Regret NOT doing fellowship?

[Stagg737]

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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.

Yea, the bolded seems to be the opposite experience from mine and many I've talked to. The private C/L docs are always typing "thank you for this interesting consult" or "thank you for including me in this patient's care" even when it's the crappiest consult to get more cases. My academic experiences have been far better with a much wider variety of consults than "patient said they wanted to die" or "Patient is delirious and 10mg of ativan made things worse, fix them". I do consults at a 1,000 bed academic center and see great cases, absolutely love it. I don't think I could ever do consults at a smaller private hospital because I'd be bored out of my mind after 2 weeks.

 

[Merovinge]

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.

Which is absolutely amazing and in many ways practicing psychiatry to the apex of the field/our training. There are days I wish I had retained all that knowledge and could to that work. I have nothing but adoration for good CL docs wherever they practice, whilst also learning that community CL is probably the literal worst job in all of psychiatry.

 

[Stagg737]

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.

Sounds like a typical week/month for me as well minus the ethics speed dial (primary teams usually get them involved) and going to court. Also have seen a couple of SILENT cases last month, excited catatonia, as well as post-ictal mania/psychosis in a guy with newly diagnosed frontal lobe epilepsy. I love treating autoimmune cases, but honestly hate FND and am grateful to have an absolutely incredible neurology colleague that I work with regularly.

 

[Celexa]

Sounds like a typical week/month for me as well minus the ethics speed dial (primary teams usually get them involved) and going to court. Also have seen a couple of SILENT cases last month, excited catatonia, as well as post-ictal mania/psychosis in a guy with newly diagnosed frontal lobe epilepsy. I love treating autoimmune cases, but honestly hate FND and am grateful to have an absolutely incredible neurology colleague that I work with regularly.

Heh I meant i was on ETHICS' speed dial because indeed it was the primary team initiating.

Did your SILENT cases have imaging findings?

 

[Stagg737]

Heh I meant i was on ETHICS' speed dial because indeed it was the primary team initiating.

Did your SILENT cases have imaging findings?

Lol, not a speed dial I ever want to be on unless I join their department.

Not that I recall. One was pretty minimal symptoms, maybe not true SILENT. Developed a chronic notable tremor after a previous lithium toxicity years earlier with nystagmus but little or no gait abnormalities, we were consulted for recs for bipolar meds at patient's request. Other one could have but Idr, ongoing symptoms were gait abnormalities after a severe toxic event requiring hemodialysis last year. Consulted for encephalopathy and agitation recs for hepatic issues. Surprisingly, his kidneys were chugging along really well despite the prior event. I can probably pull his chart up and check the CT if you want but pretty sure we didn't have a recent MRI on file.

 

[Celexa]

Lol, not a speed dial I ever want to be on unless I join their department.

Not that I recall. One was pretty minimal symptoms, maybe not true SILENT. Developed a chronic notable tremor after a previous lithium toxicity years earlier with nystagmus but little or no gait abnormalities, we were consulted for recs for bipolar meds at patient's request. Other one could have but Idr, ongoing symptoms were gait abnormalities after a severe toxic event requiring hemodialysis last year. Consulted for encephalopathy and agitation recs for hepatic issues. Surprisingly, his kidneys were chugging along really well despite the prior event. I can probably pull his chart up and check the CT if you want but pretty sure we didn't have a recent MRI on file.

Haha just curious. I'm still chasing the white whale of an unambiguous SILENT case. It ends up on differentials (including for our most recent AIE case, but have yet to have a patient where I felt we could be certain that it was either definitely what happened or even the most overwhelmingly likely cause.

 

[Stagg737]

Haha just curious. I'm still chasing the white whale of an unambiguous SILENT case. It ends up on differentials (including for our most recent AIE case, but have yet to have a patient where I felt we could be certain that it was either definitely what happened or even the most overwhelmingly likely cause.

The recent guy is the second case I've seen where we have been very confident that they're experiencing SILENT. First one was a guy who had severe Li toxicity requiring hemodialysis with all the symptoms. A week or two of treatment and his cognition was normal but still had significant movement symptoms and ataxia. Brought back 4-6 months later for encephalopathy but family said he still needed a walker to get around and gait and tremors never got better. Stabilized and was d/c'd without resolution of the neuro symptoms. Haven't seen him since but pretty sure he'd seen neuro outpatient and had an MRI with cerebellar degeneration. Pretty sad but a great experience for our sub-i's that month.

 

[Ellomate]

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

That article is form 2006! Investment and other vehicle holds true, but I'm not sure if the writer expected psych to be this popular. It was the 3rd most applied to specialty in my med school

 

[wellbutrin.girlfriend]

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

Just read this and also appreciate the very solid advice to not invest in Amazon in the year of our lord 2006

 

[clement]

I too wish I’d done a forensics fellowship and think it’s one that may be prone to garnering interest in mid to later career stages.

I ended up doing corrections out of necessity following an academic CL career and realized I really like it.

I know a handful of people with corrections backgrounds who were not fellowship trained, but now do comp evaluations for county forensic units under the stewardship of forensic trained individuals. They then extend those services to their private practice (however I think they may run into malpractice coverage issues and other bumps in the road).

Overall, I think there’s a lot more cross pollination in practice than fellowship programs might admit to someone on the fence.

I for example have had child and adolescent heavy psych er exposure as an adult psychiatrist in an undesirable geographic locale (ages 2-90+ would roll in diapered). I’m very comfortable with giving IM’s to wee ones, but have never pretended to be CAP in my spare time.

 

[FlowRate]

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

Dude, if he held that stock portfolio... that's some good foresight to have confidence in Apple in 2006. That was before the iPhone was announced. They're 100x since then. USO was his only really bad bet that I saw. I'm not a fan of stock picking, but those were some good bets...

Edit: In his follow-up, he mentioned a more short term outlook/active trading, so who knows long term.

 

[sloop]

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.

I think one of the under-appreciated things about forensics fellowship (and perhaps fellowship in general) is the way it changes the way you practice more generally. A lot of people take a purely business-like approach to fellowship, which is understandable. It is (typically) a year of attending pay you are giving up, after all. Still, I would argue that a lot of the benefits of fellowship are more intangible.

I believe that forensic fellowship made me a better doctor and a better psychiatrist. I think that having an understanding of the different levels of care in corrections and the limitations of practice in those settings was useful. I think that evaluating criminal responsibility gave me a better understanding of what it looks like when untreated or undertreated mental illness leads to the most horrific, feared outcomes. I believe that I have a better understanding of the legal regulation of psychiatry than the average general psychiatrist, and I think this has helped prepare me for an administrative position should I ever decide to enter such a role. These things are hard to assign value to, but they do have value.

I would also say that just because one can do something without a fellowship does not mean they should. My experience has been that general psychiatrists often overestimate their competence when it comes to forensic work (particularly criminal forensic work). The average psychiatrist can probably do a fair job in a malpractice case, but when it comes to more niche areas of civil law or criminal forensic issues, they often do things like misunderstand the legal standard (if they even bother to look it up), unreasonably apply the standard, or practice unethically (sometimes out of ignorance of basic practice guidelines like get paid upfront, you are compensated for your time not your opinion, etc.).

 

[Dharma]

So glad I did not choose to do a fellowship. I received a C/L fellowship offer outside of the Match years back at an excellent program and came oh-so-close to taking it. Went with the gut feeling and ultimately declined. Years later, I am much happier having made that extra 200K+ a year earlier. Would have taken me years to make that back and that money has done us well.

That stated, I was very well trained and did not need extra C/L training nor did I have any interest in joining the ranks of ivory tower medicine. Now, I am in an academic setting (not an ivory tower by any means) and my lack of fellowship training as not been a barrier whatsoever. I am board certified in addiction medicine (via Practice Pathway) however that has not made much of difference in regards to pay. (Nice having the extra knowledge under my belt since I see A LOT of addiction cases).

My advice: don't do a fellowship unless you want to be in academia working in a particular subspecialty or you have burning desire for more knowledge/training (with the exception being CAP however I have no idea how anyone can deal with parents that often). Nothing wrong with that. However it will come at the price of close to 250K which could take you decades to make back (and that's not taking into consideration dividends on investing that money had you made it earlier).

 

[clozareal]

My advice: don't do a fellowship unless you want to be in academia working in a particular subspecialty or you have burning desire for more knowledge/training (with the exception being CAP however I have no idea how anyone can deal with parents that often). Nothing wrong with that. However it will come at the price of close to 250K which could take you decades to make back (and that's not taking into consideration dividends on investing that money had you made it earlier).

Parents can definitely be a lot and can be draining, especially in certain settings. However, for me, that's one of the more rewarding parts. I enjoy helping struggling parents shift their perspective about their kid, equip them with better parenting skills, help them be more attuned to their child(ren), and feel more empowered to make a positive difference in their child's trajectory.

In my experience being out of CAP training for a few years, I don't think it's that much of a differential and I don't think it takes that long to make that back for CAP.

 

[MedMan80]

I have no regrets doing CAP, i think it helped me make up for the paucity of outpatient training that general psych gave me. I got called a Unicorn on my last job interview!

 

[Dharma]

Parents can definitely be a lot and can be draining, especially in certain settings. However, for me, that's one of the more rewarding parts. I enjoy helping struggling parents shift their perspective about their kid, equip them with better parenting skills, help them be more attuned to their child(ren), and feel more empowered to make a positive difference in their child's trajectory.

In my experience being out of CAP training for a few years, I don't think it's that much of a differential and I don't think it takes that long to make that back for CAP.

As I said, CAP is the exception.

 

[Ellomate]

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

What sort of non-correctional are you interested in specifically? A variation of criminal and civil or do you have specific interest in forensic that may make the fellowship worthwhile? Thanks!