Switch Psychiatry to Neurology

[aspiringdoc09]

Hi All,
I'm an AMG PGY 2 Psych Resident who has been thinking about switching to neurology for quite a while. The more I am in psychiatry the more I feel I'm not a future psychiatrist. I originally applied as a combined neurology/psychiatry applicant but didn't match. I may be burnt out and emotionally drained, but I feel more excited by neurology topics. There are things I like about psychiatry, don't get me wrong, but I don't know if I'm an "innate psychiatrist".

I was wondering if it would be difficult to switch over to Neurology and if so, do I need to start over as a PGY-1 due to the medicine year? Also, where do I look for open positions? Do you think I should just finish my psychiatry residency first and then pursue neurology? I'm going to my 3rd year which is outpatient psychiatry, so it will be different, but I always said I wouldn't enjoy the outpatient setting. I see myself as a hospitalist.

Thoughts/comments/advice. Has anyone done this before?

Thank you.

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[Postictal Raiden]

If you can still stomach psychiatry, you should stick with it. There’s no nirvana in medicine. It all sucks. Had I been able to tolerate my psych rotation as a med student I would’ve pursued it. Can’t be lifestyle in psych.

Neurology can be just as emotionally draining...if not more. I just came off a rough night float shift. The whole night I was chasing my tail with two actively dying patients: a massive hemorrhage and massive infarct with cerebral edema. I had to tell the wife of a relatively young patient that he’ll no longer be able use the dominant side of his body or communicate for the rest of his life. I had to tell her that he basically went from being the one who is supporting his household to needing high skilled care 24/7. And don’t get me started on the autoimmune encephalitis pt who kept seizing all night long despite being maxed out on 3 AEDs.

Perhaps I’m a little bitter from working long hours and dealing with death/crippling injuries left and right.

Point is, the grass may look greener but remember it’s fertilized with bulli****.

To answer one of your questions, you are likely to have to repeat PGY1, unless you did at least 6 months in inpatient IM during your time in residency.

Good luck

 

[aspiringdoc09]

If you can still stomach psychiatry, you should stick with it. There’s no nirvana in medicine. It all sucks. Had I been able to tolerate my psych rotation as a med student I would’ve pursued it. Can’t be lifestyle in psych.

Neurology can be just as emotionally draining...if not more. I just came off a rough night float shift. The whole night I was chasing my tail with two actively dying patients: a massive hemorrhage and massive infarct with cerebral edema. I had to tell the wife of a relatively young patient that he’ll no longer be able use the dominant side of his body or communicate for the rest of his life. I had to tell her that he basically went from being the one who is supporting his household to needing high skilled care 24/7. And don’t get me started on the autoimmune encephalitis pt who kept seizing all night long despite being maxed out on 3 AEDs.

Perhaps I’m a little bitter from working long hours and dealing with death/crippling injuries left and right.

Point is, the grass may look greener but remember it’s fertilized with bulli****.

To answer one of your questions, you are likely to have to repeat PGY1, unless you did at least 6 months in inpatient IM during your time in residency.

Good luck

Thanks for your reply. No, I haven't had 6 months of inpatient medicine. I see what you are saying though. I don't know. I feel more drawn to neurology. Maybe, I'm sick of medicine. I've been saying that too. It's a bunch of bull**** I don't care about. Maybe 3rd year will get better. I don't know. I've been feeling like this for a while, so something has to give.

 

[Splenda88]

Thanks for your reply. No, I haven't had 6 months of inpatient medicine. I see what you are saying though. I don't know. I feel more drawn to neurology. Maybe, I'm sick of medicine. I've been saying that too. It's a bunch of bull**** I don't care about. Maybe 3rd year will get better. I don't know. I've been feeling like this for a while, so something has to give.

As Ibn said, most of medicine is all BS... Finish your training in psych and find a job that suit you (e.g, inpatient psych) and start making $$$. By the time you start PGY1 in neuro, it will be your last year of psych training where you can moonlight and start making some money.

 

[Postictal Raiden]

As Ibn said, most of medicine is all BS... Finish your training in psych and find a job that suit you (e.g, inpatient psych) and start making $$$. By the time you start PGY1 in neuro, it will be your last year of psych training where you can moonlight and start making some money.

Exactly. Besides, inpatient psych pays really well from what I’ve been told.

 

[Neurogeneral]

I would try to finish what you started before making any rash decisions such as withdrawing from your program. There must be some part of psych that you like and that you drew to this specialty in the first place. Obviously, psychiatry is in very high demand, which puts psychiatrists In the driver seat to find the type of jobs that they want in terms of practice setting, compensation, life style, etc. I have also heard of psychiatrists demanding yearly additional hefty flat fees just for agreeing to come and see consults at hospitals. Telepsych seems to be huge if that is something that interests you as well. You could do a behavioral neurology fellowship which would allow you to see and treat patients with dementia.

And even after all that, you want to do neurology or some other specialty, you can always go back into training. I had a former hospitalist in my neuro program. So it’s not that uncommon.

 

[Telamir]

I think a lot of folks here would do psych if they liked it (I would've) cause of the lifestyle alone. I have a friend in addiction psych who is making very good money (close to what I make) and his work is very cush with let's face it very low liability. If you REALLY like neurology you could carve a niche out for yourself managing psychiatric comorbidities of neuro patients such as conversion disorders, mood/fatigue/pain in MS patients, psychosis/behavior in dementia patients, etc. I think that's the most interesting part of our "overlap".

 

[Phantom Spike]

You might also consider a fellowship in Sleep Medicine once you graduate. It helps you focus on a particular area (insomnia), gives you a procedure you can do (sleep studies), adds some variety to your practice (diagnosing and managing sleep apnea) and you see and potentially help patients with some neurological diseases (restless legs, abnormal movements in sleep, headaches, possible nocturnal seizures, etc.). And it's only one year and not very competitive, especially if you're willing to relocate for it. The sleep field isn't what it used to be, of course, but it's still a good option for psychiatrists.

 

[DrSatan]

You could always do a fellowship in neuropsychiatry. This would at least push you closer to neurology.

 

[liquidshadow22]

Yea agreed with above sentiments, both neurology and psychiatry suck. Atleast with psych the stress is much less for similar $$. If you are a super nerd and love learning all that minutia, then switch to neuro.

Also one important thing to consider. In order to make this decision you need to compare what type of "fellowship trained neurologist" you would rather be. General neuro can be done, but most dont want to do that. Most neurologists complete fellowship, so the question should be: would you rather be a movement neurologist, Neurocrit neurologist, Stroke neurologist, epileptologist etc. versus a psychiatrist (specialization matters less in psych).

 

[Alcmaeon of Croton]

I wonder why you choose psychiatry if you see yourself as a hospitalist since psychiatry is mainly an outpatient specialty! Maybe you had this realization during residency not before. Anyhow, I agree with those who said that you should finish your residency then make a decision. There's a lot of neurologists who have had some training in psychiatry before pursuing neurology, particularly international graduates as neurology and psychiatry are more closely tied in other countries. Also, there's a lot of US graduates that had degrees in psychology before going to medical school and ended up choosing neurology. Nevertheless, most of those pursue a career in outpatient neurology; most suitable would be cognitive, movement, and sleep.

 

[michaelrack]

I wonder why you choose psychiatry if you see yourself as a hospitalist since psychiatry is mainly an outpatient specialty!

Not true, there are a lot of psych inpatient positions out there, but you're probably not aware of them because many are at free standing psychiatric hospitals rather than psychiatric wards at general hospitals

 

[Asklepian]

As someone that actually practices both neurology and psychiatry, I can tell you these specialties are definitely not the same.
However, I couldn't divorce either specialty, and here I am now doing both. I love both at least as much as I did when I first started. But, they're very different (have different lifestyles, call expectations, approaches to diagnosis and treatment, and [to some extent] patient populations).

If you switched to neuro, you'd have the months of IM and other qualifying primary care rotations count toward your prelim year requirements, and could likely pile the rest in at the beginning of your next PGY. Then, you would delve into neuro. It may extend your residency by at least a few months, but it's certainly not an overly difficult task.

Also, remember to take things with a grain of salt from folks on SDN (including me). One size does not fit all. Most people on SDN are super helpful, but may be very speculative and, dare I say, talk out of their asses at times. That said, I wholeheartedly disagree with the sentiment of "just stick it out". What's an extra year or two of training compared to an entire career where you may be much more satisfied?

I'm happy to talk with you in more depth. Good luck.

 

[Alcmaeon of Croton]

Not true, there are a lot of psych inpatient positions out there, but you're probably not aware of them because many are at free standing psychiatric hospitals rather than psychiatric wards at general hospitals

Inpatient psych is a very special case of inpatient medicine. It has more in common with outpatient medicine than with inpatient. Number of emergencies and truly urgent situations is limited and response by a psychiatrist is not typically expected within minutes when compared to neurology or cardiology for example. At the same time, the inpatient psych ward is a unique situation that's different from any other ward although it has changed dramatically compared to what it was decades ago especially regarding times of stay. When I hear somebody say they see themselves as a hospitalist, that's not readily transferable to psychiatrist hospitalist.

 

[michaelrack]

If you don't consider inpatient psych to be "hospitalist" that's fine; I would agree, at least given the way most psychiatrists act. However, my point that psychiatry is not exclusively or mostly an outpatient specialty stands.

I think we could all agree that there is both inpatient and outpatient psych, but inpatient psych is vastly different from other inpatient work

 

[Neurologo]

Both psych and neuro are in high demand but, at least where I am, psych is in even higher demand. With tele-medicine becoming more of a norm, psych would be in a better position since all their visits can be done via tele I assume.

 

[Peace of Mind]

Do experts agree on what portion of current psychiatry is really just undiscovered neurology?

Through history psychiatry has been more than willing to let go anything with a clear etiology.

That might help the undecided figure out where to go.

I read a paper somewhere saying that nowadays we have less schizophrenia Dx than before, this phenomenon having several explanations with one of them being the discovery of schizophrenia-like neurological diseases.

As someone with a big interest in psychosis if neurology was to absorb most psychosis cases (e.g. immune, mitochondrial, etc) that would definitely make me reconsider specialties.

If you truly enjoy depression, personality disorders, anxiety… then psych is your only choice.

 

[Thama]

There isn't a consensus on that because the division between the fields is mostly arbitrary. If by this you mean what proportion of traditionally psychiatric disorders have a structural or histopathologic rather than just a network function underlying mechanism, I would say probably many but not all. But that doesn't mean that psychiatry has to abandon those diseases - there is probably room for psychiatry to expand its scope and treat organic causes of psychiatric symptoms. My experience with psychiatrists is that they tend not to be interested in going down that route for cultural and self-selecting reasons, not because there's anyone telling them it can't be part of their scope of practice.

If you like mood disorders, more power to you. If you like personality disorders, I'm not sure you pass the Turing test.

 

[oldiebutgoodie1211]

Do experts agree on what portion of current psychiatry is really just undiscovered neurology?

Through history psychiatry has been more than willing to let go anything with a clear etiology.

That might help the undecided figure out where to go.

I read a paper somewhere saying that nowadays we have less schizophrenia Dx than before, this phenomenon having several explanations with one of them being the discovery of schizophrenia-like neurological diseases.

As someone with a big interest in psychosis if neurology was to absorb most psychosis cases (e.g. immune, mitochondrial, etc) that would definitely make me reconsider specialties.

If you truly enjoy depression, personality disorders, anxiety… then psych is your only choice.

neurology will absolutely not be absorbing psychosis in either of our lifetimes..psychosis is bread and butter psychiatry and it would take a paradigm shift for that to change

 

[Telamir]

Yeeeeah....they can keep it.

 

[michaelrack]

Psychiatry and neurology started off as one specialty, then split based on presumed etiology of the disorders (organic vs. Nonorganic). The split is now historic/customary and will likely not change even if major neuroscience advances are made

 

[Telamir]

See I don’t know about that. It’s been a while but during training I saw several misdiagnosed limbic encephalitides and one case of ADEM treated as primary psychiatric problems. I also remember asking an old friend of mine doing psych residency and he didn’t even know of them never mind checked. I think and hope that might change and some of our psychiatric colleagues feel empowered to think of these etiologies and work them up as needed.

 

[michaelrack]

See I don’t know about that. It’s been a while but during training I saw several misdiagnosed limbic encephalitides and one case of ADEM treated as primary psychiatric problems. I also remember asking an old friend of mine doing psych residency and he didn’t even know of them never mind checked. I think and hope that might change and some of our psychiatric colleagues feel empowered to think of these etiologies and work them up as needed.

A psychiatrist should always be suspicious of organic etiology, but beyond basic labs I am limited in what I can do other than send to the er ( from the for profit psychiatry hospital at which I work). If the situation isn't acute, outpatient neurological evaluation would be recommended by me, instead of sending to er. Other options may be available to psych doctors working in a general hospital system

 

[deleted966724]

I feel the same as you aspiringdoc09, I'm currently a Psych resident who was in doubt about choosing Neuro or Psych during medschool. I was not THAT into the PNS, and found some psych issues like psychosis cool, so went with psych. As time goes by, I find myself reading more on Neuro topics that overlap with psych (dementias, delirium, EPS from antipsychotics) and enjoying it much more than pure psych literature. The reason for me, at least, is that I feel that I trully KNOW something when I read neuro topics - there is clinical correlation, localization,anatomopathological findings, etc..in other words, I feel that if I read something about these conditions, I'll be a better doctor (e.g. alcoholic patient with suspected Wernicke-Korsakoff Syndrome in our unit, I did a neuro exam and found a horizontal nystagmus, and coupled with confusion and ataxia, the diagnosis was made in a very palpable manner)...I know that this is not always the case, generally there is more ambiguity...but even still, I found amazing that with my observational skills, a few tools and my own knowledge I was able to do the correct diagnosis. Now, in psych on the other hand, I find the subjectivity kinda off putting: you get collateral, the mental status exam does not lend itself very well to discrete conditions (you can see that someone is psychotic for instance, but not discerne if it is from substances, schizophrenia,etc...), and you arrive in a very open-ended diagnosis most of the time, one that not only significantly changes from provider to provider, but also between DSMs, and which is mostly settled if the treatment works or not...the skills that psychiatrists use seem to be much more in line of creating a strong doctor-patient relationship, being a systemic thinker (you also consider how the patient fits into a family, or a job, or even a society), and tolerance for ambiguity. Am I wrong? Should I read more psych literature before berating the area?

 

[oldiebutgoodie1211]

I feel the same as you aspiringdoc09, I'm currently a Psych resident who was in doubt about choosing Neuro or Psych during medschool. I was not THAT into the PNS, and found some psych issues like psychosis cool, so went with psych. As time goes by, I find myself reading more on Neuro topics that overlap with psych (dementias, delirium, EPS from antipsychotics) and enjoying it much more than pure psych literature. The reason for me, at least, is that I feel that I trully KNOW something when I read neuro topics - there is clinical correlation, localization,anatomopathological findings, etc..in other words, I feel that if I read something about these conditions, I'll be a better doctor (e.g. alcoholic patient with suspected Wernicke-Korsakoff Syndrome in our unit, I did a neuro exam and found a horizontal nystagmus, and coupled with confusion and ataxia, the diagnosis was made in a very palpable manner)...I know that this is not always the case, generally there is more ambiguity...but even still, I found amazing that with my observational skills, a few tools and my own knowledge I was able to do the correct diagnosis. Now, in psych on the other hand, I find the subjectivity kinda off putting: you get collateral, the mental status exam does not lend itself very well to discrete conditions (you can see that someone is psychotic for instance, but not discerne if it is from substances, schizophrenia,etc...), and you arrive in a very open-ended diagnosis most of the time, one that not only significantly changes from provider to provider, but also between DSMs, and which is mostly settled if the treatment works or not...the skills that psychiatrists use seem to be much more in line of creating a strong doctor-patient relationship, being a systemic thinker (you also consider how the patient fits into a family, or a job, or even a society), and tolerance for ambiguity. Am I wrong? Should I read more psych literature before berating the area?

you’re not wrong

 

[Peace of Mind]

the skills that psychiatrists use seem to be much more in line of creating a strong doctor-patient relationship, being a systemic thinker (you also consider how the patient fits into a family, or a job, or even a society), and tolerance for ambiguity.

This is something that bothers me greatly about the current state of the field (and is apparently also the foundation of most psychotherapy modalities).
How to justify so much training to be an expert of the placebo effect?
People spend too much time criticizing the somatic treatments in psychiatry and completely overlook this non small detail imo.

 

[Candidate2017]

I feel the same as you aspiringdoc09, I'm currently a Psych resident who was in doubt about choosing Neuro or Psych during medschool. I was not THAT into the PNS, and found some psych issues like psychosis cool, so went with psych. As time goes by, I find myself reading more on Neuro topics that overlap with psych (dementias, delirium, EPS from antipsychotics) and enjoying it much more than pure psych literature. The reason for me, at least, is that I feel that I trully KNOW something when I read neuro topics - there is clinical correlation, localization,anatomopathological findings, etc..in other words, I feel that if I read something about these conditions, I'll be a better doctor (e.g. alcoholic patient with suspected Wernicke-Korsakoff Syndrome in our unit, I did a neuro exam and found a horizontal nystagmus, and coupled with confusion and ataxia, the diagnosis was made in a very palpable manner)...I know that this is not always the case, generally there is more ambiguity...but even still, I found amazing that with my observational skills, a few tools and my own knowledge I was able to do the correct diagnosis. Now, in psych on the other hand, I find the subjectivity kinda off putting: you get collateral, the mental status exam does not lend itself very well to discrete conditions (you can see that someone is psychotic for instance, but not discerne if it is from substances, schizophrenia,etc...), and you arrive in a very open-ended diagnosis most of the time, one that not only significantly changes from provider to provider, but also between DSMs, and which is mostly settled if the treatment works or not...the skills that psychiatrists use seem to be much more in line of creating a strong doctor-patient relationship, being a systemic thinker (you also consider how the patient fits into a family, or a job, or even a society), and tolerance for ambiguity. Am I wrong? Should I read more psych literature before berating the area?

Psychiatric diagnoses are usually longitudinal and more appropriately made in an outpatient setting over many visits and months. The standard of care for someone requiring psychiatric hospitalization used to be taper them off their medications and see the nature of their disease unfold over 12 or more months. The variability you may see is probably due to the nature of hospital work and insurance -- gotta slap some kind of label on it to be able to bill.

 

[Candidate2017]

This is something that bothers me greatly about the current state of the field (and is apparently also the foundation of most psychotherapy modalities).
How to justify so much training to be an expert of the placebo effect?
People spend too much time criticizing the somatic treatments in psychiatry and completely overlook this non small detail imo.

Therapeutic alliance isn't placebo. Medications won't work if patients don't take them, usually due to distrust or awful side effects. It's a skill to get patients to abide your treatments.

 

[Peace of Mind]

Therapeutic alliance isn't placebo. Medications won't work if patients don't take them, usually due to distrust or awful side effects. It's a skill to get patients to abide your treatments.

I agree that a good alliance increases compliance to effective treatments and that psychiatrists need to further develop this skill because of the nature of their patients.

I`m mostly referring to the efficacy of psychotherapy and comments I often hear/read from mental health professionals (including MDs) stating that patients don`t need medical treatments they only need ‘’empathetic listeners’’ and that psychotherapy is where the real work is done by addressing ‘’root issues’’ (personally I find this last statement as pseudoscientific as the chemical imbalance stuff).

Studies show that the doctor-patient relationship is the biggest predictor of outcome with specific modalities/techniques being responsible for only 10-15% of the outcome. The fact that your theoretical approach has such a little effect truly screams placebo effect. Then there are other studies showing that more experience in the field of psychotherapy doesn`t translate to better outcomes and in the study experienced therapists got worse results than newbies.

I can’t really justify the need to train in multiple therapeutic modalities and for such a long time (4 years in the US and 5 here in Canada).

When my very conservative uncle who is a pastor in a very against psych meds church tells me about members of his congregation experiencing ‘’depression’’ should I tell him to see a secular psychotherapist or a religious counselor who shares his beliefs and with whom the alliance will probably be stronger from the start.

I`m of the idea that psychiatrists have erroneously defined their field as psychology + meds despite what the big associations (APA, NIMH, CPA) say about psychiatry returning to medicine thanks to clinical neuroscience. This meant kicking out all neuropsychiatric diseases once the etiology was found (e.g. AD and other dementias, anti-NMDA encephalitis, Tourette’s, etc) and keeping their behavioral psychology/medical DSM accessible to non medical practitioners.

I`m also interested in neuroscience research, I see very interesting stuff being done by psychiatrists on the neurobiology and immunology of mental disorders; I can`t help but wonder if these guys are just shooting themselves in the foot, who is going to diagnose and manage all these neuro/immune diseases? Definitely not psychiatrists if history repeats itself.

 

[liquidshadow22]

Psych training is def excessive especially now that NPs can basically do psychopharm tx which for the most part isn't very complicated and can be learned adequately in a year and a half.

 

[liquidshadow22]

I would include more neuropsychiatry training in psych residency. More dementia rotations, movement disorder rotations, epilepsy rotations, or at least create a track for it within the 4 yr residency

 

[deathmerchant]

I feel the same as you aspiringdoc09, I'm currently a Psych resident who was in doubt about choosing Neuro or Psych during medschool. I was not THAT into the PNS, and found some psych issues like psychosis cool, so went with psych. As time goes by, I find myself reading more on Neuro topics that overlap with psych (dementias, delirium, EPS from antipsychotics) and enjoying it much more than pure psych literature. The reason for me, at least, is that I feel that I trully KNOW something when I read neuro topics - there is clinical correlation, localization,anatomopathological findings, etc..in other words, I feel that if I read something about these conditions, I'll be a better doctor (e.g. alcoholic patient with suspected Wernicke-Korsakoff Syndrome in our unit, I did a neuro exam and found a horizontal nystagmus, and coupled with confusion and ataxia, the diagnosis was made in a very palpable manner)...I know that this is not always the case, generally there is more ambiguity...but even still, I found amazing that with my observational skills, a few tools and my own knowledge I was able to do the correct diagnosis. Now, in psych on the other hand, I find the subjectivity kinda off putting: you get collateral, the mental status exam does not lend itself very well to discrete conditions (you can see that someone is psychotic for instance, but not discerne if it is from substances, schizophrenia,etc...), and you arrive in a very open-ended diagnosis most of the time, one that not only significantly changes from provider to provider, but also between DSMs, and which is mostly settled if the treatment works or not...the skills that psychiatrists use seem to be much more in line of creating a strong doctor-patient relationship, being a systemic thinker (you also consider how the patient fits into a family, or a job, or even a society), and tolerance for ambiguity. Am I wrong? Should I read more psych literature before berating the area?

We definitely need good psychiatrists. One field which has an unmet need and is a good overlap is Functional disorders. Ask any neurologist, over 25% of patients we see inpatient or outpatient are completely or partially functional. And we always have difficulty finding Psychiatrists who want to see/manage these patients. I feel like this is a perfect field for people interested in Neuro and Psych. There also might be "currently unknown" organic pathologies or underlying mechanisms that need to be discovered by someone!

It requires tremendous Neurological expertise to diagnose and Psychiatric expertise to treat these patients.

 

[deleted966724]

We definitely need good psychiatrists. One field which has an unmet need and is a good overlap is Functional disorders. Ask any neurologist, over 25% of patients we see inpatient or outpatient are completely or partially functional. And we always have difficulty finding Psychiatrists who want to see/manage these patients. I feel like this is a perfect field for people interested in Neuro and Psych. There also might be "currently unknown" organic pathologies or underlying mechanisms that need to be discovered by someone!

It requires tremendous Neurological expertise to diagnose and Psychiatric expertise to treat these patients.

Yeah, was just thinking about it today actually, that people with super psychogenic headaches, functional disorders and such are left in the dust by neuro ("not organic, sorry") and psych ("well, you have 'epilepsy', you should talk to your neurologist")...thing is, my exposure to neuro is very VERY limited, and reading giant textbooks didn't really help me. See, if I were treat these patients, I should be able to at least tell when they are experiencing something more akin to 'true pathology' and when they are more in the line of a PNES ...how can I possibly acquire these skills that my residency does not emphasize?
On the same line, do you think psychiatrists can have a more active role in diagnosing and following up people with neurocognitive syndromes? From my neck in the woods, if we see someone with suspected dementia, they are usually shiped to Neuro for the work-up, and we just manage the behavioral consequences...of course, I know that managing expectations and giving non-pharmacological alternatives is very important, but I kinda feel like a toddler, in that I'm not encouraged to apply a MoCA, review neuroimaging and labs, and arrive at a semi-precise cause for the problem, being told instead to let neuro run the show. Don't know if it is something universal or institution-dependent...

Psychiatric diagnoses are usually longitudinal and more appropriately made in an outpatient setting over many visits and months. The standard of care for someone requiring psychiatric hospitalization used to be taper them off their medications and see the nature of their disease unfold over 12 or more months. The variability you may see is probably due to the nature of hospital work and insurance -- gotta slap some kind of label on it to be able to bill.

That's a very good point,, but without any physical evidence to back it up, even longitudinal follow up turns into a game of "let's throw medications until something sticks"and attending dependent opinions. I kinda understand the sentiment that in psychiatry treatment comes first and diagnosis comes second - if at all...I've seen people on the the psych forum complaining about the trifecta schizophrenia vs schizoaffective vs bipolar that has no real implications in the treatment, because you are treating the manifestations (psychosis, mania), independently from the DSM...again, I'm just a resident, and admit that I don't have enough longitudinal follow-up to back up these claims on my on, so I'm open to correction.

 

[deathmerchant]

Yeah, was just thinking about it today actually, that people with super psychogenic headaches, functional disorders and such are left in the dust by neuro ("not organic, sorry") and psych ("well, you have 'epilepsy', you should talk to your neurologist")...thing is, my exposure to neuro is very VERY limited, and reading giant textbooks didn't really help me. See, if I were treat these patients, I should be able to at least tell when they are experiencing something more akin to 'true pathology' and when they are more in the line of a PNES ...how can I possibly acquire these skills that my residency does not emphasize?
On the same line, do you think psychiatrists can have a more active role in diagnosing and following up people with neurocognitive syndromes? From my neck in the woods, if we see someone with suspected dementia, they are usually shiped to Neuro for the work-up, and we just manage the behavioral consequences...of course, I know that managing expectations and giving non-pharmacological alternatives is very important, but I kinda feel like a toddler, in that I'm not encouraged to apply a MoCA, review neuroimaging and labs, and arrive at a semi-precise cause for the problem, being told instead to let neuro run the show. Don't know if it is something universal or institution-dependent...

Yes it definitely is hard to diagnose Functional disorders, but I think it is doable and someone has to do it. Like you said everyone is trying to wash their hands off of it. I mentioned because you seemed interested in neurology and examination as a psychiatrist. Functional disorders is definitely fascinating!.
I agree dementia management can be done by a psychiatrist. I personally would be happy to let a good psychiatrist take care of neuro-degenerative dementia patients, esp if they are interested in it.

 

[aspiringdoc09]

Hi, I've return. I don't get on SDN like I use. I took a vacation since my post, which has helped. I am burnt out, but I will admit the state of my program isn't helping the way I feel about psychiatry or medicine in general. It really sucks. I don't want to talk bad about it but it has declined since my acceptance.

Anyway, I've read you all posts and really made me realize why I have a passion for both psychiatry and neurology in the first place. I plan to try and stick it with God's help. Fingers crossed. 🙂. My intention is to apply to a neuropsychiatry fellowship, which was always my 3rd backup plan. My second backup plan was to complete a neurology residency after my psychiatry training but I'm too burnt out and ready to do my OWN thing at this point. I hate the politics.

I agree with many of the sentiments by other posters. A lot of the Functional Disorders seem to get bounced between the two specialities and no one wants to take ownership of treating them. These disorders will be great territory for the behavioral neurologists/neuropsychiatrists. Also, @Wynand in program we're similarly told to just let the neurology staff work up patient's with neurological conditions and we will handle the behavioral issues. I will say that we can do MOCAs. I often will do neurological exams and MOCAs. I flex my neurological skills all the time because its my passion. My program is well aware of my interests in neuropsychiatry and I have a strong relationship with my neurology department. I've tried convincing them to allow me to do a combine program. No luck thus far.

 

[deleted966724]

Hi, I've return. I don't get on SDN like I use. I took a vacation since my post, which has helped. I am burnt out, but I will admit the state of my program isn't helping the way I feel about psychiatry or medicine in general. It really sucks. I don't want to talk bad about it but it has declined since my acceptance.

Anyway, I've read you all posts and really made me realize why I have a passion for both psychiatry and neurology in the first place. I plan to try and stick it with God's help. Fingers crossed. 🙂. My intention is to apply to a neuropsychiatry fellowship, which was always my 3rd backup plan. My second backup plan was to complete a neurology residency after my psychiatry training but I'm too burnt out and ready to do my OWN thing at this point. I hate the politics.

I agree with many of the sentiments by other posters. A lot of the Functional Disorders seem to get bounced between the two specialities and no one wants to take ownership of treating them. These disorders will be great territory for the behavioral neurologists/neuropsychiatrists. Also, @Wynand in program we're similarly told to just let the neurology staff work up patient's with neurological conditions and we will handle the behavioral issues. I will say that we can do MOCAs. I often will do neurological exams and MOCAs. I flex my neurological skills all the time because its my passion. My program is well aware of my interests in neuropsychiatry and I have a strong relationship with my neurology department. I've tried convincing them to allow me to do a combine program. No luck thus far.

Hey man, that's amazing that you are rediscovering your passion! I've been soul searching as well, and came to a similar conclusion about medicine in general: it's mostly " a bunch of bull**** I don't care about" as you said, particuarly intra-residency politics (which can be nasty sometimes), scutwork, billing, and the general lack of autonomy that goes along with academic residencies. The "grass is greener" phenomena pointed by Ibn Alfanis may be true - I can't tell if I'd be happier admitting stroke/seizure patients on a q3 schedule for years, dealing with the additional pressure of life and death situations during residency (which I find very hard and stressful to deal with, and one of the reasons I picked psych).

About the Neurology/Psych interface, I've seen recently on our unit a couple of patients with clear organic aetiologies that no one seemed to pick on, because no one bothered to do even a cursory physical exam, so there is some room for that, as well as handling on your own basic neurologic problems, such as uncomplicated headaches. I find you idea of Neuropsychiatry excellent, btw, and there is a need for someone who can integrate both fields, but I must warn you that from what I've gathered, it is an academic subspecialty, very hard to do in the form of private practice, so if you want bigger autonomy, you'll have to contend with that. I've thought about doing a dual residency as well, but it seems such a loooong time as a resident, and I don't have THAT much passion for conditions that do not affect the mind.

 

[aspiringdoc09]

Hey man, that's amazing that you are rediscovering your passion! I've been soul searching as well, and came to a similar conclusion about medicine in general: it's mostly " a bunch of bull**** I don't care about" as you said, particuarly intra-residency politics (which can be nasty sometimes), scutwork, billing, and the general lack of autonomy that goes along with academic residencies. The "grass is greener" phenomena pointed by Ibn Alfanis may be true - I can't tell if I'd be happier admitting stroke/seizure patients on a q3 schedule for years, dealing with the additional pressure of life and death situations during residency (which I find very hard and stressful to deal with, and one of the reasons I picked psych).

About the Neurology/Psych interface, I've seen recently on our unit a couple of patients with clear organic aetiologies that no one seemed to pick on, because no one bothered to do even a cursory physical exam, so there is some room for that, as well as handling on your own basic neurologic problems, such as uncomplicated headaches. I find you idea of Neuropsychiatry excellent, btw, and there is a need for someone who can integrate both fields, but I must warn you that from what I've gathered, it is an academic subspecialty, very hard to do in the form of private practice, so if you want bigger autonomy, you'll have to contend with that. I've thought about doing a dual residency as well, but it seems such a loooong time as a resident, and I don't have THAT much passion for conditions that do not affect the mind.

I know neuropsychiatry is very academic-based and originally that was the plan. Me, my geriatric population, and the big hospital. I've also been thinking about the military too. Air Force or Army to remove me from some of this administrative nonsense but even the military has its negatives. Whether the "grass is greener in neurology or not" Idk, but something will have to give sooner or later. At this rate, I'll probably be working part-time and vacationing a lot.

 

[liquidshadow22]

Dude stick with psych, you can't do private practice in neuro. Pp psych you can easily do $300+ per hour and work 30 hours a week. Can't do that in any neuro field. Your fascination with learning neuropsych will become secondary to earning a decent income and not breaking your back every day once you are done with training.

 

[romanticscience]

Open a PP specializing in functional neurological patients. Make bank being the only person around doing that.

Become the next Freud.

 

[Chibucks15]

Dude stick with psych, you can't do private practice in neuro. Pp psych you can easily do $300+ per hour and work 30 hours a week. Can't do that in any neuro field. Your fascination with learning neuropsych will become secondary to earning a decent income and not breaking your back every day once you are done with training.

In the middle of the country you definitely can do PP. I’m an M4 applying this year and many rotations are physician owned clinics with practice rights in nearby hospitals. Smaller cities though

 

[liquidshadow22]

In the middle of the country you definitely can do PP. I’m an M4 applying this year and many rotations are physician owned clinics with practice rights in nearby hospitals. Smaller cities though

Sure you can do it but it's much more of a headache and likely won't be as financially rewarding. This is a dying model in neurology and most medical fields, the private practices are getting swallowed up by hospital systems.
Most neuro patients are Medicare or medicaid, too much overhead to deal with in comparison to running a private psych practice which you can easily do without participating with Insurance.

 

[Thama]

Dude stick with psych, you can't do private practice in neuro. Pp psych you can easily do $300+ per hour and work 30 hours a week. Can't do that in any neuro field. Your fascination with learning neuropsych will become secondary to earning a decent income and not breaking your back every day once you are done with training.

Uh what?

I get between 5 and 10 job inquiries per week, mostly for PP for 2-3 times what I make in academics. Those aren't just rural south and Midwest, they're for metros in every region of the country.

My friends who recently interviewed for PP jobs in our largish metro all had their pick of 250-300k+ jobs, and many of those places were so desperate just to have an affiliated neurologist they would basically sign off on any halfway reasonable schedule.

PP psych is stuck either taking care of mild dysphoria in worried well white people and getting paid well to do what any half-decent PCP can do in 15 seconds with a fluoxetine script, or trying to hold back the bursting dam of axis 1 patients with untreatable social factors and never getting paid a cent.

 

[liquidshadow22]

Uh what?

I get between 5 and 10 job inquiries per week, mostly for PP for 2-3 times what I make in academics. Those aren't just rural south and Midwest, they're for metros in every region of the country.

My friends who recently interviewed for PP jobs in our largish metro all had their pick of 250-300k+ jobs, and many of those places were so desperate just to have an affiliated neurologist they would basically sign off on any halfway reasonable schedule.

PP psych is stuck either taking care of mild dysphoria in worried well white people and getting paid well to do what any half-decent PCP can do in 15 seconds with a fluoxetine script, or trying to hold back the bursting dam of axis 1 patients with untreatable social factors and never getting paid a cent.

Perhaps I should have kept my argument to independent single physician private practices, this I'm sure we could agree is nearing extinction for most medical fields including neurology.

Yea psych is bull**** but I would still bet it's still a better per hour paying gig in private practice than you will see in probably most neurology offices, of course there are outliers in any field. But most neuro patients arent young or high functioning and it won't be lucrative. They tend to be Medicare patients ie. Dementia, MS, neuromuscular etc. PP psych can make 300 to 400 per hour because they don't take insurance. So if you build a busy practice you are looking at 400k to 600k per year working 40 hours. Can you do that in outpatient neuro? My guess is epileptologists are the only subspecialists that might come close to this or beat this because of EEG. Maybe the MS guys do well because of the infusions? I don't see general neuro, movement, behavioral, sleep, headache etc being as efficient from a financial perspective.

 

[Thama]

Yea psych is bull**** but it's still a better per hour paying gig in private practice than you will see in probably most neurology offices, of course there are outliers in any field. But most neuro patients arent young or high functioning and it won't be lucrative. They tend to be Medicare patients ie. Dementia, MS, neuromuscular etc. PP psych can make 300 to 400 per hour because they don't take insurance. So if you build a busy practice you are looking at 400k to 600k per year working 40 hours. Can you do that in outpatient neuro? My guess is epileptologists are the only subspecialists that might come close to this or beat this because of EEG.

Many fields can pull in that kind of money once they abandon any pretense of actually being physicians.

MS can buy a scanner and infusion center and basically print money. Headache can give everyone botox for migrane and more recently can also jump aboard the for profit infusion center deal. Any neurologist can go straight for the out of pocket pseudoscience too, but instead of charging 300/hour for Freudian *******ery it's charging 5 figures for "stem cell" infusions or chronic Lyme cocktails or whatever.

Thing is, you can be a PP neurologist and keep your soul and practice medicine and make a decent living too. About half my patients are private insurance, the others are Medicare. Plenty of procedural options that pay pretty well.

 

[Telamir]

I work hard, I make a good living, and I have a very clear conscience. Can't ask for more, to be honest.

Also I've been hearing about the fabled "300-400/hour" cash pay of psych forever...I don't know how common that is, and I suspect it's not very.

 

[liquidshadow22]

I work hard, I make a good living, and I have a very clear conscience. Can't ask for more, to be honest.

Also I've been hearing about the fabled "300-400/hour" cash pay of psych forever...I don't know how common that is, and I suspect it's not very.

300 is very common. 400-600 per hour becomes less common as the wage increases but does exist.

 

[aspiringdoc09]

I'm unsure of salaries but I hear we do really well.