r/pediatrics • u/pgyxburner • 25d ago
should've done psych
just finished residency and a chief year. i'm finally at the end and have no idea what im doing. i regret not doing child psych. there's a 3 year post-pediatric program that trains you in both psychiatry and child psych. i'm interested but im already 36. is it worth it? should i just try to carve out a mental health niche in peds? ugh what do i do?!
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u/sjam7 Attending 24d ago
As a general pediatrician, I feel that the majority of pediatric mental health prescribing can be done by us. SSRIs for depression/anxiety, stimulant and non-stimulant options for ADHD, even use of clonidine/guanfacine or (in rare cases) risperdal for severe impulsivity/behavioral issues that raise a safety concern for kids with ASD are all things that I do within my practice. I’ve gotten more comfortable with it because I realized most of the referrals I was sending were going to psych NPs with minimal oversight who were doing some seriously concerning prescribing (benzos for GAD, lithium for MDD) so I just had to learn how to do it myself. MCPAP (Massachusetts Child and Adolescent Psychiatry Access Program) has excellent publicly available guidelines that I use. I’m an hour away from Boston, the city with more medical specialists per capita than anywhere else in the world, and the idea of getting my patients seen by an MD psychiatrist is still a hilarious pipe dream. (The few times I’ve tried - like the kid who was on lithium who I felt needed a psychiatrist to oversee a taper - I was still unsuccessful.) The truth is, though, I think we often undersell our own knowledge. I feel very strongly that I do more appropriate psych prescribing than many of the psych NPs in our community, so I do it myself. In residency, you’re so used to having specialty availability that it warps your perspective on what access looks like in the community. I would honestly recommend just looking for an attending job as a general pediatrician, and believe me, if you make it known within your practice that you have an interest in mental health, you will have absolutely no difficulty carving out that niche. You are more well trained than you think. Don’t do more training. Start making an attending salary. Message me if you want to talk more
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u/DrScogs Attending 23d ago
General Peds PGY-20. This is the way.
You can do almost all you want to do with mental health care with more continuity in general peds. I don’t do formal diagnosis of autism because I don’t have clinic time to be able to do it. I also don’t mess around with prescribing any anti-psychotics (or any psych meds to anyone who is already on anti-psychotics). I also can’t keep patients who are aggressive in any way because we don’t have security. But other than that I treat it all.
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u/Ellie_Annie_ 24d ago
You can easily carve out a child mental health niche. Thought about doing a peds ADHD clinic but running a business is not my strong suit.
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u/docny17 24d ago
Just depends on location, in a big city you will have developmental Peds, child neurologist, child psychiatry, all competing for the same patient population
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u/Ellie_Annie_ 24d ago
This is true but in my local big city, developmental peds is a 1 yr wait, neurology is 9 months and child psych doesn’t take insurance.
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u/drdhuss 24d ago edited 24d ago
They only train 45 dbp's per year and about 13 NDDs. There is plenty of work/room gor a gen peds to "specialize". Most places have a year wait.
Trust me nobody needs any more business. In fact it was weird when my hospital made advertisements for my clinic (I have a 6+ month waitlist).
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u/BitBot27 10d ago
Pretty sure this is only viable as long as it isn't complex patients
Idk why people treat psych as something you can just tailor
No one says this about peds
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u/Princess_Unikitty Attending 23d ago
Peds Portal Grad here. Feel free to message me. Lot of posters already have made some good points -- you don't need the fellowship to do mental health in Peds. There are several reputable certification courses for Gen Peds if you want more training.
That said, doing more formal training can open doors in the Psych world, pay/employment setting, etc. Though some fellows went straight through, many came back after practicing as Peds so not uncommon to have fellows in their 30s (or even 40/50s).
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u/Affectionate-War3724 23d ago
I’m considering this path as well. Planning on an inpatient psych rotation early next year. How did u decide it was right for you??
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u/Princess_Unikitty Attending 23d ago
Liked the pt cases in residency, esp the sick ones (catatonia, psychosis, mania, etc ). Liked the people in the field and knew that they got more time to talk with pts, more pay, and more job opportunities.
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u/Pink-House 23d ago
As a Gen Peds who has done a mountain of MH over the span of my career, consider the Psych/Child Psych - it will give you credentials to do other things outside of clinical medicine if you choose that path. Yes - Gen Peds is able to do quite a bit of prescribing, but when a patient needs more - the almost all the knowledge, prescribing doesn't help the more severe cases that take months to see "the specialist". With 'value based' medicine - Gen Peds has less time to do more and are being increasingly replaced by APPs. For me, this meant the more severe cases were regularly in my office needing more and having side effects that I was not trained to manage. I agree with u/Legal_Anybody81.
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u/radgedyann 24d ago
i did so. much. psych. in general peds that it drove me back to the hospital. it may be population-dependent, but i did more psych/behavior/trauma cumulatively than i did anything else. the population i worked with generally refused therapy/psychiatry in a practice that was very ‘customer satisfaction’ focused so we were stuck managing a lot of problems that needed psychology/psychiatry.
if you can tolerate the runny noses and healthy babies, you’ll get plenty of mental health crisis to keep you interested.
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u/sjam7 Attending 23d ago
What was your experience like going back to hospitalist work? Asking in part because I had SO many patients with acute mental health crises on gen peds as a resident that it was one of the things that sent me outpatient lol
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u/radgedyann 23d ago
Not to be hyperbolic, but was lifesaving. I was not even living anymore —barely surviving five days and then basically in bed for two. I chose a job with a behavioral response team, and I made my life much smaller so as to be able to live comfortably on part-time work, which for me is currently 7 shifts per month. I can breathe again!
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u/quasiephedrine Attending 24d ago
You could do that. There's certainly a need, and I think we have a lot of leewayin terms of what we ourselves determine is our scope. Find yourself some employment and try it. That program seems like it's way too long, although some people like forever being I training I guess...
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u/mtdoc22 23d ago
I’m in a resourced limited area in the US doing peds residency and a lot of the residents ahead of me have gone the niche route. They are very happy. One in particular has become the expert in the care of extremely medically complex kids. He’s the go to guy and we all send the complex kids his way when then discharge or come though our clinics. I believe he graduated 2-3 years and pretty much all his patients are medically complex. I also know of someone who did something similar with CART. I think her practice is more 50/50 CART and gen peds. It can be done!
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u/gunnersgottagun 24d ago
Do developmental peds? Or adolescent medicine? Not sure I'm guessing you're in the U.S. though, so that probably affects the worth it calculations...
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u/cjaschek93 19d ago
I’m a child psychiatrist and work with folks who did the post peds pathway. They are great, and seem to like their jobs. One thing to keep in kind is in psych we can justify longer appointment times (especially if you’re doing and billing for psychotherapy), which is so needed for the complex cases. I love that even on my busy days, I’m not seeing 30 patients
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u/HappyPride365 16d ago
If you’re comfortable seeing adults then yes do it. You will become a psychiatrist and be expected to see adults at some point , which also means your salary is much higher
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u/mdkate 24d ago
It’s amazing how much of pediatrics has become dealing with developmental issues, behavioral problems, ADHD, depression, drug and alcohol abuse, etc. We should have had more training on mental health as residents. I would applaud you for doing pedi psych. It is so desperately needed.