psychopharm- psychiatrist or psychologist?

[books31]

I was having a discussion with a colleague of mine (licensed psychologist) about psychiatry and psychology. while deciding on schools, i contemplated med school. ultimately i decided on psychology and now on the road for my ph.d.
however, when i think of the highest possible routes to being a licensed psychologist, my mind wanders to either achieving the post. doc. in psychopharm, or going the psychiatry route?

If psychiatry, then obviously i will have to change my plans and apply for med school.

The colleague of mine made a comment saying along the lines of "if you plan on doing psychopharm after your ph.d. and you're going to prescribe limited meds, then why not go all the way and just be a psychiatrist."

he then went on talking about private practice, insurance, and overhead fees, etc. he said something about the insurance to cover a licensed psychologist (medical malpractice, in case something happens) would cost way too much on a salary of a licensed psychologist/psychopharm and (things in the business that i'm not dealling with yet nor know about).

i want a better understanding of this.

is he talking out of his ass and being discouraging? or should i start studying for the mcat now?

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[books31]

hello,

i thought this thread would fit well here for my concerns.

I was having a discussion with a colleague of mine (licensed psychologist) about psychiatry and psychology. while deciding on schools, i contemplated med school. ultimately i decided on psychology and now on the road for my ph.d. however, when i think of the highest possible routes to being a licensed psychologist, my mind wanders to either achieving the post. doc. in psychopharm, or going the psychiatry route?

If psychiatry, then obviously i will have to change my plans and apply for med school.

The colleague of mine made a comment saying along the lines of "if you plan on doing psychopharm after your ph.d. and you're going to prescribe limited meds, then why not go all the way and just be a psychiatrist?"

he then went on talking about private practice, insurance, and overhead fees, etc. he said something about the insurance to cover a licensed psychologist, medical malpractice etc. would cost way too much on a salary of a licensed psychologist/psychopharm and (things in the business that i'm not dealling with yet nor know anything about).

i want a better understanding of this.
is he talking out of his ass and being discouraging? or should i start looking at the next mcat test dates?

 

[PsyDr]

what is it that you want to do?


if you want to prescribe, psychiatry is generally the way to go. greater earning potential, higher prestige, etc.

if you want to study drugs, pharmd or md would be the way to go.

a prescribing psych phd would typically involve more face time, less patients.


also: a psychologist complete a post doctoral MS in psychopharmacology. it is not a post doc. no pay, etc.

 

[JockNerd]

My $0.02:

Caveat: I'm a research-focused PhD psych student. I have no regrets about going to psych grad school rather than med, and definitely chose the right one of the two for myself.

If I were interested in seeing patients and taking an integrative therapy/med approach to my clients, I would 100% go psychiatry. There is the psychopharm option, but in my opinion it's currently way too restrictive as to where and how you can practice. Realizing med school likely won't train you well to be a therapist, I'd seek additional training on the side or after med school (classes, institutes, etc.). That route has WAY more benefits.

 

[TenaciousGirl]

I agree with JockNerd. Keep in mind the road to being a psychiatrist vs. psych PhD or PsyD is very different. Psychiatrists still have to learn a broad base of medicine to become a physician on the road to specializing in psychiatry. I think that's pretty cool but it's definitely completely different. So, take your time and evaluate the two. good luck.

 

[IAmAUser]

.

 

[ronin12]

if you are planing to practice in medical model i.e evaluate / Dx pt's using interview and r/o labs and later treat them with meds or psychotherapy then it is psychiatry. Dont's be fooled by the notion that by doing 2 years crash course of psychopharm you will be able to practice psychopharmacology in a competent and responsbile manner.
This is an unfortunate development that now psychiatry , a medical speciality is being muddled with psycholoy based on few states approving prescription priviliges. These are two entirely distinct fields, being a psychologist you dont even have the basic knowledge of medical sciences which is essential for any practicing physicin i.e psychiatrist, internest, neurologist, cardiologist,surgeons etc. All of these fields cross interact with each other in today's practice of psychiatry.

if you want to practice psychotherapy / neuropsych testings, involved in behavioral research in industory or medical settings then it is psychology.

My simple advice is if you want to prescribe medications alongwith psychotherapy ,/behavioral reserach etc you should go to med school, and don't rely on psychopharm training for psychologists as a viable or even ethical route. you will be missing the most crucial element of psychiatry i.e medical school and knowledge of other medical specialities and how they interact in today's medicine.

 

[whopper]

Some of this was discussed in the Oregon psychologist prescription law thread, though I wouldn't exactly recommend reading that thread since its very long and you're probably going to have a hard time finding the juicy bits you need.

You can prescribe as far as I know if you get a Nurse Practitioner or Physician Assistant degree. These degrees are not as hard as getting an M.D. or D.O.

Getting an M.D. or D.O. is quite an ordeal. You are trained to be an M.D. (obviously) which incurs learning a great deal about things not directly related to mental health. For those who are determined to be a psychiatrist, this, while still important can be somewhat frustrating given the difficulty of the curriculum, and that you'll be years from actively doing the things you like to do. You will also get several textbooks worth of non-mental health data shoved into your brain at a very uncomfortable pace. You will have quite a bit of psychological training & knowledge readying to burst out into action, while having to wait 4 years to put it to good use.

Despite this, I still feel it is very important for prescribers of psychotropics to have this training. Several of the psychotropics carry harmful side effects, have very narrow therapeutic ranges where toxicity occurs just a small amount above the therapeutic range, and can at the worst extreme cause death. Lithium, even if safely monitored is expected to cause deletrious effects to the kidneys after 10-20 years of use. Even the SSRIs which are often seen as the least toxic meds carry medical problems & side effects.

If you'd like to use psychopharm as a psychologist, you still can. One avenue is to work as an advisor/consult to a primary practice. Primary practitioners are the largest body of mental health providers, and often times these people do not know their psychotropics well. I did work in a Family Practice clinic while in medical school, and the psychologist there filled this role, and had as much respect as the M.D.s. The M.D.s also carried the liability concerning the meds since they were the ones prescribing.

Research is another avenue. Several brilliant psychopharmacologists I've met were psychologists doing research on future meds.

Or prescribe--getting an NP, PA, MD or DO. 2 states (with Oregon probably allowing this in the near future) have allowed for psychologist prescriptions so long as they get 2 years of extra training, --and that issue has been hotly debated in the Oregon thread. (Personally I'm against, it and would advise you not do it because aside that IMHO the 2 year program doesn't provide enough training, you'll only be able to practice in 2 states (probably 3).

 

[CGOPsych]

hello,

i thought this thread would fit well here for my concerns.

I was having a discussion with a colleague of mine (licensed psychologist) about psychiatry and psychology. while deciding on schools, i contemplated med school. ultimately i decided on psychology and now on the road for my ph.d. however, when i think of the highest possible routes to being a licensed psychologist, my mind wanders to either achieving the post. doc. in psychopharm, or going the psychiatry route?

If psychiatry, then obviously i will have to change my plans and apply for med school.

The colleague of mine made a comment saying along the lines of "if you plan on doing psychopharm after your ph.d. and you're going to prescribe limited meds, then why not go all the way and just be a psychiatrist?"

he then went on talking about private practice, insurance, and overhead fees, etc. he said something about the insurance to cover a licensed psychologist, medical malpractice etc. would cost way too much on a salary of a licensed psychologist/psychopharm and (things in the business that i'm not dealling with yet nor know anything about).

i want a better understanding of this.
is he talking out of his ass and being discouraging? or should i start looking at the next mcat test dates?

At the risk of sounding like a Ph.D. psychologist - oh wait, I AM one - I would need a lot more information before giving much advice. I assume your core interest is being of help to people with mental health problems. Would this only be through direct professional services? Do you wish to do research? Do you want to teach?

As someone new to this field, you may believe that becoming a psychologist without prescriptive authority will mean you won't have the full armamentarium available to you needed to treat patients. That's far from true. Any decent psychologist has plenty of resources for getting patients their meds. And collaborating with someone who went through med school memorizing slide stains and cutting open cadavers (yechh) is a great way to get those meds for your patient safely. Almost every patient has (or should have) a primary care physician who knows them, and you'll know a psychiatrist or two you can work with.

If you take some extra training in psychopharmacology, then your thoughts on meds will often be taken seriously by your patients' physicians, although they will, appropriately, use their own judgment as well.

Professionally and intellectually, psychiatry and psychology are very different paths. You should investigate the professional lifestyle of each before making any major decisions. Psychiatric training has been tilted heavily toward biological explanations of mental illness since about the late 1970s and your training and practice will likely be such. (If I hear the term chemical imbalance one more time I'm going to throw up.) While some psychiatrists think they can practice psychology (as some psychologists think they can pick up Rx skills in a few weeks), the fact is that very few actually know a great deal about psychotherapy, personality, etc.

To be a psychiatirst you spend four years becoming an MD, then you start learning psychiatry, which as I said is very biological. To be a psychologist in the scientist-practitioner model (we're not going to even consider professional schools are we?) you'll have an undergrad in psych and then they'll slow-cook you for about five years in grad school before you do your one-year internship. That's a lot of psychology, but to master it is a very difficult task. If you're honest with yourself, you'll realize that you always feel you don't know enough, but if you love it, you'll always want to learn more. As John Kihlstrom once said, the Ph.D. is just the beginning.

If you can, read Kingsbury 1987 in the American Psychologist "Cognitive Differences Between Clinical Psychologists and Psychiatrists". As someone trained fully in both fields, he offers some very valuable insights into our differences in training and thinking.

 

[justme08]

Another route as alluded to above is maybe going the PMHNP (psych/mental health NP) route. You will learn some of the biological, chemical, hormonal interactions that affect behavior and moods as well as the assessment skills but the amount of couseling skills vs. medication management skills you will learn, as I understand it, will depend upon the school you attend.

 

[Therapist4Chnge]

I agree with JockNerd. Keep in mind the road to being a psychiatrist vs. psych PhD or PsyD is very different. Psychiatrists still have to learn a broad base of medicine to become a physician on the road to specializing in psychiatry. I think that's pretty cool but it's definitely completely different. So, take your time and evaluate the two. good luck.

Exactly.

Either route will take a great deal of work and time, so it is really important to understand what day to day work is like. I talked to a number of psychiatrists and a neurologist (as well as my undergrad mentor who is a psychologist), and they pretty much agreed that day to day work was quite different than what most lay people assume.

Psychiatry/Neurology was my backup plan because I love the hard sciences as an academic, but the day to day work was not what I ultimately wanted. The ideal route would have been MD/Ph.D.....but I couldn't find a program that fit my research interests. After having worked in an in-patient setting, I am even more sure that I made the right choice, as the day to day work that our psychiatrists do isn't what I would want to do.

As for the post-doc pharma programs.....they really should be treated as outliers, because they really only fit a small niche of people, since someone wanting to prescribe from the get-go could be better served in an MD/DO/NP/PA program when you consider the flexibility of the licensures. My reason for going into a pharma program was to enhance my understanding of meds, as I want to work in a primary care setting. Prescribing is far off if ever because of the limitations of practice.

 

[masterofmonkeys]

I think it really depends on your focus. I ended up going psychiatry mainly because of my research interests. By inclination I"m more of a psychotherapist type than a psychopharm type. And it's frustrating now as an intern because at this early stage in my career I like the psychotherapeutic training and techniques that my psychology colleagues have. And the simple truth is that due to the limitations of medical education, I will likely always be more limited in range of psychotherapeutic techniques and psychometric testing.

We are having an absolute blast collaborating together on the patients (inpatient) who are incredibly insightful, but need some serious psychopharm manipulation to have the right mindset to work with it. I'm tweaking meds, and together we're working on therapy.

This is honestly how I eventually want to practice (in a perfect world). Tag-teaming a patient, me with psychopharm and my particular foci in psychotherapy (still learning...but mindfulness, CBT, and IPT), and the psychologist with their psychometric testing, and wider range of psychotherapeutic interventions.

There are tradeoffs, and while there are certain routes that claim to be the best of both worlds (psychotherapy-heavy psychiatry residency, vs. psychologist with psychopharm postdoc vs. psychologist with mental health NP training), you will find yourself limited in some aspect of your training and ability.

It's up to you to decide which one you'd rather be more limited in.

Sorry.

 

[peppy]

Getting an M.D. or D.O. is quite an ordeal. You are trained to be an M.D. (obviously) which incurs learning a great deal about things not directly related to mental health. For those who are determined to be a psychiatrist, this, while still important can be somewhat frustrating given the difficulty of the curriculum, and that you'll be years from actively doing the things you like to do. You will also get several textbooks worth of non-mental health data shoved into your brain at a very uncomfortable pace. You will have quite a bit of psychological training & knowledge readying to burst out into action, while having to wait 4 years to put it to good use.

I think whopper makes an important point. I do think that medical school would probably be the best route for you based on your interests, but I'm not sure if it's worth it to change course if you are already well on your way towards your PhD. You really have to decide, do you like general medical/surgical topics enough to get through the med school years of focusing almost exclusively on non-psychiatric medicine? Is it important enough to you to be able to practice your ideal way that it is worth the time investment, financial costs, and stress of obtaining an MD/DO degree?

On medical school rotations, you also will probably encounter negative views about psych and mental illness due to the prevailing culture of medicine. Many non-psychiatric physicians don't have a very high opinion of psychiatrists and don't have the time or interest to deal with the emotional component of their patients' illnesses.
If (like me) you do have some enjoyment of general medicine, and think it is kind of cool to observe how surgeries are done even though you have absolutely no intention of ever performing a lap cholecystectomy as a psychiatrist , that will make med school far easier to get through.

 

[Therapist4Chnge]

MOD NOTE: Cross-posting is not allowed at SDN, so I merged the two duplicate threads. -t4c

 

[whopper]

but I'm not sure if it's worth it to change course if you are already well on your way towards your PhD. You really have to decide

I recall being in my Ob-Gyn rotation, having an overworked, overbearing & bullying resident (who was kept back a year because he was found to be too explosive, on top of that he was kicked out of a previous residency program for blowing up in anger). Delivering a baby, and having this guy screaming at me as if to intentionally screw me up. The attending looked at him funny, telling that resident to lay off.

And thinking to myself all the while, having been a psychology major who went to medical school to be a psychiatrist--I want to be in psychiatry. WTF is this all about? I'm delivering my 30th baby.

Anyways, the Ob-Gyn training does come in handy, especially when you have a pregnant patient who is psychotic & dangerous and most of the meds you need to deal with are teratogenic (can cause birth defects). It all comes together--though years of torment later.

 

[appelsoranjes]

And thinking to myself all the while, having been a psychology major who went to medical school to be a psychiatrist--I want to be in psychiatry. WTF is this all about? I'm delivering my 30th baby.

Anyways, the Ob-Gyn training does come in handy, especially when you have a pregnant patient who is psychotic & dangerous and most of the meds you need to deal with are teratogenic (can cause birth defects). It all comes together--though years of torment later.

Heard of cognitive dissonance? Delivering babies (especially a high quantity) is hardly essential in understanding teratogenic effects...although it will come in handy if you are ever stuck in an elevator with a woman in labor

 

[whopper]

True, the actual act of delivery isn't so much important, but the other data in the Ob-Gyn rotation is. Doing serum HCGs to see if a person is pregnant, or its a false positive as a result of another issue, seeing women with mental health problems as a direct result of their pregnancy & delivery, having to do psychiatry consults in the Ob-Gyn ward--it all comes together.

I had a case this last year where an Ob-Gyn doctor was claiming that a violent psychotic patient was not pregnant, and after reviewing the case, I was not convinced, and demanded he order more labs which he refused to do. We debated that issue, and I was able to stand toe to toe with him.

The patient was transferred to my unit, and I did the lab work he refused to do showing she was pregnant. During the few days it took to take these labs, get the results & then having to wait another few days (the type of labs require there be some time between labs), she was given haldol (one of the few psychotropics that has plenty of data in pregnant women)--at very high dosages with little benefit. We brought her back to the ER, they did an ultrasound and viola--she's pregnant.

Had I not had that ob-gyn training, that woman would've been given plenty of teratogenic medications.

 

[appelsoranjes]

True, the actual act of delivery isn't so much important, but the other data in the Ob-Gyn rotation is. Doing serum HCGs to see if a person is pregnant, or its a false positive as a result of another issue, seeing women with mental health problems as a direct result of their pregnancy & delivery, having to do psychiatry consults in the Ob-Gyn ward--it all comes together.

I had a case this last year where an Ob-Gyn doctor was claiming that a violent psychotic patient was not pregnant, and after reviewing the case, I was not convinced, and demanded he order more labs which he refused to do. We debated that issue, and I was able to stand toe to toe with him.

The patient was transferred to my unit, and I did the lab work he refused to do showing she was pregnant. During the few days it took to take these labs, get the results & then having to wait another few days (the type of labs require there be some time between labs), she was given haldol (one of the few psychotropics that has plenty of data in pregnant women)--at very high dosages with little benefit. We brought her back to the ER, they did an ultrasound and viola--she's pregnant.

Had I not had that ob-gyn training, that woman would've been given plenty of teratogenic medications.

Damn, did that doctor eat crow?

I would be more likely to attribute the outcome of that situation to your competence vs. the training, as I'm sure the ObGyn had much more significant training.

 

[235750]

I would be more likely to attribute the outcome of that situation to your competence vs. the training, as I'm sure the ObGyn had much more significant training.

Just because the OB/GYN came to a different diagnosis then whopper doesn't mean he/she was incompetent. Two well-trained (and competent) physicians can come to different conclusions given the same limited information. That's just medicine for you.

The point is, if whopper did not have a physician background, he/she would not have had the knowledge to challenge the OB/GYN.

The well-rounded training of physicians is one their alluring qualities. The fact that whopper as a psychiatrist has the training to stand ‘toe to toe' with an OB/GYN is amazing to me (ps nice job whopper!).

To the OP: I thought about a PhD too. That fact that you're in such a program tells me you're a smart person, and I'm sure with a year or so of work, you can be competitive for medical school. So, this is a question of how bad you want it, and how much you are willing to sacrifice

If you stay the course you're on, having the option of prescribing (in some states) after getting an MS is nice and all, but it will relegate you to a mid-leveler akin to an NP, although with less medical training. I of course have nothing against mid-levelers. It's just, don't you think it's a little ridiculous to get your PhD + MS just to be limited in the type of medication you can prescribe? If all you're looking to integrate medicine in your practice, just go all the way to an MD/DO.

I'm a nontrad and had quit my career to apply to medical school. Believe me, I understand the feeling of not wanting to get out of your safe rut. If it's not what you want, then leave, it's not worth it. It sounds simple because it is

Good luck!

 

[billypilgrim37]

Just because the OB/GYN came to a different diagnosis then whopper doesn’t mean he/she was incompetent.

I would even add that just because Whopper was "right" in this situation doesn't mean that he necessarily exercised proper clinical decision making. (now, he's told this story many times in other threads, so this is no knock on whopper, who's obviously good at his job, and who, sure, did exercise excellent clinical decision making). But there needs to be some sort of devil's advocacy on this thread.

You can make the right call and be wrong, and make the wrong call and be right. We should be careful about lauding people who make the wrong call and wind up being right, as well as punishing people who make the right call and wind up being wrong.

It's correct to send home an anxious, fit 24 year old non-smoker with chest pain with a history of panic attacks, a negative ekg, and a negative initial troponin with no family hx of cardiac disease. If you find out a day later that she dropped over dead from a heart attack the next day, you didn't make the wrong decision. You were just wrong. There's a huge difference.

 

[whopper]

Very much agree with you Billy....
2 doctors, even in good faith, & practicing the standard of care upon review of the chart can come to different conclusions.

However, and this is only in the specific case I mentioned above-the Ob-Gyn doctor IMHO was not acting in good faith, and it really was a dump job.

I ran into plenty of Ob-gyn issues in the last year because I ran a female forensic unit for 10 months. I had for example a patient with vulvar cancer--who's surgeon dumped her to my unit when she was still in need of being in a surgery ward. That ob-gyn training came in handy, especially since there are no ob-gyn doctors in the entire psychiatric hospital. I knew more Ob-Gyn than the IM doctor who covered my unit.

As for schizophrenic patients--we all know plenty of them smoke, and unfortunately plenty of them are on birth control. I was the first doctor--per their accounts to tell them smoking & birth control together are extremely dangerous which I found as a shock. I've already seen 1 patient die from the 2 together (not my patient thankfully).

 

[Faebinder]

Damn, did that doctor eat crow?

I would be more likely to attribute the outcome of that situation to your competence vs. the training, as I'm sure the ObGyn had much more significant training.

Why are you under the impression that this case is rare? This crap happens all the time with many other fields. Most of the time, it's the psychiatrist arguing with the opposing physician that the case is medical in nature not psychiatric. It takes a lot of confidence, training and medical knowledge to recognize and r/o medical etiology.

 

[whopper]

Most of the time, it's the psychiatrist arguing with the opposing physician that the case is medical in nature not psychiatric.

About once a week I had a case where the person was truly not medically cleared, but was determined to be by the ER or IM doctor.
-person who was delirious due to metastic cancer to the brain
-person who was having angina, and the ER doctor labelled him as psychotic because he didn't speak english
-person who had hepatic encephalopathy & was labelled psychotic
-person who came in with 2 broken legs, and the ER doctor labelled him as medically cleared with a completely normal physical exam
-person who just got out of surgery, and the Hgb & Hct were dropping to the point where there was an obvious internal bleed.
That last guy--he had a laceration across his chest. While he was psychotic, he got into a fight and got cut. His surgeon cleared him. Then he's on my unit, and he's bleeding, his BP is 90/50, his HR is 130, he's pale, diaphoretic, and his sheets have blood. I'm suspecting his laceration is bleeding, but he won't let me check him out. I call up the surgeon, who immediately tells me he's not taking the patient back to surgery---too bad, "your problem, not my problem"

These things happen in a hospital. I've yet to see a hospital that doesn't have this problem.

I could go on--and make this post 10 screens long.

Its a case of an IM or ER doctor or surgeon trying to lighten their load, and because of the current medical laws-if the patient is having a problem-now the new doctor is responsible. Classic thing going on at the psychiatry hospital where I worked last year was the psych units tried to only transfer their difficult patients to other units. They'd never try to transfer an easy to mange patient.

(another reason why I had a problem with the Oregon law-in no way shape or form would someone with that level of training truly be able to perform as an M.D. or D.O. in charge of a psychiatry unit).

 

[Ollie123]

As for schizophrenic patients--we all know plenty of them smoke, and unfortunately plenty of them are on birth control. I was the first doctor--per their accounts to tell them smoking & birth control together are extremely dangerous which I found as a shock. I've already seen 1 patient die from the 2 together (not my patient thankfully).

Seriously? That's not even at the level of medical training...I think that one gets mentioned in a typical high school health class. Hell, watch an hour of television and you'll probably see a commercial for birth control that mentions not to use it if you smoke.

I wonder if this was a matter of the patients not remembering, their previous doctor not caring in general, not caring because they were mentally ill and a "lost cause", or something else.. You'd think it would have come up at the pharmacy too...

As for the OP: I would absolutely recommend medicine if you want to prescribe. If the prescribing psychologist route is ever going to be viable on a national level, its certainly not going to happen right away. Its probably not a good option for many many other reasons that others have already touched on. If prescribing is important to you and you can switch, I'd do it. Though again, keep in mind the vast training differences.

 

[billypilgrim37]

To be fair, the risk of thrombosis while smoking on OCPs is quite a bit less than the risk of thrombosis while smoking while pregnant. Healthy young women who smoke should be counseled about their risks on OCPs, but the risk-benefit calculus would in most cases be firmly on the side of taking the pill.

 

[whopper]

True, but the more important point is doctors aren't just supposed to write a script, end of problem. Doctors are supposed to inform their patients of the risks & benefits of the medication.

Most doctors I see just write a script, end of story. They don't explain what they're doing, their reasoning, & what the risks & responsibilities of these medications are.

And that's doctors across the board. My wife's ob-gyn doctors have yet to have done this with her, my father in law's doctor never does this.

 

[Therapist4Chnge]

Most doctors I see just write a script, end of story. They don't explain what they're doing, their reasoning, & what the risks & responsibilities of these medications are.

And that's doctors across the board. My wife's ob-gyn doctors have yet to have done this with her, my father in law's doctor never does this.

Managed care definitely has not helped the situation, but it is scary how many people take things and don't even know why.

 

[OldPsychDoc]

Managed care definitely has not helped the situation, but it is scary how many people take things and don't even know why.

"Pacifex: A Doctor gave it to you."