Undecided about CAP

[zenmedic]

Hey everyone,

I need some advice on applying to CAP or not. I'm a PGY2 on my CAP rotation right now and really enjoying it. However, I wouldn't say I have a preference of child over adult, I enjoy them both a lot equally. I could see myself being happy practicing adult only, child only, or a mix. In my mind the main benefit of not doing the fellowship would be to stop putting my personal life on hold (prolonging my training does admittedly make me a little nauseous) and avoid the opportunity cost of 1 lost year of attending income. On the flipside, the pros of doing the fellowship would be so that I can be a true generalist, have more doors/options open for the rest of my career, and possibly going to a program with good moonlighting to offset the opportunity cost. It's tough though, because in terms of my day to day happiness I really do enjoy both fields the same.

Have any of you been faced with this decision? Any advice you all have for me would be great. Most of my attendings who I spoke with were in the black and white boat of, I couldn't stand working with kids (or adults), and decided accordingly.

Thanks!

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[TexasPhysician]

I’m probably in the boat where I don’t particularly love seeing only kids or only adults. I like the mix. It helps to keep the day fresh. Too many adults trying to manipulate my prescribing is agitating. Too many parents arguing over care plans is depressing. Together they make life enjoyable for me.

I didn’t find CAP fellowship to be strenuous. Regular moonlighting and you could earn more than your faculty.

The big difference is general PGY-4’s appeared to be leisurely watching movies at 10am while I was learning CAP. The extra year wasn’t an issue as I was moonlighting to earn what gen psych faculty were paid. It was a little extra work, but nothing close to intern year.

 

[zenmedic]

I’m probably in the boat where I don’t particularly love seeing only kids or only adults. I like the mix. It helps to keep the day fresh. Too many adults trying to manipulate my prescribing is agitating. Too many parents arguing over care plans is depressing. Together they make life enjoyable for me.

I didn’t find CAP fellowship to be strenuous. Regular moonlighting and you could earn more than your faculty.

The big difference is general PGY-4’s appeared to be leisurely watching movies at 10am while I was learning CAP. The extra year wasn’t an issue as I was moonlighting to earn what gen psych faculty were paid. It was a little extra work, but nothing close to intern year.

Thanks for your response! The fellowship does seem like a no brainer if I were to do it this way.

 

[Stagg737]

Do you want to regularly work with people under the age of 14? If the answer is yes, then go for the fellowship. If the answer is no, then don't. It's really as simple as that. The hard part for most I think is figuring that question out.

 

[Sushirolls]

What @Stagg737 said. So if you are okay with seeing young kids, do it. Leaves open doing private practice cash pay, and for CAP, that is an amazing fall back if you get chewed up by Big Box shop jobs.

 

[Merovinge]

I made $150k my pgy5 year with moonlighting modestly (I kept a very healthy social schedule that I was not willing to sacrifice). I started at 300k my first year as an attending so it was like 1/2 a year pay cut. I also banked all my vacation pgy5 year so I started working 1 month early at my attending job and got dual paid by fellowship and my first job.

I actually disagree with Stagg on the topic above. I feel my ability to take care of adolescents is markedly different than the adult psychiatrists I know. Seeing childhood onsets of bipolar disorder (for example) is just completely different from having 6 months of an academic mood disorders clinic in CAP than anything an adult psychiatrist would sniff. There also tends to be a huge difference in understanding of ADHD from my experience (basically every fellowship will have an ADHD specialist/ADHD clinic). I would say if you want to spend a meaningful part of your practice taking care of kids or adolescents and don't mind having a harder PGY4 year (aka you like learning new things), I would lean towards CAP.

 

[zenmedic]

I made $150k my pgy5 year with moonlighting modestly (I kept a very healthy social schedule that I was not willing to sacrifice). I started at 300k my first year as an attending so it was like 1/2 a year pay cut. I also banked all my vacation pgy5 year so I started working 1 month early at my attending job and got dual paid by fellowship and my first job.

I actually disagree with Stagg on the topic above. I feel my ability to take care of adolescents is markedly different than the adult psychiatrists I know. Seeing childhood onsets of bipolar disorder (for example) is just completely different from having 6 months of an academic mood disorders clinic in CAP than anything an adult psychiatrist would sniff. There also tends to be a huge difference in understanding of ADHD from my experience (basically every fellowship will have an ADHD specialist/ADHD clinic). I would say if you want to spend a meaningful part of your practice taking care of kids or adolescents and don't mind having a harder PGY4 year (aka you like learning new things), I would lean towards CAP.

I definitely like the idea of being productive my fourth year. At my program the fourth years are sitting around doing electives all year where they're done by 11AM, I would rather use that time towards additional training and certification in something I like. Would you say the fellowship is worth it even if you only want to see preteens and up? Not saying I don't want to see children, just curious what your thoughts are.

 

[Merovinge]

I definitely like the idea of being productive my fourth year. At my program the fourth years are sitting around doing electives all year where they're done by 11AM, I would rather use that time towards additional training and certification in something I like. Would you say the fellowship is worth it even if you only want to see preteens and up? Not saying I don't want to see children, just curious what your thoughts are.

I would absolutely. I don't see any children at my current job (all 12-18), but have historically worked with a lot of 4-12 year olds at my last two jobs. I prefer adolescents, although the kids have a real charm to them. I would not have my current job if I was an adult psychiatrist. I have seen too many adult psychiatrists feel comfortable with doing the work before recognizing how much diagnostic ambiguity comes from developing human brains. Adult psychiatry is often quite delineated into neat boxes where people clearly fit or do not fit diagnostic criteria, we have shades of gray all the time in child/adolescent that simply requires a lot of reps to be good at.

 

[HaileyMed]

Hey everyone,

I need some advice on applying to CAP or not. I'm a PGY2 on my CAP rotation right now and really enjoying it. However, I wouldn't say I have a preference of child over adult, I enjoy them both a lot equally. I could see myself being happy practicing adult only, child only, or a mix. In my mind the main benefit of not doing the fellowship would be to stop putting my personal life on hold (prolonging my training does admittedly make me a little nauseous) and avoid the opportunity cost of 1 lost year of attending income. On the flipside, the pros of doing the fellowship would be so that I can be a true generalist, have more doors/options open for the rest of my career, and possibly going to a program with good moonlighting to offset the opportunity cost. It's tough though, because in terms of my day to day happiness I really do enjoy both fields the same.

Have any of you been faced with this decision? Any advice you all have for me would be great. Most of my attendings who I spoke with were in the black and white boat of, I couldn't stand working with kids (or adults), and decided accordingly.

Thanks!

I wouldn't worry much about factoring in opportunity cost. Unless you think you'll lose out on relationships/time, that is. Otherwise, financially you'll make it back because the pay and opportunities in CAP are significantly better than adult.

 

[Stagg737]

I made $150k my pgy5 year with moonlighting modestly (I kept a very healthy social schedule that I was not willing to sacrifice). I started at 300k my first year as an attending so it was like 1/2 a year pay cut. I also banked all my vacation pgy5 year so I started working 1 month early at my attending job and got dual paid by fellowship and my first job.

I actually disagree with Stagg on the topic above. I feel my ability to take care of adolescents is markedly different than the adult psychiatrists I know. Seeing childhood onsets of bipolar disorder (for example) is just completely different from having 6 months of an academic mood disorders clinic in CAP than anything an adult psychiatrist would sniff. There also tends to be a huge difference in understanding of ADHD from my experience (basically every fellowship will have an ADHD specialist/ADHD clinic). I would say if you want to spend a meaningful part of your practice taking care of kids or adolescents and don't mind having a harder PGY4 year (aka you like learning new things), I would lean towards CAP.

Idk, there are nuances with adolescents and some differences in presentation/treatments, but I feel like any decent psychiatry program should teach these on their CAP rotations. There are some disorders that are bread and butter cases in children and adolescents (ADHD, autism, developmental disabilities) that CAP docs will absolutely be better than simply d/t reps like you mention. If someone wants to treat adolescents and specialize in those cases then CAP will definitely be beneficial. However, for the most common diagnoses (depression, anxiety, PDs/malignant traits) there's not going to be much of a difference between 16 year olds and 20 year olds as long as you've got a basic understanding of developmental theories which decent residencies should teach.

I would absolutely. I don't see any children at my current job (all 12-18), but have historically worked with a lot of 4-12 year olds at my last two jobs. I prefer adolescents, although the kids have a real charm to them. I would not have my current job if I was an adult psychiatrist. I have seen too many adult psychiatrists feel comfortable with doing the work before recognizing how much diagnostic ambiguity comes from developing human brains. Adult psychiatry is often quite delineated into neat boxes where people clearly fit or do not fit diagnostic criteria, we have shades of gray all the time in child/adolescent that simply requires a lot of reps to be good at.

I'm also going to push back heavily here. Any programs using the DSM as a bible or teaching residents to place patients into those neat boxes isn't teaching our field correctly. There are a small number of diagnoses (like mania) which are more distinct and clear cut (especially in adults), but most of our diagnoses do not fit into nice, distinct boxes and have significant gray areas both diagnostically and in terms of what the best, or even appropriate, treatment would be.

 

[ridethecliche]

I did the moonlight a ton PGY5 and then moonlight a ton PGY6 because it sounded like a good idea to do another fellowship on top of CAP.

I wouldn't worry much about factoring in opportunity cost. Unless you think you'll lose out on relationships/time, that is. Otherwise, financially you'll make it back because the pay and opportunities in CAP are significantly better than adult.

I'm not sure how entirely true this is.

 

[Merovinge]

Idk, there are nuances with adolescents and some differences in presentation/treatments, but I feel like any decent psychiatry program should teach these on their CAP rotations. There are some disorders that are bread and butter cases in children and adolescents (ADHD, autism, developmental disabilities) that CAP docs will absolutely be better than simply d/t reps like you mention. If someone wants to treat adolescents and specialize in those cases then CAP will definitely be beneficial. However, for the most common diagnoses (depression, anxiety, PDs/malignant traits) there's not going to be much of a difference between 16 year olds and 20 year olds as long as you've got a basic understanding of developmental theories which decent residencies should teach.


I'm also going to push back heavily here. Any programs using the DSM as a bible or teaching residents to place patients into those neat boxes isn't teaching our field correctly. There are a small number of diagnoses (like mania) which are more distinct and clear cut (especially in adults), but most of our diagnoses do not fit into nice, distinct boxes and have significant gray areas both diagnostically and in terms of what the best, or even appropriate, treatment would be.

Happy to agree to disagree. I see adults for 20-50% of my clinical work since becoming an attending and the diagnostic picture is much better delineated. Certainly people don't fit into boxes, I work at a transdiagnostic treatment center and am not trying to argue that people should be thought of as a collection of diagnosis. This is still a very different experience than explaining a differential diagnosis to a parent/kid compared to seeing adults where we have a very good idea about that is going the majority of the time (now why things aren't getting better might be a very different story).

Mental illness simply looks different when it is emerging compared to when it has been in places for years or decades. The sx are different, the presentations are different. Adolescents are NOT like slightly younger adults, I think I can speak for most pediatric physicians that hearing this type of comment elicits the same gag reflex. I went to a well above average residency that trained me extremely well and the amount of time we spent on childhood development in adult residency was a flash in the pan at best.

 

[ridethecliche]

Happy to agree to disagree. I see adults for 20-50% of my clinical work since becoming an attending and the diagnostic picture is much better delineated. Certainly people don't fit into boxes, I work at a transdiagnostic treatment center and am not trying to argue that people should be thought of as a collection of diagnosis. This is still a very different experience than explaining a differential diagnosis to a parent/kid compared to seeing adults where we have a very good idea about that is going the majority of the time (now why things aren't getting better might be a very different story).

Mental illness simply looks different when it is emerging compared to when it has been in places for years or decades. The sx are different, the presentations are different. Adolescents are NOT like slightly younger adults, I think I can speak for most pediatric physicians that hearing this type of comment elicits the same gag reflex. I went to a well above average residency that trained me extremely well and the amount of time we spent on childhood development in adult residency was a flash in the pan at best.

To add to this, 16 and in high school vs 20 and in college or working are two totally different life stages with different levels of guardian/parental involvement. They're not equivalent and general psychiatry residency would certainly help you cover a clinic day for a colleague if you really needed to but would be very different longitudinally. Also, the initial eval is so different!

 

[Mad Jack]

I did a fellowship and ended up working with adults, but still found the training incredibly beneficial. My ability to create behavioral plans and understand how to work with those with autism or intellectual disabilities has been a great help in the inpatient setting. I did my fellowship at a program where I could moonlight, so I was making a decent amount (around 135k/year) as a fellow working one weekend in four, which lessened the financial burden. I might work with kids again someday, and like that I've got the opportunity. 10/10, would do fellowship again

 

[rjs2131]

You'll be a better overall psychiatrist if you do CAP fellowship (assuming the training is solid). I feel more thoughtful in my assessment/evaluation of my adult patients, and if you enjoy therapy lots to be had working with kids/teens. I agree with the mix of kids/teens + adults being nice as well.

Also...this is location dependent but generally, seems demand for CAP > adult so probably a nice additional skillset for marketing and business purposes.

 

[mistafab]

Hot take - psychiatrists can treat children without a fellowship.

I think south of 14 years old you really get smacked in the face with lack of expertise. Good exposure in residency goes a long way for the 14-18 age group. I also posit that the 18-22 (up to 24) can be harder without child training, but can be learned with ongoing supervision/mentorship.

As a general psychiatrist however I would not see children only in a practice. I wouldn't even see 50/50, as you'd be overwhelmed with lack of specific training and wouldn't have time to get better. However a few teens mixed in can be rewarding and help you grow.

In summary, I would say that if you could envision yourself in a child-only practice, I would strongly consider moving forward with CAP training. Cap training will make you a better psychiatrist. Some CAP programs my colleagues entered can also let you earn enough to eat while you're fast tracked for the extra year.

 

[Merovinge]

Hot take - psychiatrists can treat children without a fellowship.

I think south of 14 years old you really get smacked in the face with lack of expertise. Good exposure in residency goes a long way for the 14-18 age group. I also posit that the 18-22 (up to 24) can be harder without child training, but can be learned with ongoing supervision/mentorship.

As a general psychiatrist however I would not see children only in a practice. I wouldn't even see 50/50, as you'd be overwhelmed with lack of specific training and wouldn't have time to get better. However a few teens mixed in can be rewarding and help you grow.

In summary, I would say that if you could envision yourself in a child-only practice, I would strongly consider moving forward with CAP training. Cap training will make you a better psychiatrist. Some CAP programs my colleagues entered can also let you earn enough to eat while you're fast tracked for the extra year.

General surgeons can treat kids without a fellowship, neurosurgeons can treat kids without a fellowship, but the fellowship exist for both fields (and many others) for a reason and there is also a reason why most surgeons without pediatric training transfer 17 year olds out to places with pediatric specialists despite their being virtually no difference anatomically for a 17 year old vs an 18 year old.

Look if you are in a rural place or servicing an underserved population that struggles with access I would much rather have an adult psychiatrist than an NP see the patient. Ask any questions you want on SDN, have a few colleagues in CAP, and you do the best that you can, which is all anyone can do. But if you are in a place with reasonable access to CAP (aka medium-large to large metros, child psychiatrists flock to these areas), just refer the patient. You don't need to expand some skillset that you didn't specifically train for some arbitrary increased skill points on real children.

 

[Sushirolls]

But once you are a Psych ARNP or FNP, you can see under 14yo without issue.

 

[mistafab]

General surgeons can treat kids without a fellowship, neurosurgeons can treat kids without a fellowship, but the fellowship exist for both fields (and many others) for a reason and there is also a reason why most surgeons without pediatric training transfer 17 year olds out to places with pediatric specialists despite their being virtually no difference anatomically for a 17 year old vs an 18 year old.

Look if you are in a rural place or servicing an underserved population that struggles with access I would much rather have an adult psychiatrist than an NP see the patient. Ask any questions you want on SDN, have a few colleagues in CAP, and you do the best that you can, which is all anyone can do. But if you are in a place with reasonable access to CAP (aka medium-large to large metros, child psychiatrists flock to these areas), just refer the patient. You don't need to expand some skillset that you didn't specifically train for some arbitrary increased skill points on real children.

I agree with just about everything you said. I disagree that the skills in working with kids is arbitrary for the general psychiatrist. These kids with severe spectrum illness, intellectual disability, etc eventually age out of CAP care and then head towards general psychiatrists for treatment. Out of nowhere, these general psychiatrists are "good enough" for their care despite doing zero practice in that area.

I was in a major metro in the midwest previously, and outside of state-specific programs, no general psychiatrists would touch these patients. You in turn have a bunch of adult CAP patients clogging up CAP offices, or getting substandard care at whoever would see them (usually a CMHC). They will also show up on adult psychiatry units with the same problems.

So, I stand by the hot take that a general psychiatrist should do something to continue practice in these specialty areas. It behooves a resident to get significant exposure to CAP in general psychiatry residency. A cardiac surgeon should assist in a case for problems that the pediatric cardiac surgeon does every once in a while. Just like pediatric cardiac surgery - these patients become adult pediatric cardiac surgery cases and the pool of treatment providers is virtually non-existent. The adult cardiac surgeon will be on call at some point when a crisis emerges on an adult pediatric surgery patient.

 

[Merovinge]

I agree with just about everything you said. I disagree that the skills in working with kids is arbitrary for the general psychiatrist. These kids with severe spectrum illness, intellectual disability, etc eventually age out of CAP care and then head towards general psychiatrists for treatment. Out of nowhere, these general psychiatrists are "good enough" for their care despite doing zero practice in that area.

I was in a major metro in the midwest previously, and outside of state-specific programs, no general psychiatrists would touch these patients. You in turn have a bunch of adult CAP patients clogging up CAP offices, or getting substandard care at whoever would see them (usually a CMHC). They will also show up on adult psychiatry units with the same problems.

So, I stand by the hot take that a general psychiatrist should do something to continue practice in these specialty areas. It behooves a resident to get significant exposure to CAP in general psychiatry residency. A cardiac surgeon should assist in a case for problems that the pediatric cardiac surgeon does every once in a while. Just like pediatric cardiac surgery - these patients become adult pediatric cardiac surgery cases and the pool of treatment providers is virtually non-existent. The adult cardiac surgeon will be on call at some point when a crisis emerges on an adult pediatric surgery patient.

I'm not sure if you've fully convinced me but I definitely appreciate your point. Great way to think about that I just don't have the perspective of as a CAP.

 

[ridethecliche]

I moonlit enough during CAP 1 & 2 that the financial hit was pretty significantly ameliorated. I definitely made more than I would have had I stayed at my residency program for PGY4 just by virtue of location and opportunity.
I guess I'm a bad person to ask since I'm doing a second fellowship now.... but now I get to moonlight as an attending so yolo.

 

[calvnandhobbs68]

I agree with just about everything you said. I disagree that the skills in working with kids is arbitrary for the general psychiatrist. These kids with severe spectrum illness, intellectual disability, etc eventually age out of CAP care and then head towards general psychiatrists for treatment. Out of nowhere, these general psychiatrists are "good enough" for their care despite doing zero practice in that area.

Right but to @Merovinge point the same thing happens in adult. Congential cardiac patients suddenly "age out" into adult clinics all the time or lennox gastaut or congential epilepsy patient then end up in adult neuro. If you talk to a lot of the adult cardiologists or neurologists, they actually often don't feel "good enough" for their care and will try to keep them in peds cards or neuro as long as possible (we'd have adults in their 30s seeing their peds cardiologist lol). I'm not saying it's the exact same in terms of complexity but this is not a unique situation to psychiatry.

Also, um they don't "age out" of CAP care unless the psychiatrist kicks them out for some reason. I have to be boarded in adult psychiatry to be boarded in child. I can see my 12 year old until he's 40 years old if I want.

Your other issue is that if you're not familiar with pediatric guidelines, if a case goes south you'll get raked over the coals by the child psychiatrist expert witness they get to review your case. Your burden of proof as a "non expert" is much higher to show that you can comfortably provide care in that area.

I actually very much support adult psychiatrists seeing teenagers when able as preferred to an NP but it's stuff you have to think about.

 

[clausewitz2]

As an adult psychiatrist, I definitely don't treat anyone younger than 15, and not all of the 15-18 year olds. My thinking is like this: some teenagers have precocious versions of adult mental health problems. They are unlucky enough to have a very obvious psychotic disorder, bad OCD, panic attacks etc. Them I treat and don't feel particularly de skilled. Some teenagers are not dealing with early versions of adult mental health problems. Them I refer.