epimudphuder

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I have been planning to pursue a Geriatric Fellowship for 7+ years now because I love working with older adults and enjoy the geriatric-specific settings (e.g., SNF’s, memory disorder clinics, geriatric psych units). Based on conversations I have had with my primary research advisor, however, I am having second thoughts. I am MD/PhD trained and hope to have a career that is 80% research, 20% clinical. The final two years of residency have been arranged to set aside 50% research time each year (I applied for the Loan Repayment Program, but did not get it and would like to re-apply). I am planning to submit a k-award application at the end of my residency training. My dilemma boils down to this: is a Geriatric Psych fellowship a worthwhile investment given my long-term, research-heavy goals?

Advantages for Geri Fellowship
- Credential may open doors (e.g., fellowship director, committees),
- May make me more sought after should my research career flounder
- Could make me more valuable to academic center
- Increase in clinical knowledge base

Disadvantages:
- Another year of training (I will have 12 years of post-undergraduate training at completion of residency!) and lost wages
- I have a lot of clinical and research exposure in geriatric settings and the fellowship training is likely to be moderately redundant with prior experiences
- I won’t be able to commit to 50% research time during a fellowship and therefore could not reapply for the loan repayment program
- It would delay my research and may affect the amount of time I have to invest in the k-award application/resubmission
- Doing research does not feel like work for me (I frequently do research on my own time) but my clinical experiences – while often enjoyable and interesting – still feel like work (I would never see patients in my free time!).
- Taking and spending money for a subspecialty test

An alternative that has been raised would be for me to have a post-doc/clinical faculty hybrid position that would set aside 50-60% time for research and would offer a much higher salary than a fellow would earn (this would serves a bridge position for when/if a k-application is awarded). I also potentially could be placed at clinical sites that are geripsych heavy.

Is a geri psych fellowship worth it? I am afraid that not obtaining this credential could hurt me if the research career does not work out, but I would have much more fun with the research/clinical hybrid position.

Thanks!
 

MamaPhD

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An alternative that has been raised would be for me to have a post-doc/clinical faculty hybrid position that would set aside 50-60% time for research and would offer a much higher salary than a fellow would earn (this would serves a bridge position for when/if a k-application is awarded). I also potentially could be placed at clinical sites that are geripsych heavy.
I don't know what the norms are for MD/PhD geriatric psychiatrists, but this alternative sounds much more in line with your career goals and sounds like a pretty sweet opportunity. You don't want to lose steam while trying to develop your research program.

Let's say your research career fails to launch; how hard would it be to get a clinical job if you had experience and contacts at these (as well as former) clinical sites? Would you still have the option of a geriatric fellowship if in a year or two your circumstances change?
 

Shikima

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I'd say go for it, it'll make you a better physician and you can moonlight while working. Be sure the fellowship is on board with 50% research, 50% clinical responsibilities. Future employers will jump at you and likely pay for any testing fees and CMEs.
 
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epimudphuder

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I'd say go for it, it'll make you a better physician and you can moonlight while working. Be sure the fellowship is on board with 50% research, 50% clinical responsibilities. Future employers will jump at you and likely pay for any testing fees and CMEs.
Unfortunately the 50%+ research position is NOT the fellowship but rather the alternative hybrid research post-doc/clinical position. The fellowship, while being accommodating, would probably top out at ~25%-33% research time (in clusters, not continuous throughout the year) and I think the clinical obligations would likely bleed into this research time (why write notes at night at home if they can done the next morning on a "research day"?). The only way I could see getting 50% research time in the geri-fellowship would be extending it to two years, something that could be okay with my goals but may be logistically difficult if a K-award comes in mid-fellowship (would be a good problem to have!). Also, the idea of extending clinical training two more years is a little fatiguing to think about. Thanks for your feedback - I appreciate it!
 
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epimudphuder

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I don't know what the norms are for MD/PhD geriatric psychiatrists, but this alternative sounds much more in line with your career goals and sounds like a pretty sweet opportunity. You don't want to lose steam while trying to develop your research program.

Let's say your research career fails to launch; how hard would it be to get a clinical job if you had experience and contacts at these (as well as former) clinical sites? Would you still have the option of a geriatric fellowship if in a year or two your circumstances change?
I don't think getting a clinical job will be difficult in my location especially since I am not in a part of the country that is saturated with psychiatrists (the community I am in has the problem that more psychiatrists are retiring then graduating). Also, I am part of "fly over country" so recruiting psychiatrists to my community is difficult (most come for family reasons). My concern/hesitation about not getting a geri fellowship has more to do with how lacking this credential could affect an academic career if research stalls (which it often does for those trying to make the transition from K to RO1)- not so much the clinical practice issues. You're probably right though that I could always get a fellowship later on... However, I recently read on prior SDN posts that 50% of those with initial certification in geripsych don't renew certification at 10 years... A lot to think on!
 

shan564

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I know a few people who have done the hybrid postdoc/clinical thing at my institution. All of them thought that it was a great idea - they feel like their training is recognized as being comparable to somebody who did a full fellowship. In most cases, those people take on clinical responsibilities that are in line with their research interests - in your case, that might involve opening a gero clinic (you wouldn't have any shortage of referrals, and they'd all have Medicare, so billing would be easy) or doing ECT.

Also, that hybrid position will make you better-suited to apply for a K-grant afterwards. I assume that the research in that position is funded by a T-grant? If so, you're following the NIH's expected trajectory of T --> K --> R.

As for the "pros" that you mentioned for doing a full fellowship:
Open doors to be a fellowship director, etc: That one is probably true
Make you more sought-after as a clinician: I'm not sure if this is as true as you think it is. From a clinical perspective, having a track record of demonstrated research/clinical experience in geropsych will probably be just as meaningful as having a fellowship.
More valuable to an academic center: This might be marginally true. But if you were to apply to my department (which is a well-respected academic institution with a particular interest in geropsych, an inpatient gero unit, a busy ECT service, a gero clinic, and several other gero-related facilities), your research experience and you stated clinical interest would probably be enough to get you a job here.
Increase in clinical knowledge base: Will a fellowship really give you more clinical experience than you'd get if you were an attending doing the same thing?
 
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epimudphuder

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I know a few people who have done the hybrid postdoc/clinical thing at my institution. All of them thought that it was a great idea - they feel like their training is recognized as being comparable to somebody who did a full fellowship. In most cases, those people take on clinical responsibilities that are in line with their research interests - in your case, that might involve opening a gero clinic (you wouldn't have any shortage of referrals, and they'd all have Medicare, so billing would be easy) or doing ECT.

Also, that hybrid position will make you better-suited to apply for a K-grant afterwards. I assume that the research in that position is funded by a T-grant? If so, you're following the NIH's expected trajectory of T --> K --> R.

As for the "pros" that you mentioned for doing a full fellowship:
Open doors to be a fellowship director, etc: That one is probably true
Make you more sought-after as a clinician: I'm not sure if this is as true as you think it is. From a clinical perspective, having a track record of demonstrated research/clinical experience in geropsych will probably be just as meaningful as having a fellowship.
More valuable to an academic center: This might be marginally true. But if you were to apply to my department (which is a well-respected academic institution with a particular interest in geropsych, an inpatient gero unit, a busy ECT service, a gero clinic, and several other gero-related facilities), your research experience and you stated clinical interest would probably be enough to get you a job here.
Increase in clinical knowledge base: Will a fellowship really give you more clinical experience than you'd get if you were an attending doing the same thing?
Make you more sought-after as a clinician: I'm not sure if this is as true as you think it is. From a clinical perspective, having a track record of demonstrated research/clinical experience in geropsych will probably be just as meaningful as having a fellowship.
Nice to hear this comment because my research is very geriatric psychiatry heavy and clinically focused (thank goodness Dr. Insel is moving on! Not exactly a champion of patient level/relevant research) and I am hopeful that it could make up for the lack of a formal fellowship.

Increase in clinical knowledge base: Will a fellowship really give you more clinical experience than you'd get if you were an attending doing the same thing?
- I probably would miss out on some nice mentored clinical experiences if I did not do a fellowship, but I am learning a lot since I started moonlighting and it seems that being a new attending in a geripsych setting would offer me plenty of time to learn on the job.

I will have to flush out the details of the hybrid position more to see how flexible it can be and where the research funding is coming from (I assume a training grant, but am not certain).

Thanks for the feedback shan564!
 

whopper

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Here's what I like about geripsych (I ran a geripsych unit despite that I didn't have fellowship training).

You got to know your IM.
Most geripsych patients are have some great stories to tell.
Less cluster B patients-by this time it's burned out or the cluster b person didn't make it old age but there are enough to not miss these patients.

Here's what I didn't like
Where I was at, and this is not unique, the consultants did not show up even during severe cases. I literally had to have some of my patients sent to the ER despite that I was in a university hospital because the consultants refused to show up and some of these cases were getting acute. Another thing I am proud of this is that almost all the cases I sent to the ER truly turned out to be acute and dangerous cases such as a guy with a spinal cord infection that was getting severe so each time the ER doc or consultant that had to show up to the ER immediately started bashing me without even looking into the case I always ended out on top and they looked like idiots-but they never apologized.
Despite my boast each ordeal was really stressful and I almost quit my job over these incidents a few times. A buddy of mine who was the IM doctor in charge of the medical care on our unit agreed with me each time that the consultant should've showed up and this was stressful on him too.

The way this was turning out this was a malpractice suit waiting to happen. The unit and I managed to figure out that these problems were happening on the order of every 3 weeks. We sent our complaints to the top of the department but kept getting the diplomatic/bureaucratic "we're looking into it" response because they couldn't give me the honest answer of "the administration's pissing us off over this too James, they keep blocking us despite that it's dangerous to the patients."

Some of the older patients are on their last legs in terms of years on this planet and I didn't feel right involuntarily committing some of them. When you involuntarily commit a guy in his 20s that you know you will most definitely get better that's one thing but to do this to an older guy and taking away what could be several weeks of his life while he's held against his will when he might literally have a few months left-that's where I had a problem.

Dementia patients-virtually all of them are just going to get worse. Felt helpless there.
 

michaelrack

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Some of the older patients are on their last legs in terms of years on this planet and I didn't feel right involuntarily committing some of them.
IN MS, you usually can't committ for a primary diagnosis of dementia (even dementia with psychosis). ON the other hand, the doc (or usually the family) can file for committment which gets you some extra time to treat the patient (under an order of retention) before the case is dismissed.
 

shan564

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IN MS, you usually can't committ for a primary diagnosis of dementia (even dementia with psychosis). ON the other hand, the doc (or usually the family) can file for committment which gets you some extra time to treat the patient (under an order of retention) before the case is dismissed.
If somebody is psychotic, can't you commit for psychosis NOS? I understand that it seems a bit sneaky, but you can't be 100% certain that they don't have some other cause of psychosis (highly unlikely, but possible - maybe there's a history of mania and depression that the family doesn't know about)...
Also, can't you say that the patient doesn't have capacity to decide to leave the hospital and admit to medicine with a psych consult?
 

sluox

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epimudphd, something weird is going on with your account, can't seem to start a "conversation" with you either.

don't want to post my personal email here, but I think I have info that could help you.