How do you envision patient demand for the field changing over the next x number of years (I guess buried in that is a question about how you think insurances will reimburse mental health services in the future as coverage sometimes drives demand)?
There really high demand for services for mental health (not necessarily from psychiatrists). Indeed, 1 in 3 people seeking help for mental health problems does not have a mental disorder! As for psychiatry, there is unfortunately a strong demand for psychoactive drugs from the general public and this is not going away anytime soon.
Who knows what will happen to demand or reimbursement in the future, but many plans provide truly crappy mental health coverage tantamount to no coverage at all (because the coverage provided is simply unusable). However history tells us these things ebb and flow; insurance companies find ways to cut and physicians find ways to game the system or circumvent restrictions, which the insurance companies will again react to!
Concerning the here-and-now, is it really as easy to get a job in psych after residency as everybody suggests (aka there are that many psych jobs out there)? Does this hold for academic positions as well?
It is very easy to get a job in psych. Does that mean you can get any job you want? No, of course not.
What do you mean by academic positions? If research, (i.e. academic faculty) then you will obviously have to have a strong track record and be in a position to obtain grants. If you mean a non-academic position in an academic institution (i.e. clinical faculty), it's become easier in recent years as departments are hemorrhaging faculty as they fail to compete salary wise, and demand more and more while offering less and less. If you want to obtain a faculty position at a top academic medical center, your best bet is to complete your residency training at one.
If you can't find a job you like, you can always set up your own practice providing outpatient, partial hospital, inpatient, consult, forensic etc services
How close is the field to being able to implement some of the genetic and imaging advancements for patient care as opposed to just research (for example, I've read a bit about some work looking at getting large amounts of genetic data for schizophrenic patients in the hopes of better targeting therapies)?
I use imaging all the time, and sometimes refer to neurogenetics for genetic testing. When I was a junior resident, I would order genetics myself, but now I'm of the opinion it's inappropriate for a psychiatrist to do so (unless they are an expert in medical genetics). Better to leave it to the experts who will select the appropriate genetic testing, provide counseling to the patient and family, and take the appropriate history and exam. We use imaging in the diagnoses of dementias, viral and limbic encephalitis, and to identify neurological diseases manifesting with psychiatric symptoms etc. We use genetic testing in Alzheimer's disease, frontotemporal dementia, huntington's disease, wilson's disease, mitochondrial disease, and autism (karyotyping and chromosomal microarray) already.
Mental disorders such as "schizophrenia" are artificial constructs that we invented and don't map onto real processes so most of the research that has previously done on genetics and imaging etc has been a complete waste of time. I don't see genetics making major developments to the treatment of mental illness. Look at it like this, the huntingtin gene on chromosome 4 was identified in 1983. We still have no treatments for huntington's. the genes we have found with the largest effects in "schizophrenia" (and autism etc) are rare chromsomal microdeletions etc, and only contribute a small fraction of cases (5% or so). Many cases have little to do with genetics. Psychiatric syndromes are complex genetic disorders involving often multiple genes of small effect with environmental and stochastical factors. Even if we did have the capacity to "personalize" treatments based on genetics, it is not cost-effective. Who is going to pay for the homeless psychotic guy to get some hypothetical personalized multimillion dollar treatment?
The real exciting developments we're seeing are that some of what gets labeled as "psychiatric" is actually due to brain diseases (for example autoimmune diseases causing psychosis, or the C9orf72 hexanucleotide repeat expansion and mania etc), some of which are treatable or even curable. Psychiatric disorders are syndromes. Much of what we call "schizophrenia" has more to do with the social environment, and other environmental exposures (e.g. drugs, infections) than to genetics.
Are there roles in administration, or in industry, for psychiatrists? Being frank, I guess I'm curious about your opinion about whether psychiatrists are at a disadvantage compared to higher-reimbursed specialties (i.e. Surgical subspecialists) or broader specialties (i.e. Internal medicine) when they try to jump to hospital leadership or other admin/non-clinical work later on in a career?
Psychiatrists are over represented in administrative positions. The skills you develop as a psychiatrist in managing systems issues, and working with personality disorders will come in handy in administrative positions. For example Thomas Detre, a psychiatrist, transformed UPMC into the mega monstrosity health system it is today. Many medical school deans have been psychiatrists. Herb Pardes, a psychiatrist, was the President and CEO of New York Presbytarian Hospital for many years earning over a million a year. Kenneth Davies, current CEO of Mt Sinai is also a psychiatrist, earning over 4million a year. We also have our own freestanding psychiatric hospitals that need physician leaders and pay substantially. For example steven sharfstein earned over a million a year as CEO of Sheppard Pratt for many years. Psychiatrists are in a highly advantageous position compared to other physicians to assume administrative positions. Of course there are psychiatrists in other lower level administrative positions too, including leadership of their own department. A chair of psychiatry at a top academic medical center can potentially be earning 500-800k+ a year (need to have a strong research track record and be able to bring in grants from NIH and private funding). other administrative positions include heading the american board of psychiatry and neurology (for 900k a year) or CEO of the american psychiatric association for 650k a year. obviously few become c-level executives in any field, these are just examples.
In this day and age, it is probably a good idea to do an MBA (preferably somewhere like Harvard or Stanford though not a dealbreaker by any means) if you want break into healthcare administration etc.
As for industry, quite a few psychiatrists have gone into tech trying to develop tech solutions in psychiatry; psychiatrists have always done well in pharma; a few psychiatrists have gone into management consulting or spent some time doing so. Going to a top medical school is the more important determinant especially for the latter.
What are some of the stronger neuro/biological-based residencies for psychiatry?
being more biologically based means there are deficiencies in training, but traditionally the "biological" programs are WashU, Iowa, and, UPitt, Hopkins. Of these, I think hopkins does a particularly good job of training psychiatrists though the relative lack of training in psychodynamic psychotherapy is a weakness. In this day and age there should be no "biological" psychiatrists - clinical neuroscience is an important foundation for the field though less relevant than say neuropsychiatry, but you can't be a great psychiatrist unless you also consider the psychological, social, cultural, spiritual, ethical, and medicolegal aspects of care. If you are not interested in psychological aspects of medicine, I don't see how you can be a good psychiatrist. Programs to focus on one element are necessarily producing psychiatrists whose training is not well balanced. Somehow other programs (for example columbia, mgh/mclean, and ucla manage to provide a strong training that covers the breadth of psychiatry and allows for some level of specialization according to other interests).
Any programs you see residents come from that you feel on the whole seem particularly well prepared, or, more to the point, any psych residencies you think do a really great job of training future psychiatrists?
Good psychiatrists exist in spite of their training, not because of it.
Do you guys think the gravy train is going to end in psychiatry soon? Like some guy (or committee) who decides how much physicians get paid for each service says " Why are we paying psychiatry so much, does the stuff they do even work?"
There is no "gravy train". Psychiatrists can be paid well or poorly paid (seen as low as $75/hr), but not as well as most other fields. There is a natural ebb and flow in physician compensation. Psychiatrists did very well in the 60s and 70s, and then the insurance companies decided they'd had enough of paying for endless psychotherapy, and year long+ hospitalizations, but the field adapted and survived. In the 1990s, psychiatrists' income was affected by managed care even more so, and you saw the rise of the 15 minute visit. The pendulum has swung the other way in recent years, and it's becoming more commonplace for 60 mins+ new visits and 30 minute follow ups to be standard. Of course, quite rightly, people will always be looking at whether there'sfat to cut, and whether we are providing value. You will continue to have a job and do well as long as you ask these questions for yourself. Psychiatrists aren't currently in danger of outpricing themselves, but if we do then psychologists and NPs will just take our place. If our stuff doesn't even work, then quite rightly we shouldn't be paid for it. As long as you adapt to the evolving world, and offer skills that others do not, you will continue to earn a decent living and be in demand. since most psychiatrists can't (or dont want to) do what I do, let alone an NP, I don't think I have anything to worry about.
Second, on average how many hours a week do you guys really work? I see most psychiatrist work less, like 36-40hrs a week.
I know people who work 5hrs a week to 80+hrs a week. I work 55hrs on average. biggest variables for me are how much forensic work i'm doing, and any other stuff I have to do (i.e. writing and reviewing papers, editorial stuff etc.)
