Yet another ask a resident thread - psychiatry edition

[NickNaylor]

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Hi everyone.

Throughout my training and long time here on SDN, I've done a variety of ask-me threads dating back to M1. My SDN use has fallen off lately, but I did want to open myself up to questions about psychiatry, what being a psychiatry resident is like, and more about getting into this outstanding field.

This is not a thread for questions about getting into medical school. There are plenty of other threads in this forum for those kinds of questions.

As psychiatry is becoming a more popular field lately - and yet is something you get fairly little exposure to in medical school and, really, in "real life" beyond media characterizations of psychiatry and mental health - I thought a realistic look into the field would be interesting for our soon-to-be medical students and, eventually, physicians.

So, ask away. What questions do you have about psychiatry, the work of a psychiatrist, the career, or anything else related to the field? I'm happy to answer any questions as candidly as I can.

 

[surfguy84]

Thanks for your time here...

What are the best things I can do as an M2 to bolster my psychiatry application, outside of doing well in classes and boards?

I've received various opinions in regards to psychiatry compensation. Some have told me to re-consider given low pay. Others have painted a much brighter picture, particularly given the increased emphasis on mental health and shortage of doctors in this field. What are you feelings here? How easily can a psychiatrist net 300k yearly?

 

[kb1900]

How does one get into child and adolescent psychiatry? Is it a fellowship program? Are these fellowships rare/hard to come by?

What are a few of the most common day-to-day tasks for psychiatrists? (I only shadowed a child psychiatrist at a big academic place and it was basically all just semi structured clinical interviewing 5-6 pts per day and diagnosing/writing case reports/prescribing).

How's the work/life balance as a resident at your program? Is it respresentative of most programs in the field?

What are your thoughts on the pt population and geographic location of where you'd like to eventually practice? (For example, in my hometown you practically have to drive 60 miles to get to a psychiatrist, but mental health social workers/counselers/therapists are more accessible)

Thank you for taking the time to do this! I'm sorry if a lot of these questions could've been answered by shadowing.

 

[NickNaylor]

Thanks for your time here...

What are the best things I can do as an M2 to bolster my psychiatry application, outside of doing well in classes and boards?

I've received various opinions in regards to psychiatry compensation. Some have told me to re-consider given low pay. Others have painted a much brighter picture, particularly given the increased emphasis on mental health and shortage of doctors in this field. What are you feelings here? How easily can a psychiatrist net 300k yearly?

The good news is that psychiatry remains, in general, a fairly non-competitive field. The primary exception to that is obviously the "prestigious" programs (e.g., Mass Gen), but in general it is not that difficult to get into a well-regarded program even as an average medical student.

The things you can do as an M2 are really the same general things for all fields: do well in your courses, do well on step 1, get involved with research if you can, and, if you know that you're interested in psych, try and get involved with psych-specific organizations (for example, your local psychiatry interest group, the APA, think about attending conferences, etc.). Really try and figure out if you actually want to be a psychiatrist. More so I think than in other fields, it is important to really be interested in psychiatry and interested in treating the patient population that we treat. However, the primary goal in medical school is to learn as much as you can so that you can step into your role as a physician smoothly and confidently. If you do that, regardless of the field I don't think you will have any trouble.

Regarding pay, this is a difficult question to answer as there are so many things that factor into that decision. Is it possible to make $300k out of residency? Yes. I know, for example, that a private, free-standing psych hospital near me pays that as a starting salary for new residents for 40 hours/week in the ED. The downside is that the shifts are irregular, but the pay can't be beat and you can take on additional shifts if you'd like for even more pay. $300k out of residency in an academic position is a hard sell. I would expect around $200k for an academic position though there is obviously some variability there - some places (notably large metro areas where there is an abundance of psychiatrists) will pay less while others pay more. The setting of your practice, your geographic location, your ability to market yourself, the specific responsibilities of a position, etc. all play a role in your salary.

The other benefit from an earnings perspective is that it isn't uncommon to do multiple things in psychiatry. For example, a not insignificant faculty at my program also have a part-time private practice in addition to their inpatient work. This is something that is dependent upon your contract with your "primary" employer, but many psychiatrists have their hands in a lot of different pots: perhaps a primary inpatient job with some occasional ED shifts, locums work, or their own private practice.

The point is that, from an earnings potential, psychiatry can be very lucrative. It all depends on your willingness to put in the hours and make your salary a point of emphasis. For the industrious person, though, it can be very lucrative. But that isn't a guarantee. As with all things, there are upsides and downsides to that approach. Many people get into psychiatry because it is a relatively non-rigorous path compared to the general spectrum of medical specialties. I think most people don't have that drive or interest. But if you do, you can certainly make a nice living as a psychiatrist.

 

[NickNaylor]

Thanks for your time here...

What are the best things I can do as an M2 to bolster my psychiatry application, outside of doing well in classes and boards?

I've received various opinions in regards to psychiatry compensation. Some have told me to re-consider given low pay. Others have painted a much brighter picture, particularly given the increased emphasis on mental health and shortage of doctors in this field. What are you feelings here? How easily can a psychiatrist net 300k yearly?

The good news is that psychiatry remains, in general, a fairly non-competitive field. The primary exception to that is obviously the "prestigious" programs (e.g., Mass Gen), but in general it is not that difficult to get into a well-regarded program even as an average medical student.

The things you can do as an M2 are really the same general things for all fields: do well in your courses, do well on step 1, get involved with research if you can, and, if you know that you're interested in psych, try and get involved with psych-specific organizations (for example, your local psychiatry interest group, the APA, think about attending conferences, etc.). Really try and figure out if you actually want to be a psychiatrist. More so I think than in other fields, it is important to really be interested in psychiatry and interested in treating the patient population that we treat. However, the primary goal in medical school is to learn as much as you can so that you can step into your role as a physician smoothly and confidently. If you do that, regardless of the field I don't think you will have any trouble.

Regarding pay, this is a difficult question to answer as there are so many things that factor into that decision. Is it possible to make $300k out of residency? Yes. I know, for example, that a private, free-standing psych hospital near me pays that as a starting salary for new residents for 40 hours/week in the ED. The downside is that the shifts are irregular, but the pay can't be beat and you can take on additional shifts if you'd like for even more pay. $300k out of residency in an academic position is a hard sell. I would expect around $200k for an academic position though there is obviously some variability there - some places (notably large metro areas where there is an abundance of psychiatrists) will pay less while others pay more. The setting of your practice, your geographic location, your ability to market yourself, the specific responsibilities of a position, etc. all play a role in your salary.

The other benefit from an earnings perspective is that it isn't uncommon to do multiple things in psychiatry. For example, a not insignificant faculty at my program also have a part-time private practice in addition to their inpatient work. This is something that is dependent upon your contract with your "primary" employer, but many psychiatrists have their hands in a lot of different pots: perhaps a primary inpatient job with some occasional ED shifts, locums work, or their own private practice.

The point is that, from an earnings potential, psychiatry can be very lucrative. It all depends on your willingness to put in the hours and make your salary a point of emphasis. For the industrious person, though, it can be very lucrative. But that isn't a guarantee. As with all things, there are upsides and downsides to that approach. Many people get into psychiatry because it is a relatively non-rigorous path compared to the general spectrum of medical specialties. I think most people don't have that drive or interest. But if you do, you can certainly make a nice living as a psychiatrist.

 

[NickNaylor]

How does one get into child and adolescent psychiatry? Is it a fellowship program? Are these fellowships rare/hard to come by?

What are a few of the most common day-to-day tasks for psychiatrists? (I only shadowed a child psychiatrist at a big academic place and it was basically all just semi structured clinical interviewing 5-6 pts per day and diagnosing/writing case reports/prescribing).

How's the work/life balance as a resident at your program? Is it respresentative of most programs in the field?

What are your thoughts on the pt population and geographic location of where you'd like to eventually practice? (For example, in my hometown you practically have to drive 60 miles to get to a psychiatrist, but mental health social workers/counselers/therapists are more accessible)

Thank you for taking the time to do this! I'm sorry if a lot of these questions could've been answered by shadowing.

Child/adolescent psychiatry (CAP) fellowships - as are most psychiatric subspecialties - are generally uncompetitive. Many programs go unfilled. As mentioned above, there are obviously exceptions for the more prestigious programs. CAP is probably the most popular of the fellowships, and many programs allow you to "fast track" such that you cut a year off your general training to go into the CAP fellowship, allowing you to graduate a year early (in 5 years instead of 6). Some of the specialties are less accessible than others. Forensics is probably the least accessible but even then there are plenty of programs.

The day-to-day work depends a lot on your setting. In outpatient work, you're spending anywhere from 15-45 minutes seeing follow-ups and 45-90 minutes for new patients. Most of that is medication management though some psychiatrists (usually in a cash-only setting) also see therapy patients. In inpatient work, you round on your established patients and, with new admissions, evaluate the new patients and come up with a plan. Usually there's some component of call - for example, approving new admissions, dealing with overnight issues, etc.. Depending on the setting, you may also have some outpatient or consult duties in addition to working on a dedicated inpatient unit. Again, the specific arrangement is highly variable.

It's tough to generalize work-life balance across all programs. I can say that for my own program I'm quite happy with where I am on that spectrum. Yes, there are times that I'm busy, tired, and run-down, but in general I think residency pales in comparison to my medical school experience (even when I'm taking q4day overnight home call). Is this true at all programs? Hard to say: probably not, but as I've only been at one program that's the only experience I know fairly well. Some have rigorous off-service experiences; for example, psychiatry interns may rotate in the ICU for their internal medicine months. This wasn't the case for me, which obviously makes those months easier. Some have more extensive call schedules. There's so much variability in how these things are structured that it's difficult to predict for any one program how the work-life balance will be. I would say that, in general, though, the balance for psychiatry residents is generally superior to that of our colleagues in other fields.

I will likely practice in the area that I'm currently training in. My wife and I bought a house, we have family here, etc. so we are pretty well-settled. For now I think I'd like to take an academic position out of residency and see how that goes. If I like it, then I'll likely stay in academia, get involved with teaching, etc. If I don't, then I'll probably go to the burbs and start my own practice. Obviously the populations you see will depend a lot on the setting you find yourself in. We rotate at a few different sites, each with different populations: the county hospital (obviously lots of indigent patients with limited resources), the private university hospital (generally a wealthier population), and the VA (generally similar in broad strokes to the county hospital, just with veterans). Each populations has it's strengths and weaknesses; for example, it can be frustrating dealing with the lack of resources when treating indigent patients, while, on the other hand, dealing with high-maintenance families and patients in the university hospital can be draining and, at times, more difficult than the former population. I'm less familiar with psychiatry in the rural setting as all of my training has been done in fairly large metro areas.

 

[NickNaylor]

How does one get into child and adolescent psychiatry? Is it a fellowship program? Are these fellowships rare/hard to come by?

What are a few of the most common day-to-day tasks for psychiatrists? (I only shadowed a child psychiatrist at a big academic place and it was basically all just semi structured clinical interviewing 5-6 pts per day and diagnosing/writing case reports/prescribing).

How's the work/life balance as a resident at your program? Is it respresentative of most programs in the field?

What are your thoughts on the pt population and geographic location of where you'd like to eventually practice? (For example, in my hometown you practically have to drive 60 miles to get to a psychiatrist, but mental health social workers/counselers/therapists are more accessible)

Thank you for taking the time to do this! I'm sorry if a lot of these questions could've been answered by shadowing.

Child/adolescent psychiatry (CAP) fellowships - as are most psychiatric subspecialties - are generally uncompetitive. Many programs go unfilled. As mentioned above, there are obviously exceptions for the more prestigious programs. CAP is probably the most popular of the fellowships, and many programs allow you to "fast track" such that you cut a year off your general training to go into the CAP fellowship, allowing you to graduate a year early (in 5 years instead of 6). Some of the specialties are less accessible than others. Forensics is probably the least accessible but even then there are plenty of programs.

The day-to-day work depends a lot on your setting. In outpatient work, you're spending anywhere from 15-45 minutes seeing follow-ups and 45-90 minutes for new patients. Most of that is medication management though some psychiatrists (usually in a cash-only setting) also see therapy patients. In inpatient work, you round on your established patients and, with new admissions, evaluate the new patients and come up with a plan. Usually there's some component of call - for example, approving new admissions, dealing with overnight issues, etc.. Depending on the setting, you may also have some outpatient or consult duties in addition to working on a dedicated inpatient unit. Again, the specific arrangement is highly variable.

It's tough to generalize work-life balance across all programs. I can say that for my own program I'm quite happy with where I am on that spectrum. Yes, there are times that I'm busy, tired, and run-down, but in general I think residency pales in comparison to my medical school experience (even when I'm taking q4day overnight home call). Is this true at all programs? Hard to say: probably not, but as I've only been at one program that's the only experience I know fairly well. Some have rigorous off-service experiences; for example, psychiatry interns may rotate in the ICU for their internal medicine months. This wasn't the case for me, which obviously makes those months easier. Some have more extensive call schedules. There's so much variability in how these things are structured that it's difficult to predict for any one program how the work-life balance will be. I would say that, in general, though, the balance for psychiatry residents is generally superior to that of our colleagues in other fields.

I will likely practice in the area that I'm currently training in. My wife and I bought a house, we have family here, etc. so we are pretty well-settled. For now I think I'd like to take an academic position out of residency and see how that goes. If I like it, then I'll likely stay in academia, get involved with teaching, etc. If I don't, then I'll probably go to the burbs and start my own practice. Obviously the populations you see will depend a lot on the setting you find yourself in. We rotate at a few different sites, each with different populations: the county hospital (obviously lots of indigent patients with limited resources), the private university hospital (generally a wealthier population), and the VA (generally similar in broad strokes to the county hospital, just with veterans). Psychiatric illness affects all of these populations, though there are some things that are more common in one population over the other (for example, substance use is generally more common in our indigent patients than our insured patients). Each populations has it's strengths and weaknesses; for example, it can be frustrating dealing with the lack of resources when treating indigent patients, while, on the other hand, dealing with high-maintenance families and patients in the university hospital can be draining and, at times, more difficult than the former population. I'm less familiar with psychiatry in the rural setting as all of my training has been done in fairly large metro areas.

 

[NickNaylor]

How does one get into child and adolescent psychiatry? Is it a fellowship program? Are these fellowships rare/hard to come by?

What are a few of the most common day-to-day tasks for psychiatrists? (I only shadowed a child psychiatrist at a big academic place and it was basically all just semi structured clinical interviewing 5-6 pts per day and diagnosing/writing case reports/prescribing).

How's the work/life balance as a resident at your program? Is it respresentative of most programs in the field?

What are your thoughts on the pt population and geographic location of where you'd like to eventually practice? (For example, in my hometown you practically have to drive 60 miles to get to a psychiatrist, but mental health social workers/counselers/therapists are more accessible)

Thank you for taking the time to do this! I'm sorry if a lot of these questions could've been answered by shadowing.

Child/adolescent psychiatry (CAP) fellowships - as are most psychiatric subspecialties - are generally uncompetitive. Many programs go unfilled. As mentioned above, there are obviously exceptions for the more prestigious programs. CAP is probably the most popular of the fellowships, and many programs allow you to "fast track" such that you cut a year off your general training to go into the CAP fellowship, allowing you to graduate a year early (in 5 years instead of 6). Some of the specialties are less accessible than others. Forensics is probably the least accessible but even then there are plenty of programs.

The day-to-day work depends a lot on your setting. In outpatient work, you're spending anywhere from 15-45 minutes seeing follow-ups and 45-90 minutes for new patients. Most of that is medication management though some psychiatrists (usually in a cash-only setting) also see therapy patients. In inpatient work, you round on your established patients and, with new admissions, evaluate the new patients and come up with a plan. Usually there's some component of call - for example, approving new admissions, dealing with overnight issues, etc.. Depending on the setting, you may also have some outpatient or consult duties in addition to working on a dedicated inpatient unit. Again, the specific arrangement is highly variable.

It's tough to generalize work-life balance across all programs. I can say that for my own program I'm quite happy with where I am on that spectrum. Yes, there are times that I'm busy, tired, and run-down, but in general I think residency pales in comparison to my medical school experience (even when I'm taking q4day overnight home call). Is this true at all programs? Hard to say: probably not, but as I've only been at one program that's the only experience I know fairly well. Some have rigorous off-service experiences; for example, psychiatry interns may rotate in the ICU for their internal medicine months. This wasn't the case for me, which obviously makes those months easier. Some have more extensive call schedules. There's so much variability in how these things are structured that it's difficult to predict for any one program how the work-life balance will be. I would say that, in general, though, the balance for psychiatry residents is generally superior to that of our colleagues in other fields.

I will likely practice in the area that I'm currently training in. My wife and I bought a house, we have family here, etc. so we are pretty well-settled. For now I think I'd like to take an academic position out of residency and see how that goes. If I like it, then I'll likely stay in academia, get involved with teaching, etc. If I don't, then I'll probably go to the burbs and start my own practice. Obviously the populations you see will depend a lot on the setting you find yourself in. We rotate at a few different sites, each with different populations: the county hospital (obviously lots of indigent patients with limited resources), the private university hospital (generally a wealthier population), and the VA (generally similar in broad strokes to the county hospital, just with veterans). Psychiatric illness affects all of these populations, though there are some things that are more common in one population over the other (for example, substance use is generally more common in our indigent patients than our insured patients). Each population has it's strengths and weaknesses; for example, it can be frustrating dealing with the lack of resources when treating indigent patients, while, on the other hand, dealing with high-maintenance families and patients in the university hospital can be draining and, at times, more difficult than the former population. I'm less familiar with psychiatry in the rural setting as all of my training has been done in fairly large metro areas.

 

[NickNaylor]

How does one get into child and adolescent psychiatry? Is it a fellowship program? Are these fellowships rare/hard to come by?

What are a few of the most common day-to-day tasks for psychiatrists? (I only shadowed a child psychiatrist at a big academic place and it was basically all just semi structured clinical interviewing 5-6 pts per day and diagnosing/writing case reports/prescribing).

How's the work/life balance as a resident at your program? Is it respresentative of most programs in the field?

What are your thoughts on the pt population and geographic location of where you'd like to eventually practice? (For example, in my hometown you practically have to drive 60 miles to get to a psychiatrist, but mental health social workers/counselers/therapists are more accessible)

Thank you for taking the time to do this! I'm sorry if a lot of these questions could've been answered by shadowing.

Child/adolescent psychiatry (CAP) fellowships - as are most psychiatric subspecialties - are generally uncompetitive. Many programs go unfilled. As mentioned above, there are obviously exceptions for the more prestigious programs. CAP is probably the most popular of the fellowships, and many programs allow you to "fast track" such that you cut a year off your general training to go into the CAP fellowship, allowing you to graduate a year early (in 5 years instead of 6). Some of the specialties are less accessible than others. Forensics is probably the least accessible but even then there are plenty of programs.

The day-to-day work depends a lot on your setting. In outpatient work, you're spending anywhere from 15-45 minutes seeing follow-ups and 45-90 minutes for new patients. Most of that is medication management though some psychiatrists (usually in a cash-only setting) also see therapy patients. In inpatient work, you round on your established patients and, with new admissions, evaluate the new patients and come up with a plan. Usually there's some component of call - for example, approving new admissions, dealing with overnight issues, etc.. Depending on the setting, you may also have some outpatient or consult duties in addition to working on a dedicated inpatient unit. Again, the specific arrangement is highly variable.

It's tough to generalize work-life balance across all programs. I can say that for my own program I'm quite happy with where I am on that spectrum. Yes, there are times that I'm busy, tired, and run-down, but in general I think residency pales in comparison to my medical school experience (even when I'm taking q4day overnight home call). Is this true at all programs? Hard to say: probably not, but as I've only been at one program that's the only experience I know fairly well. Some have rigorous off-service experiences; for example, psychiatry interns may rotate in the ICU for their internal medicine months. This wasn't the case for me, which obviously makes those months easier. Some have more extensive call schedules. There's so much variability in how these things are structured that it's difficult to predict for any one program how the work-life balance will be. I would say that, in general, though, the balance for psychiatry residents is generally superior to that of our colleagues in other fields.

I will likely practice in the area that I'm currently training in. My wife and I bought a house, we have family here, etc. so we are pretty well-settled. For now I think I'd like to take an academic position out of residency and see how that goes. If I like it, then I'll likely stay in academia, get involved with teaching, etc. If I don't, then I'll probably go to the burbs and start my own practice. Obviously the populations you see will depend a lot on the setting you find yourself in. We rotate at a few different sites, each with different populations: the county hospital (obviously lots of indigent patients with limited resources), the private university hospital (generally a wealthier population), and the VA (generally similar in broad strokes to the county hospital, just with veterans). Psychiatric illness affects all of these populations, though there are some things that are more common in one population over the other (for example, substance use is generally more common in our indigent patients than our insured patients). Each population has it's strengths and weaknesses; for example, it can be frustrating dealing with the lack of resources when treating indigent patients, while, on the other hand, dealing with high-maintenance families and patients in the university hospital can be draining and, at times, more difficult than the former population. I'm less familiar with psychiatry in the rural setting as all of my training has been done in fairly large metro areas.

 

[NickNaylor]

How does one get into child and adolescent psychiatry? Is it a fellowship program? Are these fellowships rare/hard to come by?

What are a few of the most common day-to-day tasks for psychiatrists? (I only shadowed a child psychiatrist at a big academic place and it was basically all just semi structured clinical interviewing 5-6 pts per day and diagnosing/writing case reports/prescribing).

How's the work/life balance as a resident at your program? Is it respresentative of most programs in the field?

What are your thoughts on the pt population and geographic location of where you'd like to eventually practice? (For example, in my hometown you practically have to drive 60 miles to get to a psychiatrist, but mental health social workers/counselers/therapists are more accessible)

Thank you for taking the time to do this! I'm sorry if a lot of these questions could've been answered by shadowing.

Child/adolescent psychiatry (CAP) fellowships - as are most psychiatric subspecialties - are generally uncompetitive. Many programs go unfilled. As mentioned above, there are obviously exceptions for the more prestigious programs. CAP is probably the most popular of the fellowships, and many programs allow you to "fast track" such that you cut a year off your general training to go into the CAP fellowship, allowing you to graduate a year early (in 5 years instead of 6). Some of the specialties are less accessible than others. Forensics is probably the least accessible but even then there are plenty of programs.

The day-to-day work depends a lot on your setting. In outpatient work, you're spending anywhere from 15-45 minutes seeing follow-ups and 45-90 minutes for new patients. Most of that is medication management though some psychiatrists (usually in a cash-only setting) also see therapy patients. In inpatient work, you round on your established patients and, with new admissions, evaluate the new patients and come up with a plan. Usually there's some component of call - for example, approving new admissions, dealing with overnight issues, etc.. Depending on the setting, you may also have some outpatient or consult duties in addition to working on a dedicated inpatient unit. Again, the specific arrangement is highly variable.

It's tough to generalize work-life balance across all programs. I can say that for my own program I'm quite happy with where I am on that spectrum. Yes, there are times that I'm busy, tired, and run-down, but in general I think residency pales in comparison to my medical school experience (even when I'm taking q4day overnight home call). Is this true at all programs? Hard to say: probably not, but as I've only been at one program that's the only experience I know fairly well. Some have rigorous off-service experiences; for example, psychiatry interns may rotate in the ICU for their internal medicine months. This wasn't the case for me, which obviously makes those months easier. Some have more extensive call schedules. There's so much variability in how these things are structured that it's difficult to predict for any one program how the work-life balance will be. I would say that, in general, though, the balance for psychiatry residents is generally superior to that of our colleagues in other fields.

I will likely practice in the area that I'm currently training in. My wife and I bought a house, we have family here, etc. so we are pretty well-settled. For now I think I'd like to take an academic position out of residency and see how that goes. If I like it, then I'll likely stay in academia, get involved with teaching, etc. If I don't, then I'll probably go to the burbs and start my own practice. Obviously the populations you see will depend a lot on the setting you find yourself in. We rotate at a few different sites, each with different populations: the county hospital (obviously lots of indigent patients with limited resources), the private university hospital (generally a wealthier population), and the VA (generally similar in broad strokes to the county hospital, just with veterans). Psychiatric illness affects all of these populations, though there are some things that are more common in one population over the other (for example, substance use is generally more common in our indigent patients than our insured patients). Each population has it's strengths and weaknesses; for example, it can be frustrating dealing with the lack of resources when treating indigent patients, while, on the other hand, dealing with high-maintenance families and patients in the university hospital can be draining and, at times, more difficult than the former population. I'm less familiar with psychiatry in the rural setting as all of my training has been done in fairly large metro areas.

 

[yanks26dmb]

Hi everyone.

Throughout my training and long time here on SDN, I've done a variety of ask-me threads dating back to M1. My SDN use has fallen off lately, but I did want to open myself up to questions about psychiatry, what being a psychiatry resident is like, and more about getting into this outstanding field.

This is not a thread for questions about getting into medical school. There are plenty of other threads in this forum for those kinds of questions.

As psychiatry is becoming a more popular field lately - and yet is something you get fairly little exposure to in medical school and, really, in "real life" beyond media characterizations of psychiatry and mental health - I thought a realistic look into the field would be interesting for our soon-to-be medical students and, eventually, physicians.

So, ask away. What questions do you have about psychiatry, the work of a psychiatrist, the career, or anything else related to the field? I'm happy to answer any questions as candidly as I can.

Thanks for doing this. Ive been drawn to psychiatry since day 1, but the lingering hold up for me is the worry I'll never get to practice any hands on medicine.

How has this been for you, and are there perhaps more physical aspects of psych that I may be unaware of?

One other q... I consider myself very much of the work to live mentality. Telepsych seems like a great way to see underserred patients while also maintaining your own balance. Any idea how hard it is to land these type of jobs and what going rate is?

Thanks for your time.

 

[NickNaylor]

How does one get into child and adolescent psychiatry? Is it a fellowship program? Are these fellowships rare/hard to come by?

What are a few of the most common day-to-day tasks for psychiatrists? (I only shadowed a child psychiatrist at a big academic place and it was basically all just semi structured clinical interviewing 5-6 pts per day and diagnosing/writing case reports/prescribing).

How's the work/life balance as a resident at your program? Is it respresentative of most programs in the field?

What are your thoughts on the pt population and geographic location of where you'd like to eventually practice? (For example, in my hometown you practically have to drive 60 miles to get to a psychiatrist, but mental health social workers/counselers/therapists are more accessible)

Thank you for taking the time to do this! I'm sorry if a lot of these questions could've been answered by shadowing.

Child/adolescent psychiatry (CAP) fellowships - as are most psychiatric subspecialties - are generally uncompetitive. Many programs go unfilled. As mentioned above, there are obviously exceptions for the more prestigious programs. CAP is probably the most popular of the fellowships, and many programs allow you to "fast track" such that you cut a year off your general training to go into the CAP fellowship, allowing you to graduate a year early (in 5 years instead of 6). Some of the specialties are less accessible than others. Forensics is probably the least accessible but even then there are plenty of programs.

The day-to-day work depends a lot on your setting. In outpatient work, you're spending anywhere from 15-45 minutes seeing follow-ups and 45-90 minutes for new patients. Most of that is medication management though some psychiatrists (usually in a cash-only setting) also see therapy patients. In inpatient work, you round on your established patients and, with new admissions, evaluate the new patients and come up with a plan. Usually there's some component of call - for example, approving new admissions, dealing with overnight issues, etc.. Depending on the setting, you may also have some outpatient or consult duties in addition to working on a dedicated inpatient unit. Again, the specific arrangement is highly variable.

It's tough to generalize work-life balance across all programs. I can say that for my own program I'm quite happy with where I am on that spectrum. Yes, there are times that I'm busy, tired, and run-down, but in general I think residency pales in comparison to my medical school experience (even when I'm taking q4day overnight home call). Is this true at all programs? Hard to say: probably not, but as I've only been at one program that's the only experience I know fairly well. Some have rigorous off-service experiences; for example, psychiatry interns may rotate in the ICU for their internal medicine months. This wasn't the case for me, which obviously makes those months easier. Some have more extensive call schedules. There's so much variability in how these things are structured that it's difficult to predict for any one program how the work-life balance will be. I would say that, in general, though, the balance for psychiatry residents is generally superior to that of our colleagues in other fields.

I will likely practice in the area that I'm currently training in. My wife and I bought a house, we have family here, etc. so we are pretty well-settled. For now I think I'd like to take an academic position out of residency and see how that goes. If I like it, then I'll likely stay in academia, get involved with teaching, etc. If I don't, then I'll probably go to the burbs and start my own practice. Obviously the populations you see will depend a lot on the setting you find yourself in. We rotate at a few different sites, each with different populations: the county hospital (obviously lots of indigent patients with limited resources), the private university hospital (generally a wealthier population), and the VA (generally similar in broad strokes to the county hospital, just with veterans). Psychiatric illness affects all of these populations, though there are some things that are more common in one population over the other (for example, substance use is generally more common in our indigent patients than our insured patients). Each population has it's strengths and weaknesses; for example, it can be frustrating dealing with the lack of resources when treating indigent patients, while, on the other hand, dealing with high-maintenance families and patients in the university hospital can be draining and, at times, more difficult than the former population. I'm less familiar with psychiatry in the rural setting as all of my training has been done in fairly large metro areas.

 

[Frogger27]

have you seen a rise in certain psychiatric disorders since the presidential election?

 

[PB&Jam]

What drove you to decide on psychiatry?

 

[Lucca]

Is forensic psychiatry still a thing? Do you know anything about it? Is academic psychiatry practice based mostly around med management and diagnosis or do academics still do things like therapy and psychoanalysis?

Thanks Nick!

 

[raf1ki]

What do you look forward to about psychiatry? The field is the one that turned me onto medicine in the first place, but as I learned more and more about it I saw that it is mostly medication management, while the clinical therapists have the time to get more hands on. Could you see yourself as interested in psychiatry if the academic side was removed from the equation and all of your time was spend with psychopharmacology?

 

[Benjoe11]

Do you ever miss blood/treating more visible issues not of the mind?? Im strongly considering child psych, I just worry I would miss more hands on illnesses.

 

[sliceofbread136]

What psych knowledge do you think would be essential to the non psychiatrist, say peds or im

 

[Goro]

Nick, I'm always interested in the paths people took. Why Psych for you???

Hi everyone.

Throughout my training and long time here on SDN, I've done a variety of ask-me threads dating back to M1. My SDN use has fallen off lately, but I did want to open myself up to questions about psychiatry, what being a psychiatry resident is like, and more about getting into this outstanding field.

 

[ciestar]

I have an interest in psych based on a more personal level, but Nick, what did you do while in med school to further explore your interest in psych? I am a member of my school's interest group but that's about it.

 

[aalamruad]

Do you feel that psych is stigmatized by your non-psych colleagues or those not involved in healthcare?

 

[NickNaylor]

have you seen a rise in certain psychiatric disorders since the presidential election?

No, although some of my colleagues have reported that some of their outpatients were quite distressed by the outcome of the election (mostly therapy patients).

 

[Pusheen]

Is there a lot of variety in your daily life and patient base or is it a lot of the same routine thing?

Do you feel more emotionally drained than you think you would be in another specialty?

 

[NickNaylor]

What drove you to decide on psychiatry?

Several different reasons - some noble, some more practical.

On the noble side:
1) I find the mind and human behavior fascinating. While people dealing with acute psychiatric complaints sucks, dysfunctional human behavior is just flat-out fascinating to me. I think psychosis is the most interesting thing I've ever learned about, seen, or treated in medicine.

2) Like all fields of medicine, psychiatry has the ability to very fundamentally improve the lives of psychiatric patients. The incredible improvements some people can demonstrate with psychiatric treatment are extremely satisfying. Taking out someone's gallbladder, performing a heart transplant, or throwing a stent in an atherosclerosed artery are all impressive feats that leave patients much better off than before they received treatment. By the same token, seeing a patient come to you with complaints of thinking the government is putting tracking devices in their electronics, hallucinating, and being completely unable to function, starting them on an antipsychotic, and seeing them regain most if not all of that function over a relatively short period of time is similarly impressive. To be fair, not all - or perhaps even most - patients have that kind of response. But for those that do, the work is incredibly satisfying, and you can fundamentally alter the trajectory of someone's like with psychiatric treatment.

3) I'm interested in how a particular diagnosis presents in an individual patient's life. Depression is depression and schizophrenia is schizophrenia, but the way those diseases manifest and impact patients' lives are incredibly unique and varied. It keeps the work interesting for me. Nearly every day on an inpatient unit a patient tells me about a unique experience that I've never heard of before.

4) I really wanted to get to know my patients. That was one of the draws of medicine for me. I found that no other field really delivered on that point as well as psychiatry.

And now the more practical:

1) Psychiatry is very much an in-demand field. There is no shortage of physicians, and in contrast to many of my colleagues there is no difficulty in finding jobs.

2) I wanted to have a say in where I matched. As psychiatry is fairly uncompetitive, opening the Match Day envelope is less of an uncertainty compared with other fields.

3) I wanted to have the freedom to spend time with my family when I eventually have kids. The same can't necessarily be said in other fields - and in others still the ability to have a high degree of control over your life can be rare - but in psych it is more the exception than the rule.

Those are just a few of the bigger points. I'm sure there are things that I'm missing, but from where I stand now those were the more important factors for me.

 

[NickNaylor]

Is forensic psychiatry still a thing? Do you know anything about it? Is academic psychiatry practice based mostly around med management and diagnosis or do academics still do things like therapy and psychoanalysis?

Thanks Nick!

1) Yes, forensic psychiatry is still a thing. I don't know much about it beyond that and to say that it is in HUGE demand where I currently am. There are only a small number (<5 from what I hear from the forensic psychology folks) of forensic psychiatrists in my multimillion person metroplex. At least in my neck of the woods, it is in very high demand. I'm guessing that's less the case in larger cities, though.

2) In general academic psychiatry is predominantly medication management, though even at my program there are psychiatrists that have psychotherapy patients or combined medication management and psychotherapy patients. There are a number of analysts (I can think of three off the top of my head) in the psychiatric faculty at my program.

The ability to do things outside of medication management is largely driven by two factors: personal interest and ability to get paid. Not all psychiatrists want to do psychotherapy. Hour for hour, medication management is more lucrative than psychotherapy when third party payers (insurance companies) are responsible for reimbursement. This is why many psychiatrists that are interested in doing a substantial amount of therapy open a cash-based practice: when you bill by the hour (instead of by the procedure), it doesn't matter what you do (i.e., medication management, psychotherapy, or both).

So yes, psychiatrists do both, though in the big scheme of things psychiatrists primarily stick with medication management while "cheaper" providers (from the perspective of, say, a hospital system) provide psychotherapy.

 

[NickNaylor]

What do you look forward to about psychiatry? The field is the one that turned me onto medicine in the first place, but as I learned more and more about it I saw that it is mostly medication management, while the clinical therapists have the time to get more hands on. Could you see yourself as interested in psychiatry if the academic side was removed from the equation and all of your time was spend with psychopharmacology?

I love psychopharmacology, so yes, I could see myself doing primarily medication management (though if I worked in the outpatient setting this is not what I currently see myself only doing). Psychotropic medications are without a doubt the most complex pharmaceutical agents that we use routinely in medicine. There is a lot to learn, and there is a lot of nuance to the agents even though we might think of them in broad classes like "antidepressants," "mood stabilizers," or "antipsychotics." I think that I would enjoy doing medication management outside of the academic setting because choosing an agent (or choosing not to use an agent) is very much about considering the nuances of the medications available to you and what you think is likely to work best for that patient. In contrast to a lot of medicine where treatment algorithms exist for common conditions, that is kind of the case by to a much lesser degree in psychiatry. There is more room for clinical judgment, thought, and using your brain than in other fields. That comes primarily because of the large amount of uncertainty in the field - something that doesn't scare me but which does make many medical students uncomfortable.

 

[NickNaylor]

Do you ever miss blood/treating more visible issues not of the mind?? Im strongly considering child psych, I just worry I would miss more hands on illnesses.

Yes. Accepting that I would likely never again use the overwhelming majority of the knowledge I spent four years learning about took time. It was a somewhat difficult thing for me to get over. I loved surgery in medical school, and in another life I could see myself being a surgeon. I like procedures. I hated it in medical school but now I really like general internal medicine.

So yeah, I do miss that. But I'm happy about my career choice and wouldn't change it.

 

[NickNaylor]

What psych knowledge do you think would be essential to the non psychiatrist, say peds or im

When I teach my medical students, I tell them up front that I want them to be comfortable diagnosing and treating MDD and anxiety appropriately. Those are by the far the most common psychiatric diagnoses any physician will encounter, thus I think it's critical that generalists (e.g., internists, family medicine docs, and OB/GYNs) be able to manage these conditions appropriately. It is unimportant IMO for an internist to know how to diagnose and treat things like bipolar disorder or schizophrenia. Those things should be referred to a psychiatrist. But uncomplicated MDD or anxiety can be appropriately managed most of the time by non-psychiatrists. If a patient fails to improve after a genuine trial of a first-line agent, then you could consider referral to a psychiatrist. However, a patient complaining of depression and meeting criteria for MDD does not automatically necessitate a psych referral.

 

[NickNaylor]

Do you feel that psych is stigmatized by your non-psych colleagues or those not involved in healthcare?

Yes, it absolutely is. Many non-psychiatry physicians have no real idea what it is we do. I guess they think it's voodoo. On the other hand of the spectrum, some seem to think we have some kind of magical powers and don't seem to understand what kinds of problems are amenable to psychiatric treatments and what kinds are not. However, there are plenty of people who think that psychiatry isn't real medicine (particularly in the lay public, though similar attitudes can be found in other physicians), that nothing that we do works, that we just throw medications at people, etc. etc.. As with all things there are little kernels of truth to these statements, but most people's understanding of what psychiatry is, the goals of psychiatric treatment, and what is and is not within our power to change is not sophisticated enough to actually have these kinds of conversations meaningfully.

Psychiatry is very much the ugly step child of medicine: some wish we weren't here, some think we don't belong, but nonetheless there is a role for us.

 

[NickNaylor]

I have an interest in psych based on a more personal level, but Nick, what did you do while in med school to further explore your interest in psych? I am a member of my school's interest group but that's about it.

I will be honest and say that I did very little to actually "explore" psychiatry. I was not an APA member, I didn't do the medical student interest group thing, didn't do any psychiatric research - really I had no psych exposure apart from my clerkship and my sub-I in Ms4. So I'm not the most well-versed in this area to be dispensing advice.

That said - and as I mentioned in a post above - I think doing these things can be helpful. Attending APA-affiliated conferences can also be an interesting way to learn more about the field and see what kinds of topics are relevant right now in psychiatry. Obviously doing research is a plus but this can be difficult.

Beyond that, I would just try and get as much clinical experience as you can. Obviously you will get some of that in your clerkship, but if you can try and do an elective or two early on in MS4 in areas other than what you did your clerkship in to get more exposure. Find faculty that you enjoy working with or who are amenable to mentoring students and pick their brain. I was fortunate enough to have an outstanding faculty mentor that was willing to talk with my candidly about the field, guide me in my application process, and just generally be a source of career advice. Try and find whoever that person can be for you.

 

[NickNaylor]

Is there a lot of variety in your daily life and patient base or is it a lot of the same routine thing?

Do you feel more emotionally drained than you think you would be in another specialty?

1) As mentioned above, you do certainly see a relatively limited number of diagnoses, but every patient with a certain diagnosis presents differently. Their story is different, how their symptoms affect them is different, and the different ways their disease has impacted their function is different. For me, this makes seeing depression for the 500th time more interesting, but not everyone agrees. So, both I guess: routine in that you generally see the same few things in general practice, but I think patients' stories are interesting, so the "routine" nature of a case doesn't become as boring.

2) Yes - it is emotionally taxing. Sometimes I finish up a day and feel physically exhausted even though I had plenty of sleep and didn't really do all that much. It can be emotionally draining. However, this is the case in other fields, too; for example, I think of heme/one, palliative care, and critical care medicine as areas that likely deal with the same issues. You eventually get desensitized because you've heard the same abjectly horrible things occurring to people so many times. But feeling emotionally drained is certainly something to think about when thinking about psychiatry. For some people, it's too difficult to get past the tragedy. For others, it's difficult to empathize and relate. Ideally there's a middle ground: you're able to feel some kind of genuine empathy without becoming overly attached emotionally. It can be a fine balance that you work out over time.

 

[Pusheen]

1) As mentioned above, you do certainly see a relatively limited number of diagnoses, but every patient with a certain diagnosis presents differently. Their story is different, how their symptoms affect them is different, and the different ways their disease has impacted their function is different. For me, this makes seeing depression for the 500th time more interesting, but not everyone agrees. So, both I guess: routine in that you generally see the same few things in general practice, but I think patients' stories are interesting, so the "routine" nature of a case doesn't become as boring.

2) Yes - it is emotionally taxing. Sometimes I finish up a day and feel physically exhausted even though I had plenty of sleep and didn't really do all that much. It can be emotionally draining. However, this is the case in other fields, too; for example, I think of heme/one, palliative care, and critical care medicine as areas that likely deal with the same issues. You eventually get desensitized because you've heard the same abjectly horrible things occurring to people so many times. But feeling emotionally drained is certainly something to think about when thinking about psychiatry. For some people, it's too difficult to get past the tragedy. For others, it's difficult to empathize and relate. Ideally there's a middle ground: you're able to feel some kind of genuine empathy without becoming overly attached emotionally. It can be a fine balance that you work out over time.

Wow, thank you for this, you sound like an awesome person!

 

[Matthew9Thirtyfive]

Interesting that you did this today. I was just thinking about looking more into psychiatry. I have some personal experience with mental illness (family members with BPD and friends with MDD, a few friends and family who have committed suicide). I always found mental illness to be extremely interesting, but seeing it first hand in the last year has sparked more than just an academic interest.

I'm doing primary care right now in the military, and I definitely like it. The patient population is pretty healthy, but we do see some pathology. I've gotten to do a bunch of procedures too, which I really like. My concern is giving that up for something less physical. How did you decide that the benefits of psych outweighed getting to do procedures and practice "real" medicine? Was it your psych rotation, or did you know going in that you would most likely do psych?

Also, seeing viral URIs and gastroenteritis all day can get boring. It makes you appreciate the I&Ds and cellulitis/thrombophlebitis cases. Being in a field where the same diagnoses varies between patients sounds interesting and like it would be difficult to get bored.

Thanks for doing this!

 

[bromo]

Why psych over neuro?

 

[sliceofbread136]

Have you had to deal with any bad outcomes? How do you deal with that on a personal level? What do you to family members of someone with a bad outcome?

 

[Jalby]

Do you ever feel guilty about calling a long time user of SDN a derp for bumping up a thread about his experience with a certain admissions department in the mid Atlantic region??

 

[aalamruad]

Do you ever feel guilty about calling a long time user of SDN a derp for bumping up a thread about his experience with a certain admissions department in the mid Atlantic region??

Do you ever feel guilty about making fun of his specialty choice in response? (I'm guessing not)

 

[Jalby]

Do you ever feel guilty about making fun of his specialty choice in response? (I'm guessing not)

Maybe you misread the title of the thread. This is ask a resident thread. I'm not a resident anymore. But hypothetically, if I was still a resident, I think I would say no and that it was totally worth it.

The people who go to medical school are used to being the best at whatever they do. They were the best in high school. They were the best in college. They expect to be the best in medical school. Some people adapt and realize that it is ok to be just good at what you do. Not everybody is going to be the chair of surgery at Mans Greatest Hospital. I'm really not sure where I am going with this, so I am going to leave it there.

 

[libertyyne]

What are your thoughts on ebm in psychiatry? Aren't some of the first line drugs for depression about as good as placebo?
Are your hours pretty sweet ?
Do you do any ECT?

 

[Dr.Kitty]

What do you see as the future of psychiatry? Since I was young I dreamed of finding a universal cure for mental illnesses like depression that applies to every patient. Do you ever see this happening? This idea might be too ahead of our time, but I think if we were able to build upon better treatment, we could revolutionize the world of mental health and eliminate the negative stigma associated with psychiatry. Can you see research playing a role in achieving better results in possibly curing different mental illnesses or would you say most of the psychiatric issues you see are bound to be lifelong and treatable? And if the latter, do you think that will ever change?

 

[Goro]

Someday, you get some actual biomarkers for illness. Until then, carry on!

Yes, it absolutely is. Many non-psychiatry physicians have no real idea what it is we do. I guess they think it's voodoo. On the other hand of the spectrum, some seem to think we have some kind of magical powers and don't seem to understand what kinds of problems are amenable to psychiatric treatments and what kinds are not. However, there are plenty of people who think that psychiatry isn't real medicine (particularly in the lay public, though similar attitudes can be found in other physicians), that nothing that we do works, that we just throw medications at people, etc. etc.. As with all things there are little kernels of truth to these statements, but most people's understanding of what psychiatry is, the goals of psychiatric treatment, and what is and is not within our power to change is not sophisticated enough to actually have these kinds of conversations meaningfully.

Psychiatry is very much the ugly step child of medicine: some wish we weren't here, some think we don't belong, but nonetheless there is a role for us.

 

[NickNaylor]

Interesting that you did this today. I was just thinking about looking more into psychiatry. I have some personal experience with mental illness (family members with BPD and friends with MDD, a few friends and family who have committed suicide). I always found mental illness to be extremely interesting, but seeing it first hand in the last year has sparked more than just an academic interest.

I'm doing primary care right now in the military, and I definitely like it. The patient population is pretty healthy, but we do see some pathology. I've gotten to do a bunch of procedures too, which I really like. My concern is giving that up for something less physical. How did you decide that the benefits of psych outweighed getting to do procedures and practice "real" medicine? Was it your psych rotation, or did you know going in that you would most likely do psych?

Also, seeing viral URIs and gastroenteritis all day can get boring. It makes you appreciate the I&Ds and cellulitis/thrombophlebitis cases. Being in a field where the same diagnoses varies between patients sounds interesting and like it would be difficult to get bored.

Thanks for doing this!

Going into medical school, I had no idea what I wanted to do. There aren't any doctors in my family, and apart from my limited shadowing experiences as a pre-med, I really didn't have that much clinical experience.

My first rotation was internal medicine. Didn't like it at all: I didn't like working with adults, didn't like the predominantly chronic diseases, and didn't feel like I was doing much. Some of the subspecialties were cool but that would obviously require completion of an internal medicine residency. No-go. My next rotation was pediatrics, and I absolutely loved it - so much so that I was planning on doing pediatrics until I did my psychiatric rotation. I had the good fortune of being at a great site for my psych rotation, had a great attending, and got to see some really interesting patients. I found the work fascinating, loved doing psychiatric interviews, and had the chance to see how incredibly powerful psychiatry can be with respect to changing someone's life. I was hooked. As mentioned above, I also really liked surgery but the lifestyle - both during residency and during independent practice - wasn't acceptable to me. I also considered dermatology but found it really boring.

So really, psychiatry just happened to be the field that I found the most interesting and satisfying. There are the things I mentioned above which I find to be "pros" for the field and, I think, somewhat unique to psychiatry.

I see that you're pre-med, so you'll have plenty of time to figure out what's interesting. You may find that procedures are where it's at for you and that you hate psychiatry. It's hard to say. My best advice is just to throw yourself into your rotations, absorb as much as you can, and try and figure out if you can be happy working in that field for the rest of your life. For me, I think psychiatry fits that bill, but everyone has their own interests and goals in life which might push them in one direction or the other.

 

[NickNaylor]

Why psych over neuro?

I really liked neurology. My schedule resulted in me doing neurology early in MS4 (due to deferring the rotation and doing a dermatology elective), after I had already decided on psychiatry. If I had done neurology during my third year, I would have seriously considered it. Obviously neurology and psychiatry run together, so those interested in one will likely be interested in the other. Neurology offers the benefit of some procedures, being a more traditional medical specialty, and, in general, being a more "rigorous" field, for lack of a better word. It's for people that like the approach of internal medicine but like the brain. There's also a bit of a difference in that neurology focuses less on behavior and the mind - and more on the physical manifestations of dysfunction in the nervous system - compared to psychiatry.

So, really it came down to psychiatry because I was already committed by the time I did my neurology rotation and realized that I really liked it. Had I done my neurology clerkship earlier, that probably would've been a tough decision.

 

[NickNaylor]

Have you had to deal with any bad outcomes? How do you deal with that on a personal level? What do you to family members of someone with a bad outcome?

Depends on what you mean by bad outcomes (I'm assuming you mean something fairly dramatic, like a suicide, some kind of violent event, etc.). Nothing like that has happened to any of my patients as far as I know.

If you're talking about less serious bad outcomes - patients being non-compliant with medications and decompensating, patients having recurrent SI, patients with substance use disorders relapsing, etc. - then yes, that happens all the time.

I remember I saw a young man in his early 20s who had a gnarly meth habit. He had been admitted to either medical services or psychiatric hospitals for psychosis due to his meth use. I was seeing this patient on a consult basis and his mother asked me to call her as he was being discharged and she didn't think he was ready to be discharged. We spoke, I stood by the team's decision that he is cleared for discharge from a psychiatric perspective and does not meet criteria for involuntary psychiatric hospitalization (and was unwilling to go to that treatment voluntarily and had no interest in substance treatment), and said that he will be discharged by the medicine team, whether she was ready for him or not. She asked me, "so what, do I just wait for this to happen again?" I told her, yes, unfortunately that is exactly what you have to do. Hopefully he will come to his senses and realize that his drug use is impacting his life in a hugely negative way and recognize that he needs treatment. Until that happens, there is very little that can be done to help him.

These kinds of conversations happen all the time: families get scared by a patient's presentation (usually psychosis), the patient improves (but is not yet at baseline), and is ready for discharge. Many people don't understand that, many times, we're stuck between a rock and a hard place: many people would clearly benefit from psychiatric treatment, but as adults (and #murica) they have the freedom to choose not to go to their follow-up appointments, not to take medications, and be psychotic. Until they are a danger to themselves or others or they are agreeable to receiving treatment voluntarily, there is nothing we can do. And as long as that's the case, they have the freedom to ruin their lives. It can be a tough conversation to have as many family members feel helpless (and rightfully so).

 

[NickNaylor]

Do you ever feel guilty about calling a long time user of SDN a derp for bumping up a thread about his experience with a certain admissions department in the mid Atlantic region??

No, I still think your recurrent bumping of that thread is ridiculous, and I'm convinced you're just a slow-play troll. But you say some funny stuff sometimes, so I have to give you props on that.

 

[NickNaylor]

What are your thoughts on ebm in psychiatry? Aren't some of the first line drugs for depression about as good as placebo?
Are your hours pretty sweet ?
Do you do any ECT?

1) EBM has its place, but I do not hold it to be the Holy Grail that many physicians do. It is important to very clearly understand what EBM is capable of doing, what it is not capable of doing, and being able to very carefully and thoughtfully interpret studies and understanding how they can influence your practice. The difficulty in psychiatry is that there are very few well-designed trials that lead to substantive insights that fundamentally change psychiatric practice. With respect to this second point, a recent meta-analysis found that SSRIs are essentially no different than placebo in the treatment of depression. As with all things, that is only one study amongst a sea of many, most with different results. It should be interpreted as such.

2) Generally, yes. My hours vary by rotation, but in general I'd say that anywhere from 40-60 hours/week is my usual work schedule. On busy rotations, it may be closer to 60-70. I have never reached 80 hours on a psychiatric rotation (though did on my medicine rotation). This includes all in-house call but does not include home call (which is only on a few rotations). All and all, not too bad - particularly since PGY-2 is generally considered to be the most difficult year in our program. Our PGY-3 year, in contrast, is 100% outpatient with normal office hours, no weekend, and no call (apart from the adage of "you're always on call for your patients" - e.g., dealing with patients in crisis, doing refills, etc.).

3) Yes. We get exposed to ECT at two of our inpatient sites as both have very active ECT services. The third of our three sites is in the process of starting an ECT program. We also have an ECT elective that gets you an ECT certification at the end of it. We get some degree of exposure to ECT with the ability to get more exposure if you're interested.

 

[NickNaylor]

What do you see as the future of psychiatry? Since I was young I dreamed of finding a universal cure for mental illnesses like depression that applies to every patient. Do you ever see this happening? This idea might be too ahead of our time, but I think if we were able to build upon better treatment, we could revolutionize the world of mental health and eliminate the negative stigma associated with psychiatry. Can you see research playing a role in achieving better results in possibly curing different mental illnesses or would you say most of the psychiatric issues you see are bound to be lifelong and treatable? And if the latter, do you think that will ever change?

No, I do not see this happening. Mental illness is very much like cancer: a combination of an innumerable number of genetic factors, environmental influences, and likely other unknown things. As our understanding of cancer has progressed, it has become increasingly clear that there is no real "cure" for cancer, and cancer as a concept is essentially impossible to completely prevent. Mental illness is much the same, and it is extremely likely that the terms "schizophrenia," "bipolar disorder," and "major depression" refer to highly heterogeneous groups of diseases, all of which are different with slightly different etiologies, slightly different presentations, and slightly different treatments.

I do think the future of psychiatry is promising as we finally now have the ability to investigate the functioning of a living, working mind, rudimentary those investigations may be. Our understanding of these things will inevitably improve as our ability to investigate them improves. And with greater understanding will come more sophisticated treatments.

Will these things be happening anytime soon? Probably not. But I do think it'll happen at some point in the future, likely in our lifetimes.

 

[Matthew9Thirtyfive]

Going into medical school, I had no idea what I wanted to do. There aren't any doctors in my family, and apart from my limited shadowing experiences as a pre-med, I really didn't have that much clinical experience.

My first rotation was internal medicine. Didn't like it at all: I didn't like working with adults, didn't like the predominantly chronic diseases, and didn't feel like I was doing much. Some of the subspecialties were cool but that would obviously require completion of an internal medicine residency. No-go. My next rotation was pediatrics, and I absolutely loved it - so much so that I was planning on doing pediatrics until I did my psychiatric rotation. I had the good fortune of being at a great site for my psych rotation, had a great attending, and got to see some really interesting patients. I found the work fascinating, loved doing psychiatric interviews, and had the chance to see how incredibly powerful psychiatry can be with respect to changing someone's life. I was hooked. As mentioned above, I also really liked surgery but the lifestyle - both during residency and during independent practice - wasn't acceptable to me. I also considered dermatology but found it really boring.

So really, psychiatry just happened to be the field that I found the most interesting and satisfying. There are the things I mentioned above which I find to be "pros" for the field and, I think, somewhat unique to psychiatry.

I see that you're pre-med, so you'll have plenty of time to figure out what's interesting. You may find that procedures are where it's at for you and that you hate psychiatry. It's hard to say. My best advice is just to throw yourself into your rotations, absorb as much as you can, and try and figure out if you can be happy working in that field for the rest of your life. For me, I think psychiatry fits that bill, but everyone has their own interests and goals in life which might push them in one direction or the other.

That's what I was planning on doing. I'm totally keeping an open mind. I was just curious. Thanks so much for taking the time to do this. 🙂

 

[kb1900]

This is an awesome thread. Thank you for taking the time niknaylor!

 

[sliceofbread136]

Last question. Tips for dealing with angry patients and family members?