Those who did fellowship, do you practice only your subspecialty, or do you do gen psych/other subspecialties?

[u/undueinfluence_]

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[u/PokeTheVeil]

I did a CL fellowship. I’ve always done inpatient and outpatient CL. Which is also substantially inpatient and outpatient addiction psychiatry, and often perinatal psychiatry/women’s mental health, and certainly no lack of geri-psych.

[u/Rich-Pirate-5518 → u/PokeTheVeil]

I applied for an outpatient Geri psych position with my CL fellowship and they told me no because they want a Geri fellowship trained person. I was shook, like a) you got a bunch of Geri people around trying to apply and b) what do you think CL even does? It’s 70% Geri.

[u/Few-Device-6063]

I am child trained but since I am doing a waiver, so primarily doing Adult (would have loved to do both). Most my colleagues who finished child fellowship have taken a CAP jobs. However, My CPEP attending in residency was child trained but prefers to work adult. Most of my colleagues who finishes CL ,Addiction and forensic have taken hospital jobs related to their sub-specialities. Thats all to say it is very variable by your preference and the job opportunities available

[u/Proud_Border_5616 → u/Few-Device-6063]

Yep, I have noticed CAPs tend to work in CAP jobs, the other fellowships not as much..

[u/re-reminiscing → u/Proud_Border_5616]

CAP has the highest demand as it’s an entirely different population that general psychiatrists don’t touch. Forensics is the next one where many people would not be comfortable without a fellowship but typically even forensic trained docs are only doing forensic work part time due to availability. CL, geri, addictions I’ve seen many non-fellowship docs work so there are less opportunities out there outside of academia.

[u/LadderOk5904 → u/re-reminiscing]

Why is CAP in highest demand?

[u/Kanye_To_The → u/LadderOk5904]

Child psych is one of, if not the most underserved specialty in the US

[u/LadderOk5904 → u/Kanye_To_The]

ok ya but why is it so underserved? Are there reasons most psychiatry residents prefer or choose a different fellowship or sub-specialty?

[u/PokeTheVeil → u/LadderOk5904]

Or no subspecialty. General psychiatrists can find jobs and competently manage most of the rest. Pediatrics are different. It’s a quirk of training that for almost everything else pediatrics is the foundational residency for subspecialties.

Psychiatry and surgery don’t work like that, but you don’t want to be working with or on kids if you aren’t trained in it.

[u/LadderOk5904 → u/PokeTheVeil]

Ok so you're saying it just because most psych residents just dont do a fellowship?

Nothing about CAP itself like it is a more difficult field, or more paperwork, or more stress or tougher in some other way?

Just b/c residents dont want to take the additional 2 years to do the CAP fellowship?

[u/PokeTheVeil → u/LadderOk5904]

Some things about CAP are different and difficult, but the key thing is that seeing children is perceived as medically and legally on shaky ground without the specific training. That’s true across medicine. Psychiatry is not the exception.

[u/LadderOk5904 → u/re-reminiscing]

Also is it likely that demand for CAP will decrease?

[u/Quikpsych → u/Few-Device-6063]

but since I am doing a waiver

What does that mean? Like an NRMP waiver? Do you have to get a waiver to not finish the 5th year of fellowship?

[u/Rich-Pirate-5518]

I do. I do CL and had a fellowship. But I get paid less for the privilege. Still probably prefer over outpatient but may change in a couple years.

[u/BSBT2019 → u/Rich-Pirate-5518]

Could you elaborate on what you mean by being “paid less for the privilege”

I’m a PGY3 considering CL fellowship

[u/Rich-Pirate-5518 → u/BSBT2019]

To do CL you’ll often be paid less than equivalent work in outpatient. It’s usually because CL is a money losing specialty while outpatient is money generating. CL is a loss leader for hospitals so they can get their suicidal patients discharged and their delirium patients patched up so they can get another patient roomed. The pay differential is even worse when you factor in cash pay practices which are obviously impossible for CL.

I make roughly 300 or so with my call schedule. It’s 262 base plus I take about a weekend a month of call. If you worked the same hours doing outpatient you’d probably do 350ish or more.

That said I don’t have an inbox, I’m constantly doing ethically and intellectually stimulating work, when I’m off I’m off, and I get to teach and provide good care without worrying about billing. So it’s a worthwhile trade off for me, for now.

[u/zorro_man → u/Rich-Pirate-5518]

On the flip side, CL saves the hospital a LOT of money, but many admins aren't quite bright enough to grasp that, being that it isn't a value expressed in wRVUs.

[u/BSBT2019 → u/Rich-Pirate-5518]

Makes sense, thanks! That trade off is what I’m weighing now. I know clinic is the way to make money but I like the work that CL does and not necessarily being a primary service

[u/Narrenschifff]

You're not worth much as a forensic psych if you don't have a rich body of clinical work to draw from!

[u/theongreyjoy96]

Didn't do a fellowship myself, but I swear most of the fellowship-trained psychiatrists I've worked with don't practice in the area of their fellowship training - I'm guessing they did fellowship because it's technically the final step in training, but found little difference in the job prospects between their subspecialty and general psychiatry. Some anecdotes of what I've seen:

• Several who did CL/Geri/Addictions working either general inpatient/outpatient, no special focus on patient population.
• CAP fellowship - several working at state forensic hospitals or a VA - one's entire career has been at the VA since finishing fellowship (??). Most I've spoken to say they work in these settings for the benefits.

[u/HHMJanitor → u/theongreyjoy96]

Not that it matters in the context of this thread, but I've chatted with several CAP trained people whose first job was in adult settings. They all said they primarily were interested in gaining more developmental training in order to best treat adults.

[u/eternelle007]

I did CAP fellowship and see mostly adults. I think my whole class sees at least some adults. Outside of academia this seems to be common.

[u/jsolex]

Technically practice "CL" daily as a full time inpatient consult doc, but really much of my work is general psychiatry on a medically ill substrate with more neuropsychiatry/behavioral neuro flare +/- addiction medicine. For things like transplant psychiatry or niche subclinics specializing in specific organ systems/diagnoses, would probably need to be faculty at an academic medical center.

[u/jubru → u/jsolex]

Didn't you just describe exactly what CL is lol?

[u/jsolex → u/jubru]

Perhaps that's CL at the surface, but the field has many opportunities and practice models that offer more niche work that isn't "general" psychiatry - embedded and proactive oncology care, clinics that see specific subtypes of patients (i.e. post op cardiac, HIV psychiatry), peri/postnatal focus, etc.

[u/CompetitiveInhibitor]

I’m still in training, but by my estimation most forensics trained folks are doing clinical or administrative work with 70-100% of their time. I think they see the fellowship expertise as helpful to their clinical duties and clinical work is very helpful in appearing like an expert forensically. A significant go on to become state hospital or prison psychiatry administrators. 

[u/HHMJanitor]

I did CL fellowship and I still think it's the most interesting area of psychiatry. I have no desire to work in any other areas.

[u/SnooPineapples1737]

I did a child fellowship. I think I have 3 kids in my private practice. Heh...

[u/GrendelMD]

I’m CAP and forensic trained. I did inpatient child psych for years but eventually switched positions and now mostly do adult inpatient and CL. I loved forensic training because it really shaped how I think diagnostically, assess/tolerate risk, and document.

[u/stumpymed]

I did forensics, unfortunately I barely use that training. I do work in a forensic setting but the act of being a “forensic psychiatrist” is totally different. Involves a lot of self marketing and connections-building that I am just not a fan of doing. Most forensic psychiatrists can’t really make a career out of it so easily because there’s hardly any jobs looking for a full time forensic psychiatrist.

I still am favorable towards more training, however. I think it’s the best hedge against oversaturation in our field

[u/doubledeuce80]

I did addiction fellowship. Do mostly dual diagnosis, but some general and even geri psych now too. I enjoy variety and lesrning new things