Should I decide on specialty with my head or my heart?

[WolfBoy3000]

Hey SDN psychiatry community,

Wanted to start with I have read countless threads on here the past several years, and find your perspectives, experiences, and wisdom invaluable - so thank you very much.

I started medical school this year at 27 y/o, primarily with the intention of becoming a psychiatrist. I now find myself really digging deep and trying to figure out whether I should be so committed to this specialty already. While I know the sage wisdom is "you'll figure it out in clerkships", please understand if I want to pursue a couple of them I should start developing a stellar CV and making connections sooner rather than later. I know it's recommended to just prepare your CV for the most competitive specialty, but if I could just decide and spend my limited time in the coming years working on research & extracurriculars that will actually get me where I want to be, that'd be preferable (if I commit to psych, I'm really hoping to do residency at a top ranking institution in NYC or CA - I'm currently at a top-ranking medical school if that matters).

Nevertheless, at this point, I do feel I am rather certain of what I want out of life in general.
These are my top priorities loosely in order:

1) reasonable income for a physician (~350K+), & job security! [will have a heck load of loans & plan on having 3-4 kids]
2) interesting, fulfilling, meaningful work [hot take (at least on the internet), but if I'm spending 50%+ of my waking hours doing something, I want to love it, for the long-haul]
3) flexibility & work-life balance [willing to work hard, but the last thing I want is to miss out on family time and all the things life has to offer because I spent all of it working; part-time and remote work options are invaluable to me, but not deal breakers as you'll see in my listed specialties]

Thus, specialties I am considering:
- psychiatry
- neurology
- ophthalmology
- ENT

If all of these were expected to make similar $ and be guaranteed job security in perpetuity, I'd pick psych 10 times out of 10. But, as many-a-neurotic-med-student have brought up, I am worried about two things: midlevel encroachment and artificial intelligence... (sigh)

My heart and passion point me to psychiatry fervently. The idea of a career at the intersection of neuroscience, psychology, and philosophy excites me immeasurably. I can think of no cooler life than spending it helping people navigate their own consciousness and life circumstances, with the goal of improving their human experience. But at the end of the day, the bills gotta get paid. If I get to the end of this finding I am 100% replaceable in the job market by a PMHNP or omniscient nurturing sexy super psychiatrist robot, I'll curse my younger self's passionate, yet idealistic, commitment to the field of psychiatry.

My head tells me that neurology seemingly has more job security in the long-haul, and at least scratches the brain-fascination itch. Additionally, it is no secret ENT/ophtho provide a handsome salary alongside an envious lifestyle. Helping restore people's vision, hearing, and ability to breathe certainly sounds meaningful long-term. I also really like the idea of being a surgeon, and it seems pretty agreed upon that hands-on, procedural work is the safest from both midlevels and AI. But again, choosing any of these 3 fields would primarily be to guarantee that my future family and self is set for success.


So what do you think? Does interest and passion trump all else, or would it be foolish to not see the writing on the wall and aim for a likely more secure career? I know no one can see the future, but in your experience, what am I not seeing?

Thank you so so much.

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[Sushirolls]

Delete #2 from your list of importance.
All will lead to being just a job, and #2 won't matter.

I choose psych for love/heart.

There are days I wish I chose different.

1) optho
2) ENT
3) Psych
4) Neurology

 

[WolfBoy3000]

Delete #2 from your list of importance.
All will lead to being just a job, and #2 won't matter.

I choose psych for love/heart.

There are days I wish I chose different.

1) optho
2) ENT
3) Psych
4) Neurology

I'd like to believe psychiatry inherently feels like more than just a job, but I do read your sentiment a lot... Even if the actual clinical duties end of feeling that way, reading material relevant to psychiatry, attending psych conferences, and being a part of your community in general seems so much cooler than the others (for me at least).

Can I ask for more detail on why you ranked them that way?

Thank you for the input!

 

[TexasPhysician]

My experience says otherwise about being more open-minded. Don’t try to figure it out now.

A friend of mine was sure he wanted to do anesthesia before medical school. At the beginning of medical school he hung out with anesthesia a lot and convinced the department chair to let him write up paper after paper. Anesthesia published a lot at my school. While he was almost never first author, he began writing up so much that he had his name on 15+ publications while in med school. Then he realized that he didn’t like anesthesia and preferred a surgical subspecialty. He thought this would look bad as his application looked 100% anesthesia. Just the opposite. He got interviews everywhere he wanted and got his top choice. They loved his ability to publish and his determination.

I thought I wanted to do Derm and published in Derm. I took a PT job in the Derm department. Then I realized I wanted to do psych. No interview questioned how I was Derm heavy early on.

It is a small percentage of students that realize their calling before medical school.

 

[finalpsychyear]

Procedurall/surgical hands down. Ur going to be 35-36 with kids when done and depending on fellowship in optho/ent ur going to be in the high 6 figs. Good luck

 

[WolfBoy3000]

My experience says otherwise about being more open-minded. Don’t try to figure it out now.

A friend of mine was sure he wanted to do anesthesia before medical school. At the beginning of medical school he hung out with anesthesia a lot and convinced the department chair to let him write up paper after paper. Anesthesia published a lot at my school. While he was almost never first author, he began writing up so much that he had his name on 15+ publications while in med school. Then he realized that he didn’t like anesthesia and preferred a surgical subspecialty. He thought this would look bad as his application looked 100% anesthesia. Just the opposite. He got interviews everywhere he wanted and got his top choice. They loved his ability to publish and his determination.

I thought I wanted to do Derm and published in Derm. I took a PT job in the Derm department. Then I realized I wanted to do psych. No interview questioned how I was Derm heavy early on.

It is a small percentage of students that realize their calling before medical school.

Point taken! Definitely striving to remain open-minded. Can I ask how you ended up deciding on psych instead? Thank you!

 

[WolfBoy3000]

Procedurall/surgical hands down. Ur going to be 35-36 with kids when done and depending on fellowship in optho/ent ur going to be in the high 6 figs. Good luck

Are you saying so for the job security? Do you feel psych salary will not be enough for me & family at that time? I see psychiatrists speak of working multiple jobs and/or doing TMS/ketamine and making surgical money (while also avoiding the surgical residency, which would likely be while my first couple kids are babies..). I know a few who do in fact. Do we no longer expect this to be possible 8 years from now? Thank you!

 

[TexasPhysician]

Point taken! Definitely striving to remain open-minded. Can I ask how you ended up deciding on psych instead? Thank you!

Someone told me that Betty Ford had scholarships to do a brief internship thing there (it’s been awhile so don’t recall what they call it). I applied for a free Cali vacation and got it. By the end, I was 95% sure I was switching to psych. I entered medical school thinking ER or Derm.

 

[Bartelby]

I disagree with the idea that you need to get into a procedural field or that it's all just a job in the end. It is a job and working conditions and pay are absolutely important, but I have no doubt I am much more engaged day to day practicing psychiatry than I would be in many other fields of medicine. I find my motivation for the subject still drives me to teach, to take on academic or other projects, and to generally look forward (or at minimum not dread) work most days.

Earing in the 300s with a 40-hour week is quite achievable. Your happiness depends a lot on what is "enough" for you financially. I believe I am far happier earning in the 300s for a sub-40 hour workweek (my current setup) than I would be earning $800,000 a year working 60+ hour weeks as a surgeon. If you realize your desire for more income can expand indefinitely and you start valuing other aspects of your work life more, psychiatry has more to offer than many fields. If you will want to earn well over the $300k's range in psychiatry that is doable but can mean the other "lifestyle" aspects start to fade away.

I have seen what AI has to offer so far and I'm not worried. Who knows where it will go, but what would it be replacing? Diagnostic interviewing? Prescribing? Psychotherapy? I suspect it will be a very useful helper for us in the next decade, but I think it will be augmenting rather than replacing. I think current AI technology has more potential to disrupt some other fields like radiology at the moment, but even there we certainly aren't seeing it yet.

Midlevels are a concern to some extent. They are more often moving into roles formerly filled by psychiatrists, which may eventually exert some downward pressure on incomes. Still, as a psychiatrist you bring a lot more to the table than a midlevel provider. The sky has been falling around this and similar "psychiatry income is doomed" issues for as long as I can remember (at least since I started medical school a little less than two decades ago). I'm still doing fine, and I suspect we will continue to do fine for quite a while.

 

[finalpsychyear]

Are you saying so for the job security? Do you feel psych salary will not be enough for me & family at that time? I see psychiatrists speak of working multiple jobs and/or doing TMS/ketamine and making surgical money (while also avoiding the surgical residency, which would likely be while my first couple kids are babies..). I know a few who do in fact. Do we no longer expect this to be possible 8 years from now? Thank you!

Yes. NPs/midlevels are doing tms/ketamine and many patients dont know the difference. If you were say already in the field and in residency probably would be ok but 8-9 years is a huge timeline. If NPs didnt exist then yeah i would rec psych. Its like saying if NPs were doing optho and ent procedures and being pumped out in excess id hesitate but luckily they can't really do that YET... way more job security in procedural fields and i dont get why being in a top school you wouldn't try and get into a field that can be likely double your avg psych salary. I wouldn't compare to the outliers who are making bank they are not employing docs but just midlevels.

End of the day its a job/salary/lifestyle balance and your a tiny bit older when your done so i would maximize my income and security esp if you have a shot at those surgical fields with a decent lifestyle. My optho and ent friends love the field/lifestyle/$$ so if your in a position to get into those thats my rec.

Edit: 1st world problens but 300k yes of course you can support a 3-4 kids household and stay at home mom, but 500-600k would be easier if your planning that type of family with colleges, grad school etc.

 

[lobstar]

1) reasonable income for a physician (~350K+), & job security! [will have a heck load of loans & plan on having 3-4 kids]

All of your options will accomplish this, outside of part-time or academic things.

2) interesting, fulfilling, meaningful work [hot take (at least on the internet), but if I'm spending 50%+ of my waking hours doing something, I want to love it, for the long-haul]

If you like all the options, then they all can accomplish this. I've had surgery friends say that surgery is both their job and their hobby lol. Same with some PhD friends, their job and their hobby are the same so it's quite fulfilling and interesting to them. A lot of the fun to a hobby or a job is the accomplishment, control, and endless replayability (like with video games). I think starting lexapro for GAD is boring, but when I go do the ED or CL and start d/cing malingerers and chronic SI, I find accomplishment and excitement in threading the needle on earliest d/c with a legally defendable note.

As for your interest in "helping people navigate their own consciousness and life circumstances" I have found that most of my outpatients want to remove their consciousness through the use of sedatives rather than navigate it.

Take some time to reflect on what you can do over and over for a career, over many years, and still be trying to perfect your skills--since that's where accomplishment and replayability come from.

3) flexibility & work-life balance [willing to work hard, but the last thing I want is to miss out on family time and all the things life has to offer because I spent all of it working; part-time and remote work options are invaluable to me, but not deal breakers as you'll see in my listed specialties]

Remote procedures aren't a thing. Telepsych and tele-stroke are things. I imagine if you are location flexible you can find a good call schedule even in a surgical field.

 

[ClosetCentrist]

Delete #2 from your list of importance.
All will lead to being just a job, and #2 won't matter.

I choose psych for love/heart.

There are days I wish I chose different.

1) optho
2) ENT
3) Psych
4) Neurology

Sushi, I really wish that you wouldn't speak in such absolutes. I get that this is where you ended up with respect to psychiatry, but there are many for whom the shine does not come off. Your perspective is absolutely worth considering - it might even be the model experience - but you do a disservice to those thinking about their long term plans when you act like it's an inevitability.

 

[Sushirolls]

Sushi, I really wish that you wouldn't speak in such absolutes. I get that this is where you ended up with respect to psychiatry, but there are many for whom the shine does not come off. Your perspective is absolutely worth considering - it might even be the model experience - but you do a disservice to those thinking about their long term plans when you act like it's an inevitability.

I processed your feedback, but it's invalid to me.
I type in simplicity for ease of reading.
It's my opinion. I'm entitled to it.
Attempting to say its disservice - I'm ignoring your post for the lack of value.
This is an open forum meant for discussion and people are adult fully capable of filtering for merits on their own. This isn't a playground with elementary school kids.

My shortened abbreviated style I've adopted in past few years, is to balance the paragraphs of lengthy responses which are disproportionately found here in the psych subforum.

If someone wants clarity or expansion on my posts then one only needs to ask.

My feedback for you, is think before you post about telling others to silence their views. I really wish you wouldn't attempt to police speech that isn't in violation of the terms/service of SDN.

 

[Attending1985]

Hey SDN psychiatry community,

Wanted to start with I have read countless threads on here the past several years, and find your perspectives, experiences, and wisdom invaluable - so thank you very much.

I started medical school this year at 27 y/o, primarily with the intention of becoming a psychiatrist. I now find myself really digging deep and trying to figure out whether I should be so committed to this specialty already. While I know the sage wisdom is "you'll figure it out in clerkships", please understand if I want to pursue a couple of them I should start developing a stellar CV and making connections sooner rather than later. I know it's recommended to just prepare your CV for the most competitive specialty, but if I could just decide and spend my limited time in the coming years working on research & extracurriculars that will actually get me where I want to be, that'd be preferable (if I commit to psych, I'm really hoping to do residency at a top ranking institution in NYC or CA - I'm currently at a top-ranking medical school if that matters).

Nevertheless, at this point, I do feel I am rather certain of what I want out of life in general.
These are my top priorities loosely in order:

1) reasonable income for a physician (~350K+), & job security! [will have a heck load of loans & plan on having 3-4 kids]
2) interesting, fulfilling, meaningful work [hot take (at least on the internet), but if I'm spending 50%+ of my waking hours doing something, I want to love it, for the long-haul]
3) flexibility & work-life balance [willing to work hard, but the last thing I want is to miss out on family time and all the things life has to offer because I spent all of it working; part-time and remote work options are invaluable to me, but not deal breakers as you'll see in my listed specialties]

Thus, specialties I am considering:
- psychiatry
- neurology
- ophthalmology
- ENT

If all of these were expected to make similar $ and be guaranteed job security in perpetuity, I'd pick psych 10 times out of 10. But, as many-a-neurotic-med-student have brought up, I am worried about two things: midlevel encroachment and artificial intelligence... (sigh)

My heart and passion point me to psychiatry fervently. The idea of a career at the intersection of neuroscience, psychology, and philosophy excites me immeasurably. I can think of no cooler life than spending it helping people navigate their own consciousness and life circumstances, with the goal of improving their human experience. But at the end of the day, the bills gotta get paid. If I get to the end of this finding I am 100% replaceable in the job market by a PMHNP or omniscient nurturing sexy super psychiatrist robot, I'll curse my younger self's passionate, yet idealistic, commitment to the field of psychiatry.

My head tells me that neurology seemingly has more job security in the long-haul, and at least scratches the brain-fascination itch. Additionally, it is no secret ENT/ophtho provide a handsome salary alongside an envious lifestyle. Helping restore people's vision, hearing, and ability to breathe certainly sounds meaningful long-term. I also really like the idea of being a surgeon, and it seems pretty agreed upon that hands-on, procedural work is the safest from both midlevels and AI. But again, choosing any of these 3 fields would primarily be to guarantee that my future family and self is set for success.


So what do you think? Does interest and passion trump all else, or would it be foolish to not see the writing on the wall and aim for a likely more secure career? I know no one can see the future, but in your experience, what am I not seeing?

Thank you so so much.

It sounds like if you do choose psych you would be wanting to do a therapy based practice based on your post. I would think a lot about preparing for that that early on because that means running a business. Get some education on what you need in that regard. Look into residencies where you can get psychoanalytic training during residency. My residency has good therapy training but I know many don’t.

 

[eyeeye_captain]

Since ophtho came up a few times, some thoughts.

350 is certainly doable and would be on the low end for an established attending. We have fairly low starting salaries though (maybe around 300 or below for general), and if you wanted to stay in NYC/CA then pay is going to be lower, it’s harder to build a patient panel due to saturation, and the COL is higher.

Job flexibility and work/life balance is definitely there. I don’t think most people really work 40 hour weeks and most call issues can be seen the next day.

Day to day practice strikes me as being substantially different from psych. Comp docs probably see around 40+ patients a day. I do retina and am happy at ~70, so fast paced. Sometimes it’s a quick fix, sometimes it’s long term. If you do retina or glaucoma, you do get some of the more longitudinal care like psych since you wind up seeing a good number of patients more often than their PCP, but they’re pretty bite size visits. There’s still enough time to build a doctor patient relationship, but the feel is different. I have plenty of patients who tell me I’m their favorite doctor, and that’s with me sticking needles in their eyes.

For me, it’s fulfilling and meaningful. Interesting depends on the day because like most jobs, you have your bread and butter for a reason. I’m fine with that, partly because it means people are doing well. I tell my patients it’s a bad idea to be an interesting case and impress me.

 

[clausewitz2]

Since ophtho came up a few times, some thoughts.

350 is certainly doable and would be on the low end for an established attending. We have fairly low starting salaries though (maybe around 300 or below for general), and if you wanted to stay in NYC/CA then pay is going to be lower, it’s harder to build a patient panel due to saturation, and the COL is higher.

Job flexibility and work/life balance is definitely there. I don’t think most people really work 40 hour weeks and most call issues can be seen the next day.

Day to day practice strikes me as being substantially different from psych. Comp docs probably see around 40+ patients a day. I do retina and am happy at ~70, so fast paced. Sometimes it’s a quick fix, sometimes it’s long term. If you do retina or glaucoma, you do get some of the more longitudinal care like psych since you wind up seeing a good number of patients more often than their PCP, but they’re pretty bite size visits. There’s still enough time to build a doctor patient relationship, but the feel is different. I have plenty of patients who tell me I’m their favorite doctor, and that’s with me sticking needles in their eyes.

For me, it’s fulfilling and meaningful. Interesting depends on the day because like most jobs, you have your bread and butter for a reason. I’m fine with that, partly because it means people are doing well. I tell my patients it’s a bad idea to be an interesting case and impress me.

"May your medical problems bore your physicians" is one of the greatest blessings one can wish on another.

 

[clausewitz2]

Moderator note: Let's keep things civil and the personal attacks to a minimum, folks.

 

[Stagg737]

A lot of good points already made, but some things from the OP to break down more:

1) reasonable income for a physician (~350K+), & job security! [will have a heck load of loans & plan on having 3-4 kids]
2) interesting, fulfilling, meaningful work [hot take (at least on the internet), but if I'm spending 50%+ of my waking hours doing something, I want to love it, for the long-haul]
3) flexibility & work-life balance [willing to work hard, but the last thing I want is to miss out on family time and all the things life has to offer because I spent all of it working; part-time and remote work options are invaluable to me, but not deal breakers as you'll see in my listed specialties]

1. is achievable in (almost) any field including all of the fields you named. Even in academics it can be possible. I work academics and while my gross salary was around $280k, I was well over $300k when benefits were accounted for. Idk anyone doing FT PP who is making under $300k other than one or two people that signed up to get taken advantage of by big telehealth companies. The location aspect is a little different convo and there's plenty of threads about it, but know your value and how to negotiate and you can hit $350k most places in psych.

2. is something I wouldn't throw out. With all due respect to Sushi, I think it's a bad take to dismiss this. If you don't enjoy something from the beginning, it's pretty rare that it will start growing on you if you make it your career. Maybe you would lose interest or burn out, but if you don't enjoy something from the start why bother in the first place? Yes, everything can eventually become a job, but this can partially be mitigated by the last point.

3. Psych also has enough flexibility that you can switch among various settings or patient populations pretty easily. You can always go back and get a fellowship and completely change what you're doing and still moonlight and make attending money while doing it at most places. A major criticism I have about NPs is "field hopping" without extra training. You can kind of do this in psych, but you should have more than adequate training to do so fairly easily once you shake the rust off (if you were well trained).

If all of these were expected to make similar $ and be guaranteed job security in perpetuity, I'd pick psych 10 times out of 10. But, as many-a-neurotic-med-student have brought up, I am worried about two things: midlevel encroachment and artificial intelligence... (sigh)

My heart and passion point me to psychiatry fervently. The idea of a career at the intersection of neuroscience, psychology, and philosophy excites me immeasurably. I can think of no cooler life than spending it helping people navigate their own consciousness and life circumstances, with the goal of improving their human experience. But at the end of the day, the bills gotta get paid. If I get to the end of this finding I am 100% replaceable in the job market by a PMHNP or omniscient nurturing sexy super psychiatrist robot, I'll curse my younger self's passionate, yet idealistic, commitment to the field of psychiatry.

As others stated, AI may supplement us but won't replace us anytime soon. To mid-levels: I've been hearing doom and gloom for 15 years about how mid-levels are going to destroy medicine and for the past 10ish years how psych is so vulnerable. I'm still waiting for this apocalypse to happen and I don't see any new signs that it will. Yes, in some areas this has been a problem and some docs have lost jobs d/t this. I've also seen a rebound in some places to re-hiring docs when NPs couldn't handle the job or created more problems.

My head tells me that neurology seemingly has more job security in the long-haul, and at least scratches the brain-fascination itch. Additionally, it is no secret ENT/ophtho provide a handsome salary alongside an envious lifestyle. Helping restore people's vision, hearing, and ability to breathe certainly sounds meaningful long-term. I also really like the idea of being a surgeon, and it seems pretty agreed upon that hands-on, procedural work is the safest from both midlevels and AI. But again, choosing any of these 3 fields would primarily be to guarantee that my future family and self is set for success

Something else to consider (probably not too heavily, but look at family history) is that it is physically easy to practice psychiatry (and neurology to a lesser extent) than a surgical field. I was highly interested in surgery as well, but my dad had back problems starting in his late 30's with multiple significant surgeries that didn't go great. Fast forward, and I had the exact same problem last year. Fortunately, it has not been nearly as bad for me and I have (mostly) recovered, but if my course is anything like my dad's idk if I could actually do a surgical procedural field past my mid to late 40's. Not saying to rule out surgery based on this, but something to consider for those with family histories of certain disorders becoming debilitating well before retirement. Also a plug to make sure you have good disability insurance, especially if you enter a surgical/procedural field.

 

[Stagg737]

My experience says otherwise about being more open-minded. Don’t try to figure it out now.

A friend of mine was sure he wanted to do anesthesia before medical school. At the beginning of medical school he hung out with anesthesia a lot and convinced the department chair to let him write up paper after paper. Anesthesia published a lot at my school. While he was almost never first author, he began writing up so much that he had his name on 15+ publications while in med school. Then he realized that he didn’t like anesthesia and preferred a surgical subspecialty. He thought this would look bad as his application looked 100% anesthesia. Just the opposite. He got interviews everywhere he wanted and got his top choice. They loved his ability to publish and his determination.

I thought I wanted to do Derm and published in Derm. I took a PT job in the Derm department. Then I realized I wanted to do psych. No interview questioned how I was Derm heavy early on.

It is a small percentage of students that realize their calling before medical school.

Idk that this is a great example because anesthesia is so surgery adjacent. Some surgical fields want to see you're published in their field or at least something similar. I know a few ortho docs at major residency programs (was my goal early in my journey) who basically said psych/non surgical pubs are basically disregarded.

I think for OP if it's really between ENT/Ophtho and psych pursuing research in all or at least some in ENT/Ophtho would be beneficial to keep things open. I'll defer if people know actual surgical PDs that have directly commented that psych research is fine though.

I'd also say that staying "open-minded" should be taken more as keep an open mind during rotations to something you may unexpectedly love. Not try and create a broadly appealing application just to keep options open. OP, if you're not genuinely interested in ENT/Ophtho and just care about the lifestyle, there are other options that could meet your goals.

 

[WolfBoy3000]

I disagree with the idea that you need to get into a procedural field or that it's all just a job in the end. It is a job and working conditions and pay are absolutely important, but I have no doubt I am much more engaged day to day practicing psychiatry than I would be in many other fields of medicine. I find my motivation for the subject still drives me to teach, to take on academic or other projects, and to generally look forward (or at minimum not dread) work most days.

Earing in the 300s with a 40-hour week is quite achievable. Your happiness depends a lot on what is "enough" for you financially. I believe I am far happier earning in the 300s for a sub-40 hour workweek (my current setup) than I would be earning $800,000 a year working 60+ hour weeks as a surgeon. If you realize your desire for more income can expand indefinitely and you start valuing other aspects of your work life more, psychiatry has more to offer than many fields. If you will want to earn well over the $300k's range in psychiatry that is doable but can mean the other "lifestyle" aspects start to fade away.

I have seen what AI has to offer so far and I'm not worried. Who knows where it will go, but what would it be replacing? Diagnostic interviewing? Prescribing? Psychotherapy? I suspect it will be a very useful helper for us in the next decade, but I think it will be augmenting rather than replacing. I think current AI technology has more potential to disrupt some other fields like radiology at the moment, but even there we certainly aren't seeing it yet.

Midlevels are a concern to some extent. They are more often moving into roles formerly filled by psychiatrists, which may eventually exert some downward pressure on incomes. Still, as a psychiatrist you bring a lot more to the table than a midlevel provider. The sky has been falling around this and similar "psychiatry income is doomed" issues for as long as I can remember (at least since I started medical school a little less than two decades ago). I'm still doing fine, and I suspect we will continue to do fine for quite a while.

Thank you for this perspective, it is greatly appreciated. I see myself being involved with research and teaching in the future, and the prospect of doing that within psychiatry truly excites me, while doing so in any other field just seems mildly interesting.

I suppose I know what is 'enough' for me, but now that I am seriously thinking about my future as a spouse and parent, a whole lot of question marks are arising. Then again, most people are not doctors and somehow make it work? Is it really worth making a couple hundred K more to not follow my true passion? That is the golden question.. Doesn't seem there is a right answer. I truly hope there will be a way for me to achieve my desired salary, whatever that is, in psychiatry 8 years from now.

If AI ends up only being helpful, that is wonderful. I guess I just get worried, because I admittedly use chatGPT to help troubleshoot personal issues quite often? Then again a psychiatrist is a prescribing physician, but when I see the midlevel mania going on and imagine that coupled alongside AI, I get.... worried. I hope you're right Dr. Bartelby, I really really do.

 

[WolfBoy3000]

Yes. NPs/midlevels are doing tms/ketamine and many patients dont know the difference. If you were say already in the field and in residency probably would be ok but 8-9 years is a huge timeline. If NPs didnt exist then yeah i would rec psych. Its like saying if NPs were doing optho and ent procedures and being pumped out in excess id hesitate but luckily they can't really do that YET... way more job security in procedural fields and i dont get why being in a top school you wouldn't try and get into a field that can be likely double your avg psych salary. I wouldn't compare to the outliers who are making bank they are not employing docs but just midlevels.

End of the day its a job/salary/lifestyle balance and your a tiny bit older when your done so i would maximize my income and security esp if you have a shot at those surgical fields with a decent lifestyle. My optho and ent friends love the field/lifestyle/$$ so if your in a position to get into those thats my rec.

Edit: 1st world problens but 300k yes of course you can support a 3-4 kids household and stay at home mom, but 500-600k would be easier if your planning that type of family with colleges, grad school etc.

Thank you for the detailed reponse.

Well thats not good news.. 8 years definitely seems far from now, but then I find threads discussing similar topics in 2017 and I can only wonder if the panic is warranted..

You're right, I have a golden opportunity in front of me to be able to be competitive for these high-paying, lifestyle specialties. That is what is making it so stressful. However, when I look into it further, it appears ENT & ophtho at least, the difference in salary from psychiatry isn't even 100K in some of the stats & job postings I see. Only thing I know is that having skills that involve my hands puts me in a more secure position... for now. Given what's been going on recently, it's entirely possible 10 years from now we'll have robots that can do basically anything, and I must say I struggle to see how that won't deflate all specialists salaries, no matter what can you do. I really am interested in those two fields, but the agonizing residency during the time my children will be babies/toddlers really makes me wonder if the juice is worth the squeeze.

Which brings me to.... follow the passion?

 

[WolfBoy3000]

1) reasonable income for a physician (~350K+), & job security! [will have a heck load of loans & plan on having 3-4 kids]

All of your options will accomplish this, outside of part-time or academic things.

2) interesting, fulfilling, meaningful work [hot take (at least on the internet), but if I'm spending 50%+ of my waking hours doing something, I want to love it, for the long-haul]

If you like all the options, then they all can accomplish this. I've had surgery friends say that surgery is both their job and their hobby lol. Same with some PhD friends, their job and their hobby are the same so it's quite fulfilling and interesting to them. A lot of the fun to a hobby or a job is the accomplishment, control, and endless replayability (like with video games). I think starting lexapro for GAD is boring, but when I go do the ED or CL and start d/cing malingerers and chronic SI, I find accomplishment and excitement in threading the needle on earliest d/c with a legally defendable note.

As for your interest in "helping people navigate their own consciousness and life circumstances" I have found that most of my outpatients want to remove their consciousness through the use of sedatives rather than navigate it.

Take some time to reflect on what you can do over and over for a career, over many years, and still be trying to perfect your skills--since that's where accomplishment and replayability come from.

3) flexibility & work-life balance [willing to work hard, but the last thing I want is to miss out on family time and all the things life has to offer because I spent all of it working; part-time and remote work options are invaluable to me, but not deal breakers as you'll see in my listed specialties]

Remote procedures aren't a thing. Telepsych and tele-stroke are things. I imagine if you are location flexible you can find a good call schedule even in a surgical field.

Thank you for the input!
When you put it that way, at this moment I feel there is no hobby I would rather have than to help restore a patient's mental functioning to a level that will allow them to live life. The cool part is I'll actually be able to have normal people hobbies outside of work as a psychiatrist! Nevertheless, ENT/ophtho provide this as well which is certainly enticing. But becoming an expert in the literal human brain and mind seems a bit more exciting to me than anything else... am I being idealistic? Even the social work aspects appeal to me.

That's disappointing most patients just want to sedate their thoughts, but I suppose that makes sense. People seek medications for a reason, and if my job is picking the right medication and offering 30 minutes of attentive listening alongside some encouraging words and hope, I think I will be satisfied. I should mention I am very interested in neuromodulation and the future of psychedelic medicine. All of these ingredients seem like a recipe for a rewarding and fascinating career. 🙂

Telepsych is the cherry on top. Hopefully the corporate overlords don't ravage it to death!

 

[WolfBoy3000]

It sounds like if you do choose psych you would be wanting to do a therapy based practice based on your post. I would think a lot about preparing for that that early on because that means running a business. Get some education on what you need in that regard. Look into residencies where you can get psychoanalytic training during residency. My residency has good therapy training but I know many don’t.

Thank you for the feedback! Yes I would love to have therapy involved in my practice, but understand the economics of medicine and how that is not exactly ideal. If I go the psych route, my dream is to own an interventional psychiatry practice with 5-10 hours of therapy a week. Time will tell if I can pull it off.

Do you mind messaging me which residency that is?

 

[WolfBoy3000]

Since ophtho came up a few times, some thoughts.

350 is certainly doable and would be on the low end for an established attending. We have fairly low starting salaries though (maybe around 300 or below for general), and if you wanted to stay in NYC/CA then pay is going to be lower, it’s harder to build a patient panel due to saturation, and the COL is higher.

Job flexibility and work/life balance is definitely there. I don’t think most people really work 40 hour weeks and most call issues can be seen the next day.

Day to day practice strikes me as being substantially different from psych. Comp docs probably see around 40+ patients a day. I do retina and am happy at ~70, so fast paced. Sometimes it’s a quick fix, sometimes it’s long term. If you do retina or glaucoma, you do get some of the more longitudinal care like psych since you wind up seeing a good number of patients more often than their PCP, but they’re pretty bite size visits. There’s still enough time to build a doctor patient relationship, but the feel is different. I have plenty of patients who tell me I’m their favorite doctor, and that’s with me sticking needles in their eyes.

For me, it’s fulfilling and meaningful. Interesting depends on the day because like most jobs, you have your bread and butter for a reason. I’m fine with that, partly because it means people are doing well. I tell my patients it’s a bad idea to be an interesting case and impress me.

Thank you for information! Ophthalmology really does fascinate me and as I can see myself doing it. Restoring vision? How cool! But the 40+ rapid fire patients per day alongside 20 cataracts in a row every week doesn't exactly appeal to my personality that craves connection & diversity. But then again they do say a job is just a job.. ? Do you find it is something some people grow to dislike?

What would you say is an average salary for mid-career in a suburban area? It's so hard to get the right numbers seeing that alot of ophtho income involves bonuses, owning surgical centers, becoming partner etc. What can an ophthalmologist really expect in 8 years given the never-ending reimbursement cuts and private equity parade?

 

[finalpsychyear]

Thank you for the detailed reponse.

Well thats not good news.. 8 years definitely seems far from now, but then I find threads discussing similar topics in 2017 and I can only wonder if the panic is warranted..

You're right, I have a golden opportunity in front of me to be able to be competitive for these high-paying, lifestyle specialties. That is what is making it so stressful. However, when I look into it further, it appears ENT & ophtho at least, the difference in salary from psychiatry isn't even 100K in some of the stats & job postings I see. Only thing I know is that having skills that involve my hands puts me in a more secure position... for now. Given what's been going on recently, it's entirely possible 10 years from now we'll have robots that can do basically anything, and I must say I struggle to see how that won't deflate all specialists salaries, no matter what can you do. I really am interested in those two fields, but the agonizing residency during the time my children will be babies/toddlers really makes me wonder if the juice is worth the squeeze.

Which brings me to.... follow the passion?

I can't answer that for you. I also am not sure you can say what exactly your passion is right now at this point without rotations. You can only anticipate being competitive early for those that need it. Optho retina friend is close to 7 fig in a PP and ent well in PP its in that ballpark too. With an aging obese population and the limited supply and demand its not changing so while nothing is a guarantee you have a higher probability of high financial success in a procedural field and yes you wlll have a harder residency but a higher guarantee of high financial success.

If your making close to high 6 figs from 35 to 50 yo, you and your 3-4 kids will be set andl work will be optional for your wife. I'm guessing you have worked hard to get into a top med school and that has put you in a position to be more competitive for these top specialities than the average joe. I only advocate procedural specialites moving forward to anyone in general. good luck.


Edit: if your really facinated with psych, finish your 15-20 year career as a surgeon then go train as a therapist for passion. My brother in law is doing this except he is retiring from IT but wants to be busy and has an interest in his pseudo retirement.

 

[WolfBoy3000]

A lot of good points already made, but some things from the OP to break down more:


1. is achievable in (almost) any field including all of the fields you named. Even in academics it can be possible. I work academics and while my gross salary was around $280k, I was well over $300k when benefits were accounted for. Idk anyone doing FT PP who is making under $300k other than one or two people that signed up to get taken advantage of by big telehealth companies. The location aspect is a little different convo and there's plenty of threads about it, but know your value and how to negotiate and you can hit $350k most places in psych.

2. is something I wouldn't throw out. With all due respect to Sushi, I think it's a bad take to dismiss this. If you don't enjoy something from the beginning, it's pretty rare that it will start growing on you if you make it your career. Maybe you would lose interest or burn out, but if you don't enjoy something from the start why bother in the first place? Yes, everything can eventually become a job, but this can partially be mitigated by the last point.

3. Psych also has enough flexibility that you can switch among various settings or patient populations pretty easily. You can always go back and get a fellowship and completely change what you're doing and still moonlight and make attending money while doing it at most places. A major criticism I have about NPs is "field hopping" without extra training. You can kind of do this in psych, but you should have more than adequate training to do so fairly easily once you shake the rust off (if you were well trained).



As others stated, AI may supplement us but won't replace us anytime soon. To mid-levels: I've been hearing doom and gloom for 15 years about how mid-levels are going to destroy medicine and for the past 10ish years how psych is so vulnerable. I'm still waiting for this apocalypse to happen and I don't see any new signs that it will. Yes, in some areas this has been a problem and some docs have lost jobs d/t this. I've also seen a rebound in some places to re-hiring docs when NPs couldn't handle the job or created more problems.



Something else to consider (probably not too heavily, but look at family history) is that it is physically easy to practice psychiatry (and neurology to a lesser extent) than a surgical field. I was highly interested in surgery as well, but my dad had back problems starting in his late 30's with multiple significant surgeries that didn't go great. Fast forward, and I had the exact same problem last year. Fortunately, it has not been nearly as bad for me and I have (mostly) recovered, but if my course is anything like my dad's idk if I could actually do a surgical procedural field past my mid to late 40's. Not saying to rule out surgery based on this, but something to consider for those with family histories of certain disorders becoming debilitating well before retirement. Also a plug to make sure you have good disability insurance, especially if you enter a surgical/procedural field.

Thanks so much for the insight and recommendations!

If what you are saying stays true for the next decade, I'm ready to dive into psychiatry and not look back. But to get to the end and find I am making $200K?.. Pain! It seems you do not think that is likely, thank you for sharing the history of this midlevel topic! I'd like to believe no matter what I can find a way to open a practice or stack jobs and get to the income I desire. But I suppose everyone thinks they are the exception..

Great to know passion still means something haha, hard to find that notion on the internet these days for some reason. When I see how the job satisfaction data of lifestyle surgeons, I can only wonder if I too would end up loving those fields, even if they aren't my first love.

The flexibility of psychiatry really seems unparalleled, and I think that may be the thing that gets me to take a leap of faith and follow my heart.

And from what I understand ENTs and ophthalmologists perform a lot surgeries sitting down? Maybe I'm wrong. Does that make a difference?
Nevertheless, the idea of practicing psychiatry late into my elder years sounds kinda badass not gonna lie.

 

[SPsych6]

Everyone will definitely have different opinions, but ultimately you need to rotate through to see what you enjoy. I am a psychiatrist and went back at 27yo. Personally, any surgical field is just like being a glorified mechanic and manual labor. I couldn't possibly imagine going into medicine and doing surgery. But other people love it! Neuro is really depressing to me. In neurology all the bad stuff has already happened, and you can't fix it (think stroke, dementia etc.)

AI is not even a thing and won't be in psychiatry. Just don't worry about it.

Midlevels are about as incompetent as they come and are on the verge of killing patients on a daily basis. Don't worry about them, you could always just go cash and people will flock to you after they have 1-2 NP experiences. We are constantly cleaning up their messes.

Work is work, but I still really enjoy what I do and you should too. Rotate through everything and see what you like. Psychiatry has so much flexibility it is crazy. You could do inpatient, outpatient, telehealth, ED, Forensics, Child etc. You want to make 600k+, not hard to do in psychiatry if you want to work more. But if you want to work 40ish hours, you can make 350-500k depending on your location. You could work corrections and make tons and only work 40hours. So maybe don't worry about the money aspect as much as the other things you were considering. You can make surgical money in psychiatry if you want, but you can't work psychiatry hours in surgery. Plus psych residency is 100, maybe 200x better than any surgical residency and it doesn't feel like you just did a mechanics job when you get home. You still feel clean.

 

[Stagg737]

But becoming an expert in the literal human brain and mind seems a bit more exciting to me than anything else... am I being idealistic? Even the social work aspects appeal to me.

Probably, there is a very long way to go in terms of true understanding of how the brain works. Yes, we understand basic circuits and neurotransmitters, but how exactly they interact to produce alterations in consciousness, cognition, and processing is still very much speculative. So being an "expert" still means a relatively poor understanding compared to what an expert is in some fields (more abstract for psych, less concrete imo). We don't really even understand how consciousness works or even what it is as a phenomena. That being said, to me that's a massive potential area of research and things to learn and understand which is part of what attracted me to the field.

Edit: if your really facinated with psych, finish your 15-20 year career as a surgeon then go train as a therapist for passion. My brother in law is doing this except he is retiring from IT but wants to be busy and has an interest in his pseudo retirement.

Counter point, please don't do this. I've encountered a few individuals in my area who were physicians in other fields and became certified counselors (2 peds, 1 FM, the others idk what previous field). They are uniformly awful at what they do and cannot help giving (usually bad) opinions on what meds patients should be on. If you want to do therapy either become a psychiatrist or go back and do a full PhD/PsyD later which can be a huge commitment to even get into a legit program.

If what you are saying stays true for the next decade, I'm ready to dive into psychiatry and not look back. But to get to the end and find I am making $200K?.. Pain! It seems you do not think that is likely, thank you for sharing the history of this midlevel topic! I'd like to believe no matter what I can find a way to open a practice or stack jobs and get to the income I desire. But I suppose everyone thinks they are the exception..

The flexibility of psychiatry really seems unparalleled, and I think that may be the thing that gets me to take a leap of faith and follow my heart.

And from what I understand ENTs and ophthalmologists perform a lot surgeries sitting down? Maybe I'm wrong. Does that make a difference?
Nevertheless, the idea of practicing psychiatry late into my elder years sounds kinda badass not gonna lie.

The only way you make $200k or less is if you choose to (academic place across town pays $190k) or drop to part time work. Even then, I've met psychiatrists working 20-30 clinical hours clearing well over $200k. When I started 3 years ago, $200k was the minimum I was willing to consider. Signed on at an academic place with $210k base and made about $30k extra in call pay and bonuses year one before benefits. Like I said above, last year my pay without benefits was around $280k, which is plenty for me in the midwest. Plenty of people where I'm at clearing $300k easily and a couple over $400k. Flexibility is unparalleled other than maybe FM or IM in BFE where you can basically be a cowboy and do everything.

Not sure about surgeons, but maybe. Develop a bad tremor or other fine motor problem and there goes your career. Have an accident that severely damages your hands/arms, done. Stroke. Done. Short of something making you incapable of sitting, communicating, or becoming cognitively incapable, there's not a whole lot of things that are going to prevent someone from practicing psychiatry from a medical perspective.

 

[bashir]

No one can really answer this for you but I'll give you my two cents anyway. Job security and pay are good enough in psychiatry. The
marginal benefit of making more money after a certain point is not worth the trade off of going to work every day in a field that doesn't excite you. Very few people in this world get to work at a job that brings them intellectual and, for lack of a better term, spiritual, fulfillment, while also making good money. If you think psychiatry will do that for you, I can't imagine that it's a good idea to go for something else.

Thank you, OP for reminding me what a privilege it is to be a psychiatrist. It's a good time to practice gratitude and the fact I ended up in this field is very high on my gratitude list.

 

[eyeeye_captain]

Thank you for information! Ophthalmology really does fascinate me and as I can see myself doing it. Restoring vision? How cool! But the 40+ rapid fire patients per day alongside 20 cataracts in a row every week doesn't exactly appeal to my personality that craves connection & diversity. But then again they do say a job is just a job.. ? Do you find it is something some people grow to dislike?

What would you say is an average salary for mid-career in a suburban area? It's so hard to get the right numbers seeing that alot of ophtho income involves bonuses, owning surgical centers, becoming partner etc. What can an ophthalmologist really expect in 8 years given the never-ending reimbursement cuts and private equity parade?

Saving vision is cool. Blindness is Big Fear number 3 behind cancer and heart attacks, so when things go right it’s great. Not so great if they don’t. In retina I deal with significantly more blinding conditions than average.

As a group we tend to be near the top of satisfaction surveys. Basically everyone I know is happy with the clinical side, it’s usually something on the practice side that gets someone hot and bothered.

Compensation in 8 years is impossible to predict. Suburban income is going to vary significantly with California and the Northeast probably dropping you 6 figures. If you went to the South/Midwest/non-CA West, mid-career is probably 600+ while working 4-4.5 days a week in classic PP. Retina higher than that. PE you would start higher but cap lower. They’re getting desperate to hire as more of the folks they bought out fulfill their contracts and retire. Kaiser is something like 400-450 but is slow paced with great benefits in a lot of nice locations.

Research in another field is fine, but research is an easy way to make connections in small fields like ophtho and ENT. If a big name or someone we know vouches for you, it’s big. If someone doesn’t know your mentors, it’s pretty easy to play the guy who knows a guy game.

Most if not all surgeries can be and are performed seated. There has been a serious push about ergonomics on the field for over a decade.

 

[annoyedpsychiatrist]

i think your definition of reasonable income is different than most peoples, lol. 350k is a very good income for most doctors, and higher than average for psychiatry. I make in the 3s, but not 350k. You can make that in psych tho

you should choose your field based on logic:

1. Whats the average salary/does it align with my lifestyle
2. Does the work enviroment align with my iifestyle
3. Do i actually have enough passion in this field to do it, and do it well
4. Seperating interest aside, can i see myself actually doing this type of work. Being interested in something and enjoying doing it day in and day out are a lot different sometimes. I dont think a lot of med students really understand real world psychiatry or what we do

 

[rjs2131]

Obviously biased given that we're in a psych thread here, but it sounds like you see yourself actually enjoying psych more than other specialties ("10/10 would pick psych if $$$ and job security weren't factors"). I actually think a good psychiatrist is incredibly difficult to replace with AI - one of the big reasons many of my patients/families value what I do is our therapeutic relationship.

You can definitely make 350k+ in psych (especially in PP - I made over that last year and took significant time off for family...I also work <30 clinical hrs/week). The other incredibly valuable thing in psych (as others have mentioned) is the ability to see patients virtually. I think our field has the most flexibility in medicine when it comes to hours + working from home.

You can almost always make more money in any field, and I don't see that changing anytime soon. What you won't get in many fields is the ability to work part-time without much hassle (overhead is very low in psych), or the longevity (the oldest psychiatrist at our practice is nearing 80).

Pick what you see yourself enjoying the most + what will give you the most time with friends/family - years from now, that'll matter more than the difference in $.

 

[Merovinge]

Something else to consider (probably not too heavily, but look at family history) is that it is physically easy to practice psychiatry (and neurology to a lesser extent) than a surgical field. I was highly interested in surgery as well, but my dad had back problems starting in his late 30's with multiple significant surgeries that didn't go great. Fast forward, and I had the exact same problem last year. Fortunately, it has not been nearly as bad for me and I have (mostly) recovered, but if my course is anything like my dad's idk if I could actually do a surgical procedural field past my mid to late 40's. Not saying to rule out surgery based on this, but something to consider for those with family histories of certain disorders becoming debilitating well before retirement. Also a plug to make sure you have good disability insurance, especially if you enter a surgical/procedural field.

This is a great point. My wife has been physically fit and healthy her entire life and still has issues with her feet/back at times and has only been a surgeon for a bit over a decade. Certainly something to be introspective about if there are any physical concerns prior to entering a surgical field.

 

[jbomba]

I'd say think moreso with your head. I was interested in other areas; anesthesia in particular. I really wanted a good work/life balance, not be beholden to a large group/big box shop for work, flexibility to take time off as I wanted. Sure I sacrificed some things by going psych to achieve this. In retrospect, the "non work stuff" makes it worth it x1000. I also make much more money, have greater flexibility, and don't have to wake up at 5am to be in a cold OR at 6 by choosing psych. There's truly nothing in the world I would do if I had to pick all over again because of the lifestyle, money, and flexibility psych allows for.

FWIW i had friends go into various fields due to ego. They had much harder and longer training, more difficulty finding a job in the city they want to be in, and in many cases making much less than I am as a "lowly" psychiatrist. If there's any inkling you are picking something because of perceived prestige, or your thoughts on career are tied to some type of ego need, slowly back away and rethink the situation.

 

[WolfBoy3000]

Everyone will definitely have different opinions, but ultimately you need to rotate through to see what you enjoy. I am a psychiatrist and went back at 27yo. Personally, any surgical field is just like being a glorified mechanic and manual labor. I couldn't possibly imagine going into medicine and doing surgery. But other people love it! Neuro is really depressing to me. In neurology all the bad stuff has already happened, and you can't fix it (think stroke, dementia etc.)

AI is not even a thing and won't be in psychiatry. Just don't worry about it.

Midlevels are about as incompetent as they come and are on the verge of killing patients on a daily basis. Don't worry about them, you could always just go cash and people will flock to you after they have 1-2 NP experiences. We are constantly cleaning up their messes.

Work is work, but I still really enjoy what I do and you should too. Rotate through everything and see what you like. Psychiatry has so much flexibility it is crazy. You could do inpatient, outpatient, telehealth, ED, Forensics, Child etc. You want to make 600k+, not hard to do in psychiatry if you want to work more. But if you want to work 40ish hours, you can make 350-500k depending on your location. You could work corrections and make tons and only work 40hours. So maybe don't worry about the money aspect as much as the other things you were considering. You can make surgical money in psychiatry if you want, but you can't work psychiatry hours in surgery. Plus psych residency is 100, maybe 200x better than any surgical residency and it doesn't feel like you just did a mechanics job when you get home. You still feel clean.

Well when you put it that way....! I do like to think I pride myself on what my mind/people skills can do rather than my hands now that I think of it. But what do you say about fields like Ophtho and ENT that allow you to do both clinic and surgical work? Yeah that's what I've been reading about neuro it seems, wondering if future medical advancements will significantly combat that con, time will tell. Regardless, I think I'd rather help sort out problems of the mind rather than the brain anyway.

I wouldn't be so sure about AI being negligible. Myself and many people I've spoken with have had success using chatGPT to navigate personal issues. Just head over to the therapist subreddit, lots of discussion & panic. Nevertheless, I'd like to believe the medical components of psychiatry will remain more AI-proof and even if not, that future patients will value the connection with an actual human being, specifically in psychiatry. I actually am really concerned for those in diagnostic specialties where the doctor-patient relationship is less critical to outcomes.

Roger that on the midlevels comment! I'm sure some are great, but I am really banking on a subset of patients intentionally seeking out the best care they can get down the line.

"Work is work, but I still really enjoy what I do and you should too." Refreshing to read, thank you Dr. SPsych6! Will be open-minded during rotations. The flexibility really is a golden perk to me. The streamlined, often restrictive nature of medicine really had me second guessing leaving my corporate job for medical school, and I think I'd be doing my past self a disservice to not pursue a more flexible specialty if I actually like it.

Great to have that insight on income and WLB. Thank you so much for the thoughtful response, it is greatly appreciated!

 

[WolfBoy3000]

Probably, there is a very long way to go in terms of true understanding of how the brain works. Yes, we understand basic circuits and neurotransmitters, but how exactly they interact to produce alterations in consciousness, cognition, and processing is still very much speculative. So being an "expert" still means a relatively poor understanding compared to what an expert is in some fields (more abstract for psych, less concrete imo). We don't really even understand how consciousness works or even what it is as a phenomena. That being said, to me that's a massive potential area of research and things to learn and understand which is part of what attracted me to the field.



Counter point, please don't do this. I've encountered a few individuals in my area who were physicians in other fields and became certified counselors (2 peds, 1 FM, the others idk what previous field). They are uniformly awful at what they do and cannot help giving (usually bad) opinions on what meds patients should be on. If you want to do therapy either become a psychiatrist or go back and do a full PhD/PsyD later which can be a huge commitment to even get into a legit program.


The only way you make $200k or less is if you choose to (academic place across town pays $190k) or drop to part time work. Even then, I've met psychiatrists working 20-30 clinical hours clearing well over $200k. When I started 3 years ago, $200k was the minimum I was willing to consider. Signed on at an academic place with $210k base and made about $30k extra in call pay and bonuses year one before benefits. Like I said above, last year my pay without benefits was around $280k, which is plenty for me in the midwest. Plenty of people where I'm at clearing $300k easily and a couple over $400k. Flexibility is unparalleled other than maybe FM or IM in BFE where you can basically be a cowboy and do everything.

Not sure about surgeons, but maybe. Develop a bad tremor or other fine motor problem and there goes your career. Have an accident that severely damages your hands/arms, done. Stroke. Done. Short of something making you incapable of sitting, communicating, or becoming cognitively incapable, there's not a whole lot of things that are going to prevent someone from practicing psychiatry from a medical perspective.

Fair enough! I like to think that when the AI overlords become sentient they will look fondly upon those within the mind / behavioral fields. Perhaps even seek their counsel hahaha. Yes they say the brain and more specifically the mind is the final frontier of science. Would love nothing more than to be a part of that.

Hahah I actually really like the idea but yes I would not do that. Spending 20 years grinding just to eventually do what I initially wanted to do doesn't exactly sound enticing.

Appreciate the info regarding salary, but that is 2025 data. If over the next decade the concerns I and many others have about AI / midlevels come to fruition and lead to salary decrease, will I find I am the least paid specialist? I guess everyone has to take a leap of faith at some point. At the end of the day, the flexibility is worth tens of thousands to me.

Great insight, thank you for your time and advice!

 

[WolfBoy3000]

I can't answer that for you. I also am not sure you can say what exactly your passion is right now at this point without rotations. You can only anticipate being competitive early for those that need it. Optho retina friend is close to 7 fig in a PP and ent well in PP its in that ballpark too. With an aging obese population and the limited supply and demand its not changing so while nothing is a guarantee you have a higher probability of high financial success in a procedural field and yes you wlll have a harder residency but a higher guarantee of high financial success.

If your making close to high 6 figs from 35 to 50 yo, you and your 3-4 kids will be set andl work will be optional for your wife. I'm guessing you have worked hard to get into a top med school and that has put you in a position to be more competitive for these top specialities than the average joe. I only advocate procedural specialites moving forward to anyone in general. good luck.


Edit: if your really facinated with psych, finish your 15-20 year career as a surgeon then go train as a therapist for passion. My brother in law is doing this except he is retiring from IT but wants to be busy and has an interest in his pseudo retirement.

Thank you, this was eye-opening. By golly that is a lot of money. But the more I think about this I get stuck in a philosophical/logical loop. 99.9% of people get along fine without making a million dollars a year, even if you account for the debt and missed income do I really need that much money to raise my family? Sure I could have a nicer house, cooler stuff, more money for the kids pursuits, but is all of that worth a lifetime of feeling I didn't pursue what I actually wanted to do? Most days I feel not at all, but some days my amygdala goes crazy, saying I am a fool to not seek the most $ possible. I'd like to believe me, my wife, and children will all find a way to be secure, happy, and successful without that extra however many million (yikes that really hurts to write lol).

I know I am extremely fortunate to even be having this dilemma, and sincerely appreciate your input and guidance. Thank you Dr. finalpsychyear!

 

[WolfBoy3000]

No one can really answer this for you but I'll give you my two cents anyway. Job security and pay are good enough in psychiatry. The
marginal benefit of making more money after a certain point is not worth the trade off of going to work every day in a field that doesn't excite you. Very few people in this world get to work at a job that brings them intellectual and, for lack of a better term, spiritual, fulfillment, while also making good money. If you think psychiatry will do that for you, I can't imagine that it's a good idea to go for something else.

Thank you, OP for reminding me what a privilege it is to be a psychiatrist. It's a good time to practice gratitude and the fact I ended up in this field is very high on my gratitude list.

I sincerely appreciate this response, thank you Dr. Bashir. Good enough should be suffice. I suppose this is almost a test of character. As someone else said, the desire for more money is indefinite. And I think so is the regret of not having pursued what calls to me.
So many people say to find joy and fulfillment outside of work, and that work is work. Yes it is, but as you have explained, I have the opportunity to pursue a truly uniquely fulfilling career in all regards. I really am holding onto the idea (supported by personal and professional experiences) that a career as a psychiatrist is inherently different than not only most jobs, but most or all other fields of medicine.

Honored to have inspired gratitude in you, thank you very much for this encouraging and insightful response!

 

[WolfBoy3000]

Saving vision is cool. Blindness is Big Fear number 3 behind cancer and heart attacks, so when things go right it’s great. Not so great if they don’t. In retina I deal with significantly more blinding conditions than average.

As a group we tend to be near the top of satisfaction surveys. Basically everyone I know is happy with the clinical side, it’s usually something on the practice side that gets someone hot and bothered.

Compensation in 8 years is impossible to predict. Suburban income is going to vary significantly with California and the Northeast probably dropping you 6 figures. If you went to the South/Midwest/non-CA West, mid-career is probably 600+ while working 4-4.5 days a week in classic PP. Retina higher than that. PE you would start higher but cap lower. They’re getting desperate to hire as more of the folks they bought out fulfill their contracts and retire. Kaiser is something like 400-450 but is slow paced with great benefits in a lot of nice locations.

Research in another field is fine, but research is an easy way to make connections in small fields like ophtho and ENT. If a big name or someone we know vouches for you, it’s big. If someone doesn’t know your mentors, it’s pretty easy to play the guy who knows a guy game.

Most if not all surgeries can be and are performed seated. There has been a serious push about ergonomics on the field for over a decade.

This information is very enlightening and useful, thank you Dr. eyeeye_captain. I think I will go the do a bit of research in the surgical fields route and ensure I do not close any doors at this stage.

May I ask, are there any types of personalities / characteristics that you find tend to thrive in ophtho more. How about less?

 

[WolfBoy3000]

i think your definition of reasonable income is different than most peoples, lol. 350k is a very good income for most doctors, and higher than average for psychiatry. I make in the 3s, but not 350k. You can make that in psych tho

you should choose your field based on logic:

1. Whats the average salary/does it align with my lifestyle
2. Does the work enviroment align with my iifestyle
3. Do i actually have enough passion in this field to do it, and do it well
4. Seperating interest aside, can i see myself actually doing this type of work. Being interested in something and enjoying doing it day in and day out are a lot different sometimes. I dont think a lot of med students really understand real world psychiatry or what we do

Hahah I said reasonable income for a physician! And according to most recent salary reports, 350K is actually around or below average across all specialists. Somewhere around median is all I ask for. I know that is achievable in psychiatry in 2025, but my concerns are whether that will be the case a decade from now. Nevertheless, your questions are very useful thank you, Dr. annoyedpsychiatrist. At this moment all my answers point towards psychiatry. My rotation will have to be truly unenjoyable to convince me otherwise, time will tell!

 

[Stagg737]

Appreciate the info regarding salary, but that is 2025 data. If over the next decade the concerns I and many others have about AI / midlevels come to fruition and lead to salary decrease, will I find I am the least paid specialist? I guess everyone has to take a leap of faith at some point. At the end of the day, the flexibility is worth tens of thousands to me.

I would say almost certainly not, at least not from midlevels. Midlevels have been an issue for a decade plus and I've heard the "coming for our jobs" argument a hundred times over. Despite that, psychiatry salaries have increased more than ever over the past 3-5 years per multiple people here despite rapid midlevel expansion. Plus, many midlevels start practicing on their own and realize they don't actually want to (too much work, too much responsibility/demand from patients, lack of knowledge, etc) and go back to being RNs. I work with several NPs that just work as RNs.

No one can say for sure what the impact of AI will be, but I very much doubt that it will lead to lowered salaries. If something happens where there is a major impact it will likely affect all non-procedural specialists and would make good therapy skills that much more valuable in our field.

 

[WolfBoy3000]

Obviously biased given that we're in a psych thread here, but it sounds like you see yourself actually enjoying psych more than other specialties ("10/10 would pick psych if $$$ and job security weren't factors"). I actually think a good psychiatrist is incredibly difficult to replace with AI - one of the big reasons many of my patients/families value what I do is our therapeutic relationship.

You can definitely make 350k+ in psych (especially in PP - I made over that last year and took significant time off for family...I also work <30 clinical hrs/week). The other incredibly valuable thing in psych (as others have mentioned) is the ability to see patients virtually. I think our field has the most flexibility in medicine when it comes to hours + working from home.

You can almost always make more money in any field, and I don't see that changing anytime soon. What you won't get in many fields is the ability to work part-time without much hassle (overhead is very low in psych), or the longevity (the oldest psychiatrist at our practice is nearing 80).

Pick what you see yourself enjoying the most + what will give you the most time with friends/family - years from now, that'll matter more than the difference in $.

Thanks a lot for the encouraging response Dr. rjs2131! I really appreciate it. You're right, now that I read what I wrote back to myself, it would go against what I believe to not go with what I truly desire. Banking on you being right about AI and future patients actually seeking authentic human doctor rapport!

Well that is quite an inspiring salary & WLB, sounds like a dream. Yes it really seems the flexibility, part-time, and remote options are worth its weight in gold. Maybe my wife and I will have a lil less fun money and my kids a bit less for college. Hopefully that'll all work out!

Roger that - at this moment that feels like psychiatry to me. Some really crazy revelations will need to happen on rotations for that to change, will keep you posted! One thing I know for sure - an 80 year old psychiatrist sounds like a cool SOB, would love to be them.

 

[WolfBoy3000]

I'd say think moreso with your head. I was interested in other areas; anesthesia in particular. I really wanted a good work/life balance, not be beholden to a large group/big box shop for work, flexibility to take time off as I wanted. Sure I sacrificed some things by going psych to achieve this. In retrospect, the "non work stuff" makes it worth it x1000. I also make much more money, have greater flexibility, and don't have to wake up at 5am to be in a cold OR at 6 by choosing psych. There's truly nothing in the world I would do if I had to pick all over again because of the lifestyle, money, and flexibility psych allows for.

FWIW i had friends go into various fields due to ego. They had much harder and longer training, more difficulty finding a job in the city they want to be in, and in many cases making much less than I am as a "lowly" psychiatrist. If there's any inkling you are picking something because of perceived prestige, or your thoughts on career are tied to some type of ego need, slowly back away and rethink the situation.

What you were seeking is precisely what I am seeking. I like the way you say non-work stuff. I'd be lying if I didn't say the lifestyle and time out of work weren't one the biggest appeals of ENT/ophtho. Now that I think of it, what horrible thinking to pursue a career with the thought of when you won't actually be working being a positive.. It is still going to be a huge amount of my time! Flexibility has been a north star of mine so far in life, and I'm not sure I see that changing, no matter what happens in rotations. We'll see!

Well I can't say I have conquered my ego just yet, if I had I probably would've just went the PA or PMHNP route and made this journey a whole lot easier! But point taken. I can sense people's subtle disappointment (mostly my family's lmao) when I say I am mostly interested in psychiatry, and I must admit it does bother me a bit, but I'll be damned if I decide what I do the rest of my life based on the approval and admiration of others.

Thank you very much for the insight Dr. jbomba!

 

[lobstar]

Thank you for the input!
When you put it that way, at this moment I feel there is no hobby I would rather have than to help restore a patient's mental functioning to a level that will allow them to live life. The cool part is I'll actually be able to have normal people hobbies outside of work as a psychiatrist! Nevertheless, ENT/ophtho provide this as well which is certainly enticing. But becoming an expert in the literal human brain and mind seems a bit more exciting to me than anything else... am I being idealistic? Even the social work aspects appeal to me.

That's disappointing most patients just want to sedate their thoughts, but I suppose that makes sense. People seek medications for a reason, and if my job is picking the right medication and offering 30 minutes of attentive listening alongside some encouraging words and hope, I think I will be satisfied. I should mention I am very interested in neuromodulation and the future of psychedelic medicine. All of these ingredients seem like a recipe for a rewarding and fascinating career. 🙂

Telepsych is the cherry on top. Hopefully the corporate overlords don't ravage it to death!

Also, I think we all take some of this too seriously. Sounds like you have a number of specialties that can be a part of a fulfilling life. Maybe psych is 95/100 in total life satisfaction (just making this up for the concept) and optho is 92/100, or neuro is 88/100, and radiology is like a 20/100 for you. It sounds like you are in your ballpark and have identified these top few. We have to make decisions with limited information sometimes; you can't tell the future. The amount of stress some med students have trying to differentiate a job with 95 happiness versus one that could be 92/100 happiness...I don't know...you (and many med students) have enough self-reflection, flexibility, and probably fortitude (although that one hasn't clearly come off in posts on here lol, but you will have completed medical school) that you could succeed and find a good life in a range of areas.

 

[clausewitz2]

Also, I think we all take some of this too seriously. Sounds like you have a number of specialties that can be a part of a fulfilling life. Maybe psych is 95/100 in total life satisfaction (just making this up for the concept) and optho is 92/100, or neuro is 88/100, and radiology is like a 20/100 for you. It sounds like you are in your ballpark and have identified these top few. We have to make decisions with limited information sometimes; you can't tell the future. The amount of stress some med students have trying to differentiate a job with 95 happiness versus one that could be 92/100 happiness...I don't know...you (and many med students) have enough self-reflection, flexibility, and probably fortitude (although that one hasn't clearly come off in posts on here lol, but you will have completed medical school) that you could succeed and find a good life in a range of areas.

You expect them to stop grade-grubbing just because they're about to not be in school anymore?

 

[AD04]

I can sense people's subtle disappointment (mostly my family's lmao) when I say I am mostly interested in psychiatry, and I must admit it does bother me a bit, but I'll be damned if I decide what I do the rest of my life based on the approval and admiration of others.

Success is the best revenge. Some of us are making ridiculous numbers. My dad at first disapproved of me pursing psychiatry. But he came around to accept it. I occasionally remind him that I'm very well off despite him not approving at first of my decision and therefore I make better choices than him. Of course, I prove it by always paying when we go out -- whether for meals or hotels or whatnot. He told me how my brother-in-law makes so much money and how good my sister has it. I ask him for the numbers and then I honestly tell him that I make more.

So when he disapproves of my later decisions, I remind him, "Do you remember when you told me not to go into psychiatry?"

Most joking, but kinda serious.

Anyways, choose the specialty that is best suited for you: the one that comes most naturally to you. Because if you're naturally good at something, you'll come to love it. The market will determine your value. If you can't outcompete a mid-level (usually someone that wants to work mommy hours with less clinical knowledge than a physician), then you shouldn't get paid more than one. But if you are naturally suited for a specialty and are willing to dedicate time to it to perfect your craft and to differentiate yourself, you can make a lot of money no matter the specialty. The variation in earnings intraspecialty is more than that interspecialty. In other words, the range of earnings among psychiatrists varies more than median psychiatrist earning vs median neurosurgery earning.

At a certain net worth, the money you make at work won't matter. What matters for your career is how much you enjoy the specialty as that will determine your longevity in it.

 

[threeroses]

Ophthalmology resident here -

I have a few points I want to suggest. Of course, I am still in residency, so I can't comment as much on salary or attending lifestyle.

First, it is clear that you have passion for psychiatry. Where does that passion come from? Have you shadowed much in these specialties or have experience in them?

I find the personalities and actual day-to-day to be extremely different between all four of these specialties. A piece of advice that an attending had given me: at the end of the day, yes, your specialty will be your job so look around you and make sure you like your colleagues - they will make all the difference. I have found this to be true. I was initially extremely passionate about OB/GYN and for the first two years of medical school, I was 100% sure I was going to be an obstetrician. In third year, I realized that I really didn't gel as much with the personalities or the lifestyle in OB/GYN. I stumbled upon ophthalmology entirely by accident and fell in love with the specialty, the community, the people.
Find your people.

I was a neuroscience major in college and was also fascinated by psychiatry, but I realized that I actually found it to be the most draining of my rotations. I ended each day utterly exhausted and had trouble disconnecting from work while at home. I realized that I wasn't cut out for all of the talking in psychiatry lol. Something to consider!

I also considered neurology, and actually came across ophthalmology through my neurology rotation. Neurology is very different from psych! The physical exam is essential, which is interesting, but I agree with a previous poster that it tends to be very sad + much more focused on nerves than the actual workings of the brain. I am someone who is very procedural and felt frustrated by the sense that we could not do much to intervene once we came to a diagnosis. Interventional neuroradiology was more interesting to me in that regard (do the thing! remove the clot! coil the aneurysm!). Food for thought.

I love ophthalmology and could see myself in no other specialty. For me, I loved the clinical aspects, the research, the elegant surgeries, and the opportunities for global service. I have found ophthalmology hopefuls and residents to be similarly obsessed - almost fervent about the specialty lol. Ophthalmology is not really a specialty that you should talk yourself into, and if you aren't passionate about it, I suspect that would be sniffed out. The match rate was 66% last year; the journey to match into ophthalmology (let alone in a location that you actually want!) can be all-consuming and is not worth it if you do not really love it. Happy to answer any further questions about ophtho you may have from a resident perspective.

ENT is often grouped in with ophthalmology but I don't think they are practically that similar. ENT is broader and has much more involved surgeries. Of the specialties mentioned, I would say ENT has the most intense residency - it is much more similar to other surgical specialties in my opinion. I personally find the orifices in question (ears, nose, throat) to be disgusting and never considered the specialty, so I can't comment much further.

At the end of the day, I think you should try to spend time with these different specialties and see what they are really like. You may be surprised, like I was, and realize that your specialty of choice is in practice not what you had hoped. Importantly, do not discount the time you will spend in residency and what that experience will be like. Residency is grueling as it is, but it is much worse if you do not enjoy your specialty. I speak from experience - the preliminary year for ophthalmology (mainly IM, some EM and ICU) is miserable in many ways. The long hours, sacrifices, and challenges feel worth it when you are really passionate about what you do.

You mention kids - I think one of the best things you can do for your children, even more than lavish them with a high salary, is love your life.

 

[esob]

If you are seriously considering ENT or ophthalmology, you should hit the ground running. If you don't stand out academically, you won't have to worry about those two because they won't be options. ENT is particularly step score dependent, and friends I know that matched ophthalmology were working on publications and networking at MS1's.

Psych and neuro are on the other end of the academic spectrum, though both can still be competitive. I've never been on any other residency committees, but I know for psych, we generally care more about the interview than we do about pedigree. I've given bad scores to people with otherwise remarkable applications because I couldn't imagine them working as psychiatrists.

The TLDR is that you will likely be able to decide on psych/neuro later in your med school journey but if you want to do ENT or ophthalmology, you need to get plugged in with a mentor early to make your application competitive.

 

[OldPsychDoc]

60+ y/o M; 20 years now in primarily inpatient practice, urban Midwest.
4 adult kids all out of house now .
All 4 gainfully employed.
3 of 4 through or currently enrolled in state universities -- so no loans except the one who did a Masters program and is employed in that field.
(The one who didn't go to college got a down payment on a modest starter home instead.)
Mrs. OPD works when she wants to, has other interests that make her happy.

We owe more on her car right now (2024 RAV4 Hybrid--she insisted--after retiring her well-worn Odyssey with 250,000 miles) than we have left on our mortgage, which should zero out the year the youngest graduates undergrad.

I won't say it's been easy or ideal...but it's been ideal for us.
I don't love every single day at work, but I love my colleagues, I adore my residents, and I know I make a difference for most of my patients.

To answer the OP's question--the head can't live very long without the heart, and the heart lasts longer with some guidance from the head--but in all seriousness: How did you make that other most consequential decision of your life--who to spend it with and raise children with?
Heart predominant? Or head?

 

[Merovinge]

To answer the OP's question--the head can't live very long without the heart, and the heart lasts longer with some guidance from the head--but in all seriousness: How did you make that other most consequential decision of your life--who to spend it with and raise children with?
Heart predominant? Or head?

I'm 20 years (and a little change) behind in life experience to you, but I think that question is substantially more consequential than subspecialty of medicine to most doctors. I wouldn't have been thrilled to be a Pediatrician, but I would much rather be a pediatrician and be with my current partner, than be thrilled to be at my current job and be with a worse partner.

I'm a cutthroat empiricist having read the books and data that who you marry/have children with is by far the most consequential choice you will ever make as a parent and this still did not really penetrate my skull while dating.