human beings since humans were created. 5,000 years ago we wore animal skin and lived in huts and caves. 200 years ago we had no electricity, running water, food was still scarce and all chores were done by hand. 100 years ago, antibiotics weren't invented and if you got a bacterial infection you either died or that organ system rotted out. 50 years ago the civil rights movement hadn't even hit full swing yet, cell phones didn't exist, nor computers or the internet.
The human condition has steadily, undeniably and dramatically improved and continues to do so. Despite that, psychiatric disease and the inability to deal with that life, appears to be as prevalent, if not more, than ever.
The human condition has steadily, undeniably and dramatically improved and continues to do so. Despite that, psychiatric disease and the inability to deal with that life, appears to be as prevalent, if not more, than ever.
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Bird, you're getting way to philosophical with all this extra time in your new gig!
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So far, this is what I've come up with:
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Maybe I am misreading what you are saying, but it feels like you are throwing some subtle shade on psychiatry or people with psychiatric conditions. Almost feels like you are implying a lot of these diagnoses are not real somehow. Please correct me if I am wrong though.
But taking what you said at face value...
Cancer is also more prevalent than ever before. Not because cancer care or health in general has gotten worse, but exactly because they have gotten better. We live long enough to get cancer, and live longer with cancer.
Psychiatric disease is more prevalent in the 21st century in large parts because:
1) We now try to diagnose and treat things that people in the past would have to just suffer with. This is good. We are reducing suffering. You can say we are just arbitrarily changing definitions, but if the changing of definition to broaden a certain category leads to decreased suffering through treating more people, I'd argue that's a good thing.
2) We are treating but not curing (unlike with your example of infectious disease, which are on the decline). Maybe one day there will be a cure for some psychiatric diseases, but for now we are just treating. This is still better than not treating though.
3) People are surviving things that would have been unsurvivable in the past. If you had a severe thought process disorder to the point that you are not functional, at many points in the past you would just die because you are ostracized and unable to fend for yourself. Now many of these people have their symptoms controlled. Yes, it increases prevalence, but in a good way.
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To clarify, I respect the field of psychiatry greatly and I believe psychiatric illness is real and deserves care, attention and treatment. Psychiatrists do a great job helping patients in need and those patients deserve our utmost respect.
I'm made an observation that probably has nothing to do with psychiatric illness at all, but likely does have a psychological explanation. I don't fully understand why, but it seems undeniable that the conventional wisdom in every generation is that "the world is going to hell," that "things just aren't as good as the good old days" that "the younger generation is ruining what the older generation built" and that "if things continue as they are today, life will be worse in the future." Yet, when you look back 25, 50, 100, 500 years, it's categorically, undeniably, proof positive true that the human condition has steadily and reliably improved. There's no reason to think it won't continue. Yet, look around, once again, the conventional wisdom is that "it's all going to hell." Clearly it's not and never has been. Things are getting better and will continue to. But that won't stop future generations from assuming the opposite, while in the moment.
So that phenomenon fascinates me and it seems to me that we, as human beings, should be able to harness this, at least a little bit, into feeling better than we tend to. Although it certainly does not guaranteed a good result for any one person, if you're a human being in 2018, there's never been a better time in human history (that we know of) where one had a greater chance of having it good. It seems to me that's got to be worth something. I believe it's a tremendous positive, if you choose to see it.
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I completely agree with you on a big-picture humanity level, but as an American millenial, I get so salty thinking about just how good the baby boomers had it.
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We have it better. And our kids will have it better than us.
Disagree. Surveillance state, worsening totalitarianism, climate change. My parents definitely had it better than me, and I think the eighties were better than now. I think the millennials have it tough with jobs and debt.
Imagine paying your way through school being a real thing. Imagine being able to afford a house on a single middle-class income. No amount of cat memes can make up for the financial leg-up the baby boomers had on us at comparable ages.
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I agree with you that from the birds eye (hehe) view things are getting better all the time. Steven Pinker wrote a great book about it too, “Better Angels of Our Nature”. But I don’t expect that to directly impact mental illness on a personal level. Personal stressors may not correlate with global improvements (ie doesn’t matter to me if infant mortality is at the lowest point ever this year if my kid is sick). But also because external stressors are only part of the complex picture. And finally because we are probably feeling better, we just don’t have good data about the burden of mental illness from before. No one cared enough about how depressed medieval serfs were to keep track (even had we had the concept by then).
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I agree.
Why is this?
For instance. Many people might believe that mobile smart phones do more harm than good. We can't imagine a life without them now, but we can remember what our life was like without them. Phone bills were less expensive, we didn't stare at our phone constantly and play games and text people. We all say things like "what would I have done without a phone?" and in reality 30 years ago we still got from point A to B, we could call our friends, and make reservations at restaurants. I for one often wish that mobile smart phones didn't exist (and in fact I was a very late adopter of the smart phone by a very long time). My life would be simpler.
Perhaps since we cannot be critical of future things that don't exist yet, but are critical of things in the past....it is easier to look in the past and say "I don't like inventions a,b,c and as a result I wished I lived in the past"
It's somewhat sad to think how often I think about wishing I could live back in the 70's, be a happy hippie, follow the Grateful Dead around, smoke a little weed, listen to good music, and not have to worry about smart phones and disability insurance guidelines, rising medical costs, rising and worsening human discourse over social issues, money issues.....ah money issues....my dad is a retired endocrinologist. He was making 300K in the 1980s, bought a big house in Suburbia, raised 4 kids, and had a lot of money left over each month after bills to pay for savings and enjoying life. I made 400K last year, am renting a house and live almost paycheck to paycheck after stashing away the max allowed retirement savings. Much rather have been in his position....
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deleted109597
Yeah, and people 20 years ago said the same thing.
We have it better. We just don't perceive it as better.
The reason so much mental illness, specifically anxiety, is around, is because we no longer have the need to stay vigilant to avoid the sabertooth cats. So our bodies invent something to be worried about. Same reason we have more autoimmune diseases, because we've killed a lot of the stuff that our bodies used to fight, so now it fights itself. When Parasites Could Be The Treatment Instead Of The Illness
I agree that people tend to think things were better twenty years ago, and that many people have it great right now. It's certainly a far better time in the US for gay people and women than fifty years ago, and I think if you are an AI researcher it's probably a wonderful time. Widening income disparity has made many people's lives much harder in the US. The high cost of housing and raising a family has made it pretty hard recently for many working class Americans. American lives are actually decreasing in length, so not so great for those folks, either. Since the war on drugs and mass incarceration, not so great for nonviolent drug offenders. It's probably not a great time to be living in, say, Honduras (which was much more peaceful a generation ago) and there are increasing numbers of climate change refugees. Not so great for them. So, I think some people are having a better time, but many marginalized groups are having a harder time.
Looking at three generations of my family, I'd say the baby bust and baby boomer generations have had it best, and I think they'd agree.
Also, no, people were not as concerned about the surveillance state or totalitarianism twenty years ago. Quite the opposite, in fact.
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I guess the problem is the future is not better for everyone, or it is MUCH better for some and minimally better for others.
75 years ago we didn't have near the income disparity as we did now. I would much rather get sick these days and be treated with in our modern health care than 75 years ago. but it's accessible by so few. The middle class is much worse off now than before. It's disappearing. Very interesting conversation.
I do feel like there are a lot of things, change for one, that are forced upon us. I used forced rather liberally as nobody has forced me to use a smart phone, but for all intents and purposes today's life necessitates you use a smart phone (for an example).
75 years ago we didn't have near the income disparity as we did now. I would much rather get sick these days and be treated with in our modern health care than 75 years ago. but it's accessible by so few. The middle class is much worse off now than before. It's disappearing. Very interesting conversation.
I do feel like there are a lot of things, change for one, that are forced upon us. I used forced rather liberally as nobody has forced me to use a smart phone, but for all intents and purposes today's life necessitates you use a smart phone (for an example).
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So life expectancy went down recently because of overdoses, suicide, and a bad flu year: Why life expectancy in America is down again
That said, its still higher today (78) than 2000 (76) or 1980 (74).
Housing costs are higher that's true, but interest rates are way lower. My parents bought their current house in 1982 at a 18% rate. I bought my house last year at 4%. Just for fun I plugged those numbers into a mortage calculator. Let's say say my parents house cost 100k in 1982. At 16% interest over 30 years, they would pay around $1500/month (ignoring taxes and insurance). At 4% for the same monthly payment, I could borrow 325k. Weirdly enough, that's about the difference in price for what she paid for it and what its valued at now.
Gas in 1990 was around 1.30/gallon. Its now around 2.49. A dollar in 1990 is worth 1.92 today. So gas has more or less kept pace with inflation more or less. Most groceries have done the same, if not gotten cheaper.
The two main issues that my generation (1983) and younger are struggling with are a) student loans and b) housing prices in select markets. Outside of major cities, real estate prices aren't terrible. Almost all of my friends own homes, even the ones with solid middle class jobs (teachers, non-profit employees, mid-level government workers, public defenders). The ones who don't live in LA, NYC, Boston, DC, or similar.
Student loans are a huge issue. My wife and I are both physicians and we pay almost 5k/month on our loans alone (after refinance) and we were fortunate enough to have no undergrad loans and go to a state medical school.
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"In the 25 years from 1990 to 2015, the extreme poverty rate dropped an average of a percentage point per year – from nearly 36% to 10%."
Decline of Global Extreme Poverty Continues but Has Slowed: World Bank
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Bingo.
And look at how all of the above posters, who live in the present, proved my point by telling me how sh***y we have it (when we don't) and how it's getting so much worse in the future (when it's not). If the ways of the past were so good, we'd being going back to them.
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There's nothing more offensive than persistent optimism.
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The richest 1% now own half the worlds health. (Richest 1% now owns half the world's wealth)
Those in extreme poverty have moved up to poverty. An advancement.
If we keep this up, the richest 1% will own maybe 80-90% of the worlds health, and the rest will just be living in poverty.
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I was caught between psych and emergency as a choice until my 2nd psych rotation, when I notice that I missed using my stethoscope.
I really, really like where I grew up. My parents paid 50k for their place in 1975. You could not buy a similar one for less than 3 million now. This means I cannot leave near my family. For me personally, this negates any perceived improvement in standard of living. Interest rates don't really make much difference at that level.
My uncle and grandfather were docs, and they certainly had better careers than are available to physicians these days.
I've noticed anecdotally that many people I meet who perceive life as better in 2018 are first generation college grads, which is what is really making their lives better. My parents and grandparents had much better opportunities as college grads/professionals than I do, and they could also afford to live in major cities and maintain a decent standard of living; they could afford to do it on one or one and a half salaries. Just not feasible these days.
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deleted109597
Hahahahahaha no.
Enemy of the State (1998) - Release Info - IMDb
Again, maybe you weren't. Or your family weren't.
But it doesn't make it not real.
And as for the other things, there's plenty of evidence that the world is better. Sure, maybe some people aren't having it as good, but when the poorest of the poor all have cellphones, when 20 years ago they likely didn't even have land lines, that's improvement. When people in most places are no longer starving to death because we have better food (Oh NOES the GMO!), that's improvement.
Gentrification sad stories aside, the ability to buy a house "near" your family for less than $3million sounds pretty absurd. How close are you considering near?
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Stop letting negativity & fear weigh you down. Make it your greatest power:
(Watch at least 10 seconds of this)
(Watch at least 10 seconds of this)
Lol. I meant that in the early 1990s we saw the fall of the East Bloc and democracy seemed ascendant. Now totalitarianism is on the rise, even in democracies.
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deleted109597
A lot of the doom and gloom comes from the constant news cycle. Ask anybody older than 60 if they think crime is worse now than when they were kids. They'll say when they were kids, when there's a ton of evidence proving it wasn't. They just didn't know about it.
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This is totally true. My mother grew up in the UK during World War II; everything was censored and they just kept calm and carried on, even when a bomb fell behind their house. Just hadn't a clue what was really transpiring across the globe or an hour south. Crazy. She does say, though, that she thinks life was fundamentally different before humanity invented the nuclear bomb and the capacity to destroy ourselves so easily. She thinks that led to increased stress and existential dread.
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I suspect you grew up in one of those places I mentioned for that kind of increase in property values.
My uncle is a family doctor as well. The first half of his career he still delivered babies and admitted his own patients. Now he's outpatient only for roughly the same money (inflation adjusted). I've straight up asked him and he thinks things are better now than they were 30 years ago though admittedly he likes being employed which is the biggest difference.
Part of your last paragraph is the huge surge in college grads. Makes them less special and so less valuable.
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same. i mean, i pretty much do this now even as a resident, but if i ever get a time machine i'll see you in veneta in 1972.
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These times are good.
Want to reach the world.....there are a plethora of ways to do it....for free.
What to learn to do something...there are literally free video instructions for just about everything.
Want to invest in good mutual funds, the cost has never been easier, even for small investors.
Want to start a business that “digital products” that can scale....for just a couple thousand bucks in a phone, camera, and computer.....you can do it.
You can go out there and win.......or you can bitch about those that have it better than you, and how your grandfather had it easy.
It is much easier to give your money away than it used to be. You can go neck deep in debt with a mortgage, two car payments, credit cards, and wonder why you need to work overtime and your spouse has to work to make ends meet.
Seriously, stop listening to the news and realize that now is the best time it’s ever been to be alive in the USA.
Want to reach the world.....there are a plethora of ways to do it....for free.
What to learn to do something...there are literally free video instructions for just about everything.
Want to invest in good mutual funds, the cost has never been easier, even for small investors.
Want to start a business that “digital products” that can scale....for just a couple thousand bucks in a phone, camera, and computer.....you can do it.
You can go out there and win.......or you can bitch about those that have it better than you, and how your grandfather had it easy.
It is much easier to give your money away than it used to be. You can go neck deep in debt with a mortgage, two car payments, credit cards, and wonder why you need to work overtime and your spouse has to work to make ends meet.
Seriously, stop listening to the news and realize that now is the best time it’s ever been to be alive in the USA.
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Overt optimism that you and others are depicting, while commendable, is not always reality.
Yes, we have eradicated polio, small pox. People no longer die of communicable diseases like they did in the past. HIV is a chronic disease now that allows people to live normal lives with treatment. One person contracts ebola in the US and it's breaking news, when just 200 years ago, maybe it would have wiped out a civilization. Many things are MUCH better.
However, many things are much worse due to the human experience. We have higher rates of substance abuse than ever before. California is set to run out of water. Sorry to the naysayers, but our own colleagues in the other realms of science have made it perfectly clear, global warming is real. I can't even visit Yosemite without seeing the valley covered in trash by senseless tourists. Our future generations are taking notice of our actions.
To tie it to something that we all relate to, it is undeniably true that physicians today are faced with more regulations, have less autonomy, more metrics to meet than ever before. Job satisfaction amongst physicians is probably the lowest than it's ever been. Hospital administrators are stretching you more thin than ever before. In fact, I've heard much of the opposite from physicians who were practicing in the 70s. They say, "back in my time, I could actually take care of patients, earn a livable wage and I had minimal student loans. I won't be encouraging my family members to go to medical school today"
"Forward progress" is all relative. If your great grandparents grew up in a third world country without running water and today you are a physician in the US, perhaps that is forward progress and you have it better than they did due to their sacrifices. However, I know plenty of people who grew up in wealthy or middle class households, and today their millennial kids can't find a job despite going to college and earning a degree.
We have made some huge improvements in our society. Millions have reaped the benefits of this. Yet, many others are worse off today than their parents. It's the attitude that "things will continue to improve" that is detrimental to future generations, causes complacency, and creates a mindset where you don't need to work hard to leave things better than you had it.
In the realm of medicine, advocacy in terms of being a physician is not so you can have a better career and experience as a physician. It's so that your residents and medical students can.
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Nobody made you do ED bud. Everyone gets crapped on somehow. You know how many stupid consults psych gets from the ED or medicine?
If you're so salty about it, write a letter to your congressman for higher reimbursement for psych for office visits with Medicare and Medicaid. Then maybe people would want to accept insurance some more.
