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. Dr. Jubbal, MedSchoolInsiders.com. 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. You can find the other specialties on our
So You Want to Be playlist. If you want to vote in upcoming polls to decide
what future specialties we cover, make sure you’re subscribed. If you’d like to see what being a psychiatrist
looks like, check out my second channel, Kevin Jubbal, M.D., where we featured Dr. Petey
Kass in a Day in the Life of a Psychiatrist. Link in the description. Psychiatry is the field of medicine focused
on understanding and treating mental health disorders and psychological distress. Psychiatrists use the Diagnosable and Statistics
Manual, currently in it’s fifth iteration, hence the name DSM-V, in assessing a patient’s
constellation of symptoms and determining if they exhibit a diagnosable disorder. But psychiatrists can 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 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 PhD 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. 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 to 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 from
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 trans cranial magnetic stimulation, or TMS for short,
ketamine, and deep brain stimulation. In an academic setting, you can work either
primarily inpatient or outpatient, but 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, and 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
is 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. At 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. 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 in 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 opportunity 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. 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, and 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 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 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. Psychiatry is a unique specialty within 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 setting. 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 call are infrequent. 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 they’re completely unaware of the seizure. The most common adverse effect is headache. 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 the emotional disorders, requiring comfort with ambiguity,
complexity, and holistic formulation. It can be more messy. If you prefer more concrete answers, localizing
brain lesions with cut and dry, black and white pathophysiology, neurology may be a
better fit. Huge thanks to Dr. Petey Kass, psychiatrist
and Insider at Med School Insiders, for helping me with the creation of this video. For anyone who wants to take their medical
school or residency application to the next level, Med School Insiders has your back. Thousands of students have used our services
and courses, and we have over a 95% success rate for our comprehensive packages. But don’t just take our word for it. Our customers have left hundreds of glowing
reviews, and we have an industry leading 99% satisfaction rating. Visit MedSchoolInsiders.com to learn more. Thank you all so much for watching! If you enjoyed this episode, check out our
other specialties in the So You Want to Be playlist. Much love, and I’ll see you guys in that
next one.
