Why is Psych not competitive?

[F0nzie]

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In terms of money anything over 300K is realistic in private practice and this is only doing 40 hours a week.

The hard part about making 300k in private practice is working the 40 hours 😉

 

[heyjack70]

The hard part about making 300k in private practice is working the 40 hours 😉

Care to elaborate?

 

[F0nzie]

Care to elaborate?

Not wanting to work the 40 hours 🙂

 

[whopper]

The thing I didn't like about private practice was feeling isolated, not having several colleagues I highly respected, and not being around people on the cutting edge. The thing I really did enjoy wasn't so much the money itself but the statement to me that I was running a successful business that was contributing to society and was efficient.

I got some type of efficiency streak in me that I like to entertain. My last house I souped it up until it was literally in the top 1% of houses in the area that were energy-efficient, drive a Prius, etc.

And in state hospitals and academia, the idea of not being efficient is more tolerated. I really hate that type of thing.

That and having some very very whiney patients. If you're part of an institution, once you're off you're off but in private practice sometimes some of these people just call you over and over and over and get on your nerves.

 

[doctorpilgrim]

Is the psychiatrist mentioned above who is doing 80 hr weeks, working 12 hrs a day, 7 days a week. I work inpatient and if I have to work 3 weeks straight, without a break, it is very hard, and that is once in while. Most I have seen is 60 hrs a week,on consistent basis.

 

[Shikima]

I know one psychiatrist working 80 hours a week almost making 1 million.
Is he working 12 hrs a day, 7 days a week. I work inpatient and if I have to work 3 weeks straight, without a break, it is very hard, and that is once in while. Most I have seen is 60 hrs a week,on consistent basis, but at least some of them admit that they are on stimulants for adult onset ADD.

I question his efficacy and I'd hate to see his prescribing record.

 

[heyjack70]

I don't know how you can work 80 hour weeks, 7 day weeks, without days off, and stay mentally sharp. Unless he is treating a cherry picked set of the worried well, with no high utilizer/demanding patients, it does not sound sustainable. Maybe with enough Provigil...

 

[Nasrudin]

I don't know how you can work 80 hour weeks, 7 day weeks, without days off, and stay mentally sharp. Unless he is treating a cherry picked set of the worried well, with no high utilizer/demanding patients, it does not sound sustainable. Maybe with enough Provigil...

Well, he probably is a sufferer of excessive daytime sleepiness....so the provigil would be indicated. 😀

 

[Amygdarya]

(med student interested in Psychiatry, long time lurker in the Psych forum)

Here is what I've been wondering: could the lower number of average work hours in Psychiatry be also a reflection of the fact that Psychiatry may be more intellectually and emotionally demanding/exhausting than other specialties?

 

[Armadillos]

(med student interested in Psychiatry, long time lurker in the Psych forum)

Here is what I've been wondering: could the lower number of average work hours in Psychiatry be also a reflection of the fact that Psychiatry may be more intellectually and emotionally demanding/exhausting than other specialties?

Definitely not. The hours are good because there are very rarely emergencies/urgencies that require a physicians immediate attention. Also there is no operating room/procedure times driving earlier AM start times

 

[Nasrudin]

I have a different impression of where the innovation is. I don't see academic hospitals as a place of innovation. Ok...sure...maybe there's innovative people toiling away pushing the field forward. And if I could stomach collating, organizing, collecting, and interpreting data maybe then I could relate to this conception.

But I'm about being a clinician. That's the only thing that interests me. The fact that every encounter is unique wherein the challenge is to become that person's therapist and diagnostician is where the thrill is for me. That's where there's more innovation in minutes per hour of work churned.

There's a lot of big people on this forum. Sounds like a Hollywood cocktail party sometimes. "Oh I love your work..." You big guys can have all that.

To me private practice is where people who are good clinicians and therapists have the most creativity at their disposal. Not pressured by the untenable position of modern mental health delivery.

And, again, I don't share admiration for the position of developing your own "eclectic" writing, teaching, non-clinical career and then shaming the clinical grunts like me for not getting a beat down in public clinics for the greater glory of Mother Psychiatry and it's unfortunate parishioners.

I'm going to go where I can innovate and be creative in the pure clinical encounter. To me the only place left for people like me is private practice. I do have concern for public infrastructure. But I don't make a habit of bearing other people's crosses. Or being remorseful for not doing so.

 

[Doghead]

Everyone talks about psych being a cash cow waiting to be milked, like all one has to do is open a practice in the suburbs marketing for upper-class housewives, whilst only accepting cash for $300 an hour. I have yet to see such a thing.

 

[WingedOx]

I hear a lot of non-psychiatrists taking on the general medical threads about Psychiatry is one of the last bastions of freedom from government interference because of the ability to do cash only and whatnot. Of course the other side of that coin is that anyone who's been well trained to deal with the severely mentally ill has seen that patients with severe mental illness tend to require heavy use of government-funded social services in their long-term care.

^more of a political point than a lifestyle point... but after working in an urban center with a rather intense psychosis and high acuity population, working with the types of pathologies you see in a cash-only practice day in and day out would probably bore me. Who knows though... I'm young and the "sertraline for soccer moms" biz could be my calling someday too.

 

[smalltownpsych]

Everyone talks about psych being a cash cow waiting to be milked, like all one has to do is open a practice in the suburbs marketing for upper-class housewives, whilst only accepting cash for $300 an hour. I have yet to see such a thing.

I knew psychologists that billed over 200 and hour in West LA just for psychotherapy. It all depends on your location and your skills and ability to generate referrals. Psychiatrists in LA definitely can bill 300 and hour and find plenty of takers especially if they are working with adolescents. What we do is completely different from other medical specialties and the business model reflects that. What I hear psychiatrists say is that you can make good money and have a balanced life. I don't hear too many saying that it is the path to wealth. I think you might be confusing psychiatry with real estate.

 

[Leo Aquarius]

Anytime you're working what I call at a 1-to-1 ratio, you're not going to get wealthy. 1 surgery to produce X number of dollars. 1 hour of therapy to get Y number of dollars. It's a good living, but not wealth. Wealth comes when your "1" becomes a 10 or 50 on the other side. 1:50 ratio....1:100. I buy this land, and in 5 years its doubled in value with tenants who pay me monthly rent. Or I write this book and it sells thousands for the next several years. When you don't have to work to generate every dollar, then you start entering that world of wealth.

 

[NotTheBestUSMLE]

Anytime you're working what I call at a 1-to-1 ratio, you're not going to get wealthy. 1 surgery to produce X number of dollars. 1 hour of therapy to get Y number of dollars. It's a good living, but not wealth. Wealth comes when your "1" becomes a 10 or 50 on the other side. 1:50 ratio....1:100. I buy this land, and in 5 years its doubled in value with tenants who pay me monthly rent. Or I write this book and it sells thousands for the next several years. When you don't have to work to generate every dollar, then you start entering that world of wealth.

Seems like there are two big ways for psychiatrists to increase their ratio: transition from solo to group practice (in-house therapists) or become rather high on the hospital administrative COC.

 

[scudiera]

Anytime you're working what I call at a 1-to-1 ratio, you're not going to get wealthy. 1 surgery to produce X number of dollars. 1 hour of therapy to get Y number of dollars. It's a good living, but not wealth. Wealth comes when your "1" becomes a 10 or 50 on the other side. 1:50 ratio....1:100. I buy this land, and in 5 years its doubled in value with tenants who pay me monthly rent. Or I write this book and it sells thousands for the next several years. When you don't have to work to generate every dollar, then you start entering that world of wealth.

To invoke a memorable former poster, vistaril would agree with this entirely. I've tried to explain to other folks that you don't get wealthy by working hard in medicine, for the most part (NSG, retina, a few other things excepted). Even those ortho docs, most of their wealth is coming from ancillary services, in other words making money on the side while they make money doing something else. It's how derm and ophtho make so much. Heck I know some PM&R doctors who've opened up their own medical day spas and offer botox on the side.

 

[WingedOx]

I know a few people in the Ophtho world. The ones making massive bank are a combination of being basically 100% surgical and farming the followup out to the ODs (the AAO considers this unethical though) and bringing in a massive number of other physicians into the practice under them while making the $$$ on the surgicenter.

I know a retina guy who was pulling down about 700k/year in his solo practice in the '90s basically just doing 1:1 clinical work, but scaled both his work and pay way back since in the end he wasn't getting to see his kids grow up with that work load.

 

[NancyPansy]

Yeah that's perplexing to me too. Seems like psych ought to be more competitive than it is. Maybe people who are into psych end up going for psychology because it allows them to do most of what a psychiatrist can (except prescribe) but they don't have to go through med school. Just a guess though.

 

[Blitz2006]

Here's my 2 cents:

Psych is not competitive as it should be because medical students are not exposed to all aspects of psych. A lot of medical students only spend their psych rotation on an inpatient unit for 4-6 weeks. No Outpatient clinic. No CL. So how are you going to attract outpatient oriented people to psych (people that want a good lifestyle, ie, people who choose derm/rheum/allergy/optho etc)?

Also, very few medical students are exposed to sub-speciality psych: addiction/forensic/neuropsychiatry/child. Other specialties, like surgery, medical students at least get to dabble with sub-specialties like breast surgery in surgery rotation, nephrology in medicine, etc. So they don't realize the diversity of psychiatry (not just treating depression/schizophrenia/bipolar in an inpatient unit).

Most people I talk to, students and residents, have no idea that neuropsychiatry exists. I mean, I'm obviously biased, but I think it's one of the most exciting and cutting edge fields in medicine. We need more people to be exposed to it.

Also, yes psychiatrists can make bank on cash only practices, $300/hr etc. But we all know this is only realistic income in big markets like SF/LA/NYC. Are medical students exposed/aware of this potential in Knoxville, TN? Probably not (and I'm not even sure if $300/hr psych practices exist in these smaller markets, doubt it?)

I mean, last week a child psych told me he charges 600/hr. That's nutty. But once again, this is here in the NYC area.


Medical students are not familiar with the current situation of psych:

1) Medscape Satisfaction Report:

http://www.medscape.com/features/slideshow/compensation/2015/psychiatry#page=12

Psych once again is #2. Only behind Derm. Damn impressive in my books.


2) http://www.medscape.com/features/slideshow/compensation/2015/psychiatry#page=3

10% increase in psych salary in 2015. I believe in 2014 it was 15%. Solid numbers.

Unlike other specialities, psych is one of the few that is climbing every year.


3) http://www.medscape.com/features/slideshow/compensation/2013/psychiatry

19% of psychiatrists earn >300k. But what's even more impressive is that 70% of psychiatrists work <40 hours/week. 20% work between 40-50 hours a week.

So 90% of psychiatrists work <50 hrs/week. This is a scary stat.

So we can extrapolate and say that if you clear 50 hrs (9-6 x 5 days a week) you can easily clear 300k, approach 350. Not bad for no on calls or wkd.

So what would happen if the majority of Psychiatrists worked cardiology/general surgery hours (55-60 hrs/week)? Very high median salaries, thats what would happen. 300k? 275k as median? Maybe. Def much higher than the 210k we are pegged at on Medscape. This would put us in the same pay range as some big guns like gas, cards (non-interventional), certain general surgery subspecialties (trauma, breast, transplant), optho (non-retina) . I mean I was on the radiology forum and saw that rads are now making 280-320k in larger markets, with a terrible job market.

And this is trickling down into med specialties. I was talking to my IM friends and checked on NRMP, cardiology has now dropped to #3 (behind Heme/Onc) and Pulm/CC is hot on its heels at #4. Why? Terrible lifestyle and crashing reimbursements. and Hospitalist is getting hot.

So people will choose Psych because of good lifestyle, climbing reimbursements.

4) The future of psychiatry/psychopharm is exciting

http://www.forbes.com/sites/matthew...es-bringing-neuroscience-back-from-the-brink/

Sure, a lot of it may be lip service/unrealistic praise, but at least there is R+D going into psychiatry drugs.

And exciting. Psych is one of the few specialties where you can easily get involved in clinical drug trials, make an impact on drug development.


5) Psychiatrists can be involved in "procedures"

Sure, I'm not saying Psychiatrists are scoping or stenting, but majority of medical students have no idea that we are involved with ECT/rTMS/VNS/DBS (or what these procedures even are)

There are now fellowships even in psychiatry coined "interventional psych"

http://academicdepartments.musc.edu/psychiatry/education/res_fell/brain/brain

Med students have no idea about this. A lot of them think we just sit on couches doing psychotherapy. How are we going to attract hardcore neuroscientists with this perception? They will end up picking Neurology.

6) Hot Job Market

http://www.nejmcareercenter.org/article/physician-shortages-in-the-specialties-taking-a-toll/

Outside of primary care, among specialties, Psych has best job market, hands down. And sure, we can talk about how medical students' need to be interested in the field, blah blah blah, and how $ is important, reimbursements, blah blah blah. But at the end of the day, it comes down to location, location, location when students rank in february.

We all know everyone has bicoastal arrogance, so no matter how exciting running a code in the ICU is, how many students will move from LA or NYC to the south or midwest to do this? Radiology is confirming that job market plays a major role in decision making. What happened in the past 2-3 years, did people suddenly stop becoming interested in reading MRI scans? Of course not. Its the bad job market, which translated into 150 open spots for 2nd round this past match.

and I'm going to take a quote on child psych from the above link:

“It’s fair to say, if you look at the data, that at least 14 percent of kids have some sort of mental or psychiatric disorder — yet there are only 7,000 child psychiatrists in the entire country,” he said. Even in “physician-rich” Massachusetts, there are only 21 child psychiatrists per 100,000 children. In Alaska, the figure is a mere 3 per 100,000. The national average is 8.7 per 100,000.

“The good news for graduates is that they can get a job anywhere they want, in any setting they want — inpatient, outpatient, court work. And to some extent, they can negotiate their compensation,” Dr. Beresin said. Even plum academic jobs, historically hard to secure, are relatively plentiful right now, in a field that produces only 320 graduates annually. “The Council on Graduate Medical Education in 1990 said we would need 30,000 child psychiatrists by 2000, so we’re way behind the curve,” Dr. Beresin observed."

If you do child-psych, you will be cherry picking where you work and laughing all the way to the bank. Game Over.

So I know Macdonald Triad presented some good data in this thread showing that psych hasn't really increased in popularity. I'm still an eternal optimist, and feel that psych will boom in the next decade among medical students. 13% increase in US MDs from 2014 to 2015 to psych, highest increase among all specialties. Let's see if that trend continues or its just white noise. I think its the beginning of an era.

 

[heyjack70]

Yeah that's perplexing to me too. Seems like psych ought to be more competitive than it is. Maybe people who are into psych end up going for psychology because it allows them to do most of what a psychiatrist can (except prescribe) but they don't have to go through med school. Just a guess though.

You need the right personality to be drawn to psychiatry. The salary is okay, but you can make more in other fields. You have to be okay leaving behind the bulk of medicine you learned in school and focusing on mental health. Not to dismiss what is learned in medical school, but I think it's tough for some people to think about not doing regular physical exams or managing physical medical issues, because that's what the majority of medical school trains you to do. A lot of medical students get relatively brief, and sometimes poor, psych rotations as well. 4-6 weeks on an inpatient unit is scratching the surface.

 

[Blitz2006]

Yes and no.

I think it is a bit exaggerated how there is "no medicine" in psych.

Geriatric psych and CL there is a fair amount of medical knowledge needed.

I worked in the UK for 4 months in Geri Psych, and I was examining patients on a daily stuff for COPD/CHF/CAP.

Obviously I would consult medicine to reaffirm my findings, but most of the time I was on the right track.

You need the right personality to be drawn to psychiatry. The salary is okay, but you can make more in other fields. You have to be okay leaving behind the bulk of medicine you learned in school and focusing on mental health. Not to dismiss what is learned in medical school, but I think it's tough for some people to think about not doing regular physical exams or managing physical medical issues, because that's what the majority of medical school trains you to do. A lot of medical students get relatively brief, and sometimes poor, psych rotations as well. 4-6 weeks on an inpatient unit is scratching the surface.

 

[MacDonaldTriad]

For the record, I truly hope Blitz2006 is right. I could die happy seeing the quality climb and the pay.

 

[heyjack70]

Yes and no.

I think it is a bit exaggerated how there is "no medicine" in psych.

Geriatric psych and CL there is a fair amount of medical knowledge needed.

I worked in the UK for 4 months in Geri Psych, and I was examining patients on a daily stuff for COPD/CHF/CAP.

Obviously I would consult medicine to reaffirm my findings, but most of the time I was on the right track.

Agreed but not the case for typical outpatient adult psychiatrist.

 

[Freddie Mercury]

Psych is not competitive as it should be because medical students are not exposed to all aspects of psych. A lot of medical students only spend their psych rotation on an inpatient unit for 4-6 weeks. No Outpatient clinic. No CL. So how are you going to attract outpatient oriented people to psych (people that want a good lifestyle, ie, people who choose derm/rheum/allergy/optho etc)?

Also, very few medical students are exposed to sub-speciality psych: addiction/forensic/neuropsychiatry/child. Other specialties, like surgery, medical students at least get to dabble with sub-specialties like breast surgery in surgery rotation, nephrology in medicine, etc. So they don't realize the diversity of psychiatry (not just treating depression/schizophrenia/bipolar in an inpatient unit).

Agreed with this - in fact, it was really my CL experience that solidified my interest in psych. Our rotation was 6 weeks, with 4 weeks of outpatient, 2 weeks CL. My inpatient experience was fairly standard fare, with a lot of sitting around once morning report was done and you saw the patients you had to see+wrote notes. Some interesting patients for sure, but as a medical student there wasn't much we could be directly involved with that wasn't already done by the attendings/residents. But on CL we were on our feet all day seeing patients (sometimes by ourselves and sometimes supervised) in every part of the hospital with a pretty wide variety of pathology. It was an exciting experience for many of us, even those not interested in psych because they got to integrate a lot of medicine into each case.

 

[SoulinNeed]

Going by my classmates, they don't feel it's prestigious. Plus, there are always a few docs on every rotation who don't consider it to be "real medicine" and they give it a bad stigma.

Honestly, it seems like it's just the prestige factor. And not even prestige to the outside world, or even in the hospital, just the prestige in medical school.

 

[Dharma]

Going by my classmates, they don't feel it's prestigious. Plus, there are always a few docs on every rotation who don't consider it to be "real medicine" and they give it a bad stigma.

Honestly, it seems like it's just the prestige factor. And not even prestige to the outside world, or even in the hospital, just the prestige in medical school.

Well if not having enough "prestige" scares them away, then good. Same goes for "stigma." "😉"

 

[Blitz2006]

I agree with you, but I think this thinking applies to the previous generation.

Also psych is far more integrated to other specialties than it was 30 years ago, involving a fair amount of "real medicine".

And of course my opinion is biased, but being apart of cutting edge neuroscience to me seems more prestigious than running the same code blue over and over and over and over again.

I mean that UVA nature paper on discovery of lymphatic vessels in the brain, which could potentially impact drastically future dementia drugs, to me that is not only prestigious, but just straight up exciting. And I would love to be apart of that movement, instead of scoping everyday, looking for polyps.

And the pharmaceuticals. $3.3 billion invested in psych drugs r and d last year. Abilify being #2 drug sold in 2014. Granted, a lot of this is evil corporate pharma, but its still shows there is a lot of energy in the psych field. Cutting edge, innovative energy.

I dunno, when I tell other non psych residents I want to do neuropsychiatry and have a special interest in psychopharmacology and neuroimaging, they look pretty "impressed".

People are choosing other factors (ie. Lifestyle, quality of life) over prestige.

Hence the reason hospitalist is booming and subspecialty like cardiology are becoming less competitive.

And prestige is so subjective. Wouldn't most of the world consider psychiatrist at Harvard more "prestigious" than an orthopedic surgeon in middle of nowhere Iowa?

This is obviously a very extreme black and white example, but my point is, once people start seeing how the job market is so good in psych, this may offset that prestige factor.

Just my 2 cents.

Going by my classmates, they don't feel it's prestigious. Plus, there are always a few docs on every rotation who don't consider it to be "real medicine" and they give it a bad stigma.

Honestly, it seems like it's just the prestige factor. And not even prestige to the outside world, or even in the hospital, just the prestige in medical school.

 

[SoulinNeed]

-

 

[Monkey House]

Look at that specialty had the highest increase in spots filled last year.....

 

[Blitz2006]

Look at that specialty had the highest increase in spots filled last year.....

Yep. 13% increase. #1

 

[Roxas]

Look at that specialty had the highest increase in spots filled last year.....

I'm just sitting here hoping it stays uncompetitive enough til I can match

 

[Dharma]

Look at that specialty had the highest increase in spots filled last year.....

Let's see if it holds up for a few years. A few extra wins after a stretch of dismal seasons doesn't make a championship team, although it helps keep the dream alive. I'm thinking it will be a bit more competitive overall, but in the end the factors that steer most away from psych are still ever-present and will keep on diverting. Last thing the field needs are droves gunning for psych primarily because of lifestyle (since the stigma and prestige factors ain't changing anytime soon). Then again, if that's one's driving incentive he's cruising along the road to misery.

 

[Blitz2006]

True, we can discuss all day this, but in the end, only time will tell.

But I was talking to an attending today (Hospitalist), and he was saying that back in the 80s, ortho and derm were super easy to match into....so anyting can happen in a decade or 2.

I'm not convinced about the stigma being a huge factor anymore. Sure, there is still stigma associated with mental health illness, but i think paradoxically, it has been a good thing for Psych. The stigma is generating discussion. People are talking about how people with mental health are sometimes ostracized. Last weekend my family friend at dinner was openly talking (finance person) about how mental health is becoming more mainstream. and of course with incidents like Robin Williams' suicide and all these shootings, the spotlight (unfortunately or fortunately, however you want to perceive it) has been put on Psychiatry somewhat (of course we still have a ways to go). I think also being in the NYC area, mental health here is more highly regarded (physicians and non-physicians) so I think my view is a bit jaded. I'm sure this is not the fact in places like rural Louisiana.

I dunno, I personally think that lifestyle and $ are the major driving factors for competitiveness, more so than say, prestige and stigma. Back in the UK where I came from, where physicians earn relatively the same amount of $ regardless of speciality, Derm is very semi-competitive as well as Radiology/Anesthesia...

So if money keeps going up, and further advances are made in the field psychiatry in fields like psychopharm, neuroimaging, psychogenetics, this could be the beginning of a boom.

Let's see if it holds up for a few years. A few extra wins after a stretch of dismal seasons doesn't make a championship team, although it helps keep the dream alive. I'm thinking it will be a bit more competitive overall, but in the end the factors that steer most away from psych are still ever-present and will keep on diverting. Last thing the field needs are droves gunning for psych primarily because of lifestyle (since the stigma and prestige factors ain't changing anytime soon). Then again, if that's one's driving incentive he's cruising along the road to misery.

 

[Blitz2006]

you make roughly the same through the NHS but in private practice derm and radiology make a lot of money even in the UK. so it's partly about the money (lots of money in interventional radiology in the UK in pp but even diagnostic). also remember there are many more psychiatry spots than derm which is another reason for lack of competition.

anesthesia i don't think is terribly competitive in either the UK or US (middling probably). anesthesia is one of the few specialties you can come to the US from another country and practice without completing a residency in many states. can't do that in psych anymore.

Yeah but my point is generally in the UK, speciality is more geared towards actual interest vs. $. Of course there are some exceptions. There are also Psychiatrists on Harley Street in London making bank, but Harley is obviously not the norm. Derm/Rads is still overall not coveted like it is here in the U.S (disregarding the last 3 years for rads obviously).

I mean I left after F2 last year, and a lot of my friends said Rads/Anesthesia was in the middle. Surprisingly too because rads is run through and only 5 years. CT Surgery is also very easy, its getting the ST3 registrar spot that is very tough. Stupid pyramidal system. Historically anesthesia has been very competitive in the U.S (ROAD), but yes, now its middling.

and lets not forget ER. Here in the U.S its joining the ranks of ROAD, whereas in the UK you need a pulse to match. But that also has to do with the fact A&Es in the UK are crumbling.

 

[Monkey House]

As psychiatry begins to learn more from the clinical neurosciences and work on new treatments and therapies derived from brain research, the field will continue to evolve. Don't underestimate the role that mobile technologies will soon play too - treatments may soon be more personal, affordable, available, and effective. Big pharma may have nothing outstanding in the pipeline, but the smart applicant will realize new forces are going to come into play soon for psychiatry and help accelerate the field. Medical school does not always do a superb job at showing the potential of psychiatry....

 

[MacDonaldTriad]

Hope springs eternal, but the more things change, the more they appear to stay the same. Thorazine, TCAs, ECT and the therapy of 50 years ago had comparable efficacy to today’s treatments. Sure, things are a little better in terms of side effects and some manualized behaviorally based therapies, but true breakthroughs in psychiatry are rare. Greater understanding of neuroscience may lead to improvements in treatments, but most do not. We used to develop drugs that were discovered by pure dumb luck, but now with the latest designer drug technology, we have clones of drugs we discovered by pure dumb luck.

 

[Blitz2006]

"Medical school does not always do a superb job at showing the potential of psychiatry...."

Bingo. Med student with me is finishing tomorrow. 2 weeks CL. 2 weeks Inpatient. She said she really enjoyed it (and I believe she was being genuine).

But 0 exposure to Neuropsych/Addiction/Child/Forensic. and 0 exposure to outpatient setting. and never seen any procedures like ECT, or therapy like DBT.

How the hell is the med student gonna want to spend 40 years of their life if this is their only exposure? and she is lucky, she got 2 weeks of CL, some only get 4 weeks of inpatient....

 

[Leo Aquarius]

....and lets not forget ER. Here in the U.S its joining the ranks of ROAD, whereas in the UK you need a pulse to match...

Emergency medicine is more like the bike lane of the ROAD to happiness. It doesn't deserve a spot on the proverbial ROAD list because, surprising to some med students, it's not a lifestyle specialty with is its demanding shift work. Yes, it pays well, but no, it's not a 9 to 5 like Derm. Plenty of EM docs have told me it shouldn't be considered a lifestyle specialty, and I agree.

 

[Blitz2006]

I dunno man.

My best friend just got attending spot at a big 4 NYC hosp.

3, 8 hour shifts, 24 hours. Another 6 to 8 hours of academic work (teaching, research).

230k. And this is Manhattan.

And on top of that he moonlights at another hosp for 185/hr in NYC.

Go Midwest and you are clearing 300k easy+ moonlighting.

Not a bad gig for 3 days/week. And a great job market. Much better than optho and radiology.

Job market is a factor a lot of people/medical students overlook...

Emergency medicine is more like the bike lane of the ROAD to happiness. It doesn't deserve a spot on the proverbial ROAD list because, surprising to some med students, it's not a lifestyle specialty with is its demanding shift work. Yes, it pays well, but no, it's not a 9 to 5 like Derm. Plenty of EM docs have told me it shouldn't be considered a lifestyle specialty, and I agree.

 

[Leo Aquarius]

I agree that a healthy job market is a real plus for EM. For Psych even more so.

 

[smalltownpsych]

As psychiatry begins to learn more from the clinical neurosciences and work on new treatments and therapies derived from brain research, the field will continue to evolve. Don't underestimate the role that mobile technologies will soon play too - treatments may soon be more personal, affordable, available, and effective. Big pharma may have nothing outstanding in the pipeline, but the smart applicant will realize new forces are going to come into play soon for psychiatry and help accelerate the field. Medical school does not always do a superb job at showing the potential of psychiatry....

...and my wife calls me a pollyanna! 😉
Only kidding, actually we need this type of continued energy and enthusiasm in the field to balance out the bleary-eyed, worn-out, tired, cynical, frustrated old dogs. 😉

 

[Shikima]

Have to be careful, a lot of hospital systems will want to hire and not pay, especially when it comes to taking call - I know of one health system that adamantly refuses to pay for call and rolls that responsibility into the annual salary of 230k.

Have to watch carefully that all of your time is accounted and reimbursed for. There will be nuances to this formula which will be individualized, but as a general rule, watch out.

 

[Monkey House]

Hope springs eternal, but the more things change, the more they appear to stay the same. Thorazine, TCAs, ECT and the therapy of 50 years ago had comparable efficacy to today’s treatments. Sure, things are a little better in terms of side effects and some manualized behaviorally based therapies, but true breakthroughs in psychiatry are rare. Greater understanding of neuroscience may lead to improvements in treatments, but most do not. We used to develop drugs that were discovered by pure dumb luck, but now with the latest designer drug technology, we have clones of drugs we discovered by pure dumb luck.

The potential of mobile technologies and new computer technology is likely to have a profound impact on all fields of healthcare - and especially psychiatry. There will soon be new ways to screen and monitor for diseases as well as deliver care to patients. Combine neurosciences, mobile, lessening stigma - there is the potential for tremendous change!

 

[D3sidud3]

Here's my 2 cents:

Psych is not competitive as it should be because medical students are not exposed to all aspects of psych. A lot of medical students only spend their psych rotation on an inpatient unit for 4-6 weeks. No Outpatient clinic. No CL. So how are you going to attract outpatient oriented people to psych (people that want a good lifestyle, ie, people who choose derm/rheum/allergy/optho etc)?

Also, very few medical students are exposed to sub-speciality psych: addiction/forensic/neuropsychiatry/child. Other specialties, like surgery, medical students at least get to dabble with sub-specialties like breast surgery in surgery rotation, nephrology in medicine, etc. So they don't realize the diversity of psychiatry (not just treating depression/schizophrenia/bipolar in an inpatient unit).

Most people I talk to, students and residents, have no idea that neuropsychiatry exists. I mean, I'm obviously biased, but I think it's one of the most exciting and cutting edge fields in medicine. We need more people to be exposed to it.

Also, yes psychiatrists can make bank on cash only practices, $300/hr etc. But we all know this is only realistic income in big markets like SF/LA/NYC. Are medical students exposed/aware of this potential in Knoxville, TN? Probably not (and I'm not even sure if $300/hr psych practices exist in these smaller markets, doubt it?)

I mean, last week a child psych told me he charges 600/hr. That's nutty. But once again, this is here in the NYC area.


Medical students are not familiar with the current situation of psych:

1) Medscape Satisfaction Report:

http://www.medscape.com/features/slideshow/compensation/2015/psychiatry#page=12

Psych once again is #2. Only behind Derm. Damn impressive in my books.


2) http://www.medscape.com/features/slideshow/compensation/2015/psychiatry#page=3

10% increase in psych salary in 2015. I believe in 2014 it was 15%. Solid numbers.

Unlike other specialities, psych is one of the few that is climbing every year.


3) http://www.medscape.com/features/slideshow/compensation/2013/psychiatry

19% of psychiatrists earn >300k. But what's even more impressive is that 70% of psychiatrists work <40 hours/week. 20% work between 40-50 hours a week.

So 90% of psychiatrists work <50 hrs/week. This is a scary stat.

So we can extrapolate and say that if you clear 50 hrs (9-6 x 5 days a week) you can easily clear 300k, approach 350. Not bad for no on calls or wkd.

So what would happen if the majority of Psychiatrists worked cardiology/general surgery hours (55-60 hrs/week)? Very high median salaries, thats what would happen. 300k? 275k as median? Maybe. Def much higher than the 210k we are pegged at on Medscape. This would put us in the same pay range as some big guns like gas, cards (non-interventional), certain general surgery subspecialties (trauma, breast, transplant), optho (non-retina) . I mean I was on the radiology forum and saw that rads are now making 280-320k in larger markets, with a terrible job market.

And this is trickling down into med specialties. I was talking to my IM friends and checked on NRMP, cardiology has now dropped to #3 (behind Heme/Onc) and Pulm/CC is hot on its heels at #4. Why? Terrible lifestyle and crashing reimbursements. and Hospitalist is getting hot.

So people will choose Psych because of good lifestyle, climbing reimbursements.

4) The future of psychiatry/psychopharm is exciting

http://www.forbes.com/sites/matthew...es-bringing-neuroscience-back-from-the-brink/

Sure, a lot of it may be lip service/unrealistic praise, but at least there is R+D going into psychiatry drugs.

And exciting. Psych is one of the few specialties where you can easily get involved in clinical drug trials, make an impact on drug development.


5) Psychiatrists can be involved in "procedures"

Sure, I'm not saying Psychiatrists are scoping or stenting, but majority of medical students have no idea that we are involved with ECT/rTMS/VNS/DBS (or what these procedures even are)

There are now fellowships even in psychiatry coined "interventional psych"

http://academicdepartments.musc.edu/psychiatry/education/res_fell/brain/brain

Med students have no idea about this. A lot of them think we just sit on couches doing psychotherapy. How are we going to attract hardcore neuroscientists with this perception? They will end up picking Neurology.

6) Hot Job Market

http://www.nejmcareercenter.org/article/physician-shortages-in-the-specialties-taking-a-toll/

Outside of primary care, among specialties, Psych has best job market, hands down. And sure, we can talk about how medical students' need to be interested in the field, blah blah blah, and how $ is important, reimbursements, blah blah blah. But at the end of the day, it comes down to location, location, location when students rank in february.

We all know everyone has bicoastal arrogance, so no matter how exciting running a code in the ICU is, how many students will move from LA or NYC to the south or midwest to do this? Radiology is confirming that job market plays a major role in decision making. What happened in the past 2-3 years, did people suddenly stop becoming interested in reading MRI scans? Of course not. Its the bad job market, which translated into 150 open spots for 2nd round this past match.

and I'm going to take a quote on child psych from the above link:

“It’s fair to say, if you look at the data, that at least 14 percent of kids have some sort of mental or psychiatric disorder — yet there are only 7,000 child psychiatrists in the entire country,” he said. Even in “physician-rich” Massachusetts, there are only 21 child psychiatrists per 100,000 children. In Alaska, the figure is a mere 3 per 100,000. The national average is 8.7 per 100,000.

“The good news for graduates is that they can get a job anywhere they want, in any setting they want — inpatient, outpatient, court work. And to some extent, they can negotiate their compensation,” Dr. Beresin said. Even plum academic jobs, historically hard to secure, are relatively plentiful right now, in a field that produces only 320 graduates annually. “The Council on Graduate Medical Education in 1990 said we would need 30,000 child psychiatrists by 2000, so we’re way behind the curve,” Dr. Beresin observed."

If you do child-psych, you will be cherry picking where you work and laughing all the way to the bank. Game Over.

So I know Macdonald Triad presented some good data in this thread showing that psych hasn't really increased in popularity. I'm still an eternal optimist, and feel that psych will boom in the next decade among medical students. 13% increase in US MDs from 2014 to 2015 to psych, highest increase among all specialties. Let's see if that trend continues or its just white noise. I think its the beginning of an era.

The point about procedures and Interventional Psychiatry couldn't be more emphasized. ECT and rTMS are covered by Medicaire, and given how the geriatric population has been shown to be the most responsive to these neuromodulation therapies, Interventional Psychiatry is going to explode all over the nation. The mechanisms of action supported by neuroscience research are compelling because they are finally allowing us to target specific circuits instead of globally nuking the brain with a drug that alters neurotransmitter levels. Psychopharmacology does have its place and is extremely beneficial, but my point is that they work synergistically with neuromodulation and psychotherapy like CBT. And one last thing - given how most psych residents are at most exposed to maybe like a week or ECT training during their residencies (unless they opt for more), there will be a tremendously high premium on developing these skills and learning the procedures. ECT has come a long way since the 1950s as it has become more efficacious and the incidence of cognitive side effects have significantly decreased. More insurance companies will surely begin to reimburse these procedures because they're remarkably effective. And I'm not just saying this because I did an Interventional Psych rotation at MUSC - obviously I'm slightly biased but there is merit. Apparently learning how to do ECT and rTMS puts you in the top 5% of people who are familiar with these techniques? I'm not sure about this but the brain stim fellow and attendings seemed confident. Anywho, keep your heads up - we are undoubtedly in for an *electrifying* future.

 

[MacDonaldTriad]

I hate to dampen your enthusiasm about the future of neurostimulation, but people have been enthusiastic about TMS for a couple of decades and it still isn’t as effective as ECT, and ECT is underused. TMS is admittedly much easier to use, but isn’t transforming itself into first line treatment. It has tried to refine itself with rTMS and sTMS and I have participated in research to look at the merits of the potential improvements. Trust me, I’m not about to quite my day job and set up TMS bars next to those oxygen bars run by Woody Harrylson. I agree it has more evidence than pyramid power or crystals, but it were going to transform the practice of psychiatry I would think it would have gained a little more traction by now. Pioneers of TMS are now retired and it still hasn’t caught on that much. My best prediction is that it will continue to grow and find a place, but it will remain second or third line within the hands of a few psychiatrists who specialize in treatment resistant cases. Its safety profile is close to perfect, but it takes a lot of visits and time. Maybe someone should create a bright light, TMS, CBT, SNRI service. People could get therapy in a bright room while getting TMS and having their meds refilled.

 

[D3sidud3]

Your points are valid and that is the general consensus in psych right now. Recent studies have shown a 30-35% remission rate similar to that of antidepressants, and ECT is at a whopping 70%+. It's worth noting that most patients receiving these treatments are refractory to at least 2 meds and the course of the illness has altered neurochemistry and structure/function via continuous inflammatory cascades, etc., yet despite this the efficacy is significantly high. The reason it's only gaining traction is due to a lack of robust data since not many studies were funded, patient reluctance due to stigma, and a host of other barriers. The pioneer of TMS in the US is still very active at MUSC. I agree that this won't be a magic bullet, but the absence of an unfavorable side effect profile is appealing. Ultimately I think the field just needs to move in the direction of embracing a multi faceted approach by normalizing circadian rhythms, using meds like you mentioned above, CBT, diet adjustments, and just overall lifestyle optimization.

 

[MacDonaldTriad]

I agree with everything you say. TMS is a good example of the difference between statistical significance and clinical significance. Power it up enough and even invisible effects can be statistically significant. It would be nice to test TMS on treatment naive patients, but they are hard to find.

 

[Blitz2006]

Everyone talks about resposne rate of ECT being 70 to 80%. What is TMS? 40 to 50% right?

And I presume its more costly than ECT, is that why insurance companies balk?

 

[MacDonaldTriad]

Who knows, almost all of the TMS studies are on people who have failed everything else multiple times. Studies that weren't started this way, failed because of lack of enrollment. It takes a lot to be ill and trust an unproven treatment.