Regret NOT doing fellowship?

[Ellomate]

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I do not have 100% conviction towards a specific fellowship. For now, my interest lies in CL, CAP, Forensics.
As I'm halfway done with residency, I'm still torn on how I should go about my career.

Psych is unique that it doesn't require a fellowship. Many regret wasting a year of attending salary as they do not practice forensic, CAP, etc upon board-certification. I personally know few child psychiatrists who does 100% adult.

Does anyone specifically regret NOT pursuing fellowship after their residency?
What would you have done differently?
What opportunities were you closed from due to not having fellowship?
Is it wise for job security as the field of medicine is quickly changing? APN, midlevel creeps, etc.
Is it financially wise to pursue fellowship? ROI make sense?

Looking for some words of wisdom from those who have been in my shoes.
Thank you

 

[Sushirolls]

Nope, I don't regret not doing one.

Do fellowship only if you have a concrete plan and the fellowship is part of that plan. Or if you plan to do academics and that that fellowship will further your plan.

Otherwise, just not worth it.

Now if you want to Sleep, Headache, or Pain then those fellowships are needed to do those.

 

[Dhingra210]

waste of time unless you want to be a C U. Ck academic

 

[michaelrack]

If you want to do pain procedures, a pain fellowship is necessary. A sleep fellowship is necessary if you want to read in-lab sleep studies and want to treat sleep apnea. However, a sleep fellowship is not financially worthwhile. C and L is a waste, unless you want to do C and L in an academic setting for some reason.

 

[Celexa]

Two reasons to do fellowship (child & adolescent aside, although not always bc there is actually quite a bit of variance in the depth and breadth of exposure to child in general residencies):

1. Your residency genuinely did not prepare you adequately in an area that you really want to work in and you need the additional training and/or network. Forensics is most likely to fall in this category.

2. You want to work in academics. That means you want to either pursue a research career or you want to be teaching faculty at an academic institution, one with residencies and fellowships, or both. Being fellowship trained is meaningful if you want to do that.

I am very happy with my decision to do fellowship and I have encountered people who regretted not doing one--specifically, i have encountered a small number of people who did not do a CL fellowship in the time period around 10 years ago when it felt more optional and securing academic faculty positions without fellowship was more frequent. For people who made that choice it is possible to end up in an awkward spot--not subspecialty boarded, but too junior to have been able to grandfather in, and the credential does matter in academia.

Never met anyone outside academics who regretted not doing a fellowship, and from what I can tell geri and addictions are both a bit more forgiving in terms of academic positions wanting the fellowship--but it's hard to tell if that's going to remain true or if they're just in the same developmental cycle as subspecialties CL was and in a decade the academic centers will strongly prefer their faculty be boarded.

I am academic faculty. I'm happy with my job and value my fellowship training but pragmatic about both the benefits and downsides of additional training. I've seen people do fellowship mainly as an anxiety behavior--thats not a good reason. No one should feel they "have to" or "should" do a fellowship. Do it if it aligns with your NON-FINANCIAL career goals.

 

[comp1]

Absolutely not. I have never met a single person who regretted not doing a fellowship and I'm around academics all the time. You can certainly have a very full and vibrant academic career without them. You can literally do anything the core psychiatric fellowships offer without completing them. I'm not saying you necessarily should, but you certainly can if you later develop some interest in them.

 

[Merovinge]

If you do decide you want to dedicate a significant portion of your practice to CAP or forensics, I would strongly recommend those 2 fellowships in particular. You might have found a few CAP that practice 100% adult, but that is quite rare. I know dozens of CAP and of those 1 previously saw children for decades and later in life shifted to 100% adult, the rest all see some amount of kids (obviously there is a selection bias for the people who choose to do CAP, the average adult resident wants nothing to do with kids and is wise to just see adults). I would definitely recommend fast tracking, as missing 2 years of attending income is a large pill to swallow, 1 feels very reasonable.

I know nothing about the forensic world, but have repeatedly heard that there is significant value to it if you want to make it a substantial part of your practice.

I am not sure you will find too many people who regret not doing fellowship, as the people who actually had a real passion for those areas almost assuredly were able to do the fellowships given how non-competitive they are.

 

[Stagg737]

I'll be an n=1. Part of me regrets not doing a forensics fellowship. I have a lot of interest in non-correctional forensics but got fairly limited exposure during residency. I skipped it post-residency as I don't want to practice forensics with certain populations while I have small children, but I am still considering taking a year off at some point in 10-12 years to do a fellowship and pivot a bit with my career.

Even so, I agree that fellowships aren't necessary for most areas. Personally, I think the only one that really should be standard is CAP. I've heard the argument "but NPs treat kids all the time!" and think it's BS. Small kids aren't little adults and both the presentations of their disorders and treatments are very different from adult populations. Unless one gets extensive CAP training during residency I do think a fellowship adds significant and necessary knowledge to one's practice, only reason there hasn't been a push to make it standard is how massive the shortage is. It's also probably the only fellowship that may have significant financial upsides in the long run as well. I say all this as someone who was on the CAP track in residency but dropped during my PGY-3 year when I realized it wasn't for me.

 

[Merovinge]

I'll be an n=1. Part of me regrets not doing a forensics fellowship. I have a lot of interest in non-correctional forensics but got fairly limited exposure during residency. I skipped it post-residency as I don't want to practice forensics with certain populations while I have small children, but I am still considering taking a year off at some point in 10-12 years to do a fellowship and pivot a bit with my career.

Even so, I agree that fellowships aren't necessary for most areas. Personally, I think the only one that really should be standard is CAP. I've heard the argument "but NPs treat kids all the time!" and think it's BS. Small kids aren't little adults and both the presentations of their disorders and treatments are very different from adult populations. Unless one gets extensive CAP training during residency I do think a fellowship adds significant and necessary knowledge to one's practice, only reason there hasn't been a push to make it standard is how massive the shortage is. It's also probably the only fellowship that may have significant financial upsides in the long run as well. I say all this as someone who was on the CAP track in residency but dropped during my PGY-3 year when I realized it wasn't for me.

The race-to-the-bottom arguments are so depressing. We know better so we need to do better. I will say that for psychiatrists who work in very rural areas I would take an adult psychiatrist who has interest in this population over the alternatives, but I would also highly recommend said docs make friends with CAP folks, attend AACAP, or have other routes to bounce hard cases off of.

 

[ObsequiousAplomb]

I don't have regrets. I admit my heart skips a beat when I get the opportunity to turn down pediatric, addiction, or geriatric referrals and direct them to the appropriate subspecialists.

 

[shoomer]

Slightly different angle, but I did not do a CL fellowship which I was strongly considering, and instead opted to fast track into CAP fellowship. I didn't necessarily see myself as a CAP person but I've legitimately enjoyed fellowship and took a job working primarily with kids. I don't regret not doing CL and I don't regret doing CAP.

I don't really think there are any major cons to doing fellowship, provided you pick a non-malignant program and financially can live okay on a trainee salary for another year. But you should have a clear desire for fellowship along with an idea of how it will help you (specific career paths, strengthening areas of weakness that you feel you will need). If you don't really want to do fellowship and enter with some vague goal such as CV boosting, you're more likely to resent that extra year and view it as a waste.

You can do plenty of things without fellowship. Fellowships will open up more niche opportunities. On a purely financial level, it probably won't put you out ahead most of the time to do fellowship.

Assess your own personality and values. I value expertise and the way I conceptualize patients/psychiatry/society as a whole led me to CAP from the very beginning without me realizing until much later. I had doubts but I felt good once I made the decision to pursue it. Whenever I said screw it, I don't need a fellowship, I felt deep down I was just picking the easiest route and not being true to myself. But everyone is different so you have to see what feels right for you.

 

[romanticscience]

I do not have 100% conviction towards a specific fellowship. For now, my interest lies in CL, CAP, Forensics.
As I'm halfway done with residency, I'm still torn on how I should go about my career.

Psych is unique that it doesn't require a fellowship. Many regret wasting a year of attending salary as they do not practice forensic, CAP, etc upon board-certification. I personally know few child psychiatrists who does 100% adult.

Does anyone specifically regret NOT pursuing fellowship after their residency?
What would you have done differently?
What opportunities were you closed from due to not having fellowship?
Is it wise for job security as the field of medicine is quickly changing? APN, midlevel creeps, etc.
Is it financially wise to pursue fellowship? ROI make sense?

Looking for some words of wisdom from those who have been in my shoes.
Thank you

No. I took this advice (#2) when I was a resident. It held true.

 

[FlowRate]

I don't regret not doing a fellowship. I did somewhat strongly consider CAP, but I wasn't geared up to fast track and I think that's the only way I would have considered doing CAP.

 

[TexasPhysician]

The job market the last 10 years has been pretty good, so I’d wager there are few people that “regret” not doing a fellowship currently. Getting in the market faster to take advantage of the “run up” has been good advice the last 10 years. Will that continue?

Those that regret it currently would generally discover that they really enjoy a smaller niche that has barriers to entry. If you want to practice addictions in private practice, you can just go do it. If you want to be the medical director at a nice addictions facility in a big city, an addictions certification/fellowship really helps. The average hospital would be happy to have any in-person psych consultant, but if you want to be C&L at somewhere like MD Anderson, I bet they strongly prefer someone fellowship trained. Sure there are exceptions, but there are certainly gigs that open up with the extra training. They aren’t always more lucrative, but they can certainly be more enjoyable for some.

 

[clozareal]

I wish I did a forensics fellowship right after CAP. Now I'm too adjusted to an attending salary to go back to a fellow salary.

I'm really happy I did CAP though because I enjoy treating children/families/parents.

 

[SPsych6]

I'll be an n=1. Part of me regrets not doing a forensics fellowship. I have a lot of interest in non-correctional forensics but got fairly limited exposure during residency. I skipped it post-residency as I don't want to practice forensics with certain populations while I have small children, but I am still considering taking a year off at some point in 10-12 years to do a fellowship and pivot a bit with my career.

Even so, I agree that fellowships aren't necessary for most areas. Personally, I think the only one that really should be standard is CAP. I've heard the argument "but NPs treat kids all the time!" and think it's BS. Small kids aren't little adults and both the presentations of their disorders and treatments are very different from adult populations. Unless one gets extensive CAP training during residency I do think a fellowship adds significant and necessary knowledge to one's practice, only reason there hasn't been a push to make it standard is how massive the shortage is. It's also probably the only fellowship that may have significant financial upsides in the long run as well. I say all this as someone who was on the CAP track in residency but dropped during my PGY-3 year when I realized it wasn't for me.

I 100% agree with this response. If you are seeing children, you should do CAP. No NP should ever be seeing children. I am board certified in adult and wouldn't never agree to see a child patient. If you want to see kids, definitely do CAP.

I also agree that if you want to do Forensics well, you should do the fellowship. It is a great way to practice without always being face-to-face with patients. I am not trained in forensics, but I have also considered the fellowship after being out a couple years. I look for opportunities to work without seeing more patients, and of the options that exist, forensics is more interesting and actually pays the best too, if you are well trained and networked.

 

[slowthai]

I 100% agree with this response. If you are seeing children, you should do CAP. No NP should ever be seeing children. I am board certified in adult and wouldn't never agree to see a child patient. If you want to see kids, definitely do CAP.

I also agree that if you want to do Forensics well, you should do the fellowship. It is a great way to practice without always being face-to-face with patients. I am not trained in forensics, but I have also considered the fellowship after being out a couple years. I look for opportunities to work without seeing more patients, and of the options that exist, forensics is more interesting and actually pays the best too, if you are well trained and networked.

What makes you want to do some work away from patients?

 

[rjs2131]

CAP here and definitely think without CAP fellowship, I wouldn't have the tools/knowledge to do my job as effectively with kids/teens/families. The extra year (fast tracking) was well worth it IMO, both from a knowledge/treatment standpoint and from a marketing standpoint (I'm in PP, and the demand for CAP seems to generally be higher than the demand for adult psych...though both are still very much needed).

This is obviously program dependent, but a few things I specifically appreciate from CAP training:
- additional family therapy experience/work
- MUCH more experience treating ADHD
- MUCH more experience with ASD

If you can get the above without CAP fellowship (i.e. just doing electives in your 4th year), it won't replace CAP fellowship but could allow you to feel comfortable enough without it. I think the investment is worth it though and given the uncertain future of our healthcare system/reimbursement/etc in general, the more marketable you are the better off you'll be.

 

[Merovinge]

I wish I did a forensics fellowship right after CAP. Now I'm too adjusted to an attending salary to go back to a fellow salary.

I'm really happy I did CAP though because I enjoy treating children/families/parents.

That's certainly one of the best, if not the best, of the double fellowship options. CAP forensics is tough work but potentially very lucrative and filled with prestige. One does need to find a forensic fellowship that lets you have significant CAP time which does take some searching.

 

[FatherPsychiatry]

I did forensic fellowship but don't engage in any direct forensic work. I had a lot of life changes happen during my PGY-4 year (having a kid, etc), and realized halfway through fellowship I didn't want to do any work that would occupy my thoughts once I clock out for the day. Some people are very good at compartmentalizing, prioritizing, time management etc. I was not one of them, and those skills are huge for forensics where you are dealing with courts, attorneys, evaluees, dates and times being moved around etc.

I still work in a forensic setting (although most of the psychiatrists here have not done fellowship), and I enjoy discussing forensic cases with my colleagues that actually do forensic work. I still regularly follow AAPL literature, grand rounds etc because I enjoy it.

Do I regret having done the fellowship? Personally no. I didn't mind deferring attending income by one more year. I was moonlighting during fellowship year which helped, and my spouse was already an attending. My student loans were in 0% interest deferment due to COVID.

The fellowship does give me some peace of mind from scope creep, because I think I could get back into some forensics work if it really came to that. I would have to do some significant informal re-training to get my skills back, although one of the benefits of fellowship is life-long mentors / friends that would help with that.

Like others said above, its really hard to put yourself back into fellowship once you've tasted the attending bucks and lifestyle, so I'd recommend doing it if you're curious about any subject and don't have any significant financial/personal obligations.

 

[SPsych6]

What makes you want to do some work away from patients?

Sometimes you just want to work on a note/paperwork without being patient-facing. I tend to go inpatient for this reason, as outpatient feels like you are constantly "On" and don't really get a break. I don't know that others feel this way though. But in general, it is nice to be able to make some income without tying it to more patient visits. There are obviously other ways to do this, but forensics is interesting, still psychiatric work and not tied to admin etc.

 

[Merovinge]

Sometimes you just want to work on a note/paperwork without being patient-facing. I tend to go inpatient for this reason, as outpatient feels like you are constantly "On" and don't really get a break. I don't know that others feel this way though. But in general, it is nice to be able to make some income without tying it to more patient visits. There are obviously other ways to do this, but forensics is interesting, still psychiatric work and not tied to admin etc.

May I suggest RTC/PHP/IOP work as well then. You take less patient-facing time and more time meeting with your team, speaking with family/collateral etc. Lets you provide higher quality care while still getting well reimbursed as all good facilities are passing on some portion of their fees to the doctors who are netting less than their salaries in raw billing.

 

[comp1]

Yeah if I ever couldn't do full time inpatient, PHP would be my second choice.

 

[OldPsychDoc]

I did an Addiction Psychiatry Fellowship, and don't regret that, but actively "use it" less than 5% of the time as a hospital psychiatrist right now.
What I NEED is Geriatric Psychiatry--there are months that 2/3 - 3/4 of my census is over 60, often over 70, and presenting with all manner of decompensated psychotic illnesses as well as major neurocognitive degeneration and just plain generalized "accelerated aging" from the hard lives they've been living. I wished I had more training on that (over and above having to cram on my own.)

 

[nexus73]

I did a forensic fellowship and have no regrets. I dabble in it, pick up a handful of cases a year. I got to see some very interesting things in fellowship I otherwise would not have been exposed to. It informs my non forensic clinical practice on a regular basis. I think it makes me slightly more marketable in general. There are some state jobs around me that actually pay a small differential for a second board certification.

 

[tr]

Sometimes you just want to work on a note/paperwork without being patient-facing. I tend to go inpatient for this reason, as outpatient feels like you are constantly "On" and don't really get a break. I don't know that others feel this way though. But in general, it is nice to be able to make some income without tying it to more patient visits. There are obviously other ways to do this, but forensics is interesting, still psychiatric work and not tied to admin etc.

I think most people feel this way actually. I don't know anyone who consistently does 35+ h/wk of patient facing work. Only people who joined Big Box straight out of residency, and they typically figure out it's not a good deal and bail within a couple of years.

I'm in academics so I and most of my clinically trained colleagues have some split where more time goes to research, education, or admin depending, rather than direct patient care. People who do private practice seem to set their prices high enough that they don't have to grind through 35h of patient encounters. Spend the rest of their time doing yoga or working on promoting their brand, or have some non patient facing side gig like forensic work.

 

[Ellomate]

Nope, I don't regret not doing one.

Do fellowship only if you have a concrete plan and the fellowship is part of that plan. Or if you plan to do academics and that that fellowship will further your plan.

Otherwise, just not worth it.

Now if you want to Sleep, Headache, or Pain then those fellowships are needed to do those.

I was thinking more for job security since IDK what will happen to medicine & psychiatry for the next 30 years.

Sleep & pain is interesting but hard to find psych in it. Are they dealing more with psychiatric co-moboridity or procedures? I can't imagine psychiatrist competing against PMNR and Gas for pain procedures.

 

[Ellomate]

I am academic faculty. I'm happy with my job and value my fellowship training but pragmatic about both the benefits and downsides of additional training. I've seen people do fellowship mainly as an anxiety behavior--thats not a good reason. No one should feel they "have to" or "should" do a fellowship. Do it if it aligns with your NON-FINANCIAL career goals.

Great point. I don't see myself in academia. Definitely feeling a lot of anxiety given future job aspect and security.

 

[Sushirolls]

I was thinking more for job security since IDK what will happen to medicine & psychiatry for the next 30 years.

Sleep & pain is interesting but hard to find psych in it. Are they dealing more with psychiatric co-moboridity or procedures? I can't imagine psychiatrist competing against PMNR and Gas for pain procedures.

No.
Whence one is fellowship trained, they practice fully in the fellowship, no restrictions, no different than the others.

 

[milan95]

Would not doing any fellowship hurt if one wants to be in academia?

 

[Celexa]

Would not doing any fellowship hurt if one wants to be in academia?

If you want to practice in that specialty area (and be somewhat protected from being pulled from it and asked to do other things, yes).

1. To have a fellowship in an area the program has to have a certain number of faculty who are boarded in that field. ALL of the faculty don't need to be, but you have to meet the minimum. So while some places may have an abundance of board certified psychiatrists in a certain area and therefore be willing to hire someone who is not, hiring someone without the specialty board cert could be a hard no in other places if they want to start or maintain a fellowship.

2. It's academia. They care about credentials. They're always going to be looking at the board certified people first. One of the main reasons institutions have fellowships in the first place is to have an internal faculty pipeline.

CL is definitely at the point where I advise anyone who wants an academic career in CL to do a fellowship.

 

[milan95]

If you want to practice in that specialty area (and be somewhat protected from being pulled from it and asked to do other things, yes).

1. To have a fellowship in an area the program has to have a certain number of faculty who are boarded in that field. ALL of the faculty don't need to be, but you have to meet the minimum. So while some places may have an abundance of board certified psychiatrists in a certain area and therefore be willing to hire someone who is not, hiring someone without the specialty board cert could be a hard no in other places if they want to start or maintain a fellowship.

2. It's academia. They care about credentials. They're always going to be looking at the board certified people first. One of the main reasons institutions have fellowships in the first place is to have an internal faculty pipeline.

CL is definitely at the point where I advise anyone who wants an academic career in CL to do a fellowship.

What if you want to practice simple gen psych in an academic institution? The answer may be obviously - well, if u want to do just gen psych in academia, you dont need a fellowship) - but at least in the institution i train at, there are so many psychiatrists who are board certified in sub specialties, but end up only practicing gen psych. So it makes me worry that even with goals of overall climbing the gen psych ladder in academia, you are expected to do a fellowship to make yourself more marketable. Perhaps you will have more insight

 

[Celexa]

What if you want to practice simple gen psych in an academic institution? The answer may be obviously - well, if u want to do just gen psych in academia, you dont need a fellowship) - but at least in the institution i train at, there are so many psychiatrists who are board certified in sub specialties, but end up only practicing gen psych. So it makes me worry that even with goals of overall climbing the gen psych ladder in academia, you are expected to do a fellowship to make yourself more marketable. Perhaps you will have more insight

Personally I have not encountered this. My experience has been that fellowship trained and boarded specialists practice in their area, except for a small number who don't by choice, and that the vast majority of academic psychiatrists practicing general psychiatry have not done fellowship. Maybe there is some regional variance for some reason I am unaware of, or it could be a strange hiring quirk at your particular institution.

 

[Merovinge]

What if you want to practice simple gen psych in an academic institution? The answer may be obviously - well, if u want to do just gen psych in academia, you dont need a fellowship) - but at least in the institution i train at, there are so many psychiatrists who are board certified in sub specialties, but end up only practicing gen psych. So it makes me worry that even with goals of overall climbing the gen psych ladder in academia, you are expected to do a fellowship to make yourself more marketable. Perhaps you will have more insight

It depends on the program. Where I trained there wasn't honestly that much "gen" psych. We had a psychosis unit and mood unit where folks were not fellowship trained, but a big chunk of things were fellowship trained like interventional/neuropsych, women's psych, c/l , CAP, and addictions. Residency programs are trying to put together subspecialty training environments so there is honestly good reason for fellowship training.

That said, some of the very best docs I worked with were psychosis specialists who did not have any fellowship training and they were smart enough to know when it made sense to consult the neuropsych team. I really enjoyed seeing attendings bring on other attendings from the same base field. I am not even sure if most places a psychiatrist can put in a consult to another psychiatrist and have the payments go through on an IP unit.

 

[TexasPhysician]

What if you want to practice simple gen psych in an academic institution? The answer may be obviously - well, if u want to do just gen psych in academia, you dont need a fellowship) - but at least in the institution i train at, there are so many psychiatrists who are board certified in sub specialties, but end up only practicing gen psych. So it makes me worry that even with goals of overall climbing the gen psych ladder in academia, you are expected to do a fellowship to make yourself more marketable. Perhaps you will have more insight

Gen psych is certainly possible in academia, but it can put you at a disadvantage. Remember that programs require so many that are boarded in subspecialties to keep fellowships open. It never hurts to have an extra CAP in case someone leaves. Also they pride themselves in having specialists where they can - C&L for consult service, etc.

 

[comp1]

You all must be talking about some extremely competitive academic places. Most teaching hospitals, like anywhere else, are in desperate need of psychiatrists, including those with just general boards. Honestly, if your own residency doesn't offer you a job at graduation from a general psych program, you might just not be that personable. However, when they do, I'm not saying you should necessarily take that job. Academics give up a heck of a lot to teach, most prominently a reasonable salary. I'm not sure compounding that by deferring even an academic attending salary by a year is a great idea if your ultimate goal is to teach.

 

[TexasPhysician]

You all must be talking about some extremely competitive academic places. Most teaching hospitals, like anywhere else, are in desperate need of psychiatrists, including those with just general boards. Honestly, if your own residency doesn't offer you a job at graduation from a general psych program, you might just not be that personable. However, when they do, I'm not saying you should necessarily take that job. Academics give up a heck of a lot to teach, most prominently a reasonable salary. I'm not sure compounding that by deferring even an academic attending salary by a year is a great idea if your ultimate goal is to

Not at all that competitive of residency programs. I’m sure there is a lot of regional variability based on many factors including program culture. I’ve seen new chairs arrive and scare everyone away. This results in scrambling for any gen psych bodies willing to follow the new order. I’ve also seen places where the support and QOL is high for faculty which results in difficulty getting in for any gen psych.

 

[milan95]

Not at all that competitive of residency programs. I’m sure there is a lot of regional variability based on many factors including program culture. I’ve seen new chairs arrive and scare everyone away. This results in scrambling for any gen psych bodies willing to follow the new order. I’ve also seen places where the support and QOL is high for faculty which results in difficulty getting in for any gen psych.

On that note, how much does institution you train at make a difference? For an example, are MGH trained child psych specialists able to pretty much write their own ticket and charge more or less what they want as opposed to a someone who did fellowship in a less prestigious institution?

 

[TexasPhysician]

On that note, how much does institution you train at make a difference? For an example, are MGH trained child psych specialists able to pretty much write their own ticket and charge more or less what they want as opposed to a someone who did fellowship in a less prestigious institution?

It doesn’t work like that. There are niche markets where it helps if you went to a brand program, but generally it won’t matter outside of academia. Your marketing ability, social skills, geography, networking, etc all play a role in gaining patients.

 

[Stagg737]

What if you want to practice simple gen psych in an academic institution? The answer may be obviously - well, if u want to do just gen psych in academia, you dont need a fellowship) - but at least in the institution i train at, there are so many psychiatrists who are board certified in sub specialties, but end up only practicing gen psych. So it makes me worry that even with goals of overall climbing the gen psych ladder in academia, you are expected to do a fellowship to make yourself more marketable. Perhaps you will have more insight

If you want to practice in academia in a certain sub-specialty then a fellowship may be (but not always) expected. This is especially true if you want to do certain fields like CAP, addiction, or forensics at a major academic program. For gen psych and even some specialty areas (like C/L or geri) fellowships are a big plus but not a requirement.

Personally I have not encountered this. My experience has been that fellowship trained and boarded specialists practice in their area, except for a small number who don't by choice, and that the vast majority of academic psychiatrists practicing general psychiatry have not done fellowship. Maybe there is some regional variance for some reason I am unaware of, or it could be a strange hiring quirk at your particular institution.

Agree, if someone goes through a fellowship process and then decides not to practice in that area, it's usually because they want more freedom/flexibility and/or want to make more money; both of which are typically going to be more restricted in academia for someone fellowship trained. Only fellowship trained docs I know/knew in academia that didn't practice at least part-time in their area of expertise were ones where their specialty didn't have openings at the time (CAP doc took an inpatient adult job while waiting for a CAP position to open, for example).

 

[Celexa]

If you want to practice in academia in a certain sub-specialty then a fellowship may be (but not always) expected. This is especially true if you want to do certain fields like CAP, addiction, or forensics at a major academic program. For gen psych and even some specialty areas (like C/L or geri) fellowships are a big plus but not a requirement.

Interesting, I would have cited geri and addictions as the areas where it is a plus but not a requirement, and the other three as more mandatory. At least the places I've been, the CL services want CL boarded docs--or at least ones experienced with academic CL, so new grads without fellowship are at a disadvantage if they want to focus on CL.

 

[splik]

Interesting, I would have cited geri and addictions as the areas where it is a plus but not a requirement, and the other three as more mandatory. At least the places I've been, the CL services want CL boarded docs--or at least ones experienced with academic CL, so new grads without fellowship are at a disadvantage if they want to focus on CL.

I think the best CL services/divisions have people of diverse backgrounds. We had people trained in addictions, forensics, CAP, neuropsych, FM/psych, med/psych, geriatrics, and someone who switched from OB, which really added to the diversity and depth of our division to handle most anything and we could consult each other when needed. I interviewed at various academic centers for C-L jobs at one point and they all seemed to value having a mix of C-L and non C-L trained, but there was definitely a preference for fellowship trained (e.g. addictions, forensic, geriatrics, neuropsych), or dual med/psych or neuro/psych etc if not C-L.

My former C-L service is now almost all C-L boarded folks and they are almost certainly worse off for it.

I do think you are right that there is more of a trend to get C-L trained folk now that it is a more popular subspecialty. In my day, it was like 75% IMGs and most fellowships didn't fill. Now slightly over hall the spots fill, and its mostly US MDs going into C-L fellowships. But it's also hard to control for selection bias, given most psych residents seem to despise C-L.

 

[Celexa]

I think the best CL services/divisions have people of diverse backgrounds. We had people trained in addictions, forensics, CAP, neuropsych, FM/psych, med/psych, geriatrics, and someone who switched from OB, which really added to the diversity and depth of our division to handle most anything and we could consult each other when needed. I interviewed at various academic centers for C-L jobs at one point and they all seemed to value having a mix of C-L and non C-L trained, but there was definitely a preference for fellowship trained (e.g. addictions, forensic, geriatrics, neuropsych), or dual med/psych or neuro/psych etc if not C-L.

My former C-L service is now almost all C-L boarded folks and they are almost certainly worse off for it.

I do think you are right that there is more of a trend to get C-L trained folk now that it is a more popular subspecialty. In my day, it was like 75% IMGs and most fellowships didn't fill. Now slightly over hall the spots fill, and its mostly US MDs going into C-L fellowships. But it's also hard to control for selection bias, given most psych residents seem to despise C-L.

In terms of CL preference I was speaking mainly to being only general psych trained vs having fellowship. I agree with you that if a service is large enough they don't have to worry about maintaining the minimum number of subspecialty boarded faculty members, wanting to do CL + another fellowship or dual medical board etc is equally competitive. But a general psych new grad is going to be at a disadvantage even if they come from a big academic program with excellent CL exposure.

 

[slowthai]

most psych residents seem to despise C-L.

Why do you think this is the case?

 

[comp1]

CL is very rough. You have an identified patient, the one in the bed, but you're really not treating them. In most situations, you literally can't. You're actually treating the primary team, and often most specifically, a horribly burnt out IM attending. It's bad enough treating other doctors when you're DIRECTLY treating them, here you have to indirectly treat them. I get that it's different in the world of private CL where people genuinely mean "thank you for this interesting consult," but the poster above asked about residency. Most psychiatric conditions have a significant social root which you are not going to be addressing on a medical floor. It's like an extra degree of difficulty from inpatient psych where you also have suicidal patients with borderline PD, but who aren't also bleeding out and declining treatment because they view it as assault.

 

[Stagg737]

Interesting, I would have cited geri and addictions as the areas where it is a plus but not a requirement, and the other three as more mandatory. At least the places I've been, the CL services want CL boarded docs--or at least ones experienced with academic CL, so new grads without fellowship are at a disadvantage if they want to focus on CL.

I interviewed where I'm currently at, Indiana, and Wake Forest for C/L positions and I'm just gen psych. I've also had e-mails directly to me from department admins (Georgetown, Nebraska, Mizzou) about C/L positions. I was less than 2 years out of residency and was working in an academic ER at the time, so I'd say my experience is pretty different. I came from a residency with a med/psych program (and am currently at one that is similar) but am just gen psych myself.

My current consult team has exactly ZERO attendings out of 8 who did a C/L fellowship. We have 3 that are med/psych trained, another did a year of OB/gyn residency before switching to psych and is a reproductive psych specialist, and another did a CAP fellowship (is leaving to be a PD elsewhere, but is being replaced by another CAP trained doc). I'm kind of our forensics "specialist"; I am certainly not an expert on forensics but just know our state laws inside out and have a lot more interest in that area (especially with ethics and capacity) than others here. We also have a separate addictions team that handles certain substance consults (buprenorphine micro-inductions and the such) who we talk to about complex substance cases or certain meds when needed.

I'm sure this will vary depending on the academic center, and elite programs will want to be able to display their prestige. Having the fellowship credentials would help get a C/L job at any academic program, but ime it's far from necessary like it would be for a field like CAP where Idk that a general psychiatrist would find a CAP position at any academic program. Also ime academic addictions is more strict when it comes to wanting a fellowship trained doc. Where I'm at they won't consider hiring someone without an addictions fellowship. Private addictions I completely agree though, fellowship is absolutely not necessary.

 

[Merovinge]

Why do you think this is the case?

If you've ever done CL at a non-academic place the question would absolutely answer itself. I had the absolute best experience on CL in med school (made we want to go into psych) and trained under amazing CL attendings in residency, saw peoples' lives literally saved by emergent ECT, catching NMS/5-HT syndrome, many autoimmune encephalopathy cases and many others I am too lazy to type up. Having done just a brief period of time in community CL, I would rather not be a doctor than go back to that work (and I like my job more than 95% of MDs).

 

[Stagg737]

Why do you think this is the case?

Because most psych residents don't want to deal with actual medicine or rounding. C/L at many programs is going to be more like a medicine rotation where you're up and about rounding on patients with a team than a psych rotation where table rounds are more common or patients are brought to the team.

Also depends on the program. If you're at a large medical center where you see legit zebras it can be an awesome experience. If you're at a smaller hospital where every consult is just for "SI" or "agitation" like what comp1 describes, it gets really repetitive, boring, and the medical team is the actual patient.

 

[Celexa]

I interviewed where I'm currently at, Indiana, and Wake Forest for C/L positions and I'm just gen psych. I've also had e-mails directly to me from department admins (Georgetown, Nebraska, Mizzou) about C/L positions. I was less than 2 years out of residency and was working in an academic ER at the time, so I'd say my experience is pretty different. I came from a residency with a med/psych program (and am currently at one that is similar) but am just gen psych myself.

My current consult team has exactly ZERO attendings out of 8 who did a C/L fellowship. We have 3 that are med/psych trained, another did a year of OB/gyn residency before switching to psych and is a reproductive psych specialist, and another did a CAP fellowship (is leaving to be a PD elsewhere, but is being replaced by another CAP trained doc). I'm kind of our forensics "specialist"; I am certainly not an expert on forensics but just know our state laws inside out and have a lot more interest in that area (especially with ethics and capacity) than others here. We also have a separate addictions team that handles certain substance consults (buprenorphine micro-inductions and the such) who we talk to about complex substance cases or certain meds when needed.

I'm sure this will vary depending on the academic center, and elite programs will want to be able to display their prestige. Having the fellowship credentials would help get a C/L job at any academic program, but ime it's far from necessary like it would be for a field like CAP where Idk that a general psychiatrist would find a CAP position at any academic program. Also ime academic addictions is more strict when it comes to wanting a fellowship trained doc. Where I'm at they won't consider hiring someone without an addictions fellowship. Private addictions I completely agree though, fellowship is absolutely not necessary.

Likely regional variance then. My experience is mainly in the northeast. Which makes sense when you look at location, age, and size of CL fellowship programs.

 

[Celexa]

If you've ever done CL at a non-academic place the question would absolutely answer itself. I had the absolute best experience on CL in med school (made we want to go into psych) and trained under amazing CL attendings in residency, saw peoples' lives literally saved by emergent ECT, catching NMS/5-HT syndrome, many autoimmune encephalopathy cases and many others I am too lazy to type up. Having done just a brief period of time in community CL, I would rather not be a doctor than go back to that work (and I like my job more than 95% of MDs).

Unfortunately this which is why I do specify, do CL fellowship if you want to do ACADEMIC CL. Most of us in CL are in it for the academic as much as the CL. Here's a partial list of things I did in just the most recent week or two I was on service:

-conclusively diagnosed an atypical functional neurologic disorder in a patient who had had a platinum workup to no avail (not as a diagnosis of exclusion)
-diagnosed an autoimmune encephalitis and treated it successfully
-had two patients with refractory agitation in the icu requiring multiple long discussions with icu, neuro, tox
-brokered an introduction between two services and turned a possible impending feud into a collaboration
-LVAD and txp evals
-was on the ethics service speed dial
-went to court for meds over objection for a patient turning down a lifesaving medical procedure who could not be transferred to psych
-debated with four of my colleagues what the hell could be going on with the current mystery patient of the week because none of us or multiple consulting services can figure it out. We have expanded the differential to obscure poisons.


Plus I have a niche outpatient practice which would be impossible outside of academia.

It's fun because I'm surrounded by genuinely curious and collaborative colleagues in psych AND the other depts. If I was stuck shipping out everything interesting and mainly dealing with dispo, I'd hate it.