IM vs Psych

[BLTsandwich]

Hello,

I am an upcoming 4th year.
Completely jaded with medicine. I'm tired, annoyed, and just want to graduate.
I have only a bit left to feign interest in away rotation + interviews. Hopefully after that I can unwind and recharge my batteries.
However, I have to pick a specialty soon.
I'm down to 2 - IM vs Psych; solely based on lifestyle.
I hate to admit it and already expect some backlash, but I don't really care anymore.
However, I do apologize if I come off disrespectful to your field.
I don't have the scores for ROAD.

People says it gets better and I'm just dragging my booty until the promise land.
IM - only 3 years residency. 7on/7off sounds sweet for me personally. Seems like most attending get out at 5pm (hold pager until 7pm). Not common, but some out by 3pm. High burn out but lots of testimonies on people loving the gig. I honestly don't see why it's such a high burn out considering the work day is like 730am-5pm for 26 weeks/year for 250-300k. Can moonlight. If I do really burn out, do part time locum or change to PCP outpatient.
Psych - 4 years training Inpatient gig is nice (8a-1pm or 3pm); 300-400k. Outpatient is chill 9a-5p with 8-12 patients (250-300k). No calls, no weekends. Telepsych job is readily available. Can pick up inpatient weekend shift for 3-4k. Some do inpatient rounds in morning and PP outpatient in afternoon but I'm not interested in that.

I want to travel. I have extensive hobbies that I want to continue. I can def find joy outside of my job (unlike some in the medical field who never did anything but study - I can't resonate with those who are unsure what to do with free time). Also hope to start family in the next 10 years. Plan on doing PSLF - both IM & Psych are able to qualify without much difficulties.

Would love your input!
Feel free to DM me if you want privacy.
Thanks!

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[NewYorkDoctors]

Well some hospitalist jobs (not all - depends on location and overall salary and package ) can be 7 on and 7 off. You could also work to be a part time primary care physician - contract with a private group for like one week a month coverage or something so you can travel

 

[CCM-MD]

I think psychiatry is a better option if you’re looking purely at lifestyle.

 

[grt398]

Based on your criteria...psych all the way. Better lifestyle. Easier residency. Ability to open your own cash practice and be fully independent working as much or as little as you want.

 

[DrStephenStrange]

Well some hospitalist jobs (not all - depends on location and overall salary and package ) can be 7 on and 7 off. You could also work to be a part time primary care physician - contract with a private group for like one week a month coverage or something so you can travel

You can't do PSLF if you work part time.

 

[Mad Jack]

Hello,

I am an upcoming 4th year.
Completely jaded with medicine. I'm tired, annoyed, and just want to graduate.
I have only a bit left to feign interest in away rotation + interviews. Hopefully after that I can unwind and recharge my batteries.
However, I have to pick a specialty soon.
I'm down to 2 - IM vs Psych; solely based on lifestyle.
I hate to admit it and already expect some backlash, but I don't really care anymore.
However, I do apologize if I come off disrespectful to your field.
I don't have the scores for ROAD.

People says it gets better and I'm just dragging my booty until the promise land.
IM - only 3 years residency. 7on/7off sounds sweet for me personally. Seems like most attending get out at 5pm (hold pager until 7pm). Not common, but some out by 3pm. High burn out but lots of testimonies on people loving the gig. I honestly don't see why it's such a high burn out considering the work day is like 730am-5pm for 26 weeks/year for 250-300k. Can moonlight. If I do really burn out, do part time locum or change to PCP outpatient.
Psych - 4 years training Inpatient gig is nice (8a-1pm or 3pm); 300-400k. Outpatient is chill 9a-5p with 8-12 patients (250-300k). No calls, no weekends. Telepsych job is readily available. Can pick up inpatient weekend shift for 3-4k. Some do inpatient rounds in morning and PP outpatient in afternoon but I'm not interested in that.

I want to travel. I have extensive hobbies that I want to continue. I can def find joy outside of my job (unlike some in the medical field who never did anything but study - I can't resonate with those who are unsure what to do with free time). Also hope to start family in the next 10 years. Plan on doing PSLF - both IM & Psych are able to qualify without much difficulties.

Would love your input!
Feel free to DM me if you want privacy.
Thanks!

There's 7 on/7 off psych hospitalist inpatient jobs, for the record. Plenty of 4 day a week outpatient jobs (8-6, usually) with 5-6 weeks of vacation out there. Locum rates for psych are typically higher than IM, but you can get equivalent rates if you're willing to shop around. PP telepsych could open the rather unique ability to travel while you work and still have enough time to enjoy yourself.

With regards to training duration, IM is 3 years but they're painful years. Psych is usually very bearable after year two, and far better than IM even in the first two years if you're looking at hours. I averaged 35-55 hours per week, depending on my rotation, throughout my adult training. You can also moonlight at many programs after intern or second year of you're a US grad, which depends on the state. This allows for significant offset of lost income. Moonlighting once every four weekends (weekend call stopped for me after second year) got me an extra $45k a year but I could easily earn far more if I worked harder. Some people would work IM hours, doing every other weekend plus an overnight a week and pull an extra $116k a year, putting total pay near $190k while still in residency. I value my free time and sanity more than money, personally, but it gives you an idea of the financial opportunities in some areas.

Don't do psych for the money or the lifestyle though. Truthfully it is miserable work for those that don't enjoy it. I really like what I do and even after a bad day I don't feel miserable after work, I almost fell satisfied at having done a difficult job well. In contrast, I would feel miserable after even my best shifts in IM. Fit is more important than anything for something you'll be doing for the rest of your working life.

 

[NITRAS]

Darn, @Mad Jack, baller resident income.

I’d just take income with a grain of salt. All you can say is that incomes change. Psych is the new thing. Lots of people going into it. It wouldn’t surprise me if incomes dropped, but who can really tell. IM is probably the second broadest field in medicine (second only to FM). You can practice in an infinite number of ways.

 

[NewYorkDoctors]

You can't do PSLF if you work part time.

So much for that plan . Just like the earth 838 Illuminati

 

[Mad Jack]

Darn, @Mad Jack, baller resident income.

I’d just take income with a grain of salt. All you can say is that incomes change. Psych is the new thing. Lots of people going into it. It wouldn’t surprise me if incomes dropped, but who can really tell. IM is probably the second broadest field in medicine (second only to FM). You can practice in an infinite number of ways.

Going to second the income thing. Psych used to be a very low paying specialty and we're one regulatory change at any time from going back to that. I would still do psych for less than I would do IM. My temperament just isn't suited to IM work, just as many in IM aren't particularly thrilled with psych work. Do what you enjoy

 

[painballer27]

Going to second the income thing. Psych used to be a very low paying specialty and we're one regulatory change at any time from going back to that. I would still do psych for less than I would do IM. My temperament just isn't suited to IM work, just as many in IM aren't particularly thrilled with psych work. Do what you enjoy

What type of regulatory change would have to occur for it to go back to being very low paying? What is keeping it at its current level of pay?

 

[niblet]

The fields are so different it's hard to imagine there's anyone who would enjoy the two equally. Do you want to diagnose and treat medical illness or psychiatric illness? I would think one of the two would appeal to you more? Can we help you determine that?

I would urge you that even if you are a work-to-live type, how much you like (or simply tolerate, I suppose) your job is not an insignificant thing.

If it is really purely about lifestyle, though, psychiatry is the choice.

 

[Mad Jack]

What type of regulatory change would have to occur for it to go back to being very low paying? What is keeping it at its current level of pay?

Compensation was garbage until the law forced insurance companies to cover mental health services to be available in the same manner as physical health services as part of the mental health and addiction parity act, if I recall correctly. By forcing coverage, providers needed to be enticed to be in-network through increased reimbursement. If that law were to be amended or changed then reimbursement could be affected quite adversely. Insurance companies have fought against it since the beginning and will likely continue to advocate for it to be changed in the future. Through an ugly cobbled future bill similar to the ACA, they could sneak in regressive changes that would devastate the field, though at the moment this seems unlikely

 

[DrMetal]

Do Internal Medicine. Here's why:

In Internal Medicine, you get a few wins here and there. You don't bat a 1000, but you bat lets say .300. Every once in a while, you succeed in convincing someone that they're diabetic or hypertensive, they accept their diagnosis and your treatment, and you watch their A1C and BP decline nicely. You feel good.

In Psychiatry, the "wins" are much harder to come by. You're batting 0.100. It's too difficult to convince people of their serious pathology (schizophrenia, BPDO, etc) and to get them to comply. It's even harder to treat the garden variety personality disorders and to deal with the malingerers. Throw in a slew of other social circumstances that are way beyond your control, and you're dealing with essentially impossible problems that'll never resolve. No thanks!

 

[Psych_hopeful]

Do Internal Medicine. Here's why:

In Internal Medicine, you get a few wins here and there. You don't bat a 1000, but you bat lets say .300. Every once in a while, you succeed in convincing someone that they're diabetic or hypertensive, they accept their diagnosis and your treatment, and you watch their A1C and BP decline nicely. You feel good.

In Psychiatry, the "wins" are much harder to come by. You're batting 0.100. It's too difficult to convince people of their serious pathology (schizophrenia, BPDO, etc) and to get them to comply. It's even harder to treat the garden variety personality disorders and to deal with the malingerers. Throw in a slew of other social circumstances that are way beyond your control, and you're dealing with essentially impossible problems that'll never resolve. No thanks!

Well said. There is nothing like seeing your patient lose 80 lbs intentionally or you catching a cancer that can be intervened upon early.

 

[Kaustikos]

Do Internal Medicine. Here's why:

In Internal Medicine, you get a few wins here and there. You don't bat a 1000, but you bat lets say .300. Every once in a while, you succeed in convincing someone that they're diabetic or hypertensive, they accept their diagnosis and your treatment, and you watch their A1C and BP decline nicely. You feel good.

In Psychiatry, the "wins" are much harder to come by. You're batting 0.100. It's too difficult to convince people of their serious pathology (schizophrenia, BPDO, etc) and to get them to comply. It's even harder to treat the garden variety personality disorders and to deal with the malingerers. Throw in a slew of other social circumstances that are way beyond your control, and you're dealing with essentially impossible problems that'll never resolve. No thanks!

Well said. There is nothing like seeing your patient lose 80 lbs intentionally or you catching a cancer that can be intervened upon early.

I think we're stretching this disparity quite a bit. Especially when you have a 4th year MS saying they're tired and jaded of medicine. I'm not seeing someone who's already like this batting even 20 with that kind of attitude. Hell, not seeing them batting **** in either specialties. They'll both ultimately end up being double AKA, trach'd, peg'd, SPC with chronic OM referred to everyone.
I'm not saying OP is going to be 100% like that. But unless his mindset change, I don't feel that either specialty. Saying you don't care AND you want to focus more on lifestyle?

OP - go into administration.

 

[Psych_hopeful]

I think we're stretching this disparity quite a bit. Especially when you have a 4th year MS saying they're tired and jaded of medicine. I'm not seeing someone who's already like this batting even 20 with that kind of attitude. Hell, not seeing them batting **** in either specialties. They'll both ultimately end up being double AKA, trach'd, peg'd, SPC with chronic OM referred to everyone.
I'm not saying OP is going to be 100% like that. But unless his mindset change, I don't feel that either specialty. Saying you don't care AND you want to focus more on lifestyle?

OP - go into administration.

Even if he wants to do admin, it will only help him if he does IM residency first.

 

[deleted456421]

Do Internal Medicine. Here's why:

In Internal Medicine, you get a few wins here and there. You don't bat a 1000, but you bat lets say .300. Every once in a while, you succeed in convincing someone that they're diabetic or hypertensive, they accept their diagnosis and your treatment, and you watch their A1C and BP decline nicely. You feel good.

In Psychiatry, the "wins" are much harder to come by. You're batting 0.100. It's too difficult to convince people of their serious pathology (schizophrenia, BPDO, etc) and to get them to comply. It's even harder to treat the garden variety personality disorders and to deal with the malingerers. Throw in a slew of other social circumstances that are way beyond your control, and you're dealing with essentially impossible problems that'll never resolve. No thanks!

Oh man. Given the current state of psychiatry (meaning frequent referrals from subpar "providers"), I feel like I get wins on the daily. Identifying akathisia, drug-induced parkinsonism, untreated catatonia, and otherwise horrible mismanagement lets me improve peoples lives surprisingly frequently. Plus, the medications we use have just as good (if not better) effect sizes than the diabetes and HTN drugs you use, especially when treating psychosis and mania. I also find my patients with borderline personality disorder easier to manage than those with chronic somatic complaints and opioid seekers, which many of my internist colleagues gripe about.

 

[DrMetal]

Oh man. Given the current state of psychiatry (meaning frequent referrals from subpar "providers"), I feel like I get wins on the daily.

You do??? God bless you. Where do you practice? I have a lot of business for you.

Plus, the medications we use have just as good (if not better) effect sizes

I don't doubt it. But what good are medications if you can't convince the patient that they have a) a problem, b) need help and c) need to comply? I don't know of many homeless schizophrenics that take their Abilify daily as prescribed and have the cognizance to seek refills when out.

borderline personality disorder easier to manage than those with chronic somatic complaints and opioid seekers, which many of my internist colleagues gripe about.

We have our issues in IM, no doubt. I feel like we just get a few more wins.

 

[aafisahar]

I think we're stretching this disparity quite a bit. Especially when you have a 4th year MS saying they're tired and jaded of medicine. I'm not seeing someone who's already like this batting even 20 with that kind of attitude. Hell, not seeing them batting **** in either specialties. They'll both ultimately end up being double AKA, trach'd, peg'd, SPC with chronic OM referred to everyone.
I'm not saying OP is going to be 100% like that. But unless his mindset change, I don't feel that either specialty. Saying you don't care AND you want to focus more on lifestyle?

OP - go into administration.

That's a win for car payments. RVUs are RVUs no matter how you come across them.

 

[Splenda88]

if you can see yourself doing either one, do what will give more $$$, better lifestyle and flexibility. As an IM hospitalist who has a semi decent gig, I think psych is the winner.

 

[DrMetal]

if you can see yourself doing either one, do what will give more $$$, better lifestyle and flexibility. As an IM hospitalist who has a semi decent gig, I think psych is the winner.

Could be true. Tele-psych is taking off too. What a great scam, er, job, that is.

 

[Candidate2017]

The fields are so different it's hard to imagine there's anyone who would enjoy the two equally. Do you want to diagnose and treat medical illness or psychiatric illness? I would think one of the two would appeal to you more? Can we help you determine that?

I would urge you that even if you are a work-to-live type, how much you like (or simply tolerate, I suppose) your job is not an insignificant thing.

I enjoyed my IM months in psych intern year despite the hours being twice that of my psychiatry months.

OP, choosing a specialty based on lifestyle (less hours, more money) doesn't account for how well you tolerate the unique challenges of each specialty. In the end, the pay, hours, and flexibility of IM and psych aren't all that different as an attending. You should consider what you can tolerate:

short or long notes
short or long visits
less patient talking or more patient talking
HTN, DM, CVD, asthma or MDD, GAD, bipolar, schizophrenia
treat disease or treat disease and personality
more specialization choices or less
employed or self employed
opioid seeking or stimulant and benzo seeking patients
less or more patient/family input on diagnosis and meds (IM patients and their families never diagnose themselves with HFpEF or refute your diagnosis of CKD 3, or disagree with your choice of abx for their sepsis or gonorrhea)

 

[Candidate2017]

But what good are medications if you can't convince the patient that they have a) a problem, b) need help and c) need to comply? I don't know of many homeless schizophrenics that take their Abilify daily as prescribed and have the cognizance to seek refills when out.

We have our issues in IM, no doubt. I feel like we just get a few more wins.

Noncompliance is an issue in any specialty. Schizophrenics who maintain their medications do very well. I'm surprised the noncompliance rate isn't higher given the frequency of serious side effects from antipsychotics.

I feel wins and losses are more dramatic in psych. A schizophrenic getting on the right meds and getting back in the work force job, a doctor overcoming their OCD germophobia, an academic overcoming crippling social anxiety to finish their PhD.

I'd rather have an IM loss than a psych loss though. You can shrug if someone isn't compliant with their b-blockers, and there's not much fanfare when a 90 year old dies of sepsis or nosocomial PNA. But fingers get pointed at the psychiatrist if a patient shoots up a school, theater or grocery store.

 

[Splenda88]

Could be true. Tele-psych is taking off too. What a great scam, er, job, that is.

There is some tele IM/FM, but I think psych is more suited for tele medicine...

In all honesty IM (hospital medicine) is very good if you do your due diligence and find the right gig. People at my place are making general surgery $$$ working ~90 hrs every 2 wks. They can take weeks off to a certain extent without anyone telling them they are not team players.

 

[deleted456421]

You do??? God bless you. Where do you practice? I have a lot of business for you.



I don't doubt it. But what good are medications if you can't convince the patient that they have a) a problem, b) need help and c) need to comply? I don't know of many homeless schizophrenics that take their Abilify daily as prescribed and have the cognizance to seek refills when out.



We have our issues in IM, no doubt. I feel like we just get a few more wins.

I love IM and frequently miss complex medical cases with truly identifiable pathophysiology. However, few things were more frustrating in medical school than encountering patients with primary psychiatric concerns who refused psychiatric help. Now I only see the people who agree to such treatment (they presumably come to a psychiatrist for medications) whilst primary care is left dealing with the rest. Honestly, I didn't go into primary care because I couldn't handle those individuals with completely absent insight, not to mention how much knowledge the field requires in general. Few people are more valuable than a good primary care doc.

 

[DrMetal]

I feel wins and losses are more dramatic

'Wins' are hard to come by in any medical specialty. I know, me arguing that we get more 'wins' in Internal Medicine is like me arguing the LA Lakers had a better season this year than the Sacramento Kings. All true, but it's only a slight advantage for IM.

But fingers get pointed at the psychiatrist if a patient shoots up a school, theater or grocery store.

Timely quote. And I think this is complete BS. No physician should be blamed (or even pointed at) for the lunacy of man. Before I went to medical school, I had not idea how much a physician was expected to 'predict' the SI or HI nature of a patient. And that a physician is somehow culpable, if she fails to ask or probe about SI/HI at every encounter? That's ridiculous. We're not in the business of predicting human behavior. If I could do that, I'd be on Wall Street.

Now I only see the people who agree to such treatment (they presumably come to a psychiatrist for medications)

If you can cherry pick like that, more power to you. I often noticed that the Axis I (sorry, I'm a brainchild of DSM4) were somewhat easier to treat. Their pathology was bad enough that they could be convinced, I guess. Axis II (personality disorders), forget about it.

 

[Candidate2017]

Timely quote. And I think this is complete BS. No physician should be blamed (or even pointed at) for the lunacy of man. Before I went to medical school, I had not idea how much a physician was expected to 'predict' the SI or HI nature of a patient. And that a physician is somehow culpable, if she fails to ask or probe about SI/HI at every encounter? That's ridiculous. We're not in the business of predicting human behavior. If I could do that, I'd be on Wall Street.

Oh damn, my post was so prescient (Texas happens). I guess my argument that psychiatrists don't have a crystal ball to predict SI/HI is undermined.

If you can cherry pick like that, more power to you. I often noticed that the Axis I (sorry, I'm a brainchild of DSM4) were somewhat easier to treat. Their pathology was bad enough that they could be convinced, I guess. Axis II (personality disorders), forget about it.

I think of outpatient psychiatry as akin to a surgical specialty. The outpatient psychiatrist and surgeon have clinic in order to screen for those who can tolerate and be successful with our procedures (therapy is actually billed as a procedural code).

 

[NonNocere]

Hello,

I am an upcoming 4th year.
Completely jaded with medicine. I'm tired, annoyed, and just want to graduate.
I have only a bit left to feign interest in away rotation + interviews. Hopefully after that I can unwind and recharge my batteries.
However, I have to pick a specialty soon.
I'm down to 2 - IM vs Psych; solely based on lifestyle.
I hate to admit it and already expect some backlash, but I don't really care anymore.
However, I do apologize if I come off disrespectful to your field.
I don't have the scores for ROAD.

People says it gets better and I'm just dragging my booty until the promise land.
IM - only 3 years residency. 7on/7off sounds sweet for me personally. Seems like most attending get out at 5pm (hold pager until 7pm). Not common, but some out by 3pm. High burn out but lots of testimonies on people loving the gig. I honestly don't see why it's such a high burn out considering the work day is like 730am-5pm for 26 weeks/year for 250-300k. Can moonlight. If I do really burn out, do part time locum or change to PCP outpatient.
Psych - 4 years training Inpatient gig is nice (8a-1pm or 3pm); 300-400k. Outpatient is chill 9a-5p with 8-12 patients (250-300k). No calls, no weekends. Telepsych job is readily available. Can pick up inpatient weekend shift for 3-4k. Some do inpatient rounds in morning and PP outpatient in afternoon but I'm not interested in that.

I want to travel. I have extensive hobbies that I want to continue. I can def find joy outside of my job (unlike some in the medical field who never did anything but study - I can't resonate with those who are unsure what to do with free time). Also hope to start family in the next 10 years. Plan on doing PSLF - both IM & Psych are able to qualify without much difficulties.

Would love your input!
Feel free to DM me if you want privacy.
Thanks!

Would you rather practice internal medicine or practice psychiatry? There are also combined IM-Psych residency programs.