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. If you want to vote in upcoming polls to decide what future specialties we cover, subscribe to the Med School Insiders YouTube channel.
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.
What is Psychiatry?
Psychiatry is the field of medicine focused on understanding and treating mental health disorders and psychological distress. Psychiatrists use the Diagnostic and Statistics Manual, currently in its fifth iteration (hence the name DSM-V) in assessing a patient’s constellation of symptoms and determining if they exhibit a diagnosable disorder. Psychiatrists can also 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 a 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 Ph.D. 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.
Clinical vs Research
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 or 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 to do more 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 transcranial magnetic stimulation (TMS), ketamine, and deep brain stimulation.
Academic vs Community vs Private Practice
In an academic setting, you can work either primarily inpatient or outpatient, but you’re 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. 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 are 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. In 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.
How to Become a Psychiatrist
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 during 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 opportunities 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!
Subspecialties within Psychiatry
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, 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 the 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 a 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.
What You’ll Love About Psychiatry
Psychiatry is a unique specialty in 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 — 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 sitting.
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 calls are infrequent.
What You Won’t Love About Psychiatry
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 the patient is completely unaware of the seizure. The most common adverse effect is a headache.
Should You Become a Psychiatrist?
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!
If you’re the kind of person who wants to help support others through their challenges, no other field goes as deep. You must be comfortable helping people work through emotionally heavy situations while holding space with them as they share upsetting and tragic stories.
If you’re considering psychiatry and neurology, they’re similar but different. Psychiatry is best for those interested in how the mind works and how to treat emotional disorders, requiring comfort with ambiguity, complexity, and holistic formulation. It can be messier.
If you prefer more concrete answers, localizing brain lesions with cut and dry, black and white pathophysiology, neurology may be a better fit.
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Thank you all so much for reading! Much love to you all.