I arranged a second med/psych externship at Tulane University and started this past Monday. My main goal for this externship is to experience med/psych in a completely new environment. I want a broader perspective of med/psych, something with which to compare my experiences at UC Davis. I also obviously want to learn as much as possible about Tulane in general and its med/psych program in particular.
I've never been to New Orleans (N'Awlins) before now, so this externship promised to be an adventure for me. Finding acceptable housing was an issue because Tulane didn't officially confirm my externship until a week and a half before my start date. Life moves at a different pace in this city. I got lucky, though, and found a great housing situation through craigslist. It is a historic landmark built in 1845, located in the Garden District, which is a fancy-schmancy part of town with beautiful mansions in ornate French New Orleans style. I am staying in a flat on the second floor of the house, rented out to me by a real estate professional in his 30's. He is a proper Southern gentleman who offers all the hospitality that comes along with that background. So far, the living situation has worked out very well.
The first two days of the externship, I worked directly with the med/psych program director at her psychiatry clinic. Then I started working at Tulane Hospital with the consult & liason (CL) team. This is basically an in-house psychiatry consult service. For example, doctors in the emergency department may consult the CL service to determine whether a patient meets criteria for placing a 72-hour mental health hold (here in Louisiana called a physician emergency certification, or PEC for short). The CL service is also commonly called in to evaluate delirium and psychosis.
I will likely be spending the majority of my remaining time at Tulane working with the CL team, along with several weekly afternoon med/psych clinics. I will also be attending "Friday School," which is basically required lectures for internal medicine interns. I'm glad to be getting a taste of the didactic training that I would be experiencing myself as a Tulane intern.
Showing posts with label Med/Psych. Show all posts
Showing posts with label Med/Psych. Show all posts
Thursday, October 4, 2012
Thursday, September 27, 2012
Priorities
The annual meeting of the Association of Medicine and Psychiatry (AMP) is being held in Chicago this weekend. This meeting is an excellent opportunity for medical students to network with dually-trained physicians and program directors, current med/psych residents, as well as the handful of other medical students applying to combined training programs. I had been looking forward to this meeting ever since I discovered med/psych earlier this year, but it unfortunately falls on the same weekend as my grandmother's 91st birthday.
The decision wasn't difficult, to skip the meeting and celebrate my grandmother's birthday. How many birthdays and other big family events have I already missed because of medical school, and how many more will I miss during residency? I am still disappointed to forgo all the networking opportunities, especially heading into interview season. But the program director at Davis offered me some reassurance when I told him why I couldn't attend: "There will be meetings every year. Go spend time with your family."
The decision wasn't difficult, to skip the meeting and celebrate my grandmother's birthday. How many birthdays and other big family events have I already missed because of medical school, and how many more will I miss during residency? I am still disappointed to forgo all the networking opportunities, especially heading into interview season. But the program director at Davis offered me some reassurance when I told him why I couldn't attend: "There will be meetings every year. Go spend time with your family."
Friday, September 21, 2012
Davis: End of the externship
My externship with the Davis combined medicine/psychiatry program ended today. I left the clinic this afternoon with a sense of satisfaction that the experience was all-around positive and that I received encouraging feedback from everyone. I'm sad to be leaving, and I'm eager to return to Davis for the interview; this speaks volumes about my gut-level feeling about the program.
I had two goals when I started this externship. First, I wanted to figure out whether combined medicine/psychiatry is right for me, or whether I might be better served by a pure medicine or pure psychiatry program. Second, I wanted to get a better feel for the UC Davis program, in particular: the leadership, the residents, the strength of the training, and the general environment of Sacramento.
On the first goal:
I am much more certain now than when I started this rotation that I want combined training. I could only feel comfortable coming to this conclusion after gaining first-hand experience in an environment that combines medicine and psychiatry to provide integrated patient care. This rotation leaned heavily toward the psychiatry end of the spectrum, much to my initial disappointment. But this limitation to my experience here at UC Davis provided a contrast that helped me appreciate the satisfaction I feel from treating patients' medical and psychiatric needs together.
Over these past four weeks, I learned why much of my clinic experience was straight psychiatry: MediCal reimbursement rules prevent billing for medical and psychiatric services in one visit. In fact, one of my last patients of this rotation lamented that she would soon have to find a new primary care provider for her medical needs because her insurance was switching over to MediCal. This is a woman with COPD, congestive heart failure, diabetes, and bipolar disorder, all of which my dually-trained attending has been managing well. She would be ill-served being forced to find a new primary care provider who just treats her medical needs. My attending says that changes to MediCal reimbursement rules are in the works to address this problem. This is a poignant lesson, though, of the types of struggles that I will likely face in choosing the combined medicine/psychiatry path.
On the second goal:
Over and over again, I was struck by how friendly and happy people are here at UC Davis. I'm left with the feeling that I would enjoy working with these residents and attendings, an extremely important feeling considering that these would be my colleagues for the next five years. Both the medicine and psychiatry programs, as well as the combined training program, are very strong. And Sacramento itself was a pleasant surprise. It's a small city with not too much going on, which suits my purposes just fine for residency. The heat was not unbearable as I was expecting. And it's close by to many attractions (e.g. San Francisco, Lake Tahoe, the Redwoods). My attending says that Sacramento is a better place to live than visit. I agree.
So, with everything said and done, my mind wanders back to about four years ago when I was visiting different medical schools. I remember walking around Colorado's medical school campus, taking everything in, thinking, "I could see myself happy here." And it turns out that I was. I get that same feeling from Davis. This is a nice starting point to have heading into interview season.
I had two goals when I started this externship. First, I wanted to figure out whether combined medicine/psychiatry is right for me, or whether I might be better served by a pure medicine or pure psychiatry program. Second, I wanted to get a better feel for the UC Davis program, in particular: the leadership, the residents, the strength of the training, and the general environment of Sacramento.
On the first goal:
I am much more certain now than when I started this rotation that I want combined training. I could only feel comfortable coming to this conclusion after gaining first-hand experience in an environment that combines medicine and psychiatry to provide integrated patient care. This rotation leaned heavily toward the psychiatry end of the spectrum, much to my initial disappointment. But this limitation to my experience here at UC Davis provided a contrast that helped me appreciate the satisfaction I feel from treating patients' medical and psychiatric needs together.
Over these past four weeks, I learned why much of my clinic experience was straight psychiatry: MediCal reimbursement rules prevent billing for medical and psychiatric services in one visit. In fact, one of my last patients of this rotation lamented that she would soon have to find a new primary care provider for her medical needs because her insurance was switching over to MediCal. This is a woman with COPD, congestive heart failure, diabetes, and bipolar disorder, all of which my dually-trained attending has been managing well. She would be ill-served being forced to find a new primary care provider who just treats her medical needs. My attending says that changes to MediCal reimbursement rules are in the works to address this problem. This is a poignant lesson, though, of the types of struggles that I will likely face in choosing the combined medicine/psychiatry path.
On the second goal:
Over and over again, I was struck by how friendly and happy people are here at UC Davis. I'm left with the feeling that I would enjoy working with these residents and attendings, an extremely important feeling considering that these would be my colleagues for the next five years. Both the medicine and psychiatry programs, as well as the combined training program, are very strong. And Sacramento itself was a pleasant surprise. It's a small city with not too much going on, which suits my purposes just fine for residency. The heat was not unbearable as I was expecting. And it's close by to many attractions (e.g. San Francisco, Lake Tahoe, the Redwoods). My attending says that Sacramento is a better place to live than visit. I agree.
So, with everything said and done, my mind wanders back to about four years ago when I was visiting different medical schools. I remember walking around Colorado's medical school campus, taking everything in, thinking, "I could see myself happy here." And it turns out that I was. I get that same feeling from Davis. This is a nice starting point to have heading into interview season.
First residency interview offer!
I got my first residency interview invitation this morning! So exciting! The whole thing feels a lot more real, now.
Late Update: My first interview offer was to Iowa's combined medicine/psychiatry program. Exciting!
Late Update: My first interview offer was to Iowa's combined medicine/psychiatry program. Exciting!
Wednesday, September 12, 2012
Be a sponge
I had lunch with the med/psych program director for my midpoint evaluation. His feedback was different than any of the feedback I have gotten during other midpoint evaluations, which more often than not are formalities and not all that helpful. "I want you to take a step back," he said. "I want you to absorb everything that's going on around you. Be a sponge."
This advice was especially interesting to me because it echoes something that a close friend told me as I headed off to medical school: "Be a medical anthropologist. Look at what works and what doesn't work in the medical system and think about how you would do it differently." So, throughout medical school, I have been purposefully doing just that. Here at UC Davis, taking a step back and observing as much as possible of my surroundings and the people around me, that is all the more important as I am trying to figure out whether this is the right residency program for me.
This advice was especially interesting to me because it echoes something that a close friend told me as I headed off to medical school: "Be a medical anthropologist. Look at what works and what doesn't work in the medical system and think about how you would do it differently." So, throughout medical school, I have been purposefully doing just that. Here at UC Davis, taking a step back and observing as much as possible of my surroundings and the people around me, that is all the more important as I am trying to figure out whether this is the right residency program for me.
Monday, September 10, 2012
Face time with med/psych residents
Last week, the chief resident took me and a few other med/psych residents out for my first recruitment dinner of the interview season. It's a great opportunity to get to know the people who I may be working with closely over the next five years. Do I like them? Would they be easy to work with? No doubt they are asking those same questions about me. This dinner was all the more important, for all of us. Because I have mostly been working with dually-trained attendings and psychiatry interns, I haven't had the opportunity to get to know my potential future colleagues.
Recruitment dinners in general have an interesting dynamic. On the one hand, it's a social event, and everyone should be having fun. I don't want to come across as boring or rigid or anything else negative, but I also don't want to have too much fun. I've heard many stories from current interns about applicants who drink too much alcohol during these recruitment dinners and end up making asses of themselves. Why anyone would do such a thing with so much in the balance is beyond me. Regardless, I did genuinely enjoy dinner and chatting with the med/psych residents.
Then, this weekend, I took a day trip to San Francisco with one of the med/psych interns and a couple of her friends. The whole day was very relaxed and a ton of fun, a showcase of what my days off could be like if I end up at UC Davis.
Recruitment dinners in general have an interesting dynamic. On the one hand, it's a social event, and everyone should be having fun. I don't want to come across as boring or rigid or anything else negative, but I also don't want to have too much fun. I've heard many stories from current interns about applicants who drink too much alcohol during these recruitment dinners and end up making asses of themselves. Why anyone would do such a thing with so much in the balance is beyond me. Regardless, I did genuinely enjoy dinner and chatting with the med/psych residents.
Then, this weekend, I took a day trip to San Francisco with one of the med/psych interns and a couple of her friends. The whole day was very relaxed and a ton of fun, a showcase of what my days off could be like if I end up at UC Davis.
Friday, September 7, 2012
Answering personal questions from patients
I was interviewing a depressed patient with my attending in the room, watching. I asked my patient if she had any thoughts of death or dying, and she said yes. "Well what of it? Haven't you had those thoughts?" This direct personal question took me aback. I faltered, then I answered her question. I knew right away that she was trying to rationalize her own morbid thoughts by normalizing them. See, you think about death, too, so my thoughts of death are normal.
Then she turned to my attending and asked him the same question, but he handled it completely differently. He sat back relaxed in his chair, looked down at the floor briefly then right back up at the patient meeting her eyes, he smirked slightly, then he said, "You know, I think it's really interesting you asked me that." His voice was saturated with sincere curiosity. "Why is it do you think you asked me that?"
I was in awe. How deftly he had flipped her question right back to her and incorporated the very fact that she had asked that question into an exploration of her depressive symptoms! The patient went right along with the flow of the conversation. My attending never did end up answering her question.
I talked with my attending about it afterward. "You're going to be asked a lot of personal questions throughout your career: Are you single? Do you have children? How much money do you make? There's always something behind the question, and it's your job to figure out what it is." He went on to say that a very real power differential exists in the clinical interview. It's not unfair; that's just the way it is. If I ever feel like a patient is interviewing me, that should give me reason to pause and wonder, Why? From there, I should let my own curiosity guide my response.
This lesson made quite an impression on me, and it gave me an important tool to use in future clinical interviews.
Then she turned to my attending and asked him the same question, but he handled it completely differently. He sat back relaxed in his chair, looked down at the floor briefly then right back up at the patient meeting her eyes, he smirked slightly, then he said, "You know, I think it's really interesting you asked me that." His voice was saturated with sincere curiosity. "Why is it do you think you asked me that?"
I was in awe. How deftly he had flipped her question right back to her and incorporated the very fact that she had asked that question into an exploration of her depressive symptoms! The patient went right along with the flow of the conversation. My attending never did end up answering her question.
I talked with my attending about it afterward. "You're going to be asked a lot of personal questions throughout your career: Are you single? Do you have children? How much money do you make? There's always something behind the question, and it's your job to figure out what it is." He went on to say that a very real power differential exists in the clinical interview. It's not unfair; that's just the way it is. If I ever feel like a patient is interviewing me, that should give me reason to pause and wonder, Why? From there, I should let my own curiosity guide my response.
This lesson made quite an impression on me, and it gave me an important tool to use in future clinical interviews.
Monday, September 3, 2012
UC Davis: Summary of the first week
My first week on medicine/psychiatry was a good one.
I am spending most of my time at the Sacramento County Primary Care Center (PCC), which mostly caters to an indigent patient population. There is a separate Integrated Behavioral Health clinic with a set of three dually trained physicians who supervise me and another fourth year student. She attends UC Davis and is applying for internal medicine residency. I am also spending a few mornings per week at a pain clinic staffed by the Medicine/Psychiatry program director.
Everyone with whom I have interacted is very nice and welcoming... and just as important, they all seem happy.
But so far, I haven't met any Medicine/Psychiatry residents. The one resident at PCC is a psychiatry intern and so is not a good person to talk with about dual training. The Medicine/Psychiatry chief resident, though, has been in close contact with me to make sure that I am having a good experience. I am looking forward to interacting more with the Medicine/Psychiatry residents. Beyond just asking them questions, I want to get a better feel for how happy they are in the program, with their training experience.
Regarding what I have discovered about the actual practice of combined medicine and psychiatry, I was surprised that the vast majority of patients who I saw at PCC were there only for management of chronic psychiatric conditions without addressing any of their medical problems. My attending says that this is mostly due to insurance reasons, because neither Medi-Cal nor Medicaid reimburse fully for office visits that address both psychiatric and medical problems. That is concerning to me but not altogether unexpected given some of the criticisms I have heard from various people about combined training programs.
I have been exposed to a lot more of mixed medicine and psychiatry in the pain clinic, where patients' chronic pain issues often stem from both physical and mental causes.
There is still so much to experience during this externship. Next week I will also see patients on the psychosomatic medicine inpatient unit.
I am spending most of my time at the Sacramento County Primary Care Center (PCC), which mostly caters to an indigent patient population. There is a separate Integrated Behavioral Health clinic with a set of three dually trained physicians who supervise me and another fourth year student. She attends UC Davis and is applying for internal medicine residency. I am also spending a few mornings per week at a pain clinic staffed by the Medicine/Psychiatry program director.
Everyone with whom I have interacted is very nice and welcoming... and just as important, they all seem happy.
But so far, I haven't met any Medicine/Psychiatry residents. The one resident at PCC is a psychiatry intern and so is not a good person to talk with about dual training. The Medicine/Psychiatry chief resident, though, has been in close contact with me to make sure that I am having a good experience. I am looking forward to interacting more with the Medicine/Psychiatry residents. Beyond just asking them questions, I want to get a better feel for how happy they are in the program, with their training experience.
Regarding what I have discovered about the actual practice of combined medicine and psychiatry, I was surprised that the vast majority of patients who I saw at PCC were there only for management of chronic psychiatric conditions without addressing any of their medical problems. My attending says that this is mostly due to insurance reasons, because neither Medi-Cal nor Medicaid reimburse fully for office visits that address both psychiatric and medical problems. That is concerning to me but not altogether unexpected given some of the criticisms I have heard from various people about combined training programs.
I have been exposed to a lot more of mixed medicine and psychiatry in the pain clinic, where patients' chronic pain issues often stem from both physical and mental causes.
There is still so much to experience during this externship. Next week I will also see patients on the psychosomatic medicine inpatient unit.
Sunday, April 22, 2012
Information about combined medicine/psychiatry residency programs
What is combined medicine/psychiatry?
A lot of people, even medical students and doctors, have never heard of combined medicine/psychiatry residency programs. So, what exactly is med/psych? A regular internal medicine residency program is three years; a regular psychiatry residency is 4 years. Combined medicine/psychiatry residency programs shorten this training period to a total of 5 years.
How are the two programs combined?
The two residencies can be combined without compromising the integrity of the training because much of the training overlaps between the two programs. For example, the psychiatry program at Duke University requires 4 months of internal medicine and 1 month of neurology during the first year of residency, while the entire fourth year is comprised of electives and research. Likewise, Duke's internal medicine program includes a 5.5 months of electives. Adding up all that time gives you about 2 years that are saved by combining medicine and psychiatry into an integrated training program.
How many med/psych programs are there?
The National Residency Match Program (NMRP) reports that 11 combined medicine/psychiatry programs participated in The Match in 2011:
How competitive are combined med/psych programs?
I tried to get a better idea of how competitive combined medicine/psychiatry programs by looking at "Results and Data" documents published by the NRMP for the last five years, 2007 through 2011. I compiled all the Match data for med/psych programs and used those data to put together this table:
There are a lot of very interesting observations in these data:
Altogether, this is a pretty thorough presentation of what a combined medicine/psychiatry residency program actually is, what programs there are, and the Match statistics. I will likely update this with a follow-up post when I have more information, which will be sometime after I have finished interviews.
In the meantime, more information can be found on The Association of Medicine and Psychiatry website.
A lot of people, even medical students and doctors, have never heard of combined medicine/psychiatry residency programs. So, what exactly is med/psych? A regular internal medicine residency program is three years; a regular psychiatry residency is 4 years. Combined medicine/psychiatry residency programs shorten this training period to a total of 5 years.
How are the two programs combined?
The two residencies can be combined without compromising the integrity of the training because much of the training overlaps between the two programs. For example, the psychiatry program at Duke University requires 4 months of internal medicine and 1 month of neurology during the first year of residency, while the entire fourth year is comprised of electives and research. Likewise, Duke's internal medicine program includes a 5.5 months of electives. Adding up all that time gives you about 2 years that are saved by combining medicine and psychiatry into an integrated training program.
How many med/psych programs are there?
The National Residency Match Program (NMRP) reports that 11 combined medicine/psychiatry programs participated in The Match in 2011:
- Charleston Area Medical Center; Charleston, WV
- Duke University; Durham, NC
- East Carolina University; Greenville, NC
- East Tennessee State University; Johnson City, TN
- Emory University; Atlanta, GA
- Medical University of South Carolina; Charleston, SC
- Southern Illinois University; Springfield, IL
- Tulane University; New Orleans, LA
- University of California, Davis; Sacramento, CA
- University of Iowa; Iowa City, IA (This program's website is especially informative and well-presented.)
- University of Kansas; Lawrence, KS
How competitive are combined med/psych programs?
I tried to get a better idea of how competitive combined medicine/psychiatry programs by looking at "Results and Data" documents published by the NRMP for the last five years, 2007 through 2011. I compiled all the Match data for med/psych programs and used those data to put together this table:
There are a lot of very interesting observations in these data:
- The average number of positions offered per year is 22 (Range 19-26) with the greatest volatility over the past two years.
- There are consistently two med/psych positions per year that are left unfilled, and those tend to be at the same institutions year after year (Kansas, East Carolina).
- The number of med/psych applicants in 2011, both US seniors and total applicants, seemed to decrease significantly from previous years.
- Med/psych applicants, both US seniors and everyone else, apply on average to about 3 programs.
- Over the past 5 years, the percentage of total med/psych applicants who were US seniors ranged from 35% (2011) to 50% (2010). Likewise, the percentage of matched med/psych applicants who were US seniors ranged from 47% (2009) to 75% (2010). There are two major points here. First, most applicants are either international students or people who took some time off after medical school. Second, US seniors have a better chance of matching to med/psych than non-US seniors.
Altogether, this is a pretty thorough presentation of what a combined medicine/psychiatry residency program actually is, what programs there are, and the Match statistics. I will likely update this with a follow-up post when I have more information, which will be sometime after I have finished interviews.
In the meantime, more information can be found on The Association of Medicine and Psychiatry website.
Sunday, April 1, 2012
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.
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.
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.
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.
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