Medical Education Discussion Forums

Hi to everyone.
I am currently a high school graduate who is considering attending medical school and after that specialize in psychiatry. But the thing that is blocking me to move forward is that I do not want to work with people with severe mental illnesses, at least for a long period.( Could work for some cases but not frequently). I have been accepted in the faculty of psychology in the university which is considered the best here(I'm non-US citizen). but the thing is that I really like medicine, biochemistry, anatomy and biology and i'm pretty good at sciences, actually I had a biotechnology major in high school which consists of biology, biotechnology, chemistry and biochemistry so I have a strong background in sciences. I would like to be the type of psychiatrist who does psychotherapy more than psychiatrists do nowadays in addition to medication management( I am interested about medications and how they function). Ive read on the Royal College of Psychiatry that there is a subspeciality of psychiatry which is medical psychotherapy but I didn't see that there is a subspeciality of that kind in US universities(im interested to attend one of US top universities during residency). so my problem is divided into two:
Can I specialize in medical psychotherapy while being a psychiatry resident and if no , can I be a psychiatrist who does psychotherapy and also does medication management when needed and earn a good living( $12-16k a month or an annual salary around $180,000-considering living in the US-)?
the second thing is that when is the best time to start a private practice? Will it much differ if I started maybe right after graduation or 5 years after?
Hope getting an answer ASAP because time is crucial to me atm.

psych11223,

I can't really help you too much, since I'm not familiar with the medical education system in your country. You don't say where you will be attending college, but I'm really only familiar with the US medical education system.

It sounds like you just finished high school and will be starting college in the fall. If your system is similar to the US system (which it probably isn't), then you would need to take the required coursework in order to apply to medical school once you graduate from college. You would apply for a psychiatry residency after medical school. If you are planning on going to medical school outside of the US, then getting into a residency in the US will be challenging as the residencies are very competitive, especially for non-US graduates.

You mention the Royal College of Psychiatrists program in medical psychotherapy. Looking on their website, it sounds like that area is basically psychiatrists who have a strong interest in psychotherapy. There are psychiatry residency programs in the US where psychotherapy training is quite extensive. There is a lot of flexibility in the types of patients a psychiatrist can see. Some psychiatrists work only with the most seriously mentally ill (schizophrenia), while others work with individuals with much more common, typically milder forms of illness (anxiety disorders).

There is also a lot of flexibility in types of treatment you can provide as a psyciatrist. While I'd say most psychiatrists today focus on medical management, there are plenty who do psychotherapy as a part of their practice. There are a smaller number who focus primarily on therapy, but some do.

As for the US, I don't think it really matters when you start in private practice. I think most people who know they want to do private practice, start that right after residency.

As for earning potential - I think a lot depends on where you live, what kind of work you do, and how much you work.

Thank you DrDave for your response.
Actually the educational system differs from the US, it is a 6 year program with 1 year internship, you have 3 Pre-clinical years and 4 clinical years. so its like the college and medical school are combined together. its a common program in Europe such as in UK (Oxford and Cambridge), Germany (Heidelberg and LMU) , Switzerland (ETH Zurich and University of Zurich) and many other countries.
Regarding residencies programs in the US for non-US graduates, why non-US graduates will face challenges? Is it a matter of language? different programs? or just a government procedure to ensure every student studies in US universities has the same qualifications compared to US medical students?
and regarding flexibility of work for psychiatrists, I recently asked a psychiatry student who studies at UCLA, she said that the bread and butter throughout training will be treating more severe mental illness and it will only be after many years of training that I could start a private practice and choose whom I want to treat. Is that 100% true? what do you think?

psych11223,

US residency spots are very competitive for international medical graduates, mostly because there are a limited number of spots. US graduates typically are the best prepared candidates for those spots, and so they typically get first preference. The remaining spots are then available for international medical graduates. Based on the data that I've seen from the NRMP website, almost all US medical school graduates matched in a residency. In typical years, only 5-7% of the US graduates who apply during the match process don't get a spot. By contrast, about 50% of students from a non-US school don't get a spot.

The good news for you is that psychiatry residency slots are not nearly as competitve as many other specialties. For 2013 there were a total of 1360 first year psychiatry residency slots available in the match. There were 749 US med school graduates who applied for a psychiary residency and 681 matched. There were an additional 1599 non-US (international) med school graduates applying for the remaining 679 slots. 649 internal medical school applicants matched in psychiatry out fo the 1599 who applied. That's around a 40% match rate.

As you can see, the odds are stacked against you. Obviously many international grads do get US residency slots, but just as many don't, and very often those spots are not in the best programs.

In my experience, psychiatry residency provided a fairly diverse range of exposure to mental illness. The first two years were mostly dealing with hospitalized patients. In order to be hospitalized, an individual usually is viewed as being a danger to self or others, or unable to care for self. While this may be caused by serious mental illness, it is frequently caused by personality disorders or substance abuse issues. The last two years of residency were much more focused on outpatient psychiatry. These individuals can have serious mental illness, but there were plenty of people with milder depression, anxiety, eating disorders, or more general life stresses. There were opportunities for seeing patients for psychotherapy as well as for medication management. Each residency program will be a little different as far as specific patient mixes and opportunities for providing psychotherapy versus medication management.

You wouldn't technically be able to start a private practice until you complete you residency. I don't see any reason why someone wouldn't be able to start a private practice right after finishing residency though. I also know plenty of people who worked "moonlighting" in psychiatry clinics during their 3rd and 4th years of residency, but I'm not sure if residents are still allowed to do this. If you go into private practice right after residency, you probably would initially want to see whatever patients you can to make a living. Depending on how good you are and where you practice (big city or rural area) you will have more or less freedom over what types of patients you can see.

Sorry for the last post its by mistake.
I had a look at the NRMP report , I thought it would be more difficult. When we are talking about going to medical school and specializing it is one of the most difficult academic programs out there, so a one must struggle through his way into becoming want he wants.
Anyway, do you have a clear idea of what exams may an international medical graduate have to do in order to be a resident in US universities?
and you mentioned:
"The first two years were mostly dealing with hospitalized patients. In order to be hospitalized, an individual usually is viewed as being a danger to self or others, or unable to care for self".
It looks like the experience with severely mentally ill people are "scary" according how you described it, but how can they be a danger for others? Is it possible that they may attack doctors? or did they attack so they hospitalized them? or it is an evaluating process that is done in advance?
As you can tell, I am interested in becoming a psychiatrist who specializes in medical psychotherapy (or in an extensive psychotherapy program) and focus more on less severely mentally ill people. I know that I will face people with more severe cases, actually its interesting because I don't meet them everyday and if I do I may not discover that they have a schizophrenia or bipolar, and I think I am ready to engage with them and treat them, but not frequently as I mentioned before, because it is hard seeing a patient suffering from a chronic/incurable disease. However, I believe I can overcome that situation.
Regarding schizophrenic people -and since you work in a hospital (I've read a lot of posts by you)- Is there a mild cases of schizophrenia? I mean there aren't exactly similar cases but is there a way to cure schizophrenia maybe with mild cases? And do medication helps schizophrenic people to live normally like any other person?
Answering this questions will help me understand ill people that I may face in future.

psych11223,

I was thinking more about the NRMP data and I think that it does not fully represent how difficult it is to get accepted into a US residency if you are a non-US student. The NRMP data only includes people who ranked programs in the residency match system. In order to rank a program, you have to have interviewed there. There are many non-US applicants who can't even get an interview. The 40% match rate is for those lucky few who managed to get an interview somewhere. I don't know what the interview rate is for international medical graduates, but if you don't have high scores on the USMLE Steps 1 and 2, you probably won't get an interview.

I'm not personally familiar with the process for applying as an international graduate. However, it looks like you would need to be approved by the ECFMG. This would mean taking USMLE Steps 1 and 2, an English language exam, and a clinical skills exam. If I were you, I'd try to get in touch with someone from your country who has gotten into a US residency, as they would be your best resource.

Most severely mentally ill people I've worked with do not seem particularly scary to work with. There have been a few over the years, but if you are careful, you typically won't have a problem. I used the phrase "danger to self and others" because that is the standard language in most states for someone to be involuntarily admitted to a psychiatric unit. Also, insurance is usually not going to pay for hospitalization unless the person needs to be in the hospital. During my residency, there were very few patients I worked with who were a danger to others, with most getting hospitalized because they were a danger to self or unable to care for themselves. While it is possible for a patient to attack a doctor, it doesn't happen very often.

As for mild cases of schizophrenia - yes they exist. There is a large spectrum in how people with schizophrenia function. In general, it is thought that schizophrenia is not curable at this time, but some people can have a nearly complete response to medication. Most people with schizophrenia do improve with medication, but most will continue to still have some residual symptoms.

Thank you for you answers DrDave.
I got a last question - I hope- in this post:
If I was a medical student whos fully trained outside the US, this means I also attended a psychiatric residency in an accredited university outside the US and wanted to practice psychiatry in the US , do I really have to redo the psychiatric residency? even if I graduated from one of the top medical schools globally? because I've read a lot about that and the one thing I saw that I have to redo the residency, and that does not make any sense if I was trained in an accredited university and one of the top out there.

psych11223,

Based on the information on this page of the AMA website, it does look like you would need to complete a residency program in the US or Canada in order to practice medicine in the United States.

I really do apologize for my questions if they take a lot of your time, but I just can't stop digging into psychiatry and especially mental disorders, I saw this video abouta schizophrenic kid on Oprah Winfrey Show : https://www.youtube.com/watch?v=WjqRYgICgdU
I think you'll only need 5 min of that video to describe his case, is that a case you consider a severe mental illness? is it the worse of schizophrenia?