Most people asking what discipline I was pursuing during my fourth year of medical school were hearing “Med-Psych” for the first time. It wasn’t the best advertised of the 12 combined training residencies approved by the American Board of Internal Medicine (ABIM). So I’d reply, “Yeah, it’s like Med-Peds, but Med-Psych.” We clearly needed to fire John down in promotions.
The Accreditation Council for Graduate Medical Education (ACGME) approves numerous combined residency programs, including a few that combine psychiatry with various disciplines: family medicine, neurology, and a triple-certified program combining pediatrics, psychiatry, and child psychiatry. Psychiatry and internal medicine may seem like a counterintuitive combination. One involves the diagnosis and treatment of neuropsychiatric illnesses that hamper subjective measures of social and personal function, with mostly unidentified disease mechanisms. The other addresses diseases within the body that exhibit measurable and somewhat predictable effects on physiology and lifespan, with comparatively well understood disease mechanisms. Yet psychiatrists and internists rely heavily on each other in the field.
Pursuing a four year psychiatry residency and a three year internal medicine residency is a daunting and inefficient seven year path. Combining the two disciplines into a five year curriculum provides interested clinicians with a feasible training alternative that views the body and mind as one. Training as a psychiatrist and an internist in real time fosters an ability to recognize patterns traditionally viewed separately from distinct perspectives. Simultaneously understanding, evaluating, and treating both systems yields tremendous insight and efficiency.
A large patient population suffers from both neuropsychiatric and chronic diseases. Numerous studies suggest these patients suffer higher mortality at younger ages, report lower quality of life measures, and utilize disproportionately higher cost resources than similar patients without neuropsychiatric diagnoses. Some Med-Psych graduates dedicate their careers to optimizing interventions and improving outcomes within these populations. Others have become experts in psychosomatic medicine or consult and liaison psychiatry, teasing out the subtleties of perplexing clinical pictures that blur medical borders, from somatoform disorders to occult autoimmune diseases presenting as psychiatric emergencies. The skills of Med-Psych training are highly marketable and relevant to nearly any area of medicine.
Training & Statistics
Each program has a very similar curriculum. Requirements from each discipline are spread evenly along five years. Most programs alternate two to three consecutive months of training blocks between each discipline throughout the year. Electives and flexibility are somewhat sacrificed for accelerated training compared to categorical medicine and psychiatry programs. The rigors of PGY-1 also extend slightly beyond a year for combined residents, with inpatient medical and psychiatric ward assignments continuing into the first half of the second academic year. It’s a unique phase that allows combined trainees to share their perspective and experience with fresh categorical interns. Med-Psych residents have also described mixed emotions when reaching PGY-3 as their categorical medicine peers graduate and PGY-4 when their categorical psychiatry peers move on. Graduates are eligible to sit for board certification in both disciplines.
During the 2016-17 residency application season, 12 programs offered a total of 24 positions to 148 applicants actively participating in the National Resident Matching Program (NRMP). Applicants represented 52 allopathic seniors and 96 international medical graduates (IMGs). Fifteen allopathic seniors and 24 IMGs matched. Sadly, the 2016 NRMP report evaluating the statistics of matched applicants excluded Med-Psych programs. There was a slight increase in programs and positions this year, with 14 programs offering 28 positions. This year’s match data were not available at the time this article went to press. However, preliminary reports indicate a large surge in categorical psychiatry applicants, making it an exceptionally competitive year for psychiatry. Considering such few Med-Psych positions and the spike in categorical psychiatry applicants, it would behoove future applicants to include broad back-up options.
Career statistics are also difficult to find. A 2010 Association of Medicine and Psychiatry survey revealed most of the 33 Med-Psych respondents practicing in academic settings, 30% of whom pursued additional clinical training or fellowships. Med-Psych clearly remains a small discipline with far fewer data reported by professional organizations that surveil typical career statistics. Even fewer journal articles have been published regarding Med-Psych physician numbers (~300 in 2001) and practice details (~30% practicing forms of medicine and psychiatry). Intuitively, most Med-Psych graduates are academically inclined and hold leadership positions within their institutions.
Each Med-Psych attending I met during away rotations held a faculty position that combined an array of clinical, administrative, research, and mentoring duties. Residents typically discuss each program’s needs and resources during job interviews, later designating full-time effort (FTE) allocations as part of their contract negotiations. Med-Psych attendings typically spend a few months assigned to inpatient teaching services and the rest divvied up between resident clinics, lectures, administrative efforts, one-on-one treatment models, and conducting clinical research. Clinic coverage is often spread throughout the week as a few half days or a couple full days. This allows for excellent daily variety between inpatient service months. The flexibility is boundless, allowing residents to find their perfect fit during job searches.
A list of active Med-Psych programs can be found here.
The Association of Medicine and Psychiatry still holds annual meetings; its website can be found here.
(2) Practice and career outcomes of double-boarded psychiatrists. – PubMed – NCBI
(3) Physicians at the medicine/psychiatric interface: what do internist/psychiatrists do? – PubMed – NCBI