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Third Year Looking For Life Advice (FM vs Psych...)

LendMeYourDeers

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Hey there SDN. I posted a very similar... Essay, I suppose, on another forum, but as I try to formulate my thoughts, thinking about my place in the world, I thought it would be appropriate to ask here as well.

This is a long post, so I really do apologise, but if you have the time and will indulge me, I would love to hear your perspective.


I am a third year osteopathic medical student who hopes to focus his work in the realm of mental/social health – “narrative medicine” as I like to say. However, I am at a cross-roads at my current point, reflecting back on the experiences I have had thus far during my rotations. To this end, I am asking myself if my path is better served through the world of Psychiatry or the world of Family Medicine – to be a psychologically minded physician. I am hoping students, residents, and even attendings read this and reply.

Before medicine, I worked for two years in residential homes for youth with behavioural needs (ODD, Autsim-Asperger’s spectrum), as well as working in a drop-in centre for at-risk youth in our small town (youth that were homeless, from abusive homes, living couch to couch, engaging in substances, and quite a number of teen pregnancies). It was work I found deeply meaningful, and the role of “narrative medicine”, their psycho-social story, pushed me to want to work in this area professionally.

I came into medical school with the eye of Psychiatry, admittedly because I was originally on a Clinical Psychology train – but thought that with the ability to do both medications and therapy, the integration of both is stronger than the two fragmented. Admittedly, I had a very specific vision of what Psychiatry is, and it was through a psycho-therapeutic lens.

Thinking back to my rotations, my Psychiatry rotation (which was in a training program) was biologically minded. It was a month that tried to give me the breadth of Psychiatry – but by trying to do so much, it fell short. Most of my outpatient week was spent sitting in the conference room studying. Any time I got to sit in during an encounter, it was a medicine management visit. Inpatient was the most robust, and I was able to do intake on mainly addiction patients. However, the two to three day stabilise and send them to outpatient was something I did not resonate well with – I wanted to know the patient’s deeper, their narratives, but that was the job for outpatient. I had trans patient who I connected well with, she came in for substance abuse stabilisation following a “straw that broke the camel’s back” situation with her boyfriend, telling me her story of abuse and searching for her place in the world. But, for the in-patient team, we were here to stabilise, not get into the “weeds”.

These “narrative medicine” moments I think back to my time in the youth center I did encounter on my FM rotations. I remember I spent a month with a county health director in a rural area of the state. He had, what was labelled as, a “HTN f/u” visit. It was all but that. A mother who was in an emotionally abusive relationship, and the previous visits with this doc were all about psyching herself up to leave her husband and move in with her sons who also wanted her safe with them. Coincidentally, my preceptor sent me to spend a day with the a LCSW in the county health-system. I saw that patient again for a therapy appointment with them. It is these interactions that give me meaning. I saw similar moments of humanity when spent a month with an FM training program – a gay patient who is on insulin, but has not been taking it properly for a little while due to life stressors with dynamics between his family and his boyfriend; a youth patient from a low-socioeconomic environment whose entire visit was sexual education counselling; a young pregnant mother engaged in SUD.

It is the humanity of the patient that makes me what to focus on the work I wish to – addictions, psycho-social health. I want to be integrative.

People like to mention that “FM has a lot of Psych!”, yet they refer to the ability to start a medication. It is not the authority to prescribe an SSRI and follow STAR-D that pulls me into this work – it’s the integration of this person’s entire story. How is that medication relating to their psycho-socio-cultural context? Just as insulin isn’t going to “fix” a diabetic patient without them changing their lifestyle, an SSRI won’t “fix” depression unless we also address the context outside the clinic room. Yet, as many psychotherapy psychiatrists have spoken about and worry on, the modern training in Psychiatry is moving towards that medication management of the severe and acute, with therapy and psycho-social medicine being referred to the psychologist. This is actually something a mentor of mine said will frustrate me in Psychiatry training (she wants me in her camp of FM). Yet, it is Psych that offers the potential for that therapeutic skill-set? Unlike the UK or Canada, we don't encourage FM to learn therapy.

In terms of residents... I found myself meshing very well with FM residents, IM residents, and even my Surg residents (my surgery lead gave me a hug on my last day wishing me good luck on my future). I "vibed", for a lack of a better term. But when on Psych, I felt such a wall between me and the resident...

I suppose I am self doubting and wondering. I only had one month of Psychiatry, but two months of FM. With the virus crisis we are currently in, I am not sure if my outpatient Child and Adolescent rotation will still happen in July. I have a dream, that one say I, as a physician, can work and “staff” at a youth centre like the one I worked it. Drop-in counselling for these misunderstood kids. Sexual health, substance health, mental health screenings for those that don’t have doctor’s, or rather have had a difficult time finding that non judgemental person that they can trust.

I ask myself, if I was an attending physician tomorrow, and my patients were these kids – in what way would I best serve them? Advocate for them?

If you read this, I really do apperciate.

Thank you.
 
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Allosteopath

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I think that if you're looking for a person's story and continually following patients throughout their lifetime, you're looking at a career in FM. I've been under the impression that FM was kind of like the hub of a spoked wheel, and helped shepherd patients to what they needed - if they couldn't help do it themselves. I think there's also fellowship opportunities you could pursue in behavioral health/psych if you chose to go the FM route.
 
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hallowmann

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I would actually suggest the opposite. I'd recommend psychiatry. The truth is you won't have the time in FM to really address the things you want to address. You won't get those meaningful narrative medicine interactions with your 15 min visits. FM outpatient docs are seeing 20-25 pts a day. There simply is not enough time to do all the things you are hoping to do. In psychiatry, you have much more of an opportunity to do that.

I honestly think your views have been colored by non-representative examples of both fields. You had an opportunity to work with a great rural FM doc, who made sure to expose you to the holistic nature of family medicine and community medicine. That's awesome. I honestly had a similar experience on my FM rotation. While you could certainly find a job like that in FM, it is certainly not very common. Student health is actually another interesting area where you get some of that balance along with more time to spend with patients. That said, its not the way the majority of FM jobs are.

As for Psych, there really is a difference between inpatient and outpatient, and you didn't get a great outpatient experience. In psych, you are spending your time getting to know your patients. You see them consistently over time, and if you are so inclined (and any good psychiatrist should be) you should be understanding their social context and how it relates to their health and treatment options. You see fewer patients and spend more time with them. I also wouldn't say you got a great inpatient experience either, but inpatient is certainly more about managing the acute exacerbation, but good inpatient does much more than that.

I'm sure you could get what you want out of and have the focus you want in both fields, but in terms of being valued for doing that, you'll have an easier time with Psych. Based on your post and what you emphasized, in my opinion I think you'd be happier at a psych program with a slight therapy (slightly less biological) focus. Honestly, everything you described with the exception of maybe some aspects of sexual health, are pretty clear components of psychiatry (addiction/substances, mental health, etc.). Sure these are a part of FM too, but in the same way that every aspect of medicine is a part of FM.

Now that all said, if you truly like the medicine side (that's honestly not clear to me based on your post), there are interdisciplinary options out there, including combined FM-Psych programs, psych fellowships in primary care or C-L, primary care fellowships in behavioral health, etc. You may want to look into some of those to see if you're interested.
 
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Candidate2017

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To address some points:

Residential facilities for at-risk kids: child psychiatrists, like some of my attendings, do staff these places. They love it.

Inpatient psych: yes, it's acute stabilization, like any inpatient service. (Break leg? Ortho fix, 2 day inpt stay, DC to therapy, stay longer bad, get DVT or PNA, hospital/insurance get mad). Psych is no different, inpatients must move on and get to work with an outpatient therapist/psychiatrist (90% of psychs are outpatient). Therapeutic alliance is needed but it is unhealthy to make inpatients bare their psyche in long sessions only to be DC'ed shortly.

Med management: every Dr needs to know their meds. AEDs ,TCAs, other mood stabilizers, SGAs, BZDs etc can be very harmful/lethal. Students only get to see "med management" cases that look simple. But they likely started out complicated and took time to stabilize to where it seems like a simple refill visit. If you want to get exposure to therapy cases while a student, stop by your local psychoanalytic institute to listen to PhD psychologists and psychiatrists discuss cases.

Therapy: you can use as much or as little in-depth therapy for outpatients. Not all patients can tolerate full-on therapy but doing a tiny bit in a visit has good evidence on outcomes. Beware the talking/listening/counseling you see with SW is not therapy. Therapy involves hard uncomfortable work that requires boundaries and accountability that challenge patients to change. Most therapy is counterintuitive as it should be a bit stressful to patients, just like physical therapy.

FM vs psych residents: FM residents are friendly. They have to be to enjoy a specialty where seeing 25-30 patients a day is the norm to earn a living. Psych residents can be friendly but I do see "the wall" you mention in some psychiatrists. It's understandable because we have to engage in a lot of heavy stuff, in addition to dealing with sometimes difficult patients, saying "No" often, and pushing people.
 
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MusicDOc124

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I recommend psych for you.

Keep in mind, you saw very limited and specific ways of practicing. You worked with a doc or two in FM who tended to work in the manner you want to work. None of the FM providers I've worked with for instance worked in the way you described - at all. Very few psych cases or anything related to mental health or addiction. The few that were happened to be referred out or were there for regular medical stuff not the psych stuff.

You can practice how you want as an attending. If you want that focus and the whole story - then do therapy AND medical management. You will be THE ONE to go to. It is sometimes difficult for patients having a therapist separate from their med management. It's just that many psychiatrists want to do 1 or the other, and just happens to be more commonly med management. Also many might do both, but the maybe the med management visits are more frequent in their model of practice. You can also do consult-liaison if you want to mix medicine with psych, though that is still short term.

Your entire post to me screams psych, and it seems the only thing that left you questioning was your experience on two individual rotations, one in psych, and one in FM. Again, my experience was basically the opposite of yours regarding each of those.

Just make your eventual practice how you want it, and psych will give you more opportunity to pursue and actually do what it is you want to do.

One additional thing: you could also apply to the 5 programs that are FM-Psych. They are 5 years long, so only 1 year longer than psych alone and you get both and complete control. However, there are only 5 and they are competitive. Psych should be your focus IMO.
 
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hallowmann

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...One additional thing: you could also apply to the 5 programs that are FM-Psych. They are 5 years long, so only 1 year longer than psych alone and you get both and complete control. However, there are only 5 and they are competitive. Psych should be your focus IMO.

I agree with your post, only wanted to add that BU opened up an FMP program in 2018, so there are now 6, but yes more selective for fit due to there being only 12 spots.
 
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Drrrrrr. Celty

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I'm not entirely sure the above people necessarily go to Psychiatrists. An abused woman probably needs a social worker and a counselor. An gay man on insulin who is feeling down because of his family probably benefits from a LGBT supportive therapist and a good PCP.

I think one of the things I realized was that for a long time I wanted to be "the family psychiatrist". The guy who brings support to a group of individuals and helps them through tough times, the good listener, and the person that can offer the setting to get people through a tough time. But I'm not entirely sure Psychiatry is really that anymore as much as the place you send people who really aren't going to be better served by a combination of light medication, helpful support, and therapy.

I would say that given your case you probably should go into Psychiatry. However you should try to look into how you feel about severe mental disorder. And how you feel when you collide with the face of severe mental disorders that are not helped by you talking to them. Or how you feel when you talk to people with mental illness who seemingly do everything to remain in the severe conditions that sustain it. Likewise how you feel about having patients with medical issues and not being able to do much about them, ex. do you want to know and adjust insulins or prescribe ones that are easier to use or treat htn?

I can say that by my Jan of 4th year I couldn't handle the above. The amount of tragedy that these people went through and then seemingly went back into left me and my philosophical base absolutely destroyed. So now I'm more happy having my small census of pts with psychiatric illness that I handle with a combination of one or two medicines and some short combination of supportive therapy and motivational interviewing.
 
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LendMeYourDeers

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I think that if you're looking for a person's story and continually following patients throughout their lifetime, you're looking at a career in FM. I've been under the impression that FM was kind of like the hub of a spoked wheel, and helped shepherd patients to what they needed - if they couldn't help do it themselves. I think there's also fellowship opportunities you could pursue in behavioral health/psych if you chose to go the FM route.

Dear Allosteopath,

"The hub of a spoked wheel...", is a poetic way to describe FM. Thank you. This is an idea that I resonate with, and some FM residents I have spoken with say my story speaks to - albeit with the Psych focus.

I too believe there are Behavioural Fellowships, but it's hard to find how many - I only can ever consistently bring up the one from California.

Other posters have alluded to some of the realities of FM I may need to consider - residency and most of FM work as an attending, is limited in how much time you can spend with the person - 15 minutes is not good care for really any issue. We shouldn't be modelling ourselves as pizza shops.

A close FM resident to me, now IM, did make a good point - "do you want to be memorising pap schedules? Sending of colon screens? Following positive screens?".

It may be more of the general health in the teens that I am attracted to, mainly because those I worked with were often marginalised and lacked access in general.

Thank you for you words,

LMYD
 

LendMeYourDeers

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I would actually suggest the opposite. I'd recommend psychiatry. The truth is you won't have the time in FM to really address the things you want to address. You won't get those meaningful narrative medicine interactions with your 15 min visits. FM outpatient docs are seeing 20-25 pts a day. There simply is not enough time to do all the things you are hoping to do. In psychiatry, you have much more of an opportunity to do that....

Dear hallowmann,

A voice of wisdom on this forum I readily recognise, that I hope you recognise as well.

Your comments on the "reality" of FM are something I am aware of, and irk me. Even in general medicine, I feel 15 minutes isn't enough for connected care. Feeling rushed is difficult, and leaves a lot to be desired. This is something my FM mentor did mention to me, and why she is getting back into practice via the VA (who are willing to offer her more time per patient). In terms of the Psych training, that's something I understand is very variable in FM - some get none, some get a week, some have access to more but they never really jump at it... The mis-diagnosis, I've heard, is common.

An FM resident, now IM, that I know talked about how their residents tried hard to get Psych rotations but were denied (when they have an in-house Psych program....)

My experiences in FM may be more of the exception than the rule, I feel that may be true. It's something a friend of mine made mention of - you'll be working "for the man" for a long time before you can do the stuff you want to. And you're right about my experiences in Psych. I wrote about this in the APA Psychotherapy Caucus and they all the vast majority of Psych rotations are poor in that they only show the medicine. Some of them struggle with there the "therapy" will be in the future of Psych, and if instead the profession is turning towards "psychotropic internists" (their words).

It would be nice to do general health stuff as well, particularly in that population. I'd love to work with marginalised LGBT youth, who often have that fragmented, if any, care.

Hmm.

Best,

LMYD
 

LendMeYourDeers

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To address some points:.....

Hello Candidate2017,

Thank you for your perspective.

You comment on the residential facilities is heard, I feel that is the type of environment I will thrive in. To make those meaningful connections that go beyond a script pad. I hope my comment on medicine was not that I don't see the role - but rather the culture of medications being the only answer for every condition I don't agree with. I've spoken to some Psychotherapy practising (in some way shape or form) Psychiatrists that ask what is the difference between us an a "psychotropic" internist if that's all the are supposed to do.

The counselling vs therapy comment is interesting, I did not think about it that way. I wonder if, then, what I ever "therapy" saw with the "med management" visits was more counselling. Over the on the Psych forum, they say that "any good doc will incorporate psychotherapy in some way in a med management visit" - but you make me ask if they are doing counselling... Maybe that speaks to the larger trend of dwindling therapy training in Psych (I have even seen some Psychiatrists advocate that it be removed all together since they don't do it, and should focus more on the medical mimics of psychiatric illness).

As well, an interesting comment about the resident difference. I suppose I relate my experience to my peer who had this rotation prior to me. With how she made it sound, she was well connected with her residents. But, I am reading that through her, and not seeing it first hand.

Thank you,

LMYD
 

LendMeYourDeers

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I recommend psych for you.

Keep in mind, you saw very limited and specific ways of practicing. You worked with a doc or two in FM who tended to work in the manner you want to work. None of the FM providers I've worked with for instance worked in the way you described - at all. Very few psych cases or anything related to mental health or addiction. The few that were happened to be referred out or were there for regular medical stuff not the psych stuff.

Hello MusicDOc124,

Indeed, that is what some have said, particularly with the Psych rotation. In the email listserv I am in with Psychotherapy practising Psychiatrists (attending and residents), they talk about how the vast majority of medical school Psych rotations are poor and only show the pure medicine of Psych, never exposing the student to the "psychology" of Psychiatry.

Your comments on FM are also interesting, as this is the same experience shared by hallowmann. An FM resident had spun it another way to me:

"I think you have seen the side of FM/IM that many don't see in the ivory towers, in that you can really tailor your practice to what you want and really meet whatever community/population you want to serve where they are at."

But you are right, the modern trends of FM, in the corporate model, don't even let you do good FM. Referring out for the majority of anything seems to be a growing trend...

Your comment on the the "one or the other" is something I have heard some Psychiatrists find worrying the newer generation. I read a comment from an academic Psychiatrist attributing the increased competitiveness in Psychiatry due to the attraction of the Biological domain for most medical students. In their opinion, they wished programs would look for students who want to integrate the too - going back to the "what's makes us different from internist?" argument.

It really makes me thing. We lived in a town near a reservation, First Nations, so many of our kids were aboriginal - a population hit with substance abuse in youth and young suicides. As well, we had a lot of LGBTQ kids, and I always saw the gaps in their care from being marginalised by mainstream intuitions. It's those experience that make me believe that health is a totality, and I want to be part of that for a group of people whose care is often fragmented (and by doing so, we set them up for failure).

For example, I'd love to engage in Transgender Medicine, being a clinician for those who have great difficulty finding anyone they can trust.

It's funny. I spoke to a Psychiatrist who was a former Paediatrician in the 80s. He told me the things he saw the most damaging in kids were isolation and deprivation - things he said his generalist paediatrics training left him unequipped to handle, and the office model wouldn't even give him the time to try. He retrained into Psychiatry, taking a Family Systems approach to therapy.

FM/Psych is something I am considering. But, alas,egos and hubris of medicine love to place important on letters more than people.

Best,

LMYD
 

acapnial

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Drrrrrr. Celty

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Boy do I have the fellowship for you: LGBT Fellowship: LGBTQ Healthcare Fellowship Education - UCLA LGBTQ Health Initiative - Los Angeles, CA

You should also think about doing an addiction medicine fellowship, most of which take residents from both FM and psych. If my institution's fellowship is to be believed, they regularly deal with many of the populations you mentioned and care a great deal about integrating the patient's lifestyle and narrative into their treatment.

I think addiction medicine is low key a hidden gem.
 
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AMEHigh

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I don’t know the answer but even in 15-20 min visits in FM you certainly get to know patients pretty well. It’s all about balance. As one progresses in their career 20 min can be plenty of time to go "in depth" with patients. You learn about their jobs, their family, their hobbies, their habits, etc.

Especially the past couple months with telemedicine some patients really just do want to talk and really don’t need any medication. Simple guidance can go a long way or just a listening ear.

As far as psych and addiction stuff within FM, that’s definitely a possibility, especially in underserved areas (both urban and rural).

I think FM and psych both have a wide variety of settings one can practice in so you can help tailor your career how you want.

Med school certainly is tough as you don’t truly get the full picture of any specialty so you really do have to go with your gut.
 
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Drrrrrr. Celty

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I don’t know the answer but even in 15-20 min visits in FM you certainly get to know patients pretty well. It’s all about balance. As one progresses in their career 20 min can be plenty of time to go "in depth" with patients. You learn about their jobs, their family, their hobbies, their habits, etc.

Especially the past couple months with telemedicine some patients really just do want to talk and really don’t need any medication. Simple guidance can go a long way or just a listening ear.

As far as psych and addiction stuff within FM, that’s definitely a possibility, especially in underserved areas (both urban and rural).

I think FM and psych both have a wide variety of settings one can practice in so you can help tailor your career how you want.

Med school certainly is tough as you don’t truly get the full picture of any specialty so you really do have to go with your gut.

Some of the issue is how we expose people to the concept of a 15-20 minute follow up and or problem focused visit. There's a difference between 15 minutes for someone who you know well and has been excellently pre-screened by an MA and 15 minutes for a new patient ( i.e the COMLEX PE) or a 15 minute visit in a resident clinic.

In the former which is how any real clinic should be run the physician at least has some semblance of control and patients who actually follow up appropriately. In the latter two control is a fantastical notion that doesn't happen. I've seen the former work out great and my current experience with the latter two be rather draining and make me want to not do outpatient.
 
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whopper

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I was asked to respond to this thread. The "humanity" aspect in psych is nice but remember you're dealing mostly with pathology. The type of thing where you get to know your patients very deeply doesn't happen as much as many people might think in several avenues of psychiatry. The old days of the person sitting on the couch are long gone and very few psychiatrists do this these days and insurance doesn't want to reimburse for it.

Remember psychiatry simply isn't the "psych." It's about treating mental illness. That is a very limited portion of the human experience and included in the human experience is also someone's physical health.

In outpatient is where you get to know patients much better over the long term, and in that arena I've even dealt with treating physical health. This happens for several reasons, e.g. I can already tell what's physically wrong and just tell the patient I'll fix it, or the patient doesn't have a PCP, or cannot afford one, etc. I of course won't treat the physical stuff if I feel it's outside my expertise but HTN, a tooth abscess (I can at least offer Amoxicillin until they see a dentist), trigeminal neuralgia, prediabetes to non-insulin diabetes I've often times treated myself.

Unfortunately in many areas psych has been demoted to only seeing a patient for a few minutes, prescribing and seeing the next patient. This predisposes to bad treatment. This field requires in-depth investigation usually more so than other fields to come to a correct diagnosis.

I own my own practice and this gives me more freedom to control the strings and spend more time with patients. This allows me to get to know them better. If you work for an institution they'll likely have you seeing patients for a more limited time and your knowledge and understanding of the patient will be more limited.
 

BorntobeDO?

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Hey there SDN. I posted a very similar... Essay, I suppose, on another forum, but as I try to formulate my thoughts, thinking about my place in the world, I thought it would be appropriate to ask here as well.

This is a long post, so I really do apologise, but if you have the time and will indulge me, I would love to hear your perspective.


I am a third year osteopathic medical student who hopes to focus his work in the realm of mental/social health – “narrative medicine” as I like to say. However, I am at a cross-roads at my current point, reflecting back on the experiences I have had thus far during my rotations. To this end, I am asking myself if my path is better served through the world of Psychiatry or the world of Family Medicine – to be a psychologically minded physician. I am hoping students, residents, and even attendings read this and reply.

Before medicine, I worked for two years in residential homes for youth with behavioural needs (ODD, Autsim-Asperger’s spectrum), as well as working in a drop-in centre for at-risk youth in our small town (youth that were homeless, from abusive homes, living couch to couch, engaging in substances, and quite a number of teen pregnancies). It was work I found deeply meaningful, and the role of “narrative medicine”, their psycho-social story, pushed me to want to work in this area professionally.

I came into medical school with the eye of Psychiatry, admittedly because I was originally on a Clinical Psychology train – but thought that with the ability to do both medications and therapy, the integration of both is stronger than the two fragmented. Admittedly, I had a very specific vision of what Psychiatry is, and it was through a psycho-therapeutic lens.

Thinking back to my rotations, my Psychiatry rotation (which was in a training program) was biologically minded. It was a month that tried to give me the breadth of Psychiatry – but by trying to do so much, it fell short. Most of my outpatient week was spent sitting in the conference room studying. Any time I got to sit in during an encounter, it was a medicine management visit. Inpatient was the most robust, and I was able to do intake on mainly addiction patients. However, the two to three day stabilise and send them to outpatient was something I did not resonate well with – I wanted to know the patient’s deeper, their narratives, but that was the job for outpatient. I had trans patient who I connected well with, she came in for substance abuse stabilisation following a “straw that broke the camel’s back” situation with her boyfriend, telling me her story of abuse and searching for her place in the world. But, for the in-patient team, we were here to stabilise, not get into the “weeds”.

These “narrative medicine” moments I think back to my time in the youth center I did encounter on my FM rotations. I remember I spent a month with a county health director in a rural area of the state. He had, what was labelled as, a “HTN f/u” visit. It was all but that. A mother who was in an emotionally abusive relationship, and the previous visits with this doc were all about psyching herself up to leave her husband and move in with her sons who also wanted her safe with them. Coincidentally, my preceptor sent me to spend a day with the a LCSW in the county health-system. I saw that patient again for a therapy appointment with them. It is these interactions that give me meaning. I saw similar moments of humanity when spent a month with an FM training program – a gay patient who is on insulin, but has not been taking it properly for a little while due to life stressors with dynamics between his family and his boyfriend; a youth patient from a low-socioeconomic environment whose entire visit was sexual education counselling; a young pregnant mother engaged in SUD.

It is the humanity of the patient that makes me what to focus on the work I wish to – addictions, psycho-social health. I want to be integrative.

People like to mention that “FM has a lot of Psych!”, yet they refer to the ability to start a medication. It is not the authority to prescribe an SSRI and follow STAR-D that pulls me into this work – it’s the integration of this person’s entire story. How is that medication relating to their psycho-socio-cultural context? Just as insulin isn’t going to “fix” a diabetic patient without them changing their lifestyle, an SSRI won’t “fix” depression unless we also address the context outside the clinic room. Yet, as many psychotherapy psychiatrists have spoken about and worry on, the modern training in Psychiatry is moving towards that medication management of the severe and acute, with therapy and psycho-social medicine being referred to the psychologist. This is actually something a mentor of mine said will frustrate me in Psychiatry training (she wants me in her camp of FM). Yet, it is Psych that offers the potential for that therapeutic skill-set? Unlike the UK or Canada, we don't encourage FM to learn therapy.

In terms of residents... I found myself meshing very well with FM residents, IM residents, and even my Surg residents (my surgery lead gave me a hug on my last day wishing me good luck on my future). I "vibed", for a lack of a better term. But when on Psych, I felt such a wall between me and the resident...

I suppose I am self doubting and wondering. I only had one month of Psychiatry, but two months of FM. With the virus crisis we are currently in, I am not sure if my outpatient Child and Adolescent rotation will still happen in July. I have a dream, that one say I, as a physician, can work and “staff” at a youth centre like the one I worked it. Drop-in counselling for these misunderstood kids. Sexual health, substance health, mental health screenings for those that don’t have doctor’s, or rather have had a difficult time finding that non judgemental person that they can trust.

I ask myself, if I was an attending physician tomorrow, and my patients were these kids – in what way would I best serve them? Advocate for them?

If you read this, I really do apperciate.

Thank you.
Note too long, over verbose, inability to consoldate and prioritize. Lacks insight into tolerance of internet strangers to a wall of text that is long enough to secure our borders.

psych, definitely psych. FM will eat you alive.
 
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hallowmann

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I was asked to respond to this thread. The "humanity" aspect in psych is nice but remember you're dealing mostly with pathology. The type of thing where you get to know your patients very deeply doesn't happen as much as many people might think in several avenues of psychiatry. The old days of the person sitting on the couch are long gone and very few psychiatrists do this these days and insurance doesn't want to reimburse for it...

I think compared to any other field, psychiatry affords you more of an ability to do this than other fields. With enough continuity, you could theoretically get to know everything you wanted to know about patients in almost any field, but I don't think other fields both expect you to do so and set you up to do so quite like psychiatry. In psychiatry, I think learning the patient's story still is a central part of the role (despite some of the erosion you've alluded to).

Your post is definitely beneficial to giving insight to OP. Like lots of specialties, there's a lot of different environments and roles in which psychiatrists can work. When I read OP's post, I picture a position ideal for a psychiatrist, but that could also be served by an FM physician with a specific interest. I think OP would have an easier time being a psychiatrist with an interest in community/preventative medicine than an FM doc with an interest in administering psychotherapy.
 
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