Seeking Career Advice

[bounds]

Hi,

Please I am seeking career advice from you all. I am a 4th year psych resident and will be graduating by June. Honestly I have been stuck on an issue for the past 6 months now and time is running out. I know I want to do a Fellowship but can't decide on either Geriatrics or Psychosomatic.

I love rotating in the psych ER and Inpatient service and in my program, we do a lot of both fields in those areas. I hate my programs specified " C& L " rotation because it was more like a power struggle with the medicine/surgery teams at the local hospital who just wanted to transfer everyone over and the hosp management really didn't stop them.

Also I am definitely not keen at all on research.

So can you guys help me with the pros and cons of either sub specialty.

Thanks

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[michaelrack]

if you're interested in academic career, either is fine

private practice: geriatrics is more lucrative

 

[whopper]

I hate my programs specified " C& L " rotation because it was more like a power struggle with the medicine/surgery teams at the local hospital who just wanted to transfer everyone over and the hosp management really didn't stop them.

Getting OT...sorry.

You and almost every other psychiaty resident I know.

If you go to a psychiatry convention full of residents, every single resident I talked to from across the country felt the same way.

It boiled down to what you mentioned and a psychiatry dept not willing to fix the problem because they either tried and didn't want the escalate the issue to a war with the other depts or the attendings didn't care because why should they? They had a resident available to them to have to deal with the bullspit consults where the IM or surgical floor was trying to dump a patient to another dept.

C&L IMHO is one of the most fascinating arms of psychiatry if it's a real consult. Unfortunately, from my own experience, on a typical day 50-100% where what I considered "dump" consults. Each time I brought up to the dept that the issue should be fixed (and I even volunteered to make a power point presentation on the issue to present to the other depts)...nope, they didn't care. After all they had a resident to dump the work on. The only thing the attending had to do was look over the consult, talk to the patient for a few minutes and sign it.

I know someone who became the C&L psychiatrist of a hospital without a psychiatry residency. She was also one of the only psychiatrists in the area so when she complained of the BS consults and told the hospital to fix their act, they had to listen. She developed PP presentations on doing consults and what the IM and surgical teams should be looking for and classic behaviors that often caused a BS consult to be started that in the end did not warrant a consult (e.g. the patient is upset becuase their football team lost with no other signs of any psychiatric disorder, and yes a football team losing is not a sign I know that). Things got better after a few weeks. That's the way it should've been handled in this situation.

 

[atsai3]

Hi,

Please I am seeking career advice from you all. I am a 4th year psych resident and will be graduating by June. Honestly I have been stuck on an issue for the past 6 months now and time is running out. I know I want to do a Fellowship but can't decide on either Geriatrics or Psychosomatic.

I love rotating in the psych ER and Inpatient service and in my program, we do a lot of both fields in those areas. I hate my programs specified " C& L " rotation because it was more like a power struggle with the medicine/surgery teams at the local hospital who just wanted to transfer everyone over and the hosp management really didn't stop them.

I think it would be extremely difficult to do a fellowship in C&L without doing inpatient C&L rotations (where you will be exposed to the 'power struggle' on a daily basis). Your inpatient C&L exposure (eg., transplant, consults, med-psych if they have one, etc) will take up like 5-6 months. Given what you've described, that's 5-6 months of pain.

-AT.

 

[st2205]

Is there really such a thing as outpatient C&L?

 

[atsai3]

Is there really such a thing as outpatient C&L?

Depends on the institution, but I suppose if I just need to provide one example, then the short answer is 'yes'.
http://uwmedicine.washington.edu/pa.../find-a-clinic/pages/clinic.aspx?clinicid=235

This advice is probably too late for you, but an alternative to doing 4 years of psychiatry residency followed by 1 year of psychosomatic fellowship would be to do a 5-year combined med/psych residency. After graduation you could work on a med/psych service. The pros and cons of combined training have been debated on SDN -- search the archives for previous threads -- but (depending on the institution) specific to the concern you identified in the original post, working for a med/psych service might allow you to sidestep some of the 'power struggle' issues. At Duke, for example, medicine is always trying to dump patients onto med/psych -- but the med/psych team really does have freedom in determining who would actually be a good candidate for their services. (Again, this may vary by institution-- I have no idea whether the med/psych services or med/psych units at other institutions operate similarly or dissimilarly.)

-AT.

 

[nitemagi]

Yes there is. Good psychosomatics fellowships will include clinics in sub-subspecialty clinics in psychosomatics, such as psych-oncology, psychoderm, etc. An avenue to creating a good niche practice, IMO.

 

[michaelrack]

Depends on the institution, but I suppose if I just need to provide one example, then the short answer is 'yes'.
http://uwmedicine.washington.edu/pa.../find-a-clinic/pages/clinic.aspx?clinicid=235

This advice is probably too late for you, but an alternative to doing 4 years of psychiatry residency followed by 1 year of psychosomatic fellowship would be to do a 5-year combined med/psych residency. After graduation you could work on a med/psych service. The pros and cons of combined training have been debated on SDN -- search the archives for previous threads -- but (depending on the institution) specific to the concern you identified in the original post, working for a med/psych service might allow you to sidestep some of the 'power struggle' issues. At Duke, for example, medicine is always trying to dump patients onto med/psych -- but the med/psych team really does have freedom in determining who would actually be a good candidate for their services. (Again, this may vary by institution-- I have no idea whether the med/psych services or med/psych units at other institutions operate similarly or dissimilarly.)

-AT.

If you are interested in psychosomatics, do a 4 year psych residency followed by 1 year fellowship.

If you do a med/psych residency, less than 12 months of the 60 month residency will be done on the med/psych ward. And a lot of dumps do come to a typical med/psych ward.

I say this as someone who did a med/psych residency (although in a place without a med/psych ward) and who is board-certified in both; and who has some limited experience attending on a med/psych ward (at univ of MS); and has grandfathered into the psychosomatic boards.

 

[DrBosse]

I've done consultation-liason rotations at two very different institutions. One of them had a LOT of bad, inappropriate consultations, and an otherwise underutilized service, and the other had nothing but good, reasonable, respectful and interesting consultations, and usually 50 patients on their list at a time. So my conclusion is the appropriateness of consultations depends on the respect the psychiatry department has in general. The fellows in psychosomatics at the latter institution were very happy and people were clamoring to get in to that program.

 

[whopper]

outpatient C&L?

Yes. A problem here, and IMHO this tends to detect doctors who don't care, are that with insurance billing, they will not reimburse us (as far as I know) for talking to the other doctor.

I have a few cases here and there where the physical medical problem is interacting with the psychiatric problem to a great degree. In these cases, I sometimes try to talk to the other doctor because that person is not giving me the patient's records and their opinions, and I get blown off by his staff members. Other times I talk to some doctors and they do talk to me but they're not considering the interaction in more than a superficial level.

Others, however, are willing to truly look into the problem as much as you would want a doctor to do if if were you having the problem.

I've noticed that if both doctors are in the same institution, it ups the chance of the doctors talking to each other, if anything due to propinquity. A guy is less likely to blow you off when both of you are sitting in the doctor's lounge, the superbowl is playing and you guys male bond.