Psychiatry vs primary care?

[futuredo32]

Long story as short as I can make it
I'm a DO PGY-1 in a new psych program. The PD is nice, the attendings are nice, the residents are nice. It's not a perfect program, but I don't have any dire concerns about the program itself.
Due to the new ACGME rules about needing an attending on the premises, we're doing outpatient psych first.
I did a traditional rotating internship last year (needed to stay in Michigan at the time for family reasons and didn't think I'd match at the one local progam where I had an interview). IM in this DO hospital was really anxiety provoking, the interns were the house officers without an attending for backup (there were IM residents and they totally helped a lot, but sometimes they were busy and at the end of the year, the IM resident who was helping me was a pgy1). So, at that time, I hated IM just because it was so anxiety provoking to have a patient crashing and for me to be the one dealing with it. But, other than that, I like IM. (however, I like the idea of doing inpatient and outpatient and apparently, that's going to be phased out).
I liked FP a lot and kinda thought about applying FP, but at the time I liked psych more and don't like the lower acuity of illness as much as one can find in IM.
I thought about applying to a combined primary care psych program earlier this year (and posted about it under a different name and learned that most people really don't practice both.)

I thought I would LOVE psychotherapy, however, a patient had a really common issue and I had pretty severe countertransference that I didn't anticipate. The attending is letting me transfer this patient to someone else, but this is definitely not the only patient who will have this issue and even if I tried to avoid seeing patients with this issue, I would feel unable to continue therapy with them if this issue popped up. Has anyone had this and overcome it? Is it realistic to think that with insurance reimbursement being what it is that I could do tons and tons of psychotherapy?

Did anyone else miss primary care and end up being glad they stayed in psychiatry? I kinda miss using my stethoscope. When a patient comes in complaining of a sore leg, I want to look at and examine the leg. When a patient says they have a sore throat, it's so discouraging for me to tell them to go and see their pcp for that instead of me looking in their throat and prescribing an antibiotic if appropriate. I sincerely miss the rest of medicine. I do actually like most of the psychotherapy patients I see unless they have issues with things I have issues with.

Thank you for any advice

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[splik]

Hello - it sounds like you would like to find a way of providing comprehensive care to your patients integrating your medical and psychiatric knowledge rather than defecting to internal medicine. It definitely is possible to deal with medical problems as a psychiatrist within the scope of your competence. As a resident, this will be very dependent on your program and your particular attending. The programs I was interested in were the ones where the residents still would deal with patient's medical problems whilst on call or even in clinic and where a strong background in medicine was seen as a plus (i am coming into psych from IM). As a psychiatrist I think you should be able to deal with basic medical problems and know when to refer and there are some things that you can treat yourself. There are systemic limitations however (what follow up does the patient have?, what will insurance companies cover?, does the patient have a pcp?, how comfortalbe are the nurses?, what is the hospital policy? etc)

There are also a number of subspecialities where providing this sort of integrated care is welcome - geriatric psychiatry, addiction psychiatry, consultation-liaison psychiatry, pain medicine, sleep medicine, neuropsychiatry, and hospice and palliative medicine are probably the most 'medical' psychiatric subspecialities and may be worth looking into. Personally i am interested in consultation-liaison psychiatry and hospice and palliative medicine - these, along with geriatric psychiatry are growth areas for the future. There is going to be a lot of opportunity for service development here, reformulating health policy, looking at collaborative or intergrated care etc.

As for the counter-transference issues- whilst more common within psychotherapy, it can occur in any encounter, and if you continue long enough you may experience this problem again even in internal medicine. It is good that you recognize that powerful feelings were generated and I would suggest seeking your own psychotherapy to explore this further. I assume you have discussed this in supervision anyway. There are few areas in the country where psychiatrists will be able to sustain large psychotherapy practices (NYC, Boston, LA, SF) and it is and will be largely cash-only. However, there has definitely been a slight upswing in psychotherapy within psychiatry over the past 5 years.

 

[Wednesday]

I came from an ob/gyn internship and find myself missing ob/gyn quite a bit. I have positioned myself so that I am working with obs and pregnant women, so I use my knowledge a lot, but it's definitely not the same. Overall though, I am happy that I am in psychiatry and think I do the most good for my patients in this field. This is, of course, an individual decision and I think you're going to have to do some soul searching. I did have a few thoughts reading your post.

First of all, I would have been a disaster starting out with therapy patients before I'd had any psychiatry training yet. Therapy is hard and a completely new set of skills. As an outpatient (and inpatient sometimes) consultation psychiatrist I use my medical knowledge all the time to give opinions on if psych meds are causing problems for patients (I diagnosed an inpatient with serotonin syndrome this weekend in fact when neuro and IM missed it). I don't diagnose and treat throat problems, but honestly that doesn't sound much fun to me. If you really think that's something you'll enjoy, you might want to really think about family practice.

The reason I'm saying IF you really enjoy it is because you may be looking back at your primary care days with rose colored glasses on because what you've been thrust into is HARD and you probably weren't really prepared for it. Treating sore throats seems satisfying and easy compared to figuring out what you're supposed to do in psychotherapy, which is slow and can be very confusing. I thought it was helpful doing inpatient rotations because you talk about all of the things you see in outpatient with your attending and see the different patient pathologies play out on the inpatient unit. You get to have strong countertransference and see that for some patients everyone has the same countertransference as you do and then figure out how to deal with it. It's much harder when you're in an office by yourself with the patient. In regards to countertransference, I agree with the PP, it happens in every field. The difference is though, that in fields other than psychiatry, most clinicians ignore it because they weren't trained in how to identify and/or deal with it as we are. Again, this is a personal preference, if you like being in the dark about these things, you may want to switch fields.

Most psychiatrists don't do a lot of straight therapy, but I hope that ALL psychiatrists incorporate their knowledge of therapy into their interactions with patients. Ideally all doctors would do this. Learning about therapy is learning about how people think and behave and interact and enact. It's learning about your patients' and your inner lives which have bearing on everything we do.

Finally, I'll say that being a psychiatrist is a hard job. Patients are in such pain and they want you to make them better FAST (which is nearly impossible). I find it difficult to watch people in such pain and know how LONG it's going to take for them to "feel better" (if it ever happens) and to see some patients and know what they're doing is destructive (asking every provider for benzos) and that it would take a lot (maybe more than they can muster) to change the course of their life. Personally I find it rewarding, but difficult. Personal psychotherapy is to key to a lot of this. If you're going to stay in psychiatry, find yourself a good therapist!

Good luck.

 

[whopper]

There are combined FP/psychiatry programs.

Something I learned from people boarded in many areas, several of them tend to become a jack-of-all-trades, learned in several areas but never really get very specialized in one area (except my fellowship PD), though I can say I've seen doctors boarded in one area and not even good in that one thing.

 

[futuredo32]

Thanks so much for the advice
What a difference from OB to psych!!!!!!!!!!!!

I miss both the ease of treating a sore throat, but also the variety in primary care. But, I sat out a year after graduating because I didn't match in psych *and had to stay local for family reasons* and then did a pretty rough TRI *again because it wasn't confident I would match in psych* so, at one point, I really thought I was sure I wanted to do psych. I have a week and a half to decide. I did see a therapist to discuss this yesterday and he suggested FP would probably be a better fit since I had a really pretty strong countertransferrence. The therapist was really nice, but I didn't particularly enjoy being a patient in this setting, I can't believe so many patients LIKE going to therapy- I'd rather take Step 1, 2, and 3 all over again , I definitely can't see myself going to a therapist regularly, so at this point, I am leaning more toward primary care

Thanks again

 

[pysch4sure]

Psychiatry is a primary care field

 

[futuredo32]

Psychiatry is a primary care field

When I referred to primary care, I was really meaning fp/im, but you're right.