Psychiatry vs neurology .. help

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NeuroKlitch

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I have posted this already in the neurology forum but would like to get this forums perspective . MS3 here . I've been struggling for the past weeks and months trying to make a decision between neurology and psychiatry . My question is whether a neurologist with a great deal of interest in schizophrenia would be able to set up a practice in which he would also treat them in addition to the regular neurology patients. I am completely fascinated by schizophrenia/schizoaffective disorder and has been one of the main things that have been holding me back from committing myself completely to neurology. I also love the lifestyle potential , and the idea of having a close relationship with all my patients and being there with them through their problems , and think the psychopharmacology is very fascinating . While In neurology there is not one single pathology that I am deeply as fascinated with, I love the brain , neuroanatomy , and the puzzle of correlating brain lesions/regions with pt presentation and like that I will be able to retain a greater majority of my medical knowledge in the long run .. Any advice ? Has anyone else went through this same struggle. How did you ultimately decide on psych?




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I went to med school wanting to be a neurologist and just matched psych (by choice). For me felt like I psych would more easily facilitate having my own practice and being able to spend more time talking with my patients. This is an over generalisation of Neuro but In general my favourite patients are not very old people on vents. I also want to practice without a fellowship and that is more rare in neuro than psych. There's stuff about neuro I think I'll always miss to an extent but for me I switched to psych 3rd year and am very happy so far. Doing outpatient really solidified it because I could see the extent that psych could help people in their lives long term whereas a lot of my inpatient experience was stabilise and release.
 
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The answer is basically no to your question. Baring some exceptional change, schizophrenia is one of the illnesses most squarely in the purview of psychiatry. It is also as fascinating as you feel now; I don't feel even 1% less interested in the psychopathology of schizophrenia then when I started training. I will say your general statement makes me think you will do better in psychiatry, just lean towards a more "biologic" program and you will get plenty of neuroanatomy and psychopharmacology. I would try to find a program with neuropsychiatrists, with whom I think you will get along with swimmingly.
 
Don't forget that this is a very personal choice and only you can decide. Everyone here is thinking "of course psychiatry, what are you thinking..."
Good luck,
 
There is a thing known as Neuro/Psych combined......might be what you are looking for. True about Neuro having to do a fellowship. I just got done talking to a new neuro attending about this. He said he had no choice unless he did not want a decent job.
 
Neuropsychiatry? Is that a fellowship after psychiatry? Wouldn't that be the ideal option for the OP?
 
I could see someone (a highly motivated and laser-focused someone) possibly developing a career in academia as a neurologist specializing in cognitive deficits in schizophrenia, "soft signs" in developmental and prodromal syndromes, etc...but it would be a very narrow niche.
 
Also remember that there are about a dozen combined neurology/psychiatry 6-year residency positions across the country (probably more now). People often look down on the idea because you will almost certainly end up practicing in one field or the other (not both). However, if you have the time, the endurance, and you don't need money right away... why not? One thing is for sure, you would definitely come out of that experience knowing if you wanted to be a psychiatrist or a neurologist. I briefly pondered the idea of doing a combined neurology/psychiatry program, but frankly I'm bored to tears by any part of the nervous system inferior to the medulla.
 
Thanks for all the great responses . I think at this point , if I'm honest with myself and where the majority of my interest lay , I think I have a higher potential to become a "great" psychiatrist as opposed to becoming just a good neurologist. Although I do find myself at times being tempted by neurologies higher earning potential with fellowships , I think psychiatry will probably suit my overall needs and lead to a higher overall satisfaction. But only one way to know for sure which is through scheduling electives as one of you suggested.


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If you are confident that you like schizophrenia patients more than you like stroke or seizure patients, I don't think you will regret coming to the Psych side. There is plenty of room in psych for someone who enjoys neuroanatomy and organic brain lesions.
 
Shikima said:
It's too bad psych doesn't focus on TBIs more and effectively has ignored this allowing Neuro and PM&R to take over.
Click to expand...

There is an emerging literature on post TBI depression with some interesting preliminary work
 
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NeuroKlitch said:
I have posted this already in the neurology forum but would like to get this forums perspective . MS3 here . I've been struggling for the past weeks and months trying to make a decision between neurology and psychiatry . My question is whether a neurologist with a great deal of interest in schizophrenia would be able to set up a practice in which he would also treat them in addition to the regular neurology patients. I am completely fascinated by schizophrenia/schizoaffective disorder and has been one of the main things that have been holding me back from committing myself completely to neurology. I also love the lifestyle potential , and the idea of having a close relationship with all my patients and being there with them through their problems , and think the psychopharmacology is very fascinating . While In neurology there is not one single pathology that I am deeply as fascinated with, I love the brain , neuroanatomy , and the puzzle of correlating brain lesions/regions with pt presentation and like that I will be able to retain a greater majority of my medical knowledge in the long run .. Any advice ? Has anyone else went through this same struggle. How did you ultimately decide on psych?




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Click to expand...

If you really want to understand Schizophrenia and maintain a fascination, you need to do research. The syndrome gets pretty mundane after a while, and as Splik said once the patients are stable most of your work involves figuring out how to get them behaviorally activated etc. Our current pharmacotherapy is pretty straightforward (though plenty of lazy psychiatrists don't know the literature and mess this up) and becomes likewise routine after a while. Danny Weinberger (world's premier SCZ researcher over the past 40 years) went through his psychiatry with a similar mindset to you and then began a long and most successful career at NIMH (while completing a neurology residency at GWU on the side- tough to do that today!) making some of the most fundamental contributions in neuroimaging and genetics. (however one of his long time collaborators Tom Hyde is a neurologist by training and ran the NIH neuro clinical service). Anyway, routine clinical practice will rpobably get boring for you after a while, so assuming this disaster of a budget doesn't hold and the NIH is still solvent, research is where you want to be
 
OldPsychDoc said:
I could see someone (a highly motivated and laser-focused someone) possibly developing a career in academia as a neurologist specializing in cognitive deficits in schizophrenia, "soft signs" in developmental and prodromal syndromes, etc...but it would be a very narrow niche.
Click to expand...
All I ask is that we have some junior faculty with frickin laser-focused career goals, is that too much to ask? That is doctor Evil, I didn't go to evil medical school for six years to be call mister.
 
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@NeuroKlitch I have already replied to your Neurology thread, but to expand on that a little: I'm also quite interested in neurology as well as Psychiatry, and you and I share interests in neuroanatomy/localization of functional deficits. Three pathways related to these interests are Psychiatry + neuropsychiatry fellowship, neurology + behavioral neurology fellowship and combined Neuro/Psych residency - these options have been discussed in this and your Neuro thread.

As much as I enjoy neurology, it was fairly easy for me to choose Psychiatry over it. Here's how my thinking went:
1) "bread and butter" cases: I will work with depressed patients any day but, as LasVagus put it, "I'm bored to tears by any part of the nervous system inferior to the medulla" - so that's one vote for Psychiatry;
2) things that I like about one specialty that the other doesn't have, and how critical they are for me: neuroanatomy/neuroradiology in neuro and psychotherapy in psych - I can find ways to scratch my neuroanatomy/neuroimaging itch in psychiatry (as I described in your neuro thread) but there is no place for psychotherapy in neuro - so it's another vote for psych (and to make thing even more interesting, there is place for neuroanatomical thinking in psychotherapy!);
3) daily clinical work (aka the grind) vs. intellectual stimulation (aka the excitement): I found both neuro and psych intellectually stimulating, if in somewhat different ways, but I like the focus on interacting with patients and getting to know them in clinical psychiatry more than anything in neuro (I could take or leave procedures) - another vote for Psychiatry;
4) pay: neurologists make more than psychiatrists on average, but this is not the most important issue for me;
5) life style and career longevity: look, I'm actually a hard working person (I got along surprisingly well with surgeons, as I really respected their work ethics and could hold my own) - but as an older student I have to consider the reality of having less stamina as I age - and, although outpatient neuro has a reasonable life style, psychiatry offers the most flexibility (I can work like crazy on inpatient/ED/consults as long as I enjoy it and ultimately taper into part time outpatient) and longevity than pretty much any other specialty - so psych it is again;
6) as an additional reason, not that I don't care about patients with stroke, MS or epilepsy etc. but I really do give a d*mn about psychiatric patients - and I believe I should join the ranks of people treating and advocating for them, especially considering how poorly they are often treated by medical and surgical (even neuro!) services compared to other patients including neuro patients - because while nobody doubts that MG is a medical illness, somehow anhedonia/fatigue/psychomotor ******ation of depression are still widely believed to be moral failings.
 
NeuroKlitch said:
I have posted this already in the neurology forum but would like to get this forums perspective . MS3 here . I've been struggling for the past weeks and months trying to make a decision between neurology and psychiatry . My question is whether a neurologist with a great deal of interest in schizophrenia would be able to set up a practice in which he would also treat them in addition to the regular neurology patients. I am completely fascinated by schizophrenia/schizoaffective disorder and has been one of the main things that have been holding me back from committing myself completely to neurology. I also love the lifestyle potential , and the idea of having a close relationship with all my patients and being there with them through their problems , and think the psychopharmacology is very fascinating . While In neurology there is not one single pathology that I am deeply as fascinated with, I love the brain , neuroanatomy , and the puzzle of correlating brain lesions/regions with pt presentation and like that I will be able to retain a greater majority of my medical knowledge in the long run .. Any advice ? Has anyone else went through this same struggle. How did you ultimately decide on psych?

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Click to expand...

Check out the National neuroscience curriculum initiative:

www.nncionline.org

This gives you a sense of ways in which correlating regions, etc., may be increasingly informative in psychiatric practice. Others might not agree, but this is a joint effort of some leading program directors, and clearly many leaders in the field share their optimism- they have published multiple perspectives in JAMA and Biological Psychiatry. Good news for someone with your interests hoping to explore them in psychiatry!
 
Between med school and residency, I've now done 4 months of neuro. Never inpatient, but lots of consults and outpatient. You have to be really turned on by localization to like neuro. While I do appreciate and enjoy the utility of the exam in neuro, I find that they don't have time/interest in talking to patients, generally. And on consults/inpatient it's a lot of old people with strokes who can't talk anyway. I think that's what it comes down to... do you like talking to patients or not?

There are some faculty who do indulge in some patient-talking on slow clinic days, but it's not the usual focus of their practice.

And by talking to, I don't mean just taking an HPI. The goal of an efficient HPI is often to avoid talking to the patient.
 
FlowRate said:
Between med school and residency, I've now done 4 months of neuro. Never inpatient, but lots of consults and outpatient. You have to be really turned on by localization to like neuro. While I do appreciate and enjoy the utility of the exam in neuro, I find that they don't have time/interest in talking to patients, generally. And on consults/inpatient it's a lot of old people with strokes who can't talk anyway. I think that's what it comes down to... do you like talking to patients or not?

There are some faculty who do indulge in some patient-talking on slow clinic days, but it's not the usual focus of their practice.

And by talking to, I don't mean just taking an HPI. The goal of an efficient HPI is often to avoid talking to the patient.
Click to expand...

Yeah, it sort of came down to this for me as well. Neurologists certainly spend a lot of time with their patients, but they are basically making their patients do clinically-relevant tricks, not actually listening to them especially closely.
 
what do you think is more lucrative/efficient? outpatient neurology or outpatient psychiatry? outpt neuro probably requires more time with each patient, so you can probably see more volume in psychiatry in the same amount of time?
 
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Combined Neuro/Psych resident here.

Briefly, psychosis is a great example of how the two fields are intertwined, despite what we arbitrarily designate one or the other. For example, 3% of new-onset psychosis ends up being autoimmune encephalitis. The BSNIP consortium has looked at endophenotypes in psychosis with profiles including EEG, fMRI, and other more "neurological" testing on top of the psychiatric workup.

As stated by above posters, psychosis is much more the realm of psychiatry clinically, but in research there is a lot of leg room.

I'm available by PM for any questions you have.

-Asklepian
 
If you really want to see the fascinating neuro/psych cases, realize that you probably want to be in an academic setting, whether or not you do research. There are more and more non-research positions in academic medicine these days.
 
Floridly manic patients are way cooler than find-the-lesion. FYI I think neuro is second best.
 
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