Medical student very interested in practicing Psychiatry but with some reservations

[sporky2]

Hello everyone,

Like the title says I am a medical student(third year) who is very interested in applying for Psychiatry residency but I have a few reservations about the field and I wanted to get your opinion on them. For context the other field that I am considering is Neurology.


1.Future of the field with an increasing amount of midlevels

I have read people say that worrying about Psych NPs is overstated as "Psychiatrists are in high demand" but I can't help but feel it seems inevitable that the bubble is going to burst. It seems that wherever I was rotating Psych related there were more Psych NPs in training there than medical students. It only seems to reason that hospitals in the future will hire fewer and fewer Psychiatrists to cut costs, while outpatient Psychiatrists will have to compete with Psych NPs for patients. I know that Psychiatry is already on the lower end of physician salaries and Neurologists make more in general.

2.Perceived lower barrier to entry and respect

Another thing that bothers me with choosing Psychiatry is how it seems that in becoming a Psychiatrist you are choosing the path of most resistance to treat psychiatric patients. The fact that Psych NPs can essentially do the same job as me with far less training essentially dilutes the accomplishment becoming a doctor in my head. I think that a common question I will have if I become a psychiatrist is wondering "why did I do all of those extra years of training to become a doctor when I'm just doing the same work an NP does?". In Neurology it seems that this is less of a problem as far less NPs choose to do Neurology and I would feel more like a "doctor", as petty as that sounds. Additionally, I think so many Psych NPs flooding into the field will dilute the respect that people will have for psychiatrists. Common questions I get in my head regarding this are "If so many NPs can seemingly do this job just fine why do we need doctors in the first place?" or "Psychiatry must be easier to master if so many NPs are practicing it". I know these questions can sound petty but they have been gnawing at me as I think about choosing Psychiatry over Neurology.

Thanks for the help.

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[comp1]

You're already a med student, so your questions seem off to me. I'm guessing you're not in a clinical year yet and that might be why. Your questions seem geared more towards, should I be a nurse or a doctor? And you've already chosen doctor, so what NPs do or don't do doesn't impact you nearly as much as you seem to think it might. There are more than enough jobs for every PMHNP and psychiatrist that wants them and there's no formal body forecasting any changes in that during your career, contrary to the chicken little stuff you appear to be imbibing.
My advice, and I think it's pretty important, is to do a rotation in neurology and in psychiatry. I know neurology is not core everywhere any more (it should be), but it sounds like you really need to see them both in action. Then, make a decision solely based on the actual work done in the specialties. Don't focus on some sort of psychic forecasting of job markets and DEFINITELY don't focus on what you think will make you (or your parents) feel more like a doctor. Just base it on the clinical experience and how well you see yourself fitting in.

 

[wolfvgang22]

Let me know when most NPs can figure out the difference between NMS and malignant catatonia and recommend the proper course of treatment. The NPs I supervise, as much as I appreciate them, have difficulty with distinguishing personality disorders from other disorders, struggle with accurate diagnoses in general, require guidance regarding the management of psychotic disorders, and have no training in psychotherapy. They frequently get tripped up with failing to recognize problems such as hallucinations due to parkinsons.They do ok in treating some garden variety illness but when things get complex my phone or instant messaging blows up with requests for guidance.

Also, median salary of psychiatrists is actually fairly good. I earn roughly $285,000 annually, work 4 days per week now, and see about 10 patients per day. I am not the highest paid psychiatrist in my organization, it's about average in my state. I'm allergic to over work and enjoy my hobbies.

 

[G Sheb]

My $0.02.
This is going to be fun.

1.Future of the field with an increasing amount of midlevels

I do not think we would ever be replaced by nurses who took an online course and had a few hours of supervision.
The training you will get in residency - the breadth and depth of patient presentations, the literature on treatments, the therapy skills, the nuances of medical presentations, the intensive supervision - means you will be way more qualified to provide care in any setting really. That you came from medical school means you're already proven you have skills and qualities that put you at a significant advantage to do the work you need to do.
Now if you do a shoddy job, prescribe a benzo, a stimulant, an antipsychotic, an SSRI for every patient you see, were lazy in residency and didn't want to learn, cut corners because you don't like what you do... yes, you MIGHT be replaceable, but that's on you, not on the training.
The only reason psych NPs are in demand is because they can't find enough of you to do the job.

Now please bare in mind that this is an online forum and so you need to take every opinion for what it's worth.
You will hear the doomsayers. But the reality is that if you read the forum they've been doomsaying for more than a decade.
What happened in the meantime?
Psychiatry is more in demand than ever. Salaries have gone up. You can find almost any job in any setting in any location you want.
These are the facts. One could chose to follow the opinions of anonymous posters on here or.. follow the evidence.
I would recommend you do your own research. Talk to psychiatrists at your medical school. Look up jobs..etc

2.Perceived lower barrier to entry and respect

All I can say is that I get tremendous respect by physicians and lay people where I'm at.
There has been an increasing awareness of the importance of mental health.
People want to address their issues with depression, anxiety, substance use, compulsive habits..etc, and they realize that mental health treatment could be life changing.
Your work on SMI cannot be addressed by anyone else really.
You are going to be uniquely positioned to address these issues.

 

[Sushirolls]

Time to pick a specialty for you is fast approaching, and a daunting question. One of the few remaining big life direction doors to choose.

Your question is pertinent to you and one worth asking.

Many on here will down play the impact of ARNPs on healthcare and its future trajectory, but the fact you are considering it now is wise. Kudos for you.

The future of how things will unfold in our country, in healthcare and in psychiatry is difficult to predict. But if you are more risk averse and value security in your job above the many other attributes to weigh in picking a specialty, you might want to even avoid psychiatry AND neurology.

The impact of what might be ChatGPT on fields, Neurology and the complexity fear in strikes in midlevels isn't a guarantee of insulation either. Both fields will likely need a minimum of a med director physician who oversees midlevels, or potential AI tools - but the rank and file employee may diminish. Who knows.

But going back to if you value job security, insulated from midlevel encroachment, you need to be in a more hands on technical field. That means surgical.

If you toss out the concerns of midlevel encroachment and are narrowed down to Neurology versus Psychiatry then we'd need to know more of the variables that you value to shape which is better choice.

 

[Merovinge]

FWIW I make more than the people I know in Neurology and I believe the fields pay very similarly across the country. Neurology is a tough field in that the training has brutal call/hours and many attendings have jobs that have IP/call responsibility. The gravity of neurologic conditions is no joke and it can be very draining work (I absolutely adore most neurologists I know personally and have worked with as an aside).

When patients come to see me, the last thing they are saying is how great of a job the last NP they saw was. They are saying how much they appreciate my evaluation or consultation. I don't see that changing anytime soon, particularly with the race to the bottom in NP training that is not present in MD training/residency.

Past that, just read this post again. Comp1 did such a nice job with recommendations I am simply quoting them for emphasis.

You're already a med student, so your questions seem off to me. I'm guessing you're not in a clinical year yet and that might be why. Your questions seem geared more towards, should I be a nurse or a doctor? And you've already chosen doctor, so what NPs do or don't do doesn't impact you nearly as much as you seem to think it might. There are more than enough jobs for every PMHNP and psychiatrist that wants them and there's no formal body forecasting any changes in that during your career, contrary to the chicken little stuff you appear to be imbibing.
My advice, and I think it's pretty important, is to do a rotation in neurology and in psychiatry. I know neurology is not core everywhere any more (it should be), but it sounds like you really need to see them both in action. Then, make a decision solely based on the actual work done in the specialties. Don't focus on some sort of psychic forecasting of job markets and DEFINITELY don't focus on what you think will make you (or your parents) feel more like a doctor. Just base it on the clinical experience and how well you see yourself fitting in.

 

[finalpsychyear]

you'll have a job in psychiatry in 5-7 years. Expect the salary to be closer to 200k inflation adjusted at that time and supervising multiple psych NPs unless they have already reached autonomy. All non procedural fields will go this way to battle cost reduction. Not saying the care is the same by a long shot but that's an entirely different convo. People on here already practicing likely aren't' going to be impacted. The clinic i work at switched to only hiring NPs going forward as soon as insurers paid the same. its dollars and cents for most places these days.

Edit: admin are smart in how to market this. We are "providers" now.. not dr. xyz so patients remain confused that everyone is the same. Also many places calling patients "clients".. hilarious what a travesty we allowed to happen with mid levels.

What I tell others is seek fields such as rads and gas where the mid level approach is not there or better yet go into a surgical sub field ie ortho, ent, optho where there is no threat.

 

[Candidate2017]

Midlevels do jobs physicians don't want to do: heavy call, being pill mills, etc. NPs don't cut costs, especially inpatient psychiatry. A psychiatrist can handle 20+ inpatients efficiently, in terms of psychiatric and medical issues. NPs can't. On the outpatient side, no one wants to see an NP. NPs create lots of misdiagnoses and side effects for patients, who are extremely grateful when they are able to get in to see a psychiatrist who can get them the correct diagnosis and meds, and some therapy. The people who prefer NPs are generally substance seekers (whom you can refer out to NPs).

The problem with NPs occurs when you work for The Man. In addition to seeing your patients, The Man will want you to "supervise" NPs, i.e., take on liability while The Man takes the billings. You will have to stand up for yourself and say no.

There is a lack of respect in psychiatry, but from substance seekers and the personality disordered. You may be able to avoid sub seekers in neuro, but not difficult personalities. Neuro residency is heavy on hours, more than IM and a little less than surgery. If you're willing to work neuro hours, I feel surgery or IM plus fellowship, is a better bang for the buck in terms of lifestyle and respect.

Regarding pay, my former neuro attendings always complained. "F---, my psychiatrist spouse/friend/family member works so little and makes so much money. I don't understand, how do you guys do that? BTW do you want to switch to neuro?"

 

[Merovinge]

Regarding pay, my former neuro attendings always complained. "F---, my psychiatrist spouse/friend/family member works so little and makes so much money. I don't understand, how do you guys do that? BTW do you want to switch to neuro?"

Haha one of my best friends is in neuro and she said the exact same thing to me when she was juggling call, IP rounding and OP practice and making less than I did with 35 hours/week no call.

 

[Sushirolls]

*The Man, which I refer to as Big Box Shops, is ever expanding its market share of the healthcare industry.

 

[sporky2]

You're already a med student, so your questions seem off to me. I'm guessing you're not in a clinical year yet and that might be why. Your questions seem geared more towards, should I be a nurse or a doctor? And you've already chosen doctor, so what NPs do or don't do doesn't impact you nearly as much as you seem to think it might. There are more than enough jobs for every PMHNP and psychiatrist that wants them and there's no formal body forecasting any changes in that during your career, contrary to the chicken little stuff you appear to be imbibing.
My advice, and I think it's pretty important, is to do a rotation in neurology and in psychiatry. I know neurology is not core everywhere any more (it should be), but it sounds like you really need to see them both in action. Then, make a decision solely based on the actual work done in the specialties. Don't focus on some sort of psychic forecasting of job markets and DEFINITELY don't focus on what you think will make you (or your parents) feel more like a doctor. Just base it on the clinical experience and how well you see yourself fitting in.

I think it's more so that as Psychiatrist I'm going to be sharing space in the field with NPs much more so than if I chose Neurology. It's a question of not whether I want to be a nurse but whether if I look back and see that the sacrifice of becoming a Psychiatrist was worth it when NPs are being hired to do similar jobs. It's mostly just due to my ego and its a me problem, and I know that but it's still a problem I have to face.
You are correct that we no longer have core rotations in Neurology. I'm planning to do one in my fourth year to get a feel for the specality but I have heard it has hard hours/call. I did do my Psychiatry rotation and I loved it. I can definetly see myself being happy in it.

 

[sporky2]

Time to pick a specialty for you is fast approaching, and a daunting question. One of the few remaining big life direction doors to choose.

Your question is pertinent to you and one worth asking.

Many on here will down play the impact of ARNPs on healthcare and its future trajectory, but the fact you are considering it now is wise. Kudos for you.

The future of how things will unfold in our country, in healthcare and in psychiatry is difficult to predict. But if you are more risk averse and value security in your job above the many other attributes to weigh in picking a specialty, you might want to even avoid psychiatry AND neurology.

The impact of what might be ChatGPT on fields, Neurology and the complexity fear in strikes in midlevels isn't a guarantee of insulation either. Both fields will likely need a minimum of a med director physician who oversees midlevels, or potential AI tools - but the rank and file employee may diminish. Who knows.

But going back to if you value job security, insulated from midlevel encroachment, you need to be in a more hands on technical field. That means surgical.

If you toss out the concerns of midlevel encroachment and are narrowed down to Neurology versus Psychiatry then we'd need to know more of the variables that you value to shape which is better choice.

Yes I've always heard that the non-procedure specalities will at risk to midlevel encrochment, AI, what have you. Unfortunatly I'm not very good at procedures and hate the OR. I love the brain and the patholgies that result from it so Neuro and Psych have always been on my radar because of it. In Psych I love the relationships you form as well and love the psych interview while in Neuro I love how the physical exam can tell you so much about the patient's pathology. I think after my Neuro rotation I can better quantify how much that translates to actually practicing it.

 

[sporky2]

you'll have a job in psychiatry in 5-7 years. Expect the salary to be closer to 200k inflation adjusted at that time and supervising multiple psych NPs unless they have already reached autonomy. All non procedural fields will go this way to battle cost reduction. Not saying the care is the same by a long shot but that's an entirely different convo. People on here already practicing likely aren't' going to be impacted. The clinic i work at switched to only hiring NPs going forward as soon as insurers paid the same. its dollars and cents for most places these days.

Edit: admin are smart in how to market this. We are "providers" now.. not dr. xyz so patients remain confused that everyone is the same. Also many places calling patients "clients".. hilarious what a travesty we allowed to happen with mid levels.

What I tell others is seek fields such as rads and gas where the mid level approach is not there or better yet go into a surgical sub field ie ortho, ent, optho where there is no threat.

Yes a decrease in salary and supervising multiple NPs is a large worry of mine. It's hard not to see that as the future when I see many NPs rotating with me in different facilities. I am sure there will be ways to stand out and make a good living as a Psychiatrist but I feel that Neurology is better positioned in the midlevel future even though it's not procedural.

 

[Dantes]

Just to give more info, neuro salaries have actually gone up quite a bit over the past few years and you can do a 9-5 outpatient gig with no call or IP if you want after residency. If you add procedures (Botox, EEG, EMG) you can make quite a bit. Neuro salaries I see now are higher than psych, but the difference isn't large enough to worry about and there's still huge variation. Also the residency is tougher, especially PGY-1 and 2.

To your other point, anesthesiologists are making a killing right now despite the rise of CRNAs. I don't think psych will have anything to worry about for a while given the extreme shortage. But no one can 100% predict the future. Look at rad onc and EM. I think once you rotate through both you'll have a better idea of what you want to handle on a day-to-day basis. Do what you like more and don't worry about the background noise and speculation.

 

[shoomer]

Who's to say that midlevels won't encroach upon Neurology more in the future as the other fields saturate?

 

[finalpsychyear]

Just to give more info, neuro salaries have actually gone up quite a bit over the past few years and you can do a 9-5 outpatient gig with no call or IP if you want after residency. If you add procedures (Botox, EEG, EMG) you can make quite a bit. Neuro salaries I see now are typically higher than psych, but the difference isn't large enough to worry about and there's still huge variation. Also the residency is tougher, especially PGY-1 and 2.

To your other point, anesthesiologists are making a killing right now despite the rise of CRNAs. I don't think psych will have anything to worry about for a while given the extreme shortage. But no one can 100% predict the future. Look at rad onc and EM. I think once you rotate through both you'll have a better idea of what you want to handle on a day-to-day basis. Do what you like more and don't worry about the background noise and speculation.

Anesthesia is making a killing right now because the OR demand is off the charts and even with CRNA there is a massive shortage. The time required to train as a CRNA is one of the longest. The next 10 years it's going to be steady. The rate at which obesity is out of control causing more surgeries is going to keep this field without any issues.

Neuro is not going to get a swarm of Nps due to its higher complexity. EEG/EMGs can be good. I'd tell anyone in a heartbeat to go into gas or rads the latter of which has a demand growing more than any field due to imaging exploding.

 

[finalpsychyear]

Who's to say that midlevels won't encroach upon Neurology more in the future as the other fields saturate?

True. I think it will take more time due to the complexity. Surgical fields are overall most protected and rads is basically right there with them.

 

[comp1]

I'm glad the NPs at least now have to compete with ChatGPT for who will bring about the apocalypse. </s> It's good you're going to rotate through neuro. You should have a pretty good idea the first week if it's something that you find interesting enough that you're willing to put up with the significant challenges. For me, I couldn't ever see myself doing anything other than psych after I experienced it, but I get that won't be the case for everybody in the field.

 

[wolfvgang22]

Rads is fun and all but they get sued more often than we do.

 

[PikminOC]

Time to pick a specialty for you is fast approaching, and a daunting question. One of the few remaining big life direction doors to choose.

Your question is pertinent to you and one worth asking.

Many on here will down play the impact of ARNPs on healthcare and its future trajectory, but the fact you are considering it now is wise. Kudos for you.

The future of how things will unfold in our country, in healthcare and in psychiatry is difficult to predict. But if you are more risk averse and value security in your job above the many other attributes to weigh in picking a specialty, you might want to even avoid psychiatry AND neurology.

The impact of what might be ChatGPT on fields, Neurology and the complexity fear in strikes in midlevels isn't a guarantee of insulation either. Both fields will likely need a minimum of a med director physician who oversees midlevels, or potential AI tools - but the rank and file employee may diminish. Who knows.

But going back to if you value job security, insulated from midlevel encroachment, you need to be in a more hands on technical field. That means surgical.

If you toss out the concerns of midlevel encroachment and are narrowed down to Neurology versus Psychiatry then we'd need to know more of the variables that you value to shape which is better choice.

Exactly 💯

 

[hamstergang]

Now please bare in mind that this is an online forum and so you need to take every opinion for what it's worth.
You will hear the doomsayers. But the reality is that if you read the forum they've been doomsaying for more than a decade.
What happened in the meantime?
Psychiatry is more in demand than ever. Salaries have gone up. You can find almost any job in any setting in any location you want.
These are the facts. One could chose to follow the opinions of anonymous posters on here or.. follow the evidence.
I would recommend you do your own research. Talk to psychiatrists at your medical school. Look up jobs..etc

I just want to emphasize this part for the OP. We can show you threads on this forum from literally more than 10 years ago making the same predictions about NPs taking over psychiatry (and other parts of medicine), but since then salaries have not gone down. Supply of jobs remains high. These predictions may eventually be right, but is there any reason to believe they're more right now than they were at any point over the last 10 years?

 

[finalpsychyear]

I just want to emphasize this part for the OP. We can show you threads on this forum from literally more than 10 years ago making the same predictions about NPs taking over psychiatry (and other parts of medicine), but since then salaries have not gone down. Supply of jobs remains high. These predictions may eventually be right, but is there any reason to believe they're more right now than they were at any point over the last 10 years?

You are seeing encroachment in er which was not the case several years ago and definitely cut their salaries. The schools are pumping out more than ever and online is a dime a dozen now. This was not the case several years ago. All mid levels likely autonomous by end of this decade is happening.

Edit: i don't care personally about this effecting me as i work on avg now 60 hrs week.This is just my warning to those coming into non procedural fields in the next 5-7 years.

 

[sporky2]

Anesthesia is making a killing right now because the OR demand is off the charts and even with CRNA there is a massive shortage. The time required to train as a CRNA is one of the longest. The next 10 years it's going to be steady. The rate at which obesity is out of control causing more surgeries is going to keep this field without any issues.

Neuro is not going to get a swarm of Nps due to its higher complexity. EEG/EMGs can be good. I'd tell anyone in a heartbeat to go into gas or rads the latter of which has a demand growing more than any field due to imaging exploding.

I think you hit the nail on the head. While I love Psych I think going into Neurology allow me to future-proof myself more as NPs have not and most likely will not enter Neurology as much due to the higher barrier of entry.

 

[sporky2]

Just to give more info, neuro salaries have actually gone up quite a bit over the past few years and you can do a 9-5 outpatient gig with no call or IP if you want after residency. If you add procedures (Botox, EEG, EMG) you can make quite a bit. Neuro salaries I see now are higher than psych, but the difference isn't large enough to worry about and there's still huge variation. Also the residency is tougher, especially PGY-1 and 2.

To your other point, anesthesiologists are making a killing right now despite the rise of CRNAs. I don't think psych will have anything to worry about for a while given the extreme shortage. But no one can 100% predict the future. Look at rad onc and EM. I think once you rotate through both you'll have a better idea of what you want to handle on a day-to-day basis. Do what you like more and don't worry about the background noise and speculation.

Thank you for your response. I really wish I could just go off of what I liked the most and leave it at that but it feels like my responsibility to my wife and future children to at least speculate the future of the field I will be going into. Whatever I do will be providing my family's income over the next 40 years and I think it's fair to at least notice what's going on with Psych NPs currently. Bceause of this, I can't help but weigh this into my decision making in choosing a speciality. I love Psych and it is so interesting but this has just been a nagging problem I've had ever since being on my Psych rotation.

 

[shoomer]

Anesthesia is making a killing right now because the OR demand is off the charts and even with CRNA there is a massive shortage. The time required to train as a CRNA is one of the longest. The next 10 years it's going to be steady. The rate at which obesity is out of control causing more surgeries is going to keep this field without any issues.

Neuro is not going to get a swarm of Nps due to its higher complexity. EEG/EMGs can be good. I'd tell anyone in a heartbeat to go into gas or rads the latter of which has a demand growing more than any field due to imaging exploding.

I don't see complexity as the limiting factor for midlevel proliferation. Because midlevels can practice independently, but also can work in a supervised role under physicians. Increase the number of midlevels working under physicians and you decrease the number of physicians needed overall.

Hospital administration cares more about bottom line and saving money whenever possible. I've rotated with neurologists who order imaging for everything for defensive purposes, even when they can localize very well with their exam skills. It's not so far-fetched that admin can see this and think a midlevel can do the same thing for less pay, even when it's missing the forest for the trees.

Psych is more susceptible to midlevels for sure, I won't deny that. The shortage of psychiatry is profound enough for us to not be significantly hurt by midlevels yet, and for the near future at least. That may change one day, but I don't think any non-procedural field is truly safe long-term. I do think there will eventually be a tipping point to where midlevels will start causing enough bad outcomes to where independent practice is more trouble than it's worth. But who knows how far out that is.

 

[dl2dp2]

Thank you for your response. I really wish I could just go off of what I liked the most and leave it at that but it feels like my responsibility to my wife and future children to at least speculate the future of the field I will be going into. Whatever I do will be providing my family's income over the next 40 years and I think it's fair to at least notice what's going on with Psych NPs currently. Bceause of this, I can't help but weigh this into my decision making in choosing a speciality. I love Psych and it is so interesting but this has just been a nagging problem I've had ever since being on my Psych rotation.

This very much depends on where you are and what you do. See other threads re: the prestige of the specialty.

The average neuro salary is maybe 20-30k higher, but the average neuro job is more hours. Hour by hour they are probably comparable and/or neuro is perhaps slightly less effective in making more money. I.e. if you have a full time psych job that's 40 hours without call, and you pick up a side gig for 10, you end up making more than a neuro where an average job is 50 hours with call.

The best psych jobs are much better than the average neuro job. It may even be better than the best neuro jobs. Best psych jobs are comparable to the best lifestyle specialties in medicine. If you work hard as a MS3, match well into a top program in a top market, get really good subspecialty training, set up a productive and lucrative practice, you can make a lot of money and do really well in psych, likely much better than in neuro, and often better than anesthesia. The per-hour income is vastly better. This has to do with economics: the top psych practices are cash. There are very VERY few neuro practices that are cash.

Top psych jobs are untouchable by NPs. That's not a concern. Do you really think any professional family with a child who has bad behavioral problems with let an NP evaluate them if they had the money to pay for an MD? No. Not in a million years. If I *had* the money to pay for mySELF and I had what I consider to be "real depression", would I pay for an NP to write my meds? Never ever ever.

So, if you truly "love psych" more on a day to day basis, I think it's much more logical to actually go into psych AND *excel* than go into neuro and do stuff you won't enjoy AND make less money per hour just because on AVERAGE an average neuro job pays more. Are you average or are you better than average?

 

[smalltownpsych]

Doesn’t seem wise to not do what you want out of a fear that psychiatrists will be encroached by NPs. They will encroach and psychiatrists will still be needed and make money. As a psychologist, my field has been encroached on dramatically more and for longer and I still make two to three times the average midlevel. Just like prior poster said, people will pay for expertise.

 

[TexasPhysician]

NP’s are encroaching on most fields. NP’s now have GI and Cardiology fellowships.

NP’s in my area are doing Neuro and Sleep independently.

 

[Bartelby]

I think dl2dp2 nailed it. If you excel at psychiatry, it is hard for me to imagine that good career opportunities will dry up in the near future (the next 10-20 years). We should all remember that things ebb and flow, and that AI, midlevels, changing reimbursements, etc. can seriously impact the income of pretty much any specialty. For that reason, I would recommend aiming for financial independence relatively early rather than banking on earning a high salary for the next 40 years. That goes for psychiatry, neurology, and pretty much any specialty (though the procedural / surgical specialties likely have a higher built-in wall against this kind of encroachment).

As dl2dp2 pointed out, if you are a well-trained psychiatrist offering niche cash services that seems relatively insulated from typical midlevel concerns. I think even just being a below-average but not outright incompetent psychiatrist anywhere in the country will get you a very solid salary package with reasonable hours for the foreseeable future. If you want to future-proof, though, being excellent at what you do and thinking about how you can distinguish yourself from less experienced providers doesn't hurt.

 

[Bartelby]

I just want to emphasize this part for the OP. We can show you threads on this forum from literally more than 10 years ago making the same predictions about NPs taking over psychiatry (and other parts of medicine), but since then salaries have not gone down. Supply of jobs remains high. These predictions may eventually be right, but is there any reason to believe they're more right now than they were at any point over the last 10 years?

And to second this comment, I made the decision to go into psychiatry a little over a decade ago. I was by far most interested in psychiatry but seriously considered other specialties. I was told (by medical professionals in real life) that I would make $100k or less, that I was wasting my talents, and by non-medical people that I gave up on being a "real" doctor (always as a "joke" of course!). Having seen how things went for me I don't regret choosing psych for a minute! This goes double because EM was my main second choice, and if you browse their forums it seems many are not pumped about their choice of specialty. No one can guarantee the future, but the doomsaying is not new.

 

[G Sheb]

I think dl2dp2 nailed it. If you excel at psychiatry, it is hard for me to imagine that good career opportunities will dry up in the near future (the next 10-20 years). We should all remember that things ebb and flow, and that AI, midlevels, changing reimbursements, etc. can seriously impact the income of pretty much any specialty. For that reason, I would recommend aiming for financial independence relatively early rather than banking on earning a high salary for the next 40 years. That goes for psychiatry, neurology, and pretty much any specialty (though the procedural / surgical specialties likely have a higher built-in wall against this kind of encroachment).

As dl2dp2 pointed out, if you are a well-trained psychiatrist offering niche cash services that seems relatively insulated from typical midlevel concerns. I think even just being a below-average but not outright incompetent psychiatrist anywhere in the country will get you a very solid salary package with reasonable hours for the foreseeable future. If you want to future-proof, though, being excellent at what you do and thinking about how you can distinguish yourself from less experienced providers doesn't hurt.

This doesn't only apply to cash pay practice though.
Many positions are paying $200+/hour for 60 minute evaluations, 30 minute followups. 1 hour admin work/day. That's plenty to provide high quality care. Some of them telepsych.
You do the math. For an 8 week vacation and a 40 hour week work, that's 350K+.
Even in comparisons to "top fields" like dermatology or whatever, that is not a bad deal. At all.

So much energy is wasted and people are terrorized from the supposed incoming NP swarm.
But this is not reflected in the objective data AT ALL.
Just focus on being a good psychiatrist and the opportunities will line up.

 

[calvinhobbes]

My high school chemistry teacher can probably treat patients better than an NP. I would not be worried about NP’s. Psychiatrists are constantly cleaning up their messes and many patients do not want to see an NP due to bad word of mouth. As a psychiatrist you will always be a physician with more knowledge and training than an NP can never, ever attain or even dream to hold that status. NPs can whine all they want, but they second they get independent practice, their liability is real and then they all complain that they want some “supervision.” OP, I would do what you enjoy. Keep in mind the income potential in psych is very high, because it is so versatile, not so much with Neuro. But at the end of the day who cares, if you’re happy and enjoy your life and making good money, a difference of 10-20k isn’t going to matter, especially if you can do telepsych for a few hours here and there in a week and make up for it, if you choose. NPs are actually dragging their profession down with their million new grads and poor clinical skills. They will become their own downfall, just look at the hysteria on TikTok about their “board certified neurology” NPs who have no idea what the eff they’re talking about 😂 An major ER in NY used to allow independent NPs as recently as last month, but after one sent a patient with DKA home without any labs or proper treatment and the patient died, now that ER no longer allows independent practice of an NP (even though the State does), and now each MD has to see the patient and sign off before discharge (so, even huge organizations are noticing the pain and liability of hiring NPs).

 

[TheFuture_22]

Choose the field that you have the most interest in. Once you become an attending, the pressure to continue learning and refining your skills lessens. If you choose a field that you truly are passionate about, keeping up with the field and refining your skills no longer feels as much like work and becomes easier to do. It will be much easier to set yourself apart from the mid levels if you choose the field you are most passionate about. Sure, physicians start out with a distinct advantage over mid levels because of the major differences in our training, but if you become complacent and stagnant you will become replaceable in any field.

 

[finalpsychyear]

if you want true job protection go surgical, rads, and gas as their supply and demand at least till 2030 is looking solid.

The other fields are all much more likely to be encroached. The online glut of NPs is happening. Feel covid boosted it even more. How bad no one knows. Likely won't affect the attendings now in practice who are established anyways but the docs in the future will be calling our time the "golden" years sadly.

 

[Styrene]

Psychiatric NPs do not do the same job as psychiatrists

 

[comp1]

Choosing a specialty based on anything other than you enjoy doing it and are good at it is an absolute recipe for burn out. That mindset is much more dangerous to you and your family than anything NPs could ever do.

 

[OldPsychDoc]

My high school chemistry teacher can probably treat patients better than an NP. ...

They'd at least be better at alleviating the stimulant supply crisis.

....
There is a lack of respect in psychiatry, but from substance seekers and the personality disordered. You may be able to avoid sub seekers in neuro, but not difficult personalities. Neuro residency is heavy on hours, more than IM and a little less than surgery. If you're willing to work neuro hours, I feel surgery or IM plus fellowship, is a better bang for the buck in terms of lifestyle and respect.
....

Plenty of substance-seekers in neuro...the chronic pain/headache/"only valium treats my vertigo" folks are all over the place.
We at least get better training and supervision in boundaries and countertransference than they do.
And I've said it before, most of the time, anything that smells "behavioral" to them--or any other specialty--and you'll get plenty of love and respect if you're able to take it off their hands.

 

[Stagg737]

I think you hit the nail on the head. While I love Psych I think going into Neurology allow me to future-proof myself more as NPs have not and most likely will not enter Neurology as much due to the higher barrier of entry.

This just isn't true and NPs are invading neuro as well. There is just such a massive shortage (and growing) in psychiatry with relatively low threshold to meet "standard of care" that employers are desparate to hire a warm body. I could throw a dart at a map of the US right now and have have a job pretty much anywhere within months, and I (along with many others here) get spammed daily about open jobs.

Thank you for your response. I really wish I could just go off of what I liked the most and leave it at that but it feels like my responsibility to my wife and future children to at least speculate the future of the field I will be going into. Whatever I do will be providing my family's income over the next 40 years and I think it's fair to at least notice what's going on with Psych NPs currently. Bceause of this, I can't help but weigh this into my decision making in choosing a speciality. I love Psych and it is so interesting but this has just been a nagging problem I've had ever since being on my Psych rotation.

You shouldn't be worried about this at all. The need is so high and growing that the number of practicing psych NPs could double and we'd still have job security. I applied for several positions and instead of taking one of them, I ended up in a position that didn't exist that I proposed to a department chair. I had prepared pretty well for my initial meeting with him and an administrator to justify the position and I didn't even present anything before being asked when I wanted to start. I also believe 100% that I could have done this at multiple other places I was looking at, but didn't need to. This is in addition to the unfilled jobs I constantly get spammed about.

Also, idk what your psych rotation experience was but all of my psych rotations in med school (5 in total) 5-6 years ago everyone talked about how desperately more psychiatrists were needed. I've also met a grand total of 1 psych NP who I think legit functions at the level of a psychiatrist, and she's been a psych NP for probably 25 years now and read more journal articles than most physicians I know.

I won't tell you what you should do, but if you're going to pick neuro over psych d/t worrying about NPs, you're being dumb.

My high school chemistry teacher can probably treat patients better than an NP. I would not be worried about NP’s. Psychiatrists are constantly cleaning up their messes and many patients do not want to see an NP due to bad word of mouth.

And this is why I have no concerns about my job security. A solid 30%+ of my outpatient work (both in residency and now) involves cleaning up the terrible treatment plans and incorrect diagnoses made by NPs that patients previously saw. The more of these "fast track psych NPs" enter the work force, the more we'll be seeing this and the more patients will need good psychiatrists. If anything, the NP encroachment in psychiatry is only helping my job security and I have no concerns whatsoever about this in the next 15-20 years.

if you want true job protection go surgical, rads, and gas as their supply and demand at least till 2030 is looking solid.

This is 1/3 correct. Rads has job protection issues outside of mid-levels (AI, international docs reading 50 scans/hr, telehealth, etc) and anesthesia was one of the first battlegrounds for mid-level encroachment and continues to be a significant battle ground. Just look at the crap show that Atrium Health created by firing almost 100 anesthesiology physicians and replacing them with CRNAs.

 

[Sushirolls]

Choosing a specialty based on anything other than you enjoy doing it and are good at it is an absolute recipe for burn out. That mindset is much more dangerous to you and your family than anything NPs could ever do.

Disagree, everything will become a job in the future. Rote, mundane, routine, repetitive.
Accepting this fact could permit people to go into other fields and do just fine.
Psychiatry though, I believe it will be much, much harder to go into it from the start viewing it just as a job.

Ever talk with the folks pushing 10+ years military service? They are typically counting down the days until they hit their magic retirement pension threshold of 20 years service.
So many jobs, people clock in, clock out.

 

[liquidshadow22]

Let me know when most NPs can figure out the difference between NMS and malignant catatonia and recommend the proper course of treatment. The NPs I supervise, as much as I appreciate them, have difficulty with distinguishing personality disorders from other disorders, struggle with accurate diagnoses in general, require guidance regarding the management of psychotic disorders, and have no training in psychotherapy. They frequently get tripped up with failing to recognize problems such as hallucinations due to parkinsons.They do ok in treating some garden variety illness but when things get complex my phone or instant messaging blows up with requests for guidance.

Also, median salary of psychiatrists is actually fairly good. I earn roughly $285,000 annually, work 4 days per week now, and see about 10 patients per day. I am not the highest paid psychiatrist in my organization, it's about average in my state. I'm allergic to over work and enjoy my hobbies.

the problem cited above are very rare. Perhaps only relevant to a C/L psychiatrist. Overall i agree they will struggle with re: to C/L and inpatient psych, but probably not so much that it makes much of a difference to a hospital administrator who is doing the hiring.

Most bread and butter outpatient psych is fair game to be stolen by NPs and i believe this market will continue to be eroded by the onslaught of psych NPs.

Re: OP, i do believe that Neurology is more protected from encroachment than psychiatry FWIW. However psychiatry is a much easier lifestyle specialty to practice over the longhaul compared to neurology.

 

[comp1]

I'm kind of sad that some physicians find that the practice of medicine must become rote. I've only been out of residency 10 years, but each day still seems like a new and different challenge.

 

[Stagg737]

the problem cited above are very rare. Perhaps only relevant to a C/L psychiatrist. Overall i agree they will struggle with re: to C/L and inpatient psych, but probably not so much that it makes much of a difference to a hospital administrator who is doing the hiring.

Most bread and butter outpatient psych is fair game to be stolen by NPs and i believe this market will continue to be eroded by the onslaught of psych NPs.

Re: OP, i do believe that Neurology is more protected from encroachment than psychiatry FWIW. However psychiatry is a much easier lifestyle specialty to practice over the longhaul compared to neurology.

Yet they continue to be grossly incompetent at this en masse with practices like starting 2 SSRIs and a benzo for run of the mill depression/anxiety or 3 antipsychotics for obvious PTSD...

They may continue to flood the market, but their general incompetence will keep us in demand for decades to come.

 

[psyspy]

Lots of optimism here, but I will say that you won't find jobs for 300k+ in relatively desirable areas. Take that as you will

 

[liquidshadow22]

Yet they continue to be grossly incompetent at this en masse with practices like starting 2 SSRIs and a benzo for run of the mill depression/anxiety or 3 antipsychotics for obvious PTSD...

They may continue to flood the market, but their general incompetence will keep us in demand for decades to come.

I believe it but what are the consequences? How often do NP actually get into any nursing board complaints or malpractice issues as result? My guess is very infrequently. Patientz continue to see them for care. Just go on zocdoc and you'll see thousands of psych NPs with rave reviews

 

[ksharp33]

Yet they continue to be grossly incompetent at this en masse with practices like starting 2 SSRIs and a benzo for run of the mill depression/anxiety or 3 antipsychotics for obvious PTSD...

They may continue to flood the market, but their general incompetence will keep us in demand for decades to come.

Most patients cannot tell the difference between an NP or MD/DO. In fact, most patients refer to their NP as their "psychiatrist."

Also, patients love to get benzos/stimulants from their NP. The same medications that their MD/DO may have denied.

 

[dl2dp2]

Lots of optimism here, but I will say that you won't find jobs for 300k+ in relatively desirable areas. Take that as you will

False. Also, unlike for other specialties, salary and geography don't always correlate in this field. Salaries are often higher in CA/NY due to larger state-sponsored salary lines for public sector jobs. It's reasonably straightforward to get a job anywhere with 300k+ expectations as a clinician outside of academia/govt, etc. The MEDIAN job perhaps is below 300k at desirable areas. That's different from "you won't find jobs...".

 

[clausewitz2]

False. Also, unlike for other specialties, salary and geography don't always correlate in this field. Salaries are often higher in CA/NY due to larger state-sponsored salary lines for public sector jobs. It's reasonably straightforward to get a job anywhere with 300k+ expectations as a clinician outside of academia/govt, etc. The MEDIAN job perhaps is below 300k at desirable areas. That's different from "you won't find jobs...".

And I can tell you that even in mid-size cities, you can find VA jobs that get reaaaaaal close to 300k with any reasonable valuation of those guv'mint bennies.

 

[heartsink]

I believe it but what are the consequences? How often do NP actually get into any nursing board complaints or malpractice issues as result? My guess is very infrequently. Patientz continue to see them for care. Just go on zocdoc and you'll see thousands of psych NPs with rave reviews

This is a concern of mine as well.

NPs are not held to the standards of the medical boards, they're held to the standards of nursing boards. As I understand it, suing them is also less money payout (for lawyers + pts) vs. physicians, so less likely for lawsuits to go forward.

Until or unless the malpractice lawsuit laws change to catch up with independent practice, NPs will continue getting off almost scot-free regardless of how many patients they harm...

 

[psyspy]

False. Also, unlike for other specialties, salary and geography don't always correlate in this field. Salaries are often higher in CA/NY due to larger state-sponsored salary lines for public sector jobs. It's reasonably straightforward to get a job anywhere with 300k+ expectations as a clinician outside of academia/govt, etc. The MEDIAN job perhaps is below 300k at desirable areas. That's different from "you won't find jobs...".

Should've included "most employed jobs". Niche things like prison will probably get you higher than that

 

[DOswag]

Lots of optimism here, but I will say that you won't find jobs for 300k+ in relatively desirable areas. Take that as you will

What's the definition of a relatively desirable area? I looked for jobs in multiple states recently as I'm about to get out of the military (and was trying to decide on where to live since my family has lived in several places as you can imagine with military) and there were plenty of 300K jobs out there. I don't know if people would necessarily consider the places I was looking as desirable locations by their standards but they weren't out in the boonies by any means. But they weren't CA, NY, FL etc. I will be moving to a city of over 1 million people and the job I ended up taking has the potential to make more than 300.