Psychiatry

A specialty at a crossroads. Once dominated by Freud and Jung but now becoming evidence-based like the rest of medicine. The psychoanalyst’s couch being replaced by the SSRI. Now as much pharmacotherapy as behavioral therapy.

No specialty is more polarizing for medical students. I don’t think anybody hates psychiatry (because how could working with the insane not be interesting) but people are very clear early in their psychiatry rotation whether they will consider matching into it. The specialty seems daunting at first. How is it possible to classify something as complex as human behavior and then develop a rational strategy for treating its dysfunctions? Can progress or a cure ever be objectively demonstrated? If these questions bother you then you will find psychiatry frustrating.

The only specialty besides radiology in which you can probably get through the day without touching a patient. It’s not that psychiatrists don’t know how to do physical exams, just that their area of interest does not lend itself to traditional physical exam skills. We all need to learn to listen to our patients but this is probably all a good psychiatrist really needs to do to nail a diagnosis, apart from asking the occasional leading question.

Not very competitive which leads to the same sort of thing you see in other non-competitive specialties, that is, a wide range of abilities in people who apply for it. Some of the worst residents I have ever seen were in psychiatry-but also some of the best. Some people match into it out of a real love for the specialty. Others, particularly foreign medical graduates, use it to establish a toehold in the United States.

About the worst intern I have ever seen was a guy from some South American diploma mill whose only redeeming characteristic was that he made the third year medical students look good. I was a third year medical student at the time and helped him out as much as I could by identifying the location of major organs for him and keeping him up to date on the latest guidelines for normal blood pressures. You know, complicated things like that. He didn’t actually ask me what all of those squiggly lines meant on the EKG but I know he was thinking it.

A good psychiatrist, on the other hand, can work what seem like miracles. So pick your program carefully.

Also a “lifestyle” specialty. Very much a nine-to-five job. There are psychiatric emergencies but Vitamin H will keep the patient fresh until morning. Many, many different ways to practice with a wide range of income potential depending on what you do and how well you do it.

Radiology

What’s there not to like about Radiology? Good pay, relatively easy residency, no rounding, no physical exams, no urine spattered drunks, no drug seekers, and empathy is optional. If you play your cards right you can spend your career sitting in a darkened room like some ancient Greek oracle looking at interesting pictures and making profound but strangely non-committal comments. Is it any wonder that radiology is one of the more competitive specialties?

You can do interventional radiology as well and get the best of both worlds. That is, patient contact with the ability to retreat into your mysterious lair when you get tired of it.

I am jealous of radiologists. As an Emergency Medicine resident I spend my day thinking to myself, “Thank God I am not that poor slob. His residency is brutal.” But not when it comes to the radiology residents. That, my friends, is the life.

The big worry of radiologists is that they will be replaced, either by off-shore sweatshop radiologists working for Indian minimum wage or by advances in imaging technology which will make studies so easy to read that the radiologist will be like the guy bringing punch to your prom date. Helpful, but not a real factor in your chances to score later on.

These fears are unfounded. As long as medicine continues to operate in a predatory legal environment, the carnivorous lawyers are not about to let their prey scamper away to the green pastures of safety beyond the big water. In this respect the lawyer is the radiologist’s friend. Sure, you may get a “wet read” on a CT at 3AM from Bangalore but liability being what it is an American (and thus litigatable) radiologist is going to have to sprinkle holy water on it.

With this being the case, why bother having somebody on the other side of the world look at it if he can’t cover your ass? Most of us can (or will learn how to) distinguish the big killers and the common things on x-rays, CTs and MRIs anyways so there is no real service being offered here.

Will imaging technology ever get so good that he radiologist will be redundant? Don’t bet on it. Better images will paradoxically lead to the need for a more precise and expedient diagnosis. One day, when every patient who enters the hospital walks through a whole body scanner a la Star Trek, we will still need radiologists to make sense of it all.

Nuclear Medicine

Radiology’s slightly slow cousin Wilbur. A two-year residency after a preliminary year in anything. The use of radioactive isotopes which are ingested, injected, or inhaled to make images of the body using gamma ray cameras (Scintilography). Different from radiology where external radiation (well, except for MRI) is used to produce an image of anatomy, nuclear medicine uses internal radiation to produce an image of physiological function.

Thnk things like PET, SPECT, radionuclide angiocariography (RNA), multiple gated acquisition (MUGA), and the like. Not to mention V/Q scans, bone scans, and all kind of whiz-bang, golly gee image modalities.

Can you get a job just specializing in Nuclear Medicine outside of academia? Probably not. I was thinking about it as I looked for a way to escape the empathetic talons of Duke and did a little research. Generally speaking, most places want their nuclear medicine guys to be double-boarded in radiology and nuclear medicine. As a result nuclear medicine is functionally a radiology fellowship. Either that or it is used as an “in” to radiology.

There are very few nuclear medicine residency programs because of this.

If I am wrong about his than I am willing to be corrected.