Worth staying in psychiatry if the only part you really love is the therapy?

[futuredo32]

I've spent eons agonizing over primary care versus psychiatry and I have come to the conclusion that maybe not choosing one but instead doing both is the answer for me, though isn't all that practical and wouldn't be the answer for most people and will have challenges in the future.

Long story short, I'm currently a psych resident. I love the psychotherapy but really really miss the whole rest of medicine that isn't covered by psychiatry- the chf, uris, diabetes, derm issues, etc etc. I was planning to finish my psych residency and then apply to do a second residency in fp (and actually a geriatric fellowship) with the goal being that I would work in two totally different settings- one with fp pts and prescribing antidepressants or anxiolytics when needed and then an outpatient psychotherapy practice with psych meds as needed (I know not a lot of people do this and a combined fp/psych residency would have been ideal).

Just hoping to get some opinions on whether or not my enjoyment of psychotherapy was reason enough to finish my psych residency? I know it doesn't pay all that well, neither does fp, money isn't all that important to me, but job satisfaction is.

I did a fp rotation last month and also spent time in the continuity outpatient clinic during the same month and it was just like amazing for me to do two things I love and I didn't feel like anything was missing. I'm currently doing an addictions rotation with two fps who got grandfathered into addictions and they go to the hospital in the am and round on addiction pts and go to their office in the afternoon which is 90% fp and 10% addictions, so in my mind, it's really not that different than what I'd like to do.

I like outpatient psych, hate inpt psych and I like the longterm relationships outpatient doctors develop with their patients. So C/L wouldn't really work for my interests. If I had to pick either fp or psych and a second residency wasn't possible, I'd jump off the psychiatry ship now and do fp, but I would really rather do both.

Any thoughts or opinions are appreciated

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[TexasPhysician]

If you find greater joy in what you describe, I'd do both residencies. Consider discussing it with the FM PD at your facility. Maybe he/she could help you transition to a program that would give you some credit from your psych residency.

So what if you lose a little extra time and money if it all makes you happy.

 

[DebDynamite]

I know someone who did both IM and peds. He now practices IM three days a week and peds two days a week. Of course it can be done. How many extra years will you end up training by doing that? Not sure if it really matters in the long run.

The only thing to consider would be the funding issues as my understanding is that there is less funding for an individual who has a certain years of training under their belt. So, if you can transfer into a combined program you would not have to consider that as a potential problem. I'm specifically referring to the funds that your sponsoring institution receives via the government for their residents. You might want to find out more about that.

 

[futuredo32]

Thanks so much for both replies.

I would so strongly prefer not to move and there isn't a combined program where I live. I'm ok with spending the extra time in doing a second residency and the limited gov't funding for my second residency will make things harder. I know some programs are really bleeding financially and can't take anyone without the full funding, but some programs are doing ok financially and it won't be an issue for them, hopefully there will still be some of the programs doing ok financially in two years

Doing both is definitely an option that would make me happy. I spent forever trying to pick one and it was awful, being able to do both, it's amazing.

 

[TexasPhysician]

I know someone who did both IM and peds. He now practices IM three days a week and peds two days a week. Of course it can be done. How many extra years will you end up training by doing that? Not sure if it really matters in the long run.

The only thing to consider would be the funding issues as my understanding is that there is less funding for an individual who has a certain years of training under their belt. So, if you can transfer into a combined program you would not have to consider that as a potential problem. I'm specifically referring to the funds that your sponsoring institution receives via the government for their residents. You might want to find out more about that.

Transferring to a combined program from psych WOULD still have funding problems.

There are tons of FM programs. Reduced pay to FM docs and the rise of NP's will continue to scare people away from FM. Finding a spot even with reduced funding I wouldn't expect to be a big problem if you are a decent applicant otherwise. Who knows until you try though?

 

[F0nzie]

I felt the same way you did during the first 3 years of residency. I was contemplating doing FM or EM and working in urgent care or an ED.

At this point, as a 4th year, I will go out there and make a living with psych and see what happens. I may do a fellowship or I may do another residency in the future.

I find myself getting bored no matter what specialty I am rotating through. Everything becomes repetitive. I have found that reading up on areas that interest me help.

 

[futuredo32]

I felt the same way you did during the first 3 years of residency. I was contemplating doing FM or EM and working in urgent care or an ED.

At this point, as a 4th year, I will go out there and make a living with psych and see what happens. I may do a fellowship or I may do another residency in the future.

I find myself getting bored no matter what specialty I am rotating through. Everything becomes repetitive. I have found that reading up on areas that interest me help.

Thanks It's actually really comforting to read your post. I have talked to the other residents in my program and all of our attendings and I was the only one who missed medicine and was kinda feeling like an oddball.

I took one of those quizzes to see what medical specialty is a good fit for you (I wasn't going to let a quiz determine my future or anything) and I am one of those people who is totally content about knowing a little about everything, EXCEPT psychotherapy. FP is perfect for someone who likes to know a little about everything but they can't do psychotherapy (well, they could but they couldn't do it well I guess).

As for the combined residency, it'd be quicker, but I am actually switching from my current psychiatry residency (our pd left and what followed were a lot of problems and uncertainties within the program) to another psych residency, so that's probably enough switching for now. And, I don't live in a state where there is a combined program and I am not looking to move. I am so certain that I want to do a second residency in FP that I'm going to see if my program will allow me to volunteer in a free primary care clinic on Saturdays when I'm not working and during my vacation time to keep my medical skills "fresh."

 

[ZBend]

I felt the same way you did during the first 3 years of residency. I was contemplating doing FM or EM and working in urgent care or an ED.

At this point, as a 4th year, I will go out there and make a living with psych and see what happens. I may do a fellowship or I may do another residency in the future.

I find myself getting bored no matter what specialty I am rotating through. Everything becomes repetitive. I have found that reading up on areas that interest me help.

Thanks It's actually really comforting to read your post. I have talked to the other residents in my program and all of our attendings and I was the only one who missed medicine and was kinda feeling like an oddball.

I took one of those quizzes to see what medical specialty is a good fit for you (I wasn't going to let a quiz determine my future or anything) and I am one of those people who is totally content about knowing a little about everything, EXCEPT psychotherapy. FP is perfect for someone who likes to know a little about everything but they can't do psychotherapy (well, they could but they couldn't do it well I guess).

As for the combined residency, it'd be quicker, but I am actually switching from my current psychiatry residency (our pd left and what followed were a lot of problems and uncertainties within the program) to another psych residency, so that's probably enough switching for now. And, I don't live in a state where there is a combined program and I am not looking to move. I am so certain that I want to do a second residency in FP that I'm going to see if my program will allow me to volunteer in a free primary care clinic on Saturdays when I'm not working and during my vacation time to keep my medical skills "fresh."

My dilemma is that everyone seems to give me the same advice of doing what I'm interested in, but things are trickier than that. I like diagnosing and treating "mundane" things like hypertension and diabetes and doing the occasional procedure, but once you start talking about intracellular pathways or receptors, I zone out.

On the other hand, I find myself drawn to knowing more about the pathophysiologic and neurochemical origins of psychiatric diseases, but I feel like I might get bored with seeing mostly depression or bipolar patients (or any of the bread and butter psych cases) all day and only managing their psychiatric conditions.

It's weird because I know I wouldn't really want to do general primary care full-time, but just doing psych cases just doesn't feel like enough at this moment.

 

[futuredo32]

My dilemma is that everyone seems to give me the same advice of doing what I'm interested in, but things are trickier than that. I like diagnosing and treating "mundane" things like hypertension and diabetes and doing the occasional procedure, but once you start talking about intracellular pathways or receptors, I zone out.

On the other hand, I find myself drawn to knowing more about the pathophysiologic and neurochemical origins of psychiatric diseases, but I feel like I might get bored with seeing mostly depression or bipolar patients (or any of the bread and butter psych cases) all day and only managing their psychiatric conditions.

It's weird because I know I wouldn't really want to do general primary care full-time, but just doing psych cases just doesn't feel like enough at this moment.

If I were a med student in your shoes, I'd apply to a combined fp/psych or im/psych. For a lot of reasons, people tend to end up practicing one and not the other from some posts I've read on the board, but some people practice both and i think it's 5 years. If nothing else, it will buy you more time to decide. Even if I left psych and did fp tomorrow, the knowledge and skills I've gained in psych thus far would really help in fp Just my two cents. A lot of people think the combined residency isn't such a good idea because you don't get as much of either and kinda get short changed, but someone very wise told me to think of residency as a foundation, the learning doesn't stop after residency, it's just something to build on.

 

[F0nzie]

After feeling competent enough to practice psychiatry after 3 years of residency, I was quite frustrated with having to do a 4th year. How long is this going to drag out, right? To my surprise, I have found 4th year quite refreshing. I was able to disengage from the same old grind and revitalize specific interests within the field. This balanced approach that was lacking in the first 3 years of residency seemed to magnify my sense of loss for not choosing another field in medicine.

I also think Psychiatry is one of the harder fields (mental marathon) if you plan on doing the exact same thing for 40 hours a week. You hear about other residents in medicine getting stressed out when they anticipate that one difficult patient is going to take up all their time. After working full schedules in Psychiatry, I sure wouldn't mind seeing some relatively stable individuals for some friendly chit chat who just need me to look in their throat or listen to their lungs.

The job prospects in Psychiatry are very good. There is such a great need that you can work 20 hours here, 10 hours there, or start a private practice on the side. Many other fields with job market saturation cannot say this. A lot of psychiatrists take advantage of this to keep things fresh. In some cases, it may even help you maximize your earning potential.

 

[nitemagi]

Boredom is common throughout all of medicine, especially in primary care.

There are niches quite unfilled for psychiatrists who are competent and willing to manage primary care issues, as well as high quality psychosomatics (C/L in hospitals being one aspect). There's also an open niche for psychiatrists that are GOOD at psychotherapy. Most aren't. Even fewer are good at more than one.

While medicine can seem appealing [Hey I applied to IM/Psych residencies too], ultimately boredom comes when you've reached a level of mastery over a topic and are only continuing to do the same thing the same way without challenge. There is nearly Always a next level to the work.

Examples to challenge yourself - what kinds of therapy skills can I develop to convince a skeptical patient to take their prescribed medication? How about learning and using a brief therapy to improve someone's mood in a session when they're severely depressed and can feel the benefit and optimism? How about using therapy to help someone who doesn't want to cooperate with being helped, or sabotages it (eg brief strategic therapy, or paradoxical therapies). How about mastering treatment for Psychosomatics subspecialties to be an expert consultant for other medical specialties (psychoderm, psycho-oncology). How about mastering tx for conversion disorders? How about mastering medication mgmt for the diabetes or insulin resistance of an antipsychotic, AND getting them to consistently use it?

These are real challenges within our specialty that vastly underserved, and can all involve using your medical knowledge and psychotherapy training (though may require you to do MORE psychotherapy training than you've done so far).

While I get the appeal of going back to medicine, I think the tradeoff may not be worth it -- the time you have to spend with medical pt's negates any real psychotherapy time with them. I think a larger opportunity would be to become an outstanding clinician who treats the people who fall between the cracks, who aren't well treated by traditional psychiatry, or by traditional medicine (plenty are marginalized or turfed by both).

Just my thoughts. The need and the challenge exists in treating those others don't, which is the in-between. You can do that as a psychiatrist who masters treatment of medical conditions within psychiatric, and good therapy. Which may involve a C/L fellowship.

 

[BlueLotus]

I'm glad to see this discussion!

I thought that I may know my preferred career path during my TRI. It is helpful to know that sometimes these paths are not clear even after nearly completing the degree!

The APA 2010 resident census listed 5 D.O.s, 40 M.D.s, and 13 IMGs who filled the 58 PGY-1 combined program slots. Applicant numbers and details were not listed, though it appears that it may be more difficult for D.O.s to match into these programs.

I didn't know that it may be possible to train in FM after completing a Psych degree. A creative way to do both is good, too!

 

[Armadillos]

After feeling competent enough to practice psychiatry after 3 years of residency, I was quite frustrated with having to do a 4th year. How long is this going to drag out, right? To my surprise, I have found 4th year quite refreshing. I was able to disengage from the same old grind and revitalize specific interests within the field. This balanced approach that was lacking in the first 3 years of residency seemed to magnify my sense of loss for not choosing another field in medicine.

I also think Psychiatry is one of the harder fields (mental marathon) if you plan on doing the exact same thing for 40 hours a week. You hear about other residents in medicine getting stressed out when they anticipate that one difficult patient is going to take up all their time. After working full schedules in Psychiatry, I sure wouldn't mind seeing some relatively stable individuals for some friendly chit chat who just need me to look in their throat or listen to their lungs.

The job prospects in Psychiatry are very good. There is such a great need that you can work 20 hours here, 10 hours there, or start a private practice on the side. Many other fields with job market saturation cannot say this. A lot of psychiatrists take advantage of this to keep things fresh. In some cases, it may even help you maximize your earning potential.

Could you expand in this a little bit more?

At first glance to me it seems somewhat counter intuitive that you like 4th year more, but its also making you miss other fields of medicine more than before? Is it just that you have more "time to think" now so your realizing it more, or is it more related to the fact you feel like you now have a better understanding of the full scope of what it means to be a psychiatrist and it makes you miss other aspects of medicine?

 

[michaelrack]

. A lot of people think the combined residency isn't such a good idea because you don't get as much of either and kinda get short changed, but someone very wise told me to think of residency as a foundation, the learning doesn't stop after residency, it's just something to build on.

The combined residencies aren't as good at building a foundation in psychotherapy as most straight psych programs.

 

[futuredo32]

I'm glad to see this discussion!

I thought that I may know my preferred career path during my TRI. It is helpful to know that sometimes these paths are not clear even after nearly completing the degree!

The APA 2010 resident census listed 5 D.O.s, 40 M.D.s, and 13 IMGs who filled the 58 PGY-1 combined program slots. Applicant numbers and details were not listed, though it appears that it may be more difficult for D.O.s to match into these programs.

I didn't know that it may be possible to train in FM after completing a Psych degree. A creative way to do both is good, too!

It's kinda sad, but I did a TRI before psych. I did a TRI for other reasons, not because I was undecided. I was 100% "sure" I wanted to do psych, and then when my TRI was nearly over and I matched into psych, I had doubts.

There's no guarantee of getting a fp residency after a psych residency.

 

[futuredo32]

Boredom is common throughout all of medicine, especially in primary care.


Just my thoughts. The need and the challenge exists in treating those others don't, which is the in-between. You can do that as a psychiatrist who masters treatment of medical conditions within psychiatric, and good therapy. Which may involve a C/L fellowship.

It could be because I'n not a primary care attending, but the variety of conditions you see in a primary clinic makes it seem impossible for it to be boring.

I think for a lot of people, C/L is a great choice. Personally, I love the doctor patient relationship that evolves over time in both psych and fp, so for me, I don't see that this option would work for me.

 

[ZBend]

If I were a med student in your shoes, I'd apply to a combined fp/psych or im/psych. For a lot of reasons, people tend to end up practicing one and not the other from some posts I've read on the board, but some people practice both and i think it's 5 years. If nothing else, it will buy you more time to decide. Even if I left psych and did fp tomorrow, the knowledge and skills I've gained in psych thus far would really help in fp Just my two cents. A lot of people think the combined residency isn't such a good idea because you don't get as much of either and kinda get short changed, but someone very wise told me to think of residency as a foundation, the learning doesn't stop after residency, it's just something to build on.

It could be because I'n not a primary care attending, but the variety of conditions you see in a primary clinic makes it seem impossible for it to be boring.

I think for a lot of people, C/L is a great choice. Personally, I love the doctor patient relationship that evolves over time in both psych and fp, so for me, I don't see that this option would work for me.

Yeah, I'm still trying to figure things out and a combined program might be the solution. Even if I end up doing one of them primarily, at least I won't have any lingering doubts. Still, I'm gonna have to think about this more since I really am just lost at the moment.

C/L confuses me though. I tried looking it up and none of the explanations really helped. What do they do exactly? Are they taking care of a psych patient's diabetes/HTN/etc, or are they simply taking care of the psych problems of a generally complicated patient? I haven't found a specific explanation of what their daily work is like and I'd appreciate any clarification on this.

 

[nitemagi]

It could be because I'n not a primary care attending, but the variety of conditions you see in a primary clinic makes it seem impossible for it to be boring.

I think for a lot of people, C/L is a great choice. Personally, I love the doctor patient relationship that evolves over time in both psych and fp, so for me, I don't see that this option would work for me.

Inpatient/Hospital C/L is the primary but not only model for C/L related work. Outpatient specialization in Psychosomatic conditions could allow for both - an ongoing relationship, and treatment of medically related psychiatric conditions.

The biggest issues for physicians after 10 yrs of practice are boredom and burnout. I hear a lot more of boredom from PCP's (while there's a breadth of illnesses, the mgmt is very routine). I'm never bored because not only are there constant surprises, but every case feels like a challenge. So often we set limits mentally as to what we can do and can't do, essentially turfing many cases as unsolvable. But by asking the question "If I pretend this actually is a case that has a solution, what would it be?" -- Then I'm more interested in thinking outside the box, reading whatever I can get my hands on, and challenging myself to be a better clinician and not be satisfied with the status quo.

I frankly don't believe that it's the number of conditions treated that makes something interesting. If you find psych conditions BORING, that's something else. Then you very well may be in the wrong specialty. If you're Bored because you don't feel challenged, then I'd say again you're looking to solve that via breadth what may be solved through exploring depth in your clinical work.

 

[vistaril]

Yeah, I'm still trying to figure things out and a combined program might be the solution. Even if I end up doing one of them primarily, at least I won't have any lingering doubts. Still, I'm gonna have to think about this more since I really am just lost at the moment.

C/L confuses me though. I tried looking it up and none of the explanations really helped. What do they do exactly? Are they taking care of a psych patient's diabetes/HTN/etc, or are they simply taking care of the psych problems of a generally complicated patient? I haven't found a specific explanation of what their daily work is like and I'd appreciate any clarification on this.

imo, there is no such thing as a 'C/L psychiatrist' anymore than there is such a thing as a consult-liason urologist, surgeon, cardiologist, etc.......C/L psychiatrists may be consulted when a pt on some other service of the hospital(medicine, surgery, ob, rehab, etc) has an issue where psychiatric care may benefit them(ideally during their hospitalization). There are certain areas where C/L psychiatrists see more than someone not working on a consult service.....conversion d/o and capacity evals being two obvious examples. I like consults, but the majority of what you are going to see as a C/L psychiatrist are bread and butter psych. And no, as a C/L psychiatrist you do not take care of DM or HTN.

 

[F0nzie]

Could you expand in this a little bit more?

At first glance to me it seems somewhat counter intuitive that you like 4th year more, but its also making you miss other fields of medicine more than before? Is it just that you have more "time to think" now so your realizing it more, or is it more related to the fact you feel like you now have a better understanding of the full scope of what it means to be a psychiatrist and it makes you miss other aspects of medicine?

All I am saying is that 4th year gave me the opportunity to focus on aspects of psychiatry that interested me. Which made me miss medicine less. It was an unexpected outcome. The drive to seek gratification from primary care was replaced by very interesting niches within Psychiatry.

 

[futuredo32]

I frankly don't believe that it's the number of conditions treated that makes something interesting. If you find psych conditions BORING, that's something else. Then you very well may be in the wrong specialty. If you're Bored because you don't feel challenged, then I'd say again you're looking to solve that via breadth what may be solved through exploring depth in your clinical work.

In inpatient, I find the patients so similar and the evals are monotonous beyond belief and a lot of nights, I feel like I see the same pt 5 times in a row. Some nights, the pts are really almost the same except a few details.

In outpt (we did 12 months of outpt before any inpt), I have mostly therapy/med pts and not so many med mgmt only pts. I enjoy my appt's with my outpt therapy pts and they don't bore me, I like the dr/pt relationship I have with each of them and I focus more on that than the way the serotonin receptors do this or that. BUT, to hear an attending or another resident talk about "an interesting case", that bores me to tears. So, I guess I find my pts interesting because they are my pts and I like the dr/pt relationship and constantly making sure the rapport is good and trying to keep the therapeutic alliance strong.

 

[Armadillos]

All I am saying is that 4th year gave me the opportunity to focus on aspects of psychiatry that interested me. Which made me miss medicine less. It was an unexpected outcome. The drive to seek gratification from primary care was replaced by very interesting niches within Psychiatry.

O gotcha, I must have misread your other post, I thought you were saying the opposite