Switching from psych to psych/fp or psych/im?

[cheerfully]

I'm currently a PGY-1 in a psychiatry residency program. I love the PD, psych attendings and other psych residents. However, I've come to the realization that I would be much happier in either a combined FP/Psych residency or IM/Psych residency.

Since the specialties are so similar, do I have to reapply via ERAS or could I email the program directors assistants? Are the combined psych residency programs really competitive? Also, I'd really rather not mention this to my PD at this point, is it necessary to do so?

Any advice would be much appreciated.

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[digitlnoize]

As a student applying to psych, would you care to detail why? What is it that draws you to the combined programs?

It may not matter, but have you considered C-L?

 

[billypilgrim37]

The chance of this working out is very low except possibly if you reapplied as a pgy1 next year. There are only a handful of these programs and they generally fill every year. Most of them do not have flexibility to just make a new spot. As PDs are already suspicious of folks interested in extra-boards' motivation, you better have an extremely good reason for the switch. You should talk to your current PD sooner than later if you are serious about this.

 

[cheerfully]

As a student applying to psych, would you care to detail why? What is it that draws you to the combined programs?

It may not matter, but have you considered C-L?

I did really like my C/L rotations as a student, however, the aspect I like most about either primary care or psych is the long-term relationship that I could build with a patient in an outpatient setting and you just don't get that in C/L.
I think that as a student, I enjoyed my psych rotations more than any other and decided early on that I wanted to do psych and maybe didn't keep as much of an open mind to other possibilities as I should have. Additionally, as a student, I really found FP and IM to be pretty overwhelming due to the broad scope. However, late last year and during the first part of my PGY-1 year, I think I've developed more confidence so that FP and IM don't seem so overwhelming.
I like the idea of a combined residency and combined practice for a few reasons-
1.There are many people who present to their PCP with psychiatric illnesses who absolutely wouldn't go to a psychiatrist and I'd like to be able to successfully treat those patients. Also, a lot of patients with early dementia see their PCPs, not a psychiatrist and I'd like to be able to diagnose them and manage them for not only the AD meds, but also any behavioral meds they may need.
2. I like the variety of primary care, but I also like psych quite a bit and I would like the opportunity to do some inpatient psych and treat the more complicated psych patients
3.I think that sometimes, patients with psychiatric illnesses don't really get the attention from their PCPs that they deserve or need, ie sometimes things get blown off as being due to anxiety, depression, etc.
4.I want to do psychotherapy, but I'd also like to remove a mole every now and then too.
I guess this is just a case of wanting to have my cake and eat it too. I understand that PCPs can't be experts in every field and it's often necessary for them to refer patients to specialists and I wouldn't mind referring patients to cardiology or other specialties, but I just really like psych so much that I'd prefer to treat those patients without referring them.

The chance of this working out is very low except possibly if you reapplied as a pgy1 next year. There are only a handful of these programs and they generally fill every year. Most of them do not have flexibility to just make a new spot. As PDs are already suspicious of folks interested in extra-boards' motivation, you better have an extremely good reason for the switch. You should talk to your current PD sooner than later if you are serious about this.

Like tell my current PD now? I really don't want to irritate her or even lose my current spot, especially considering the fact that I might not even get a single interview in a combined program. I wouldn't mind restarting as a PGY1 at all.

 

[billypilgrim37]

Like tell my current PD now? I really don't want to irritate her or even lose my current spot, especially considering the fact that I might not even get a single interview in a combined program. I wouldn't mind restarting as a PGY1 at all.

You won't get a single interview in a combined program without your current PD knowing.

 

[atsai3]

Like tell my current PD now? I really don't want to irritate her or even lose my current spot, especially considering the fact that I might not even get a single interview in a combined program. I wouldn't mind restarting as a PGY1 at all.

Now may be a little too early, but you will definitely need to inform your program director before you have a guaranteed spot at another program. There is no way around it. In order to swing from tree to tree, you have to let go of one branch before grabbing on to the next one.

Transfer process discussed in detail in previous threads here and here.

 

[cheerfully]

Thanks for the advice. It's not like I want to leave my PD in a bad position or anything, but I also wouldn't want to lose my current spot if I couldn't at least get an interview in one of the combined programs. Complicating issues even more is that we don't get any vacation time at all until February, so I'd actually have to call in sick to interview.

 

[BobA]

I don't think you would lose your spot if you told your PD you were considering leaving, but hadn't made up your mind yet. Especially if you're good at your current program.

And from my limited understanding, you'd need a letter from your current PD to even be considered at another program, right? I mean, the other program would want to make sure you're currently in good standing.

 

[atsai3]

At a minimum you need a letter of good standing ("bob has completed all requirements to date and no disciplinary actions are pending"

but it would be nice if you could get a LOR ("we're sorry to see bob go. He will be an asset to your program"

Either way you need to let your PD know.

Aside from what is logistically required, giving your PD a heads up is a good thing to do because it allows your PD to begin looking for a replacement (otherwise your co residents will be picking up the slack

When you have the first convo, nothing has to be definite (,im thinking about looking around for a transfer opening... if I applied would you support it? I wanted to give you enough of a heads up so that you have enough time to recruit a replacement"

 

[cheerfully]

Thank you so much for the advice. I would feel much more comfortable securing a primary care/psych spot first (or at least an interview for a spot) and then discussing it with the PD, but that's not an option.

I'll ask my PD when I can meet to discuss this.
Thanks again

 

[cleareyedguy]

You may like the combined residency, but will you use it for the next few decades?

If the main issue is wanting to have an extended outpatient relationship, you can likely find a CL type job with significant outpatient responsibilities. This could be within a clinic (HIV or cancer, for example) or within a private practice that you would do in addition to the CL work.

I say this because for most people who double board in fairly disparate specialties, they end up doing FP or medicine or psych or neuro, they DON'T end up doing some self-created amalgam.

 

[michaelrack]

I say this because for most people who double board in fairly disparate specialties, they end up doing FP or medicine or psych or neuro, they DON'T end up doing some self-created amalgam.

agree, although I think the self-created amalgam is a little more common among FP-psych than IM-psych

 

[billypilgrim37]

agree, although I think the self-created amalgam is a little more common among FP-psych than IM-psych

As is ADHD.

 

[cheerfully]

You may like the combined residency, but will you use it for the next few decades?

If the main issue is wanting to have an extended outpatient relationship, you can likely find a CL type job with significant outpatient responsibilities. This could be within a clinic (HIV or cancer, for example) or within a private practice that you would do in addition to the CL work.

I say this because for most people who double board in fairly disparate specialties, they end up doing FP or medicine or psych or neuro, they DON'T end up doing some self-created amalgam.

I really do think I would use it for all of my career and maybe I am a little ADHD, I do like variety. Worst case scenario if I did get a spot in a combined psych residency is that I would pick one or the other and really, it wouldn't be a bad thing to be a PCP who really knows psych well.

Even if I did find a job in a cancer clinic for example, the heme/oncs would be the ones handling all of the medical issues, no?

 

[SpiritiualDuck]

it wouldn't be a bad thing to be a PCP who really knows psych well.

I have worked with folks that have completed combined programs and if your goal is to know either specialty really well, you won't. The best folks are the ones that do one or the other.

 

[peppy]

agree, although I think the self-created amalgam is a little more common among FP-psych than IM-psych

Since I know you have firsthand experience, do you have any thoughts about what kind of goals would make a combined program a good idea vs. straight psych?
(Not that I am looking to switch myself, just curious since it seems it's pretty common for students with an interest in psych to consider the combined path).

 

[notdeadyet]

For those who came to medical school without the intention of winding up in psychiatry, I'd guess about 80% or so go through a period where they consider a combined residency program. I think it's just part of the decision process for many before they bite the bullet and sign on for psychiatry.

I considered it for a long time before I realized that combined residencies end up equaling less training in both psychiatry and FP/IM than a psychiatrist or primary care provider receive. I also realized that it didn't make a lot of sense unless I pictured going into academics at a program that had combined residencies. The image I had of working somewhere remote and having both a primary care and psychiatry practice just wasn't realistic.

Lastly, if you're going to be a psychiatrist in a medical setting, you're going to be a psychiatrist. Medical knowledge and familiarity will no doubt help you, but maintaining that medical knowledge is do-able without a second board certification. It requires reading and practice. And if you aren't willing to do that as a psychiatrist, you likely wouldn't be doing that being double boarded either, so it seemed pretty moot.

I'm sure combined residencies are fantastic things for a very, very small subset of people, but that number is probably in the dozens nationally. There's a reason there aren't more slots.

 

[WannaSwitchBack]

I would have to chime in with others and point out that it is very hard to end up knowing psych "really well" if you do a combined program. Not saying it can't be done, however as you go further down the psych residency path, you will perhaps understand more of what I am saying. Just in the world or psychiatry, there are so many options when it comes to where you want to focus (as evidenced by my original post and user name) that choosing what you want to do, and do exceptionally well, can be hard. For example, you have stated that you want to be able to do psychotherapy combined with the occasional procedure. I have to tell you that you would really need to be a resident a long, long time to pull that one off, bc the combined programs don't offer as much opportunity for that.

My program, for example, has a very strong training when it comes to therapy. I have inherited many patients from residents who came here to do fellowships, after completing their general training, and seen firsthand how they were not as skilled in in their therapy skills as those of us who trained here are. They have passed off many patients to me and missed a lot of opportunities, for example, to hold boundaries with the cluster B's. It's not that the residents are not as bright, they just missed the personality pathology bc they were not as trained. I could give more examples but I think that should suffice. Further, because my program focuses so much on therapy, we often miss out on some of the more advanced psychoharmacology that is being taught at other institutions. There are a handful of attendings that we seek out here for their psychoharm skills. Everybody past the pgy2 level has figured this out. Not that the average attending here won't do, it's just that well, some are much better than others. This is all in a four year program for general psych. So.... finding a program where you can learn either IM or FP plus general psych plus therapy, is doubtful. You can certainly learn to become a jack of all trades, and they are needed, but be prepared to refer out a lot. Be prepared to do that if you switch.

That said, the idea of CL plus outpatient is really an excellent one if you want some medicine plus psych. I would really recommend that. Also, it's important to consider that what you think you want to do now may not be what you want to do in a couple of years. That is part of the average residents' maturation through the residency process. I would really give it a lot of thought before you end up doing something that you mighty regret later. Good luck with your decision.

 

[michaelrack]

Since I know you have firsthand experience, do you have any thoughts about what kind of goals would make a combined program a good idea vs. straight psych?
(Not that I am looking to switch myself, just curious since it seems it's pretty common for students with an interest in psych to consider the combined path).

It is useful if you want to go into academics- obviously if you want to be an academic at a place with a combined program, but also if you want to be an academic at a place with traditional programs. For example, at a residency without a combined program, someone who is dually trained in IM/psych could practice primarily in the dept of psych but also train primary care residents in psychiatry. When I was an academic attending, I practiced mainly psych but also supervised IM residents in outpt clinic 1/2 day a week as a general IM attending while also giving them lectures in psych topics.

 

[michaelrack]

That said, the idea of CL plus outpatient is really an excellent one if you want some medicine plus psych..

The psychosomatic boards is what killed IM/PSYCH. When psychosomatics became official, the popularity of IM/psych declined.

 

[cheerfully]

Thanks for all of the input. I know of two PCPs in practice together who are also specialist in addiction medicine. They see patients in their office for primary care complaints and they take turns rounding for consults and for inpatients in the chemical dependency unit. I guess I really wanted something similar- mornings for inpatient psych and a few outpatient psychotherapy sessions and afternoons in a completely different office for regular primary care complaints including anyone who had depression/anxiety, but also sore throats, htn, dm, etc.

I really really love psychiatry, but I just can't help feeling like I would really miss primary care types of complaints.

 

[michaelrack]

I really really love psychiatry, but I just can't help feeling like I would really miss primary care types of complaints.

either 1. do a combined residency and go into academics

or

2. do fp/psych and join a large primary care group, and make it known to the group that you would be willing to see any of their pts with psych issues in addition to seeing the standard primary care pts.

 

[atsai3]

2. do fp/psych and join a large primary care group, and make it known to the group that you would be willing to see any of their pts with psych issues in addition to seeing the standard primary care pts.

If that sort of thing really gets cheerfully up out of bed in the mornings, that might not be a bad way to go. But it would be an awfully severe tax on your productivity: not only would you get patients with psych issues, but you would also quickly start collecting all of the "difficult" patients, needy patients, etc -- anyone who requires more than a 5-10 minute primary care appointment. Only you wouldn't get extra time to manage them.