Residents Switching Into Psych on the Interview Trail

[Sir James Bond]

I always love hearing about applicants we meet on the interview trail coming from other specialties into psychiatry. I met two residents switching out of pediatrics, another one from general surgery, another from urology, and another - believe it or not - leaving radiology. I interviewed mostly on the west coast which is where I met them. Anyone else?

---

Members don't see this ad.

 

[kindasorta]

I had a neurosurgery resident making the leap.

 

[BS81]

OB/Gyn and Path

 

[shan564]

Met a few FP applicants and a resident who switched from radiology a couple of years ago.

 

[tobi44]

I always love hearing about applicants we meet on the interview trail coming from other specialties into psychiatry. I met two residents switching out of pediatrics, another one from general surgery, another from urology, and another - believe it or not - leaving radiology. I interviewed mostly on the west coast which is where I met them. Anyone else?

interesting, I guess psych does have some draw power if people are jumping ship from higher paying/competitive specialties to get into it.

Does anyone know if the reverse it true, how often do psych residents try to switch into something else?

 

[Leo Aquarius]

We have a former general surgeon in my psych intern class as a matter of fact. And I interviewed over lunch one girl leaving her peds residency after 1 year.

 

[shan564]

interesting, I guess psych does have some draw power if people are jumping ship from higher paying/competitive specialties to get into it.

Does anyone know if the reverse it true, how often do psych residents try to switch into something else?

I met a psych resident who was planning to switch into IM. But he never actually wanted to do psych... he just took a psych job because it's less competitive and he's an IMG.

But I did wonder the same thing when I saw this thread.

Interesting anecdote - I met one person along the interview trail who spent most of his career with the military, where you're paid according to your military rank, not your medical rank. So he came across a lot of senior attendings (in all sorts of fields) who would start a psych residency, since they could continue to earn their attending salary. He once had an admiral working under him as a resident, which sounds insane.

 

[Doctor Bagel]

We have 3 former anesthesiology residents in our adult and child programs.

 

[markglt]

switched out of fm in pgy2....
always wanted psych...took the fm spot b/c it was guaranteed......very painful 1.5 years....USIMG with average scores/grades..

 

[snowowl]

I had this same conversation with a pediatrics resident a couple weeks ago. She left a psychiatry residency after 1 year and is now very happy in the world of peds. I asked if this was an uncommon phenomenon and two more residents in the room looked up and said, "oh no, we both switched out of different fields too."

Later on I asked a clerkship director at my school about people switching residencies, and he just laughed and said he sees it all the time--switching in and out of basically every field. It's just not something people wear on their sleeves and project out to everyone in the room, especially since those decisions often involve substantial costs/sacrifices. Gotta crack a few eggs to make an omelette, right? The impression I got from him was: What else would you expect of a bunch of high-functioning people in their late 20's? Made a lot of sense to me.

Just goes to show, I suppose... The match is pretty sophisticated as far as placement systems go, but time marches on and things do change. So no matter how perfect or disastrous the process seems, it's best to keep working hard and always move forward with an open mind.

 

[TheSearch]

Yes, it is not uncommon to switch. Sometimes it takes a "trial period" of being in another specialty before one can recognize what he really wants. One of our former psych chiefs was a former surgery resident at an Ivy program. I myself switched from a big name pathology program to psychiatry, and I have no regrets. Every day in psych is fascinating.

 

[nancysinatra]

Yes, it is not uncommon to switch. Sometimes it takes a "trial period" of being in another specialty before one can recognize what he really wants. One of our former psych chiefs was a former surgery resident at an Ivy program. I myself switched from a big name pathology program to psychiatry, and I have no regrets. Every day in psych is fascinating.

I'm curious what drew you to path, and then why you switched to psych. To me these two specialties seem like they would be complete opposites.

 

[shan564]

I'm curious what drew you to path, and then why you switched to psych. To me these two specialties seem like they would be complete opposites.

I've met a lot of people who were deciding between path and psych. And a lot of people think that these fields are "complete opposites," but I think they're more similar than we often recognize. I think they're both more intellectual than some other fields, and often require the doctor to think about problem-solving on a daily basis. Pretty much every other field requires you to follow an algorithm in your clinical decision-making process.

 

[nancysinatra]

I've met a lot of people who were deciding between path and psych. And a lot of people think that these fields are "complete opposites," but I think they're more similar than we often recognize. I think they're both more intellectual than some other fields, and often require the doctor to think about problem-solving on a daily basis. Pretty much every other field requires you to follow an algorithm in your clinical decision-making process.

I think that emphasis can really vary in psychiatry. There are plenty of places where psychiatry basically just means "open up the DSM and ask the patient if they have x number of problems and if so give seroquel or zoloft +/- some speech that incorporates about 3 sentences of supportive psychotherapy."

Whereas (and this is just speculation) -- in path if you make one wrong diagnosis, that's it.

Where do you see problem solving coming into pathology, by the way? The last thing I'd want to find out is that the pathologist looking at some biopsy "has developed his/her individual way of approaching this issue." No, I'd pretty much just want the standard.

 

[kindasorta]

I think that emphasis can really vary in psychiatry. There are plenty of places where psychiatry basically just means "open up the DSM and ask the patient if they have x number of problems and if so give seroquel or zoloft +/- some speech that incorporates about 3 sentences of supportive psychotherapy."

Whereas (and this is just speculation) -- in path if you make one wrong diagnosis, that's it.

Where do you see problem solving coming into pathology, by the way? The last thing I'd want to find out is that the pathologist looking at some biopsy "has developed his/her individual way of approaching this issue." No, I'd pretty much just want the standard.

It's not problem solving so much as being able to use your muscle of interpretation. Whereas in IM, there's no interpretation of edema, or CP, or fever. No interpretation of the algorithm that inevitably follows. Looking at an image requires some utilization of creativity, even if the demand is that in your creative understanding you still come up with the acceptable answer.

 

[nancysinatra]

It's not problem solving so much as being able to use your muscle of interpretation. Whereas in IM, there's no interpretation of edema, or CP, or fever. No interpretation of the algorithm that inevitably follows. Looking at an image requires some utilization of creativity, even if the demand is that in your creative understanding you still come up with the acceptable answer.

I don't really agree with that. Not all chest pain is cardiac, so it certainly has to be interpreted. As do any EKGs that are ordered. Edema has many causes, some benign, others serious. So again some thought is required.

Are you a med student or resident? I'm just asking because if you aren't a resident yet, then you are romanticizing psychiatry if you think we have the luxury of applying "interpretation" to the patients' complaints most of the time. Do a couple shifts at a VA or county hospital ER, and you'll see--it's pretty algorithmic. We just have no objective data to go on. Of course we also apply "clinical judgment" but they do that in other fields too. I'm just saying I don't see how we're better in terms of "interpretation." (Unless you're a Freudian analyst maybe.)

And I still fail to see how path is creative either. That's the last thing I'd want from a pathologist. Pathologists should have the highest inter-rater reliability of all the medical fields, no? Whereas our inter-rater reliability has got to be among the lowest, although I wouldn't say that's due to "creativity." When someone comes in who's clearly Cluster B and their chart says "bipolar-schizophrenia" then "creativity" is not what comes to my mind.

 

[kindasorta]

I don't really agree with that. Not all chest pain is cardiac, so it certainly has to be interpreted. As do any EKGs that are ordered. Edema has many causes, some benign, others serious. So again some thought is required.

Are you a med student or resident? I'm just asking because if you aren't a resident yet, then you are romanticizing psychiatry if you think we have the luxury of applying "interpretation" to the patients' complaints most of the time. Do a couple shifts at a VA or county hospital ER, and you'll see--it's pretty algorithmic. We just have no objective data to go on. Of course we also apply "clinical judgment" but they do that in other fields too. I'm just saying I don't see how we're better in terms of "interpretation." (Unless you're a Freudian analyst maybe.)

And I still fail to see how path is creative either. That's the last thing I'd want from a pathologist. Pathologists should have the highest inter-rater reliability of all the medical fields, no? Whereas our inter-rater reliability has got to be among the lowest, although I wouldn't say that's due to "creativity." When someone comes in who's clearly Cluster B and their chart says "bipolar-schizophrenia" then "creativity" is not what comes to my mind.

Being a resident you're also very biased and limited in your view of psychiatry. You have people looking over you and judging your work. I can't imagine you think your VA rotations or whatever rotations you go on, or your supervised "therapy" sessions are representative of what it's like to be an outpatient PP psychiatrist. The creativity in psych, for me, is in how I'm afforded the ability to choose how I practice in the confines of my own office.

 

[PistolPete]

Met a FP intern and neuro intern who are trying to match into our psych program.

I myself have had certain days where I've wondered if I should have gone into a field other than psych, and others where I'm happy to be in psych, so it's been an interesting experience. Gonna stick it out.

 

[nancysinatra]

Being a resident you're also very biased and limited in your view of psychiatry. You have people looking over you and judging your work. I can't imagine you think your VA rotations or whatever rotations you go on, or your supervised "therapy" sessions are representative of what it's like to be an outpatient PP psychiatrist. The creativity in psych, for me, is in how I'm afforded the ability to choose how I practice in the confines of my own office.

What office are you talking about? Aren't you a med student? If not I'm sorry but that's what I thought.

It is really great that you are excited about your future office based outpatient private practice psychiatry business, but why wouldn't IM or other docs have the "creativity" to choose how they practice too? I can tell you there are lot of outpatient allergists in my city, not to mention dermatologists who do almost exclusively office based outpatient private practice work. If by creativity you mean working in your own office and not having a boss, well, I'd simply call that "a ubiquitous arrangement throughout medicine." And there's always oversight--assuming you don't want some state medical board on your back.

I suppose you could say that psychiatry has more outpatient opportunities than, say, critical care, or trauma surgery. But again no medical field really seems "creative" to me.

 

[Residentcool]

interesting, I guess psych does have some draw power if people are jumping ship from higher paying/competitive specialties to get into it.

Does anyone know if the reverse it true, how often do psych residents try to switch into something else?

I know of an ENT attending who was in psych initially and then went into ENT. I think it happens both ways.

 

[Leo Aquarius]

They say psychiatry is the most switched-into specialty. At least that what the attendings at my program have said.

 

[vistaril]

I know of an ENT attending who was in psych initially and then went into ENT. I think it happens both ways.

something like this would be extremely extremely uncommon. The reverse is easily 50x more common(going from a procedural or surgical field to psych)

 

[vistaril]

Being a resident you're also very biased and limited in your view of psychiatry. You have people looking over you and judging your work. I can't imagine you think your VA rotations or whatever rotations you go on, or your supervised "therapy" sessions are representative of what it's like to be an outpatient PP psychiatrist. The creativity in psych, for me, is in how I'm afforded the ability to choose how I practice in the confines of my own office.

I would argue that as an upper level resident I actually have *more* creativity now than I will ever have.

You mention those therapy sessions, and(because patients arent paying), I can go off in whatever direction I want(within reason of course). It's *really easy* to recruit patients exactly the type of patients you want to engage in whatever type of therapy you want to do when you are free. You want to get a dbt group going? Easy.....You want to do cbt for anxiety d/os? Easy.....you aren't going to have those same freedoms in private practice. Regarding the supervision, your supervisor isn't going to limit you that much. They are there to help you....and I can't speak for how every program goes, but it's not like most of the sessions are going to be viewed or reviewed by your supervisor.

As for the creativity of the psychopharm in outpatient private practice......there are really two different groups of psychiatrists: those who try to use informal algorithms based on the little evidence based medicine that is out there(which I would support), and those who just throw meds randomly at patients. The first is not 'creative' in any way(it can be a bit boring), and the second I wouldn't neccessarily call creative either.....it's part laziness and part lack of knowledge base.

 

[vistaril]

When someone comes in who's clearly Cluster B and their chart says "bipolar-schizophrenia" then "creativity" is not what comes to my mind.

my new slogan: "when in doubt, abilify"

 

[nancysinatra]

my new slogan: "when in doubt, abilify"

I'm not sure what's more disturbing--the slogan, or the fact that you have a slogan.

 

[vistaril]

I'm not sure what's more disturbing--the slogan, or the fact that you have a slogan.

well I was being sarcastic.....but looking at how many Abilify prescriptions are filled last year, it's pretty obvious that it is being used that way across the country.

 

[thenthdegree]

I've got to say that I also identify the relative freedom of psychiatry attendings to try different approaches as one of my main attractions to the field. During my psych rotation (wholly inpatient) we had a patient who was quite a "frequent flyer" come in to see us for the first time. She had had 6-7 presentations to the ED followed by admission - in the past 3 months - for aggression, inappropriate behavior, etc. Our attending cut her insane med regimen in half and implemented a behavioral approach to dealing with her outbursts - and voila, no admissions so far (in the next 4-month period).

I discussed this with him in some of our conversations, and other cases - he agreed that psych generally afforded the attending more discretion over treatment than other fields. Maybe it's only because other docs had made poor decisions that he had the chance to change anything. But to me, it seems that the nature of many psychiatric conditions - poorly-understood etiology, poorly-understood neurochemical basis, poor neuroanatomical mapping - lends itself to giving attendings a freer hand to say, "well, this has elements of x and y, but also has features of z, so let's treat with this." Again, it's definitely advisable to use algorithms, when they exist, at least initially. But I have to say that psychiatry - more than any other specialty I've been party to - is where the attending's clinical experience and reasoning ability played a role. Not to mention the ability to actually talk to patients and get a good history. Inpatient is probably a better example than outpatient, since you see more of the chronic, poorly-controlled cases which are the most in need of new approaches.

tl;dr give everyone abilify.

 

[OldPsychDoc]

well I was being sarcastic.....but looking at how many Abilify prescriptions are filled last year, it's pretty obvious that it is being used that way across the country.

Well it IS a lot easier than spending 45 minutes with a patient explaining exactly what is meant by "borderline personality", why you think they have it, and how to effectively start recovering from it.

 

[xlithiumx]

Well it IS a lot easier than spending 45 minutes with a patient explaining exactly what is meant by "borderline personality", why you think they have it, and how to effectively start recovering from it.

And if the practice model is "grinding" through 4 patients an hour, then one, by definition, cannot provide evidence based and effective treatment for that patient. No neurosurgeon books the OR for 30 minutes when she knows the procedure will take 6 hours. Why do we accept this type of behavior in our profession? Better yet, why do we let people wrap it up in the misleading language of "medical psychiatry" or "neuropsychopharmacology?" Don't our patients deserve better? Particularly those with personality disorders who are quite likely to provoke major negative countertransference in their providers and alienate them further from the care they need.

 

[vistaril]

And if the practice model is "grinding" through 4 patients an hour, then one, by definition, cannot provide evidence based and effective treatment for that patient. No neurosurgeon books the OR for 30 minutes when she knows the procedure will take 6 hours. Why do we accept this type of behavior in our profession? Better yet, why do we let people wrap it up in the misleading language of "medical psychiatry" or "neuropsychopharmacology?" Don't our patients deserve better? Particularly those with personality disorders who are quite likely to provoke major negative countertransference in their providers and alienate them further from the care they need.

that all sounds fabulous, but who is going to pay for it?

 

[vistaril]

Well it IS a lot easier than spending 45 minutes with a patient explaining exactly what is meant by "borderline personality", why you think they have it, and how to effectively start recovering from it.

unfortunately, that's only part of the 'abilify for all' group......you also have the augmentation for dysthymia subset, the non-borderline 'soft psychosis'(whatever that means) set, the ptsd 'with some paranoia' group, the bipolar maintenance group, and 2-3 others Im am forgetting.....

 

[xlithiumx]

that all sounds fabulous, but who is going to pay for it?

You mean, who's going to pay YOU for it, I suppose. I'd propose that you choose to work in a lower volume shop and make less money while providing clinical care than has a chance to be effective.

Shoot, work at a community mental health center. Those at least allow for 60 minute intakes with full 30 minute follow-ups. At least in my liberal midwest state, there are lots of psychotherapists at the CMHCs. Sick patients get multidisciplinary treatment that they need.

Or, VA work is also great in that regard.

Unless you have a HUGE name and reputation, which will take years to build, I just don't think you can be a top quartile earner in psychiatry AND provide very thorough and excellent clinical care to all of your patients.

If you want employed 230K, be prepared to move to a VERY underserved area, or accept that you will be selling your patients and your profession short.

So, in my career, to answer your original question, I'll be paying for it. I'll be choosing to make less money than I could in order to do a job that I feel serves my patients and their needs. You can make your choices for yourself.

 

[vistaril]

You mean, who's going to pay YOU for it, I suppose. I'd propose that you choose to work in a lower volume shop and make less money while providing clinical care than has a chance to be effective.

Shoot, work at a community mental health center. Those at least allow for 60 minute intakes with full 30 minute follow-ups. At least in my liberal midwest state, there are lots of psychotherapists at the CMHCs. Sick patients get multidisciplinary treatment that they need.

Or, VA work is also great in that regard.

the problem is that the therapists at CMHCs are often of very low quality. Yes, it looks good to have such resources available....but in reality if the providers are not up to snuff(and honestly cmhcs arent known for having the best and the brightest), the care isn't going to be that great.

The VA is also great with respect to schedule(very light) and resouces(a ton), but there are a host of other reasons(that dont have to do with money) why many people dont want to work at a VA. Heck if one is just interested in money I know people who 'work' at the VA, then because they are so well rested from their VA job go out and work hard somewhere else in evenings and weekends to make another 100-120k or so. So the total money that route can be good. But as I said, a lot of people don't want to work at VAs for other reasons.

 

[BS81]

Now I'm curious. What are some of these reasons?

Sent from my DROID RAZR using SDN Mobile

 

[vistaril]

Now I'm curious. What are some of these reasons?

Sent from my DROID RAZR using SDN Mobile

1) A lot of the patients, especially chronic ptsd patients, are just being seen to keep their service connected %. The validity of the original dx is often questionable to begin with, and they have no incentive to get better. These pts are very easy, but you aren't generally doing much for them and it's not very stimulating. Note that this doesnt apply to every ptsd pt of course.

2) The whole service connected game in general. To work at the VA you basically have to just tell yourself that the massive amounts of govt fraud in this area is just out of your control and go along with it. A lot of people would get frustrated with this. A tremendous percentage of the patients you see at the VA will have some sort of service connectedness agenda. Which complicates treatment of course.

3) The VA has a policy of really going out of their way from a customer service angle for veterans. So some of the same rules seen in private practice or even a cmhc wouldnt apply. For example, pts can repeatedly show up late without any issues. Pts can come at 2pm if they had a 10am appt and they will be fit into the schedule regardless if they have a reason. This is a va national policy. Additionally, you see drug seekers just bounce from one VA doc to another frequently.

4) All of the annoying charting based on VA protocols. It seems small, but having to do the suicide risk assessment, alcohol screen, safety screen, and 4 other screens for many patients with every clinical encounter gets old.

 

[nancysinatra]

well I was being sarcastic.....but looking at how many Abilify prescriptions are filled last year, it's pretty obvious that it is being used that way across the country.

I know! I was being sarcastic too, ha ha!

 

[nancysinatra]

You mean, who's going to pay YOU for it, I suppose. I'd propose that you choose to work in a lower volume shop and make less money while providing clinical care than has a chance to be effective.

But you just took a 230K job yourself! ;-)

 

[nancysinatra]

2) The whole service connected game in general. To work at the VA you basically have to just tell yourself that the massive amounts of govt fraud in this area is just out of your control and go along with it. A lot of people would get frustrated with this. A tremendous percentage of the patients you see at the VA will have some sort of service connectedness agenda. Which complicates treatment of course.

There's an upside to working in a fraud-infested system. Lately, instead of getting mad about all the fraud I've witnessed in the past 4 years, I've changed my outlook, and now I'm thinking of ways I can get involved. And not just at the VA with its service connected fraud. There's medicare fraud to be had too. There's tons of opportunities in SSD funds. Not to mention the new drug I'm developing, called Xicomex, which combines xanax, soma and vicodin all in one pulse dosed system and will go straight to generic. And then there's plain old quackery. The options are limitless.

 

[nancysinatra]

unfortunately, that's only part of the 'abilify for all' group......you also have the augmentation for dysthymia subset, the non-borderline 'soft psychosis'(whatever that means) set, the ptsd 'with some paranoia' group, the bipolar maintenance group, and 2-3 others Im am forgetting.....

And then there are some attendings where they barely even bother to identify a reason--they just give abilify to everyone, literally.