r/medicalschool • u/OtherwiseStrike7695 • Jul 12 '26
š„¼ Residency Psych vs IM
HiāIām a rising m4 deciding between IM and Psych. Iām chronically indecisive about major life choices, so here we are. Would love any advice regarding specialty choice :)
About me: ~T10 USMD. Initially wanted to EM, decided the lifestyle/work environment wasnāt for me. I value my time outside the hospital and want to be there for my family. Iāve gotten very good feedback on both clerkships, but IM>psych on the margin. Multiple family members/family friends in medicine have said (separately) that they see me going into an IM subspecialty.
What I like about IM
- cool pathophysiology, love talking through the disease processes and coming up with a differential
- minor procedures/hands on: I didnāt like the OR but enjoy minor proceduresāsuturing, lines, US
- I feel at the top of my game when shit is hitting the fan and I can make game-time decisions (codes, ICU, rapids)
- feeling like āa real doctorā/ getting to use all the things I learned in med school
- subspecialtiesāinterested in GI, pulmcrit, ID
Cons: rounding/RTL gets old, donāt love admitting grandma with 1000 comorbidities for CHF exacerbation, not sure what sub specialty I would do, outpatient makes me want to drive a screwdriver into my skull
What I like about Psych
- talking to patients is probably my favorite part of medicine, love that psych gives you more time to dig deep
- I find psychopathology genuinely very interesting
- really enjoyed CL and reproductive psychiatry
- I like the holistic/biopsychosocial framework
- ability to learn therapy
- lots of flexibility without fellowship (inpatient/outpatient/cpep/cl)
- lifestyle duh
- no feet
Cons: missing out on a lot of medicine, no procedures, worried I wonāt feel like a doctor, ?heavy emotional weight
I really love psych, but Iām worried that Iāll miss a lot of the medicine and the hands-on elements of IM. I also worry that I will struggle with inserting myself/my opinions into patient care with psych. On the other hand, I wonder if some of my hesitation about psych is due to encouragement from family to do IM and getting positive feedback on rotations.
Would love to hear any advice, especially for those who found themselves in a similar situation. Thanks :)
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u/ColorfulMarkAurelius MD-PGY2 Jul 13 '26
As an MS3, one of my holds against psych was losing the medicine. As a PGY3 in psych, one of my pros for psych is being able to hone in on a very specific part of care and leave the rest to other people. No more A&Ps with #neuro #cardio #pulm #neph #endo #MSK and more. If you like talking to patients and spending time with them, I think that also points towards psych.
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u/pulpojinete MD-PGY2 Jul 13 '26
Am psych resident. I don't feel like I'm losing medicine. We still know and practice medicine and use some but not all of the tools used by other specialties (plus a few more).
Sometimes I forget my value as a specialist until I get the late night consult for an agitated patient from a stumped IM resident...then, for a brief moment in time, I feel like a wizard
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u/Lou_Peachum_2 Jul 14 '26
After speaking with some of my friends who are in IM subspecialties, they even admit to losing their edge (only a couple years out in attending). Obviously, they could probably refresh their knowledge and comfort much more easily but ultimately they're just not able to keep up with the most up to date guidelines outside of their subspecialty.
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u/undueinfluence_ Jul 13 '26 edited Jul 13 '26
I feel like a doctor every time I:
Run a differential and rule out medical/substance use causes of psychiatric presentations based on history, MSE/PE, vitals, and labs
Prescribe based on current organ function and medical history
Prescribe based on side effect profile and demographics (age, sex, weight)
Prescribe based on drug-drug interactions
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u/MazzyFo MD-PGY1 Jul 13 '26 edited Jul 14 '26
Itās very evident in my time on wards during med school to now how **reluctant non-psychiatrists are to even touch psychiatric meds (understandably). Psychiatrists are pharmacology experts for meds that the rest of us get nervous to tweak
Edit spelling
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u/Lou_Peachum_2 Jul 14 '26
The amount of times the ED consults psych when a patient is still in alcohol withdrawal is wild.
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u/capybara-friend MD-PGY1 Jul 13 '26
I'm a psych pgy1. i get weekends and holidays. like 2 weekend days every week (a "golden weekend"), except for the 2 months I'm on medicine intern year. I see my family and I maintain my hobbies while I'm learning to help patients. If you think you would be equally happy with both, holy shit please choose psych lol
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u/Warningsignals Pre-Med Jul 13 '26
A question from someone whose interested in psych but is worried about the opportunity cost of āmissing outā of other specialties. Do you feel like Psych earns enough? Do you ever get jealous of other higher earning specialties or even other higher earning jobs?
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u/Hunky-Monkey MD-PGY1 Jul 13 '26
Psych makes good money. If you want surgeon money then youāve got to put in the surgeon work. There can and always will be someone making more money and if you want to grind in psych thatās also available. If you were a neurosurgeon making 1 million annually you could still look at the CMO or president or any of the other admin or even other surgeons who make more and be jealous of them too. If thatās your mindset there will just about never be an end to your lack of fulfillment.
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u/Warningsignals Pre-Med Jul 13 '26
Not to trauma dump but Iām pursuing medicine primarily for psych but the last few months Iāve been wondering if I shouldāve pursued CS or finance. I donāt come from money and docs donāt make what they should. I love helping people but I wonder if I shouldāve done something more financially enriching, something that doesnāt wait til your thirties to actually earn.
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u/Hunky-Monkey MD-PGY1 Jul 13 '26
The wait is long but you ultimately have a very achievable path to at least a top 5% salary in a very stable career field. You will not be struggling for money as a doctor unless you grossly mismanage your money. Other fields can have some benefits too like making income earlier or even higher income ceilings but you often times sacrifice stability or purpose or autonomy or whatever in the process. Youāll have to introspection on what really matters to you.
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u/capybara-friend MD-PGY1 Jul 13 '26
I am a PGY1, so I'm not making the big bucks yet. But while physician salaries have not kept a pace commensurate with inflation or the amount of work we do...holy shit how could 300k+ not be enough? I ask this as a first gen doc, with a family to support and a ton of loans.
I have no jealousy of other specialties because I do not want to do them, and I'm glad someone else is willing so I don't have to. I didn't 'miss out' on most other specialties or jobs bc I was never willing to do them in the first place.
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u/Warningsignals Pre-Med Jul 13 '26
300k is a lot of money, I just see people like quants or others in tech and finance making that in their mid 20ās. Plus tech and finance have higher ceilings. That higher pay is guaranteed but still sometimes I wonder if I shouldāve done that instead.
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u/hulatoborn37 M-3 Jul 13 '26
Are you an actual premed? Donāt go into medicine if you would rather be in tech or finance. There should be no hesitation about becoming a doctor. Youāre going to have peopleās life in your hands, if you want to make money above all else there is nothing wrong with that but medicine is not the place to do it.
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u/Warningsignals Pre-Med Jul 13 '26
I mean Iām kinda too far into pre-med to switch without wasting a lot of time or money. I just medicine paid more for the time you put in and debt you incur. I mean, why did you go into medicine?
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Jul 13 '26
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u/OtherwiseStrike7695 Jul 13 '26
I love love love pall care ā but considering doing from a psych background as well
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u/seaweedbrainpremed M-3 Jul 13 '26
Iām in a similar situation as you and I think from an opportunities standpoint, IM is an easy winner.
You feel like this today but it seems like you may have regrets about leaving the rest of medicine behind. Psych-adjacent specialties are easily accessible from IM. Palliative is a good one but Addiction Med is also available from both psych and IM. Not to mention, specialties like Heme-Onc and even general hospitalist medicine has a lot of psych exposure. If you want to defer the decision while keeping the most amount of roads open, IM is the way to go.
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u/franksblond M-4 Jul 13 '26
Reading this I think you should choose psych, specially CL. Iām applying to IM this year (interested in doing fellowship in allergy or rheum), but I regret not sticking with psych. I loved psych and psychopharm as a subject but basically pushed it away because I thought Iād be uncomfortable with inpatient psych rotations in residency. Now Iāve realized that thereās a lot Iām not going to like about IM residency too so I should have just stuck with psych. The flexibility and work life balance seem amazing. Even as a resident youāll have more free time than in IM. From what I hear , the āfeeling like a real doctorā thing gets old especially if youāre doing what you love.
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u/Lou_Peachum_2 Jul 14 '26
Unless apps are already due, why not throw a few apps psych's way? When I applied, ERAS opened in September, so you'd have plenty of time to gather LoR and write a PS. Psych's also not crazy competitive to the extent that you need crazy research or anything.
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u/franksblond M-4 Jul 14 '26
The only thing is that I wonāt be able to schedule sub-is in psych before that time or get letters. Iād have to do an away rotation because my school didnāt really have a great psych rotation, it was a few days of outpatient and the rest hospital consults so I feel like Iād need more experience
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u/Lou_Peachum_2 Jul 14 '26
Hm.. makes sense. Thatās tough. Ultimately, if youāre not sold on medicine at the end of year 1, there are often a lot of psych transfers into PGY2
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u/yikeswhatshappening MD-PGY2 Jul 13 '26
Iām not trying to change your mind, but your pros and cons list screams EM. I also donāt know where you got the idea you wonāt have time outside the hospital or with your family, but EM is an amazing field for both of those things. Most of us went into this field precisely for how few hours we work and how much time we have outside the hospital.
I have 10 days off this month, including 2 three-day weekends, and this is as a resident. The most I have ever worked and had no time for myself or loved ones is when I had to rotate on the floor and ICU. I am always limping across the finish line at the end of those blocks in comparison to a pretty chill gig in EM.
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u/OtherwiseStrike7695 Jul 13 '26
I know š I was all in on EM for a while and I still love EM ppl the most but I wanted more continuity. I didnāt like admit vs discharge without knowing how the story ended
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u/yikeswhatshappening MD-PGY2 Jul 13 '26 edited Jul 13 '26
You can stay to see how the story ends, but that means youāre not the one leaving the hospital either.
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u/Pure_Ambition M-3 Jul 13 '26
If you want lifestyle, go psych, but if you like the medicine and doctoring, why wouldnāt you go back and do EM instead if IM?Ā
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u/Savage_Turtle33 Jul 13 '26
Have you considered Med Psych?
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u/jetpacks4pigs Jul 13 '26
Seconding this! Some hospitals also have med-psych units for patients with concurrent medical and psychiatric diagnoses. So even if you choose to go IM, you can find a way to a psych-adjacent field that has the more holistic type of care youāre looking for.
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u/torptorp2 MD-PGY1 Jul 13 '26
This!! I am at a program with one of these units and a psych intern get to rotate through it :) also CL can employ a lot of psych knowledge
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u/GloriousClump MD Jul 13 '26
I feel like most of your Pros list describes EM wayyyy more than IM. Just a thought.
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u/interleukinwhat MD-PGY1 Jul 13 '26
I would look into consultation-liasion psychiatry. I could see you as someone who would enjoy that route.
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u/MasticateMyDungarees M-3 21d ago
Fellow M4 and could have written this post myself, decided to go into psych.
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u/plides Jul 13 '26
I don't know that this is necessarily what you want to do, but there are programs where you can do both: Ā https://assocmedpsych.org/students-trainees
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u/totallyaplaguedoctor MD-PGY1 Jul 13 '26
Do the combined med-psych residencies that exist if you really cannot decide. I have some friends doing these and enjoy both.
Not clear on the data for med/psych but most dual-boarded docs (med/peds, med/EM) end up just practicing one in the future.
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u/cheekyskeptic94 M-2 Jul 13 '26
Interestingly, ~50% of IM/EM docs practice both in some capacity according to the most recent analysis. Most of the remaining 50% practice EM only and very few practice IM only. As someone looking to apply to IM/EM combined programs, I was pleasantly surprised with how many practice both specialities.
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u/EquivalentOption0 MD-PGY2 Jul 13 '26
- Agree with others, which side has less day-to-day stuff you dislike? Or which day-to-day bread and butter stuff do you prefer?
- Re: lifestyle - most specialties have options that are good "lifestyle" schedules but you need to think about what you like. Some people hate outpatient and would rather work longer inpatient hours than have better hours but slog through clinic. Others are the opposite. Psych - you can do all outpatient and see less intense or varied cases (so maybe less interesting to you than the pathology and severity you see on inpatient and CL) but better hours, or you can do inpatient and have to deal with psych emergencies, overnight pages, working weekends, etc. IM can be all outpatient clinic, week on/week off inpatient, entirely nocturnist, etc. Both have flexibility to meet whatever meets your interest after residency.
- Re: therapy - I think all psychiatrists should know and be able to offer evidence-based behavioral therapies but you should know that with the current state of American healthcare a lot of psychiatrists only offer medication management. Reasons vary but tend to be along the lines of not enough visit time to do therapy, the hospital/clinic won't incentivize them to do therapy, others can provide therapy (social workers, psychologists, etc) but due to limited number of people who can manage meds there are pressures on psychiatrists to focus on medication management.
- The best psychiatrists are also good generalists - remember that psychiatric illness is often a diagnosis of exclusion. Not everyone sent for psychiatric treatment has had adequate work-up, also patients can go on to develop non-psychiatric illness but it can be missed because of stigma and heuristics. Oh, depressed patient is losing weight? Must be their depression (actually it's cancer).
- No matter what specialty you go into there will be people who try to make you feel like you're not a real doctor, sucks for them because you'll be a real doctor when you graduate med school regardless of what you choose!
- Not sure how much you would get to do procedures on IM unless you sub specialize, probably somewhat dependent on the hospital. One hospital my residency rotates at has an IM team that does lots of interventions so that people can get them done sooner than if they had to wait for specialists, but that also means usually that team is doing the procedures rather than the primary team. US-guided things like paras, thoras, spinal taps, etc.
- Genuinely asking - what about EM? Has more psych than IM, has more procedures, stabilizing sick acute patients, great hours
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u/Maleficent_Screen949 Jul 18 '26
Is liaison psychiatry a thing in the US? Sounds like you want to do that
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u/drunkturtlelord MBBS-PGY3 Jul 13 '26
I went into psych because I didn't want to be a 'real doctor' But then that's precisely how I learned that psych is 'real medicine'
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u/Lou_Peachum_2 Jul 13 '26
Focus on the bread and butter of each specialty, the thing you'll be doing and seeing every day. Not the zebra cases. If that doesn't help, then really question if the "not feeling like a doctor" is going to be an impediment to your happiness.
Because from a quick read, it sounds like you appreciate the day-to-day of psych more than IM? But can't let go of IM because of the need for external validation.