Why I chose psychiatry

[shan564]

Every few months, somebody comes by to ask if psych is right for them (or something along those lines). I love selling psychiatry to med students, so I figured I'd start a thread to pre-empt some of that. Maybe some of you guys can also share your reasons for choosing psych.

When a med student asks me why I chose psychiatry, I usually respond by saying "if you spend enough time with me, you'll hear me say 'I chose psychiatry because...', followed by one of at least 10 different reasons." Leaving out the obvious stuff (good lifestyle, deep relationships with patients, etc.), here are some of those reasons off the top of my head (I'll probably come up with more later):

-There is so much left to learn in neuroscience, which is great if you're interested in research or fringe stuff
-The ambiguity is fun - I get bored of the algorithmic approach in other specialties
-I love the challenge of trying to elicit the subtle signs
-Patients tend to be young and have a long life ahead that you can help
-You really get to fix people and put them in remission
-Corollary to the above two things: with treatment, most of your patients will lead long full lives with minimal symptom burden (as opposed to other specialties, where your role is often to slow down the deterioration of a chronic disease)
-Most of your patients will get better
-Many people haven't been diagnosed due to under-recognition of psychiatric symptoms, so you can change somebody's life when they just thought that this is how they are
-Many people have been mismanaged due to under-training of PCPs, so you really get to lend a specialist insight
-Many people have been mismanaged due to lazy psychiatrists out there, so you get to clean up a lot of messes

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[Leo Aquarius]

I always love this question too.

For me, I realized in med school that 1) the very best part of me was my interaction and connection with patients (you want to dedicate yourself to what you're naturally good at), and 2) medicine must be, above all, about deep patient-physician therapeutic relationships and psychiatry makes that the most important element of all specialties (many other specialties really do a disservice by de-emphasizing this, but rads and path get a free pass).

Other things I have come to love that I couldn't appreciate as a med student:
- Psychiatry totally changes you for the better because you learn about human behavior and nature, about abuse and emotional scars, about peoples' difficult lives, and it matures you a lot as a human being.
- You're like a rock star to your patients. They will follow you if you move locations. They will tell their family and friends to go see you. If you're really good, you become this great big inspirational force in lots of lives.
- You can heal people just by listening.... amazing. Some session I speak maybe 10 words max and the patient feels much better. It's all about showing you care... you can't fake it. Asking key questions at the key moments really count.
- No call if I don't want it. I can find plenty of jobs where I don't have to ever be on call again. Yes!
- Billions of cities across America need my services and are ready to pound down my door to have me. Job offer? Meet my 20% bonus on top of your offer and I'll think about it.

What I don't like at all:
- In some circles the stigma of being a psychiatrist. But I'm doing a fellowship and that will change my title so it won't really be as much an issue. But America is turning a corner and more people see us as vital doctors in society.

 

[MrWonderful]

This is very valuable. Keep em comin'!

 

[thoffen]

A lot of your responses have a kernel of "patients get better when I treat them". Either I'm much more cynical or much worse of a psychiatrist.

 

[Doctor Bagel]

A lot of your responses have a kernel of "patients get better when I treat them". Either I'm much more cynical or much worse of a psychiatrist.

This times 100. Some patients get better and lots don't. Or at least they get nowhere near cured. Working with my current patients, they've been to the state hospital and they've had their clozapine trials and they're still pretty darn sick. Cure or very substantive recovery isn't possible for lots of our patients with currently available treatments. This is true for patients with schizophrenia and for patients with generalized anxiety disorder. Again not to say you can't help, but eradication of symptoms might not occur.

 

[MacDonaldTriad]

Often, 10% improvement makes more than half the difference in QOL.

I liked psychiatry enough to ignore the perceived lack of respect and under pay. Nether one of which ended up being true. Well, I will always accept more money, but we have little to complain about.

 

[Doctor Bagel]

But not to leave on a negative note, here's where I do like psychiatry. I don't regret doing it over any other specialty (well, except sometimes derm which was actually a realistic possibility for me).

- I like the patients, at least most of them, even with all the different categories of patients we see -- people with personality disorders, neurotic high functioning types, spmi types, addicts
- you get to actually spend time with patients and have human interactions with them
- you get to learn about yourself (especially if you take the time to do this). I think it can make you a better doctor
- I like the ambiguity too
- interesting intersections between our work, the legal system and public policy
- I like working with psychiatrists more than most other types of doctors
- lots of work flexibility and options
- relatively good lifestyle. I don't think I could handle having to show up to work at 5 am every day

 

[smalltownpsych]

A lot of your responses have a kernel of "patients get better when I treat them". Either I'm much more cynical or much worse of a psychiatrist.

This times 100. Some patients get better and lots don't. Or at least they get nowhere near cured. Working with my current patients, they've been to the state hospital and they've had their clozapine trials and they're still pretty darn sick. Cure or very substantive recovery isn't possible for lots of our patients with currently available treatments. This is true for patients with schizophrenia and for patients with generalized anxiety disorder. Again not to say you can't help, but eradication of symptoms might not occur.

I was wondering about that too. They must not be working community mental health where the systems are so broken that it can be quite an uphill battle. From personal experience working in these settings, focusing on the improvements and successes is vital to keeping positive. When I was at the state hospital I used to say that if I heard one more burnt-out staff say, "this patient will never get better", I was going to smack somebody. Each individual has to fight against this and other defeating dynamics IMO. Although not a psychiatrist, I chose this field for many of the same reasons listed above, but also would add that I love this field because I also get to treat the sick systems both in families and organizations.

 

[OldPsychDoc]

...
-Patients tend to be young and have a long life ahead that you can help
-You really get to fix people and put them in remission...

As I've always said, we save more Life Years than any discipline outside of Peds.
Much more satisfying getting a 23 year old on the right track in life than tweaking an 73 year old's antihypertensives.

 

[Doctor Bagel]

As I've always said, we save more Life Years than any discipline outside of Peds.
Much more satisfying getting a 23 year old on the right track in life than tweaking an 73 year old's antihypertensives.

Of course this is assuming that you're not a geriatric psychiatrist.

 

[Doctor Bagel]

I was wondering about that too. They must not be working community mental health where the systems are so broken that it can be quite an uphill battle. From personal experience working in these settings, focusing on the improvements and successes is vital to keeping positive. When I was at the state hospital I used to say that if I heard one more burnt-out staff say, "this patient will never get better", I was going to smack somebody. Each individual has to fight against this and other defeating dynamics IMO. Although not a psychiatrist, I chose this field for many of the same reasons listed above, but also would add that I love this field because I also get to treat the sick systems both in families and organizations.

And maybe seeing people who are new to seeing psychiatrists. I don't get many new to psychiatry patients -- probably most of the people I've seen throughout training and beyond had seen other psychiatrists (and good psychiatrists, too) before. If these people were going to show dramatic improvement easily, it would have happened already. It hasn't, and that's why they're still seeing me and haven't been transitioned to their pcp.

 

[clausewitz2]

I was wondering about that too. They must not be working community mental health where the systems are so broken that it can be quite an uphill battle. From personal experience working in these settings, focusing on the improvements and successes is vital to keeping positive.

There was much rejoicing while I was on an ACT team when one gentleman finally stopped getting kicked out of apartments secondary to massive water damage that always resulted from him trying to flush things like shoes down his toilet.

 

[FlowRate]

My (student-perspective) reasons echo those of the experienced psychiatrists above:

1. Favorite part of being a doctor is building a relationship with patients + I have been told by supervising docs that it's something I'm good at.
2. Psychiatry is like hard mode in that respect -- these patients require people who are skilled at forging relationships, tolerating affect, explaining things on the patient's level -- and I enjoy that challenge.
3. Really fun to think about, especially with the advances being made in neurobiology and population health/integrated care.
4. Enjoy that psychiatry is largely "grey area," requiring logic and creativity.
5. High amount of individual flexibility regarding inpatient/consult/emergent/call/outpatient. Most psychiatrists I know do a mix of things and I think that helps keep work exciting.
6. I have sort of a soft spot for "difficult patients" and dislike how they sometimes get treated--we get to help them fit into the system more smoothly (most relevant to CL).

 

[clausewitz2]

My (student-perspective) reasons echo those of the experienced psychiatrists above:

1. Favorite part of being a doctor is building a relationship with patients + I have been told by supervising docs that it's something I'm good at.
2. Psychiatry is like hard mode in that respect -- these patients require people who are skilled at forging relationships, tolerating affect, explaining things on the patient's level -- and I enjoy that challenge.
3. Really fun to think about, especially with the advances being made in neurobiology and population health/integrated care.
4. Enjoy that psychiatry is largely "grey area," requiring logic and creativity.
5. High amount of individual flexibility regarding inpatient/consult/emergent/call/outpatient. Most psychiatrists I know do a mix of things and I think that helps keep work exciting.
6. I have sort of a soft spot for "difficult patients" and dislike how they sometimes get treated--we get to help them fit into the system more smoothly (most relevant to CL).

Okay, so it's you who's been stealing my thoughts.

 

[splik]

Okay, so it's you who's been stealing my thoughts.

Some people would say this is a first rank symptom

 

[splik]

-Corollary to the above two things: with treatment, most of your patients will lead long full lives with minimal symptom burden (as opposed to other specialties, where your role is often to slow down the deterioration of a chronic disease)

what planet are you on?! severe mental illness shaves many years off patient's lives (10-25 years depending on the studies), they are at higher risk of developing many of the chronic diseases that lead to deterioration, and are often significantly impaired even if they have few symptoms as drugs seem to do little to improve functionality and may even worsen functioning as in the case of neuroleptics

 

[shan564]

A lot of your responses have a kernel of "patients get better when I treat them". Either I'm much more cynical or much worse of a psychiatrist.

This times 100. Some patients get better and lots don't. Or at least they get nowhere near cured. Working with my current patients, they've been to the state hospital and they've had their clozapine trials and they're still pretty darn sick. Cure or very substantive recovery isn't possible for lots of our patients with currently available treatments. This is true for patients with schizophrenia and for patients with generalized anxiety disorder. Again not to say you can't help, but eradication of symptoms might not occur.

Like everything in medicine, when I say "most of your patients get better," I thought it was obvious that "most" doesn't mean "all"... I'm talking about the majority of psychiatric patients, not the minority who have to live in a state hospital despite clozapine and ECT. Also, "better" doesn't mean "asymptomatic" - just that they are better after treatment than they were before treatment (in contrast to your average COPD/CHF/CKD/diabetes patient, who will continue to deteriorate over time, but your job is to slow that down).

Today, I saw 5 patients in about 3-4 hours in clinic (1 new, 4 f/u). 2 of the 5 still have some substantial positive symptoms, but much better than they were before treatment. 1 of the 5 has minimal positive symptoms that barely interfere with life. 1 of the 5 has no more positive symptoms but has significant negative symptoms, but is still fairly functional (enjoys exercising, gardening, is actively dating). The last one has no psychotic symptoms whatosever, and is now showing signs of OCD that has also improved significantly on SSRIs, is about to start a new job, just had a baby, and is pretty close to being asymptomatic.

And this was an unusual day with disproportionately severe patients. I had a medical student with me, and I pointed out to him that my patients today happened to be sicker than average. But still, 100% of them were "better" than they were before they started seeing a psychiatrist.

what planet are you on?! severe mental illness shaves many years off patient's lives (10-25 years depending on the studies), they are at higher risk of developing many of the chronic diseases that lead to deterioration, and are often significantly impaired even if they have few symptoms as drugs seem to do little to improve functionality and may even worsen functioning as in the case of neuroleptics

I said "most of your patients," not "all of your patients." Most patients with mental illness aren't "severe." A good chunk of my patients are mood disorders in remission, anxiety disorders that are improving with SSRIs and CBT, etc.

But I could have been more clear. I meant to contrast managing chronic mental illness with managing chronic physical illness. I like the fact that my primary goal is to alleviate the patient's symptoms rather than just slowing down their deterioration (i.e. COPD, CHF, CKD, diabetes, and most of the other patients I saw as an intern on internal medicine).

 

[technopoly]

My (student-perspective) reasons echo those of the experienced psychiatrists above:

1. Favorite part of being a doctor is building a relationship with patients + I have been told by supervising docs that it's something I'm good at.
2. Psychiatry is like hard mode in that respect -- these patients require people who are skilled at forging relationships, tolerating affect, explaining things on the patient's level -- and I enjoy that challenge.

As a student, I would also add that I enjoy the process of earning rapport with patients who are generally not so loose with their trust; when a patient starts to open up after a lot of failed attempts- that's really rewarding.