Torn PGY3 needing advice

[zenmedic]

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Hello all,

I’m looking for some perspective as I wrap up PGY3. I applied to Interventional Pain at the beginning of this cycle and have a solid number of interviews so far, but I find myself at a crossroads.

To be honest, a primary driver for applying (alongside my interest in MSK and procedures) is the desire to develop a skillset completely distinct from psychiatry. To be clear I love psych, but I have significant concerns about the future of the field, specifically regarding NPs and the potential impact of AI. While I realize pain management has its own set of headaches especially declining reimbursements and the nightmare of increased prior authorizations, it feels like a way to diversify and protect my clinical utility with only one additional year of training. You don't see hospitals allowing mid levels to perform spinal cord stimulations or complex injections in the same way they let NPs have equal practice rights to psychiatrists.

The main drawback is the opportunity cost. I’m tired of training and eager to finally start my life. I even have a great inpatient offer lined up for after graduation if I want it. I’m feeling torn between the long term security of a dual board certification with a procedural skillset vs the immediate appeal of entering the workforce.

Any thoughts or advice would be great.

 

[Cath Up]

Hello all,

I’m looking for some perspective as I wrap up PGY3. I applied to Interventional Pain at the beginning of this cycle and have a solid number of interviews so far, but I find myself at a crossroads.

To be honest, a primary driver for applying (alongside my interest in MSK and procedures) is the desire to develop a skillset completely distinct from psychiatry. To be clear I love psych, but I have significant concerns about the future of the field, specifically regarding NPs and the potential impact of AI. While I realize pain management has its own set of headaches especially declining reimbursements and the nightmare of increased prior authorizations, it feels like a way to diversify and protect my clinical utility with only one additional year of training. You don't see hospitals allowing mid levels to perform spinal cord stimulations or complex injections in the same way they let NPs have equal practice rights to psychiatrists.

The main drawback is the opportunity cost. I’m tired of training and eager to finally start my life. I even have a great inpatient offer lined up for after graduation if I want it. I’m feeling torn between the long term security of a dual board certification with a procedural skillset vs the immediate appeal of entering the workforce.

Any thoughts or advice would be great.

I am a PGY4.

You will have 12 years of post-high school training. My opinion is that doing a 13th year to future-proof your career could be better used both financially and practically towards that same end.

If you took even 1/4 of the time and effort expended in 1 fellowship year (conservatively say 500 hours) and pursued less common psych skills/jobs/arrangements or built relationships in those areas ( e.g. a certain type of therapy, SNF rounding, partial hospitalization attending, medical director stuff, job cobbling, remote call gigs, startup or corporate work, small private practice vacation coverage, licensure in multiple states, clinical expertise in a niche, etc) that would both protect you from encroachment and would contribute to financial goals which would further buffer from your concerns.

 

[comp1]

Pain and psych are only technically possible. I have never actually met anyone who did it. I tend to agree with the above poster. I vote take the inpatient job. If there is something NPs aren't doing now, they will be. There certainly is advanced pain training available for NPs and with just a year, they might end up with more experience than you specific to procedures given what psych residency is like. The good news is that there is plenty of mental health business for everyone.

 

[michaelrack]

I did something similar- a sleep medicine fellowship after a combined psychiatry/internal medicine residency. Sleep medicine provided a skill set that was mostly distinct from psychiatry. And I practiced mostly sleep medicine until 2015 (a little over 10 years); after that psychiatry became my primary practice specialty. Although I still do a little sleep medicine (read a few sleep studies and prescribe cpap); I could no longer get a competitive job in the field- there have been too many advances in the field such as vagal nerve stimulation and advanced ventilatory modes that I don't currently have a specialist level of knowledge of.
And the economics of sleep medicine have completely changed (but that's a long story for another time).

I guess my point is: do a pain medicine fellowship if you love the field and want to make it a significant part of your practice (75%+) after training. Otherwise you are going to lose your skillset in this field and after a few years away won't be able to be a competitive pain specialist anymore.

 

[Taddy Mason]

Pain and psych are only technically possible. I have never actually met anyone who did it.

Not so. I worked with a psychiatrist who did a combined IM/psych residency followed by a Pulm/critical care fellowship. For a number of years he did ICU work plus psych 2 days a week and then later settled into a practice where he did 50/50 outpatient Pulm and psych.

OP, I think doing the fellowship is worth it given your concerns with the job market, which are fair and valid. I say this as someone who has been in the job market for the past 3 months, is fellowship trained, and finally just secured a job albeit in the middle of nowhere in a state halfway across the country from where I’ve lived for the past 8 years and away from my where my 5 year old will be residing (going from 50% custody to just the summer and holidays……).

 

[hebel]

I suggest running this by the pain forum as well.

My concern is that with a pain fellowship you end up being more of a jack of all trades, but master of none. Your psych skills will atrophy. I would ask the pain forum how realistic it is for you to be a skilled interventional pain focused attending with the year fellowship coming from a base psych residency. Otherwise, the idea of doing non-interventional pain sounds pretty unpleasant (or painful 😂) and wouldn't be very future proof either.

 

[mistafab]

Half your post is driven by fear. Horrible way to live your life.

Just do what you feel would be most satisfying and let the chips fall where they may. You're setting yourself up for heavy regrets.

Hello all,

I’m looking for some perspective as I wrap up PGY3. I applied to Interventional Pain at the beginning of this cycle and have a solid number of interviews so far, but I find myself at a crossroads.

To be honest, a primary driver for applying (alongside my interest in MSK and procedures) is the desire to develop a skillset completely distinct from psychiatry. To be clear I love psych, but I have significant concerns about the future of the field, specifically regarding NPs and the potential impact of AI. While I realize pain management has its own set of headaches especially declining reimbursements and the nightmare of increased prior authorizations, it feels like a way to diversify and protect my clinical utility with only one additional year of training. You don't see hospitals allowing mid levels to perform spinal cord stimulations or complex injections in the same way they let NPs have equal practice rights to psychiatrists.

The main drawback is the opportunity cost. I’m tired of training and eager to finally start my life. I even have a great inpatient offer lined up for after graduation if I want it. I’m feeling torn between the long term security of a dual board certification with a procedural skillset vs the immediate appeal of entering the workforce.

Any thoughts or advice would be great.

 

[Stagg737]

I will add as an N=3 that I know a few psychiatrist who were also trained and practiced pain management. Common theme was that they all prescribed lots of opiates but ZERO of them did procedures and I don’t know any psychiatrists doing procedures in pain, even injections. I’m sure it’s probably possible, but too many anesthesiologists around here pain certified, so why let psych do procedures when so many procedural specialists are available?

As a side note, at our hospital the inpatient pain management team is 100% nurses and NPs. It’s literally the only service not overseen by physicians. It’s completely wild to me, but if mid-level encroachment is your fear, then pain isn’t going to protect you unless you’re actually doing interventional procedures.

 

[Sushirolls]

There are (sadly) CRNA only pain groups - and doing all procedures.
Not a buffer from midlevel encroachment.
Pain patients can be a headache. Psych patients can be a headache.
The pros/cons of each are mostly similar; not an escape hatch. Neither out shines the other in today's climate.
Pick the one you like better.

 

[randomdoc1]

As someone who is fire with zero fellowship training. Choosing training in hopes it will make things set for life is like putting a ton of money in 1 stock. Almost no one can predict the market. There will always be competition. I find it far higher yield to have market efficiency and financial literacy. Choose the training if you love it for its principles. These days generally degrees don’t really promise anything. It’s how we navigate the execution. If you are above the bell curve in market value, I argue there is definitely an audience for evidence based care, you cannot be outcompeted. It’s called market correction.

 

[splik]

The main drawback is the opportunity cost. I’m tired of training and eager to finally start my life. I even have a great inpatient offer lined up for after graduation if I want it. I’m feeling torn between the long term security of a dual board certification with a procedural skillset vs the immediate appeal of entering the workforce.

Any thoughts or advice would be great.

As a psychiatrist, BC in pain medicine does NOT provide any long-term security. The board certification is largely useless. What matter is your actual interventional pain skills and procedure logs and being up to date. Without that, you will become deskilled and won't be able to get credentialed by hospitals etc to do such work. In addition psychiatrists are more limited with what jobs they can get in interventional pain - it will be private practice, academics, the VA or working in the middle of nowhere. about half of pain trained psychiatrists are not doing pain, and a lot of the ones who are aren't focusing on interventional work. In employed settings, many places don't know what to do with a psychiatrist like this. Which department would they be under? That said there are definitely hospital systems that have psychiatrists doing interventional pain and if outside of academics usually in less desirable areas.

While psychiatry is a great background for pain medicine, it is the worst for interventional pain. The whole set up is anti-thetical to the psychiatry model. In addition, the evidence base for procedures for non-cancer chronic pain is largely weak, non-existent, or flat out negative. That puts it at risk of greater reimbursement declines if not non-reimbursement.

I would do the fellowship if you have a passion for working with pain and are interested in procedures. Consider doing a 2 year fellowship if you are serious about honing in your procedural skills. Most psychiatrists don't want to do procedures which is one of the reasons there are so few interventional pain psychiatrists. If you need to be using your hands or get satisfaction out of doing procedures, that is a good reason to do the fellowship.

Some pain psychiatrists pivot towards ketamine and are better placed to be offering IV ketamine infusions.

NPs aren't doing spinal stimulator implants, but they are doing nerve blocks, joint injections, steroid injections, botox etc.

I know people like to shìt on fellowships in this forum, but I do believe subspecialization (which can be achieved in other ways) does help to keep you competitive in the market.

 

[zenmedic]

Thanks for the replies everyone. All the input is making me feel I should withdraw my app, as I do really love psych. I enjoy pain too, but all things being equal I would pick psych, I'm just really worried about its future. But like many of you have said I can subspecialize further within psych, I'm just not sure what I would do. Just to clear some things up, I have a lot of interviews already from anesthesia based pain fellowships. So statistically I have matched into fellowship based on how many programs I can rank. When I was looking into pain as a pathway via psych, my understanding is that as long as a psych makes it through a reputable ACGME pain fellowship with adequate procedures numbers, they will be able to land a job where they perform all the interventional procedures they feel comfortable with. Some of the programs I am interviewing at have the fellows perform >800 epidurals per year for example. Similar to other fields like palliative, sleep, etc, which are accessible via many different residencies. When psychiatrists are discriminated against in the interventional pain job market is if the group requires anesthesia call or EMGs (would require PMR residency). I could be wrong about this though.

 

[splik]

Thanks for the replies everyone. All the input is making me feel I should withdraw my app, as I do really love psych. I enjoy pain too, but all things being equal I would pick psych, I'm just really worried about its future. But like many of you have said I can subspecialize further within psych, I'm just not sure what I would do. Just to clear some things up, I have a lot of interviews already from anesthesia based pain fellowships. So statistically I have matched into fellowship based on how many programs I can rank. When I was looking into pain as a pathway via psych, my understanding is that as long as a psych makes it through a reputable ACGME pain fellowship with adequate procedures numbers, they will be able to land a job where they perform all the interventional procedures they feel comfortable with. Some of the programs I am interviewing at have the fellows perform >800 epidurals per year for example. Similar to other fields like palliative, sleep, etc, which are accessible via many different residencies. When psychiatrists are discriminated against in the interventional pain job market is if the group requires anesthesia call or EMGs (would require PMR residency). I could be wrong about this though.

Yes you would be able to land a pain job, but the options will be more limited than for those coming from anesthesia or PM&R.
If you are able to match into a competitive pain fellowship, I don't think you need to be worrying so much about your future in psychiatry. It's the psychiatrists at the lower end of the spectrum that are most likely to struggle or be replaced by NPs.

you can also consider non-interventional pain psychiatry as a niche. A not insignificant part of my practice is working with chronic pain. My treatment focus is heavily on things like ACT, EEAT, hypnotherapy and patients with nociplastic pain. Not many people doing that. For some reason, I also get people coming to me for headaches/migraines which I evaluate and treat (including triptans, TCAs, SNRIs, memantine, propranolol, VPA, CBZ, candesartan, CGRP inhibitors, devices) but heavily focusing on who is your headache rather than technical interventions. I also provide complex case consultation to pain docs and PCPs on patients with pain and addiction, somatoform pain disorders, and factitious disorders as well as second opinion chart reviews on complex pain cases. There are a good number of pain psychologists but very few psychologically informed psychiatrists working in this space and people will pay for it.

Perhaps I am being naive, but I believe the core skills of a good psychiatrist is being able to formulate a case from multiple perspectives, understand and navigate systemic factors, and addres medico-legal and ethical dimensions of care in addition the biological, psychological, social, cultural and spiritual. If you can do that well and convince others of the value, then you won't be competing with NPs or anything else. I know things could change at any point, but right now I have more work than I could want.

 

[zenmedic]

Yes you would be able to land a pain job, but the options will be more limited than for those coming from anesthesia or PM&R.
If you are able to match into a competitive pain fellowship, I don't think you need to be worrying so much about your future in psychiatry. It's the psychiatrists at the lower end of the spectrum that are most likely to struggle or be replaced by NPs.

you can also consider non-interventional pain psychiatry as a niche. A not insignificant part of my practice is working with chronic pain. My treatment focus is heavily on things like ACT, EEAT, hypnotherapy and patients with nociplastic pain. Not many people doing that. For some reason, I also get people coming to me for headaches/migraines which I evaluate and treat (including triptans, TCAs, SNRIs, memantine, propranolol, VPA, CBZ, candesartan, CGRP inhibitors, devices) but heavily focusing on who is your headache rather than technical interventions. I also provide complex case consultation to pain docs and PCPs on patients with pain and addiction, somatoform pain disorders, and factitious disorders as well as second opinion chart reviews on complex pain cases. There are a good number of pain psychologists but very few psychologically informed psychiatrists working in this space and people will pay for it.

Perhaps I am being naive, but I believe the core skills of a good psychiatrist is being able to formulate a case from multiple perspectives, understand and navigate systemic factors, and addres medico-legal and ethical dimensions of care in addition the biological, psychological, social, cultural and spiritual. If you can do that well and convince others of the value, then you won't be competing with NPs or anything else. I know things could change at any point, but right now I have more work than I could want.

How did you get that training in headache medicine? And then how were you able to market your skills to other physicians who were seeking a pain consultation? That sounds like a great setup. I've heard neurologists and interventional pain specializing in headache but not general psychiatrists.

 

[comp1]

Yes you could get a job at the VA doing outpatient pain medicine after the fellowship, but I do think it is very notable that two of the posters above described the psychiatrists they knew who did a pain fellowship as...also internists.

 

[Stagg737]

How did you get that training in headache medicine? And then how were you able to market your skills to other physicians who were seeking a pain consultation? That sounds like a great setup. I've heard neurologists and interventional pain specializing in headache but not general psychiatrists.

You can do a fellowships specifically in headache medicine:

Headache Medicine Fellowships

Find AHS-recognized headache fellowship programs that offer specialized clinical training, research experience, and mentorship.

americanheadachesociety.org

Personally, I got enough training specifically with management of headaches in my general psych residency which included rotations in our pain clinic to feel very comfortable managing them. I prescribe all the things Splik mentioned above other than CGRP inhibitors and devices. Psychotherapy for pain can also be very helpful as mentioned, though I’ve most frequently incorporated eclectic CBT (mostly with ACT) into management with these patients.