How I decided on a combined medicine/psychiatry residency

The third-year medical student has three jobs: 1) To learn how to take a good history and do a good physical exam; 2) To learn how to present patients, both written and orally; and 3) To figure out what field of medicine to specialize in. I found this last job to be the most difficult.

Pre-med and the pre-clinical years

To provide some context, I came into medical school having worked for four years researching the neurobiology of eating disorders. I very much enjoyed and valued my pre-med experience in psychiatry, but I also wanted to keep an open mind when it came to other possible specialties and career paths. This translated into me looking practically everywhere except at psychiatry.

During the first two years, when I was just in the classroom and didn't yet have any practical clinical experience, I investigated various specialties: emergency medicine, neurology, neuroradiology, interventional radiology, surgery.

The third year

Over this past year, as I've gained clinical experience in various fields, I have tried to be purposeful and methodical about how I evaluate each specialty as a possible career. This process of elimination is pretty typical for third-year medical students. I had all but ruled out many possible specialties before third year, but I also tried to keep an open mind. I liked most of my clinical rotations and seriously thought about careers in those specialties.

• I was very interested in emergency medicine, ever since my first year, but eventually nixed it because I want to have continuity of care and to treat the whole patient rather than one acute problem at a time.
• I seriously considered surgery but reluctantly decided against it because of lifestyle issues.
• I got excited about anesthesiology but vetoed it because I want more significant patient interaction.
• I loved pediatric neurology and only recently crossed it off the list because I decided that I don't like general pediatrics enough to do the training. Also, even though I figured out that I could probably handle the sad stories and poor outcomes, I decided that it's just not what I want.

Then there were my internal medicine and psychiatry clerkships. I loved them both.

Internal Medicine

Last Summer, on a warm evening after a long day at the hospital, I was lying underneath a tree in the park talking on the phone with my sister. She asked me how I was liking internal medicine, and my immediate response was that I love the puzzle. I have a patient with a given set of symptoms and a unique history, and based on both of those, I have to decide on what labs and studies to order to figure out what is causing that particular constellation of symptoms and how to treat it. I told my sister that the inpatient setting gives me more time to sit down and really talk with my patients, as well as to thoroughly think through the differential diagnosis. I like internal medicine because it involves both thinking and doing.

Looking back, my most memorable and favorite medicine patients all had psychiatric comorbidities. After awhile, my medicine residents were giving me the "difficult" psychiatric patients because they knew that I was drawn to those patients.

Psychiatry

Then there was my psychiatry clerkship. I looked forward to it with excitement but also some trepidation. What if I liked it? Could I really become a psychiatrist? I worried about that because there truly is a distinction between the practice of medicine and the practice of psychiatry.

It turned out that I did very much like psychiatry. I found that reading for psychiatry was easy because I was so interested in the subject matter... I spent much longer talking with my patients than I needed to... I wrote much longer notes than I should have because I had so much to say and was so fascinated by my patients... I jumped into psychotherapy with some of my patients even though that's way beyond the scope of a third-year medical student....

Discovering med/psych

Liking psychiatry so much posed a problem because I held a mental block against it. Much of that mental block likely came from my desire to practice medicine, not solely treat mental illness. About midway through my psychiatry clerkship, responding to what I recognized as ambiguous reservations against psychiatry, I started researching various psychiatry fellowships. That's when I "discovered" combined medicine and psychiatry residency training programs.

I hadn't even known that such programs existed. Thinking back to my internal medicine clerkship and how much I enjoyed it, I immediately started daydreaming about what I could do with training in both internal medicine and psychiatry. I stayed up way too late that night researching med/psych programs.


The more I thought about med/psych as a training path, the more excited I got. I could continue my work in anorexia and bulimia or focus on binge eating and obesity. I could do geriatrics. I could do palliative care. I could do international and refugee medicine. So many possibilities! I'm the type of person who likes to keep my options open. Med/psych training could give me the best of both worlds; I could have my cake and eat it too!

I realized, though, that I was getting all excited about med/psych with a very limited amount of information, only what was available on the various program websites and the Association of Medicine and Psychiatry website. I needed more information, better information.

Talking with med/psych program directors

A few of the med/psych programs stood out to me, both because of the quality of the integrated curriculum and the general feel of the institutional culture. The directors of these programs wrote open letters describing med/psych, promoting their respective program, and inviting those interested in med/psych to contact them with any questions. Recognizing that contacting these program directors could potentially be self-defeating, I decided that it was worth the risk because I needed to talk with someone - multiple people - in the med/psych world.

I e-mailed three program directors and actually talked on the phone with two of them. I was blown away by how open and friendly and helpful they were, that they would set aside time from their lives to talk with me about med/psych. They answered my myriad questions, settling two major concerns about pursuing both medicine and psychiatry.

• Concern #1: You'd just end up choosing one or the other eventually, so why waste time training for both? Response: We actively encourage our graduates to establish a practice that incorporates both medicine and psychiatry, and most of them do find a niche for themselves. Even if your practice ends up being predominantly medicine or predominantly psychiatry, you will draw upon your training in the other and be a better doctor for it. I doubt that you'll ever regret your training. Both program directors said essentially the same thing in different ways, and I agree with them.
• Concern #2: A combined program would leave you less well trained in both medicine and psychiatry than if you completed a pure residency in one or the other. Response: Our pass rate is 100% for both the medicine and psychiatry boards. Our graduates report feeling very well prepared for both boards and for the responsibilities of being an attending physician. That speaks for itself.

Talking with current med/psych residents

I asked those program directors to put me in touch with current med/psych residents. Being in the middle of this stressful decision-making process, I wanted to talk with someone whose memories of that process are more fresh in the mind. How did you discover med/psych? Did you seriously consider other specialties, or medicine alone, or psychiatry alone? Why did you end up deciding on med/psych? Did you know what you wanted to do with med/psych before residency? I felt that these questions needed to be addressed now as opposed to during an externship or on the interview trail.

One resident answered that he decided on med/psych simply because he wanted to treat the whole patient, not just a set of symptoms. This struck a chord with me. I thought back to my medicine rotation and remembered how frustrated I felt when the psychiatry consult service swooped in to evaluate patients with psychiatric concerns: I wanted to be a part of that aspect of my patient's care. I also thought back to my psychiatry rotation and my frustrations when the smallest medical issue was outsourced to internal medicine. I want to treat the whole patient, too.

Enthusiasm flowed freely from every resident I talked with. Everyone was happy. Everyone was 100% satisfied with their career choice. Everyone would do it over again the same way in a heartbeat. And talking with each successive resident, that enthusiasm rubbed off on me. The vague intuitive sense of rightness I originally felt when I discovered med/psych crystallized into certainty that a combined medicine and psychiatry training is perfect for me.

Trying on med/psych for size

I can't count how many times I've been asked, "What are you going into?" or "Do you know yet what you're specializing in?" It's especially bad toward the end of third-year and even worse when I start a new rotation. So pediatrics and OB/Gyn have offered me numerous opportunities to see how med/psych fits. Rather than hedging, I started answering decisively, "I am going to do a combined medicine and psychiatry residency program."

Reactions have been interesting, ranging from "Oh, what a waste of talent," to probing my reasons for choosing a less traditional training path, to "Wow, that's awesome!" The negative reactions didn't get me down, and the positive ones only stoked my excitement for med/psych further. These self-observations are incredibly helpful in making the final leap to a decision that without overstatement will profoundly shape the rest of my life.

So I've taken that leap. I will apply to combined medicine/psychiatry residency programs.