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  • So you want to be a psychiatrist.

  • You like the idea of being a shrink, doing talk therapy, and having people all figured

  • out.

  • Let's debunk the public perception myths of what it means to be a psychiatrist, and

  • give it to you straight.

  • This is the reality of psychiatry.

  • Dr. Jubbal, MedSchoolInsiders.com.

  • Welcome to our next installment in So You Want to Be.

  • In this series, we highlight a specific specialty within medicine, such as psychiatry, and help

  • you decide if it's a good fit for you.

  • You can find the other specialties on our So You Want to Be playlist.

  • If you want to vote in upcoming polls to decide what future specialties we cover, make sure

  • you're subscribed.

  • If you'd like to see what being a psychiatrist looks like, check out my second channel, Kevin

  • Jubbal, M.D., where we featured Dr. Petey Kass in a Day in the Life of a Psychiatrist.

  • Link in the description.

  • Psychiatry is the field of medicine focused on understanding and treating mental health

  • disorders and psychological distress.

  • Psychiatrists use the Diagnosable and Statistics Manual, currently in it's fifth iteration,

  • hence the name DSM-V, in assessing a patient's constellation of symptoms and determining

  • if they exhibit a diagnosable disorder.

  • But psychiatrists can help patients with other conditions, even if they aren't classified

  • DSM illnesses – including psychological distress from pain, trauma, difficult relationships,

  • or other high stress situations.

  • If you've ever confused psychiatrists with psychologists, you're not alone.

  • Psychiatrists are medical doctors, meaning they have their MD or DO, and they've completed

  • 4 years of medical school, followed by residency, and sometimes also fellowship.

  • They can diagnose and treat mental conditions using either medication or non-medication

  • treatments, such as psychotherapy.

  • While psychiatrists can use medications to treat patients' more severe symptoms, they

  • rely on talk therapy training to help people with more mild symptoms, or, with problems

  • that wouldn't necessarily respond to medications.

  • Psychologists, on the other hand, have either Master's or PhD level training, and while

  • they're able to diagnose and treat mental illness, they can only use non-medication

  • treatments.

  • Sometimes you'll see psychiatrists and psychologists working together, with psychologists focusing

  • on therapy, and psychiatrists usually focusing their expertise on medication, although they

  • can do either.

  • While some think that psychiatrists go into the field because they subconsciously want

  • to fix their own problems, or that they're highly eclectic and strange, this isn't

  • quite true.

  • As a psychiatrist, you'll have to be adept at relating to a wide range of individuals,

  • and that also requires well developed interpersonal skills.

  • And while it has a useful handbook, psychiatry is much more than just memorizing DSM criteria

  • and slapping on diagnoses to patients.

  • Psychiatrists use the DSM as a guide, but they formulate patients more holistically

  • than that – they're looking at the psychological, socioeconomic, and physiologic causes of their

  • symptoms as well, not just the symptoms themselves.

  • There are a few ways to categorize psychiatry.

  • As a clinical psychiatrist, you'll be seeing patients, doing therapy, and generating treatment

  • plans.

  • If practicing inpatient, you'll see patients admitted to the psychiatric ward or consult

  • service, meaning those treated primarily in other areas of the hospital, but requiring

  • secondary psychiatric care.

  • As a consultant, you'll educate primary teams on various psychiatric and psychological

  • conditions affecting their patients and provide them with your psychiatric treatment recommendations.

  • With inpatient, you're dealing with more severe cases that often require more critical

  • treatment.

  • These patients often have multiple psychiatric conditions and are generally more complicated

  • than those you would see in an outpatient clinic.

  • There's also a great deal of medicine involved as these patients often have multiple medical

  • issues that either worsen or mimic psychiatric symptoms.

  • For example, certain medical issues like cancer, brain injuries, or COVID can result in delirium

  • or agitation, which can both look like psychosis or depression.

  • With outpatient, you'll be primarily combining psychotherapy with medication management for

  • patients with whom you'll have more longitudinal relationships, as they'll come to the office

  • multiple times over months to years.

  • With outpatient, you also have more flexibility in managing things beyond traditional psychiatric

  • diagnoses, like sleep, pain, or distress from various stressors.

  • If you focus on research, you can choose from bench or clinical work.

  • With bench research, you often work in a lab and do research at the cellular or molecular

  • level to explore foundational neurobiology that may help explain the brain function of

  • people with psychiatric conditions.

  • With clinical research, you could explore the efficacy of different medications and

  • treatment options in treating specific patient populations or psychiatric conditions.

  • Interventional psychiatry is an exciting new area exploring brain stimulation through trans

  • cranial magnetic stimulation, or TMS for short, ketamine, and deep brain stimulation.

  • In an academic setting, you can work either primarily inpatient or outpatient, but associated

  • with an academic teaching hospital.

  • This offers less flexibility in your practice, but will allow you the opportunity to do research,

  • work with medical students and residents, and pursue academic leadership.

  • You'll be working at a medical center that is likely pushing to advance the field, but

  • will be at the whim of the bureaucracy of the hospital, and your appointment types,

  • meaning appointment length and therapy vs. medication management ratios, will have a

  • limit set by the institution.

  • In a community setting, you'll work with hospitals or outpatient clinics run by the

  • county or city public health departments.

  • Patients will primarily be Medicaid or uninsured, meaning you'll have the opportunity to work

  • with underserved patients and a greater proportion who are severely mentally ill.

  • Dual diagnoses amongst this patient population is not uncommon, meaning a substance use disorder

  • plus a separate mental health diagnosis.

  • For these reasons, this work can be highly rewarding, as this is a population with less

  • access, but it can also be highly frustrating working with a socioeconomically disadvantaged

  • population, as medication and appointment adherence may be problematic, as is access

  • to other resources.

  • Private practice entails one or more physicians setting up their own shop outside of a larger

  • medical center.

  • They have complete control and autonomy, seeing patients as they choose.

  • This has the greatest amount of flexibility in most domains, including how much they charge,

  • which insurances they take, the balance of therapy versus medication, and visit durations.

  • However, this is running a business, and there are of course risks associated with that.

  • At the beginning, you'll have to do more work to build a patient population, which

  • may mean making less money at first than you would with an established group or medical

  • center.

  • With psychiatry, you don't have to choose a single type of practice.

  • You could do academia a few days per week, and some private practice on other days with

  • a smaller psychiatry group.

  • After 4 years of medical school, psychiatry residency is 4 years, unless you go into a

  • child psychiatry fellowship, in which case you can skip the final year, making it a 3

  • year residency.

  • More on fellowships shortly.

  • As a PGY1, meaning your first year out from medical school, you'll do primarily general

  • medicine rotations, like inpatient and outpatient medicine, emergency medicine, neurology, and

  • the like.

  • You'll spend some time on psychiatry, usually inpatient, from a few months up to half a

  • year, depending on your program.

  • As a PGY2, you're now completely immersed in your psychiatric training, primarily on

  • inpatient and consult psychiatry services, though some programs will offer a small amount

  • of outpatient training in this year.

  • As a PGY3, you'll focus on outpatient psychiatry, rotating in different specialty clinics, each

  • devoted to a specific diagnosis, patient population, or age group.

  • For example, you could attend bipolar clinic or anxiety clinic, or go to child clinic or

  • LGBT clinic.

  • Your fourth and final year will be highly variable, although most commonly this will

  • be repetitions of rotations you've done in previous years.

  • You'll also have more opportunity for elective and research time to pursue your interests.

  • Hours in psychiatry residency are pretty relaxed, mostly 8-5 on most rotations, with some overnight

  • and weekend call shifts, the frequency of which is highly dependent on the program,

  • with some programs having none.

  • In terms of competitiveness, psychiatry is more attainable, with an average Step 1 in

  • the 2020 cycle of 227 and Step 2CK of 241, and a 90% match rate.

  • In the MSI Competitive Index, psychiatry ranks at 18 out of 22 in terms of competitiveness.

  • Psychiatry has increased in competitiveness in recent years for a few reasons.

  • More medical students are understanding the importance of work/life balance, for which

  • psychiatry has a strong advantage.

  • There are more options within the field than ever, thus attracting a wider variety of individuals,

  • and it's also becoming a less stigmatized field.

  • Mental health is finally becoming more mainstream, as it should.

  • After completing residency, you can subspecialize further with fellowship.

  • All fellowships are 1 year in duration, except for child psychiatry, which is 2 years.

  • In child psychiatry, you'll be working with children and adolescents, most commonly dealing

  • with depression, anxiety, eating disorders, ADHD, and autism.

  • You'll work closely with their parents as well, thus incorporating a high degree of

  • psycho-education and family counseling.

  • Child psychiatry is more focused on non-medication based strategies, including therapy and mindfulness

  • practice, compared to other psychiatry subspecialties.

  • Psychosomatic is best suited for those who want to work in the overlap between psych

  • and medicine, specifically with medically hospitalized patients who have psychiatric

  • needs.

  • You'll manage complicated patients, such as someone with schizophrenia who is also

  • on chemotherapy, and finding the best medication for the mental disorder that won't negatively

  • interact with the chemotherapeutic agent.

  • Psychosomatic specialists are often embedded in clinics for a particular medicine subspecialty,

  • such as oncology or palliative care, which allows psychiatrists to further subspecialize

  • with patient populations they are most interested in.

  • Geriatric psychiatry includes working with older adults and learning how to manage psychiatric

  • illness in more medically frail and complicated patients with other comorbidities.

  • You'll also be doing life-processing, meaning coping with end of life stressors, such as

  • death of friends, spouses, and one's own mortality.

  • If you're interested in this field, you'll have great flexibility in where you work,

  • even in big cities, as there's high demand for the specialty with our aging population,

  • but currently low supply.

  • Forensic psychiatry focuses on the overlap between psych and the law.

  • You'll evaluate patients in situations related to legal matters, such as insanity evaluations

  • if the defendant pleads insane.

  • When it comes to legal issues related to psych, these are the experts.

  • For example, you'll act as an expert witness in court cases and evaluate medical records

  • to assess malpractice.

  • This isn't a clinically focused subspecialty.

  • Rather, you'll be serving as an expert evaluator, but most forensic psychiatrists also do part

  • time outpatient general psychiatry work as well.

  • Addiction focuses on substance use disorders and dual diagnoses patients, meaning they

  • have both substance use disorder and a primary psychiatric disorder.

  • You'll often find yourself working in rehabilitation facilities or outpatient clinics.

  • Public psychiatrists practice in community or underserved patient populations, doing

  • advocacy work for legislation that affects these communities, op-ed writing for publication,

  • and lobbying.

  • You'll be working with the most vulnerable patient populations, which can be very satisfying.

  • Interventional psychiatry is not an ACGME-accredited subspecialty, meaning it's not as official

  • as the rest.

  • This is for those who are interested in psychiatric procedures, like electroconvulsive therapy

  • (ECT) for severe depression or transcranial magnetic stimulation (TMS) for OCD and depression

  • treatment.

  • This also includes ketamine assisted therapy or ketamine infusions for depression.

  • Some of your patients will have deep brain stimulation electrodes placed by neurosurgeons,

  • and you'll manage the patient's psychiatric care before and after surgery.

  • Psychiatry is a unique specialty within medicine.

  • It's the least algorithmic, meaning you'll never simply follow an algorithm when treating

  • a patient.

  • Rather, you must think deeply and holistically about each of your patients.

  • If 2 patients have the same disorder, you likely won't be using the same 2 treatment

  • plans.

  • If you enjoy spending time with patients, psychiatry is hard to beat.

  • It's one of the few specialties left where you can regularly have 45-60 minute appointments.

  • And most of your patients will need your treatment long term, if you prefer longitudinal relationships

  • and having a deeper connection.

  • You'll see them develop and improve with time, and being a part of that is satisfying.

  • Psychiatry offers flexibility in your career β€” you can work in multiple clinical settings

  • or with multiple patient populations and even have multiple jobs at once.

  • You're able to tailor your career to meet your goals unlike other specialties, where

  • you generally must take one job in one setting.

  • And finally, the quality of life and hours are hard to beat, both during and after residency.

  • It's pretty much just regular business hours, and overnight emergencies or weekend call

  • are infrequent.

  • Psychiatry is not for everyone.

  • It's a hands-off specialty, so if you enjoy the physical exam or procedures, you won't

  • get that with psychiatry, unless of course you go into interventional psych.

  • It's also a less concrete specialty dealing with uncertainty.

  • Our understanding of mental illness is still developing, and it can be difficult to know

  • exactly how to help patients.

  • You'll sometimes try multiple treatment options with little success, and that can

  • be frustrating.

  • Psychiatrists also often deal with difficult patient populations, such as those with substance

  • use disorders, severe mental illness, or personality disorders that can be challenging to manage.

  • And in private practice, it can be isolating, although this is less of an issue in other

  • practice settings.

  • You may come across some anti-psychiatry stigma amongst the general population, due to influences

  • from conspiracy theorists, scientology, and cruel treatments from decades ago such as

  • lobotomy and shock therapy.

  • Modern day electroconvulsive therapy is done under anesthesia, is safe, does not involve

  • any convulsions or broken limbs, as the patient is on paralytics, and they're completely

  • unaware of the seizure.

  • The most common adverse effect is headache.

  • How can you decide if psychiatry is for you?

  • If you're interested in the brain, both in how it works and how it can cause mental

  • illness, and if you enjoy talking with people in depth and hearing their stories, psychiatry

  • may be for you.

  • Many medical students enter their psychiatry rotation assuming they won't like it, but

  • when they give it a chance, they'll often find it more interesting than they expected.