While valued in all medical specialties, strong interpersonal and communication skills are especially crucial for psychiatrists, who interact with the most emotionally vulnerable of patients. Fervor for caring for the troubled often trumps board scores and class rankings when psychiatry residency directors select their best candidates.
“Certainly, if a med student does well on the boards and gets good grades, that’s desirable. But psychiatry as a field tends to put less emphasis on the numbers than do the highly competitive surgical specialties,” says David A. Baron, DO, a psychiatry professor at the University of Southern California’s medical school in Los Angeles and psychiatrist-in-chief at the university’s hospital.
Psychiatrists need to be great listeners and have tremendous curiosity about patients’ lives, says Robert G.G. Piccinini, DO, the president-elect of the American College of Osteopathic Neurologists and Psychiatrists (ACONP). He discovered his flair for the field as a third-year medical student on a medicine rotation. One evening, while completing normally quick transition-and-handoff patient visits at the end of a long shift, he came upon a middle-aged man seated at the edge of his bed, eyes fixed on the floor.
“Obviously, something was wrong,” Dr. Piccinini remembers. “I ended up spending three hours with the patient just talking with him. I had a knack for drawing him out.”
Although Dr. Piccinini had previously been leaning toward a career in geriatric internal medicine, he soon realized that psychiatry was his calling.
“People began to notice that I was able to get stories from patients that nobody else could,” Dr. Piccinini says.
As a med student, William J. Resch, DO, also flirted with other specialties before falling for psychiatry. “I came to realize that psychiatry fit my personality better than any other field,” he says. “In many other medical specialties, you treat patients algorithmically. With psychiatry, you can’t do that. There is no one-size-fits-all treatment.
“Psychiatry is tremendously intellectually stimulating, as well as challenging. I knew I would never get bored with the field.”
Child and adolescent psychiatrist Alyse F. Ley, DO, gravitated toward her subspecialty because she likes working with teams of professionals to help pediatric patients thrive at home and at school.
“You can work with teachers, counselors and other physicians and really improve a child’s life,” Dr. Ley says. “It’s so rewarding. Most of the kids do very well.”
Psychiatrists require exceptional empathy and emotional resilience. They have to understand what patients are feeling and respond appropriately, Dr. Piccinini says. Unstable or frustrated patients may insult and swear at their psychiatrists. Many adult patients are noncompliant, and some try to manipulate their psychiatrists with calculated lies.
“A patient recently called me during the weekend to say he was having a hard time. ‘What has changed?’ I asked. ‘I went off my meds a month and a half ago,’ he replied. When I have such conversations with patients, I have to be forgiving and measured in my response,” says Dr. Piccinini, who practices in Sterling Heights, Mich. “I can’t get upset. I have to choose my words carefully.”
More difficult to deal with are patients who are deliberately deceitful because they are abusing their medications. “I’ve had patients who call and say, I’ve lost my Xanax. Can you write me a new prescription?’ ” Dr. Piccinini says. “I’ll say, ‘It’s tough to be you.’ I’m not going to reward their obviously bad behavior.”
Psychiatric patients can be physically aggressive as well. “We had one patient who went into a psychotic state and ended up pushing my partner’s head into the wall, breaking the plaster,” Dr. Piccinini recalls. “I had to tackle the person to the ground. Violence is a risk that we deal with.”
The most difficult aspect of psychiatry, however, is patient suicide. “Every time, it hurts,” says Dr. Piccinini. “I examine everything I did with that person to see if I could have done anything else.”
Caring for people with mental disorders demands a “marathon commitment” to patients, as Dr. Piccinini puts it. The field is not for those who relish quick fixes and immediate results.
Body, mind and spirit
Educated in the whole-patient approach to care, graduates of osteopathic medical schools tend to be well-prepared to train in the specialty of psychiatry.
“To be a good psychiatrist, you need to understand disease and illnesses in a broader context, which is very much like osteopathic philosophy,” Dr. Baron says.
“The biopsychosocial model of osteopathic medicine resembles that of psychiatry,” agrees Dr. Resch, the program director of the AOA-approved psychiatry residency associated with the Ohio University Heritage College of Osteopathic Medicine in Athens. “In psychiatry, you look at the whole body, the outside influences on the patient, and the stressors that factor into mental illness, such as poverty, joblessness, relationships, traumas and homelessness.”
Some DO psychiatrists perform osteopathic manipulative treatment on patients, but touch is controversial in psychiatry. For the most part, patients who have been physically or sexually abused should not be treated with OMT, osteopathic psychiatrists say.
Jimmie P. Leleszi, DO, a child and adolescent psychiatrist who is board certified in hospice and palliative medicine, uses osteopathic manipulation in combination with medications to alleviate the suffering of dying children.
OMT is also sometimes used as an adjuvant therapy for pediatric patients with anxiety, attention-deficit/hyperactivity disorder, autism and many other conditions.
Well-regarded in the broader psychiatric community, osteopathic medical graduates are welcome in many of the 215 psychiatry residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME), as well the 18 AOA-approved psychiatry residencies.
Because the osteopathic medical profession historically has had fewer than a handful of psychiatry residencies, numerous ACONP leaders, such as Dr. Piccinini, trained in ACGME programs and later obtained AOA recognition of their training and AOA board certification. Some ACGME-trained DOs pursue dual certification to enhance their career opportunities.
“Since osteopathic medical students can get into many of the top ACGME psychiatry programs, some of the osteopathic programs aren’t filling,” Dr. Baron says. “Many osteopathic students feel they may have more career options if they go to an MD program, but that’s not necessarily the case. It depends on what you want to do with your career.”
Students generally match into psychiatry residencies, which are four-year programs, from their fourth year of medical school. Because not all of the AOA-approved psychiatry residencies fill, it is sometimes possible to match into osteopathic programs from traditional rotating internships or transfer into psychiatry after a year in a primary care residency program.
Beyond residency, psychiatrists may pursue fellowships in such subspecialties as child and adolescent psychiatry, addiction medicine, forensic psychiatry, geriatric psychiatry, and hospice and palliative medicine. Although most psychiatric fellowships are ACGME-accredited, there are four AOA-approved programs in child and adolescent psychiatry, one in forensic psychiatry, two in geriatric psychiatry, one in addiction medicine and seven in hospice and palliative care.
Aspiring osteopathic psychiatrists do not need top scores on the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA).
According to a report on the 2011 AOA Match by the American Association of Colleges of Osteopathic Medicine, those matching into psychiatry as their first-choice specialty had average scores of 438 on Level 1 and 413 on Level 2.
“I value life experiences and volunteer experiences above board scores,” says Dr. Resch, whose psychiatry residency is based at the Chillicothe (Ohio) Veterans Administration Medical Center. “If you have a good strong story or personal statement or a background in some type of socially minded activity, that will impress me more than high COMLEX scores.”
Dr. Resch looks favorably on applicants who have volunteered with the National Alliance on Mental Illness, hospice organizations, Big Brothers Big Sisters and any other nonprofit that would indicate someone’s “extraordinary psychosocial skills,” he says.
“We consider the whole application,” says Dr. Ley, the director of the dually accredited psychiatry residency at Michigan State University in East Lansing. “We want to see a personal statement that is meaningful. We want to see someone who has a passion for psychiatry.”
The MSU residency receives approximately 60 applications from DO students and more than 300 from MD students for five openings a year. “Some years we’ll have more osteopathic candidates who are excellent, so we’ll have three DOs and two MDs,” Dr. Ley says. “Other years, the program may have three MDs and two DOs.”
Dr. Baron advises students to serve elective rotations in the psychiatric programs that interest them, especially if attracted to a competitive residency such as USC’s, which receives 500 or so applications a year for a dozen openings. For those looking toward academic careers in psychiatry, he recommends taking part in one of the summer programs for medical students at the National Institute of Mental Health. The institute also has programs for premeds.
Osteopathic medical schools vary widely in the caliber of their psychiatry instruction and rotations, Dr. Baron says. He suggests that DO students seek out psychiatrist mentors and shadowing opportunities in the early years of med school. Premeds who think they may be interested in psychiatry should apply to medical schools with affiliated psychiatry residencies.
Beyond dazzling rotations and personal statements, residency candidates need to stand out during their interviews. Dr. Resch uses performance-based interviewing techniques, in which candidates respond to scenarios. He also closely observes interviewees when he takes them on hospital tours.
“Throughout the tour, we encounter patients, staff and physicians. I pay attention to the fluidity of candidates’ interactions with other people,” Dr. Resch says. “I assess their social awareness and adeptness.”
In the hospital’s psychiatric wings, he gauges the comfort level of interviewees. “We like to see calm, relaxed individuals rather than people who are tense,” he says.
With the demand for mental health services greatly exceeding supply, the career prospects are sunny for psychiatrists, who are needed in all parts of the country, in both urban and rural communities.
“There is such a need for psychiatrists, you can go anywhere and have a job,” Dr. Resch says.
Across the U.S., only 4% of medical students go into psychiatry, according to Dr. Ley.
“Psychiatry is a less popular field than it should be. In my opinion, it has to do with stigma,” she says. “People sometimes have a misunderstanding of what psychiatrists do. Some think that all we do is prescribe medications all day long. In fact, more than 80% of psychiatric drugs are prescribed by primary care physicians.”
In addition, because they don’t do procedures for the most part, psychiatrists aren’t paid as well as most other medical specialists. According to a 2012 Medscape survey, psychiatrists make $170,000 a year on average, just $5,000 a year more than general internists and $12,000 more than family physicians.
“Psychiatrists are paid a little bit more than primary care physicians, but our residencies are longer,” Dr. Ley notes.
But enterprising psychiatrists can do well financially, Dr. Piccinini maintains. In addition to having a solo or group practice, they can be employed part time or full time in academia, do diverse consulting work, and manage patients in a variety of care settings.
A subspecialist in both forensic and geriatric psychiatry, Dr. Piccinini has done outside work for many clients besides seeing patients in his private practice. “In addition to working for courts, prosecutors and defense attorneys, I’ve had corporations hire me to profile death threats to their executives,” he says. “And I’ve done violence risk assessments for universities that are concerned about particular students.”
Dr. Baron is a consultation liaison psychiatrist, who works with hospitalized patients at the request of medical and surgical teams. “This is an excellent area for osteopathic physicians to get into because DOs are trained to be well-rounded doctors,” he says.
Also a sports psychiatrist, Dr. Baron consults with the U.S. Olympic team and chairs the World Psychiatric Association’s section on exercise, psychiatry and sports.
While psychiatrists can have complex, richly rewarding careers, they also are able to maintain work-life balance, Dr. Resch points out. “As much as I love psychiatry, I also love other parts of my life,” he says.
Dr. Resch strongly encourages osteopathic medical students to consider specializing in psychiatry. “The future of psychiatry is bright, with new treatment modalities coming out all the time, beyond medication,” he says. Moreover, the White House’s BRAIN (brain research through advancing innovative neurotechnologies) initiative suggests that mental health research and treatment is a growing priority for the federal government.
“Psychiatry is an amazing, wide-open field,” Dr. Resch insists. “I’ve thoroughly enjoyed it.”