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Institute Research Number 116 ISBN 1-58511-116-3
DOT Number 070.107-014 O*Net SOC Code 29-1066.00
CAREER AS A
HELPING PEOPLE HELP THEMSELVES
ALL YOU HAVE TO DO IS LOOK AROUND ANY ONE OF YOUR CLASSES TO SEE THE
tremendous variations in people. In your classes, students are all of similar age, but their personalities and behaviors are so different. There is that boy who literally falls apart if he has to get up in front of the room and speak. And there is the class clown who loves the attention and disrupts anything and everything. Then there is the shortest boy in the class who acts so tough and walks with an
exaggerated swagger. Of course, your teacher is pretty fair to all, but she certainly has her favorites in class, and those she obviously dislikes and picks on most of the time. Why does the teacher do that? Why is the boy so scared of his own shadow? Does the class clown crave attention? Does the shortest boy have a Napoleonic complex? If you are consistently, rather insatiably curious about the whys of human behavior you have the makings of a psychiatrist. To put it simply, what makes a person tick engages the psychiatrist. Psychiatrists are medical doctors who have additional training in the healthcare of the human mind. To psychiatrists, the complexity of human behavior is an attraction. A general practitioner makes decisions based on lab data, but the psychiatrist considers the intertwining of the physical, mental, genetic, and environment which makes up the whole person and influences behavior and decisions which people make. The psychiatrist treats the individual with a combination of biological interventions or medicines, and forms of therapy. Psychiatrists try to understand the reasons for human actions so that they can help individuals modify their behaviors. They do this in a wide range of environments. Psychiatrists work in private practice, academic institutions, residential treatment centers and hospitals. They conduct research, do therapy, and teach. They work with young children all the way through to geriatric patients. Psychiatrists work with a very wide variety of human challenges from addiction, to anxiety, to anorexia. This is a field which is very exciting at this time in the history of science and healthcare. Through genetic research and new discoveries in the area of neurology, ideas about human behavior are rapidly changing. This field is complicated, challenging, and evolving. While psychiatrists work in many different environments, all except those engaged in research have similar duties.
What psychiatrists do: Evaluate medical and psychological data and make a diagnosis Create a treatment plan Monitor and change treatment as appropriate Work with other professionals to provide a coordinated approach Conduct individual and/or group therapy
WHAT YOU SHOULD DO NOW
YOU CAN START NOW TO EXPLORE WHETHER YOU HAVE THE APTITUDES AND
personal traits to become a psychiatrist. Since psychiatrists spend up to 14 years in college, medical school and residency training, it would be beneficial now to find out if this is the right career for you, before you spend the time and money on lengthy schooling. Preparation for this field takes years of very hard work, and if you aren’t truly drawn to it, you won’t make it. Take the Right Classes. While you can have any undergraduate college major to prepare for medical school, you will have to take certain required general and organic chemistry, physics, biology and math, so take the preparatory courses now. Take any sociology or psychology courses your high school offers. Take all the required courses for the best college you can attend. Medical school admission is still highly competitive and you want the best grades and the best colleges to help give you an advantage. Get Involved With People in a Helping Way. If you have a mentor or tutoring program at your school, volunteer. You want to work with people in a helping way. Check out the Candy Striper programs at a local hospital, or volunteer at a convalescent program. Help with younger children at the Y or local Boys and Girls Club. Find out if you are a natural helper. Develop your listening skills in these environments. This may help you decide which group of people appeals to you most, for example, child and adolescent, geriatric, or general populations. If you find out this field really intrigues you, you will be far ahead of others who don’t decide on psychiatry until five or 10 years down the road. At least, you won’t be wasting time going in the wrong direction.
PEO PLE HAVE BEEN REC OG NIZED AS INSANE OR BEING ABNORMAL FOR A VERY
long time. In the Stone Age, mental illness was treated by trephining. This procedure involved chipping a hole in the skull to let the evil spirits escape. Some people actually survived this treatment. Mesopotamian tablets from the second millennium BC, described what we now label as mania, depression and paranoia. The Old Testament refers to “madness and confusion of the mind.” And Hippocrates described postpartum depression. At this time, forms of insanity were thought to be caused by the gods. In the seventh and eighth centuries, Islamic culture acknowledged insanity, and mental hospitals of a sort were in operation. By the Middle Ages, insanity was still thought of as God’s punishment for sins. Prayer was the manner of treatment. Religious orders were the first groups to serve and treat those who were thought to be insane. Bloodletting and other gory procedures also were utilized. While most of those who were insane were kept at home, by the 15th century, monasteries began to accept some “lunatics.” Hospitals began to accept some mentally ill individuals along with the usual medical patients. In 1547, King Henry VIII designated St. Mary’s Hospital of Bethlehem in London solely for insane poor people. Bethlem Hospital, as it was called, eventually became referred to as Bedlem, hence the source of our current use of the word bedlam. By 1681, Bedlem Hospital became a tourist attraction. People came daily to see the “lunatickes.” Visitors wanted to see the freaks and monsters. Insanity was no longer thought to be caused by demons or evil, but was seen as a temporary situation that would go away. Besides Bedlem, the mentally ill were boarded with individual families or sent to jail to be released when they recovered their faculties. The English Parliament passed the Vagrancy Act of 1714. The Act differentiated “pauper lunatics” from rogues, vagabonds and vagrants. It allowed lunatics who were so-called mad to be safely locked up. More hospitals were built to accommodate the insane, and private madhouses came into existence. There was no regulation of the madhouses and abuse was common. In 1773, the first asylum was built in the US, in Virginia. Treatment included bloodletting, and straight jackets.
The treatment of the mentally ill was abysmal until the advent of Philippe Pinel, who was considered the father of psychiatry. Pinel was born in 1745 in France. He received his MD in 1773. Pinel was a medical writer until a friend of his became mentally ill and later died. In 1793, Pinel instituted a new manner of treatment for the mentally ill. He called it moral therapy. The patients were housed in clean, comfortable environments and given simple work as therapy. Pinel became director of the insane asylum in Paris in 1794 and is known for negating the demonic theory of mental illness and eliminating many of the barbaric treatments including bloodletting, purging, and confinement with chains. Benjamin Rush was considered the father of psychiatry in North America. He was a contemporary of Pinel’s and also advocated more humane treatment. Although Rush still approved of bloodletting, he instituted moral treatment. Under his direction, many large mental hospitals were constructed in the countryside, the thought being that the patients would be separated from the environments which had caused their problems. Dorothea Dix was also an influential reformer around this time. She was responsible for many of the improvements in the treatment of the mentally ill. The medical model for treatment of mental illness finally began to emerge in the 19th Century. The term psychiatry was first used in 1808. Freud was responsible for psychoanalysis, but the field of psychiatry was around before Freud. Advances came rapidly as much more was learned about anatomy and the nervous system. The first classification system for mental disorders was developed by Kraepelin in 1883. Kraepelin also invented the terms neurosis and psychosis. Freud was responsible for the “talking cure.” By talking out their symptoms and experiences with a psychiatrist, a patient could be cured. Freud presented his theories at a gathering of physicians in 1909. Freud’s theories led to what was called the mental hygiene movement, where talk therapy fortunately replaced the popular theory of eugenics which advocated sterilization to cure mental illness. While Freud was responsible for advancement, in the 1920s and 1930s, doctors were still removing teeth, tonsils and some intestines to alleviate mental illness. The theory was that infection from these organs caused insanity. Since more mental illness seemed to occur in urban areas, it was also thought by some that urban ills caused mental illness. Lobotomies were still common, where a portion of the brain was removed to cure mental illness. At this time, most individuals with
psychological problems were in mental institutions and most psychiatrists worked in mental hospitals. World War II gave the impetus for change and advancement in this field. At least one out of five men was rejected for military duty due to mental problems. Also conscientious objectors were assigned to help out in mental hospitals. The conscientious objectors made the public aware of some of the terrible conditions in the hospitals. Up until the 1950s, more and more individuals were confined to mental institutions. Since the 1950s the trend has been to treat individuals in communities. While the majority of psychiatrists used to work in hospitals, only about one in five does now. The deinstitutionalization was fueled by several factors. There were advances in medication which allowed individuals to function and receive ongoing treatment while in the community. And reductions in available funding made it necessary to return individuals to the community. Today the majority of psychiatrists work in the community. There are still a variety of theories as to the cause of mental illness. But at least no one anymore believes the devil did it, except for some of the patients.
WHERE PSYCHIATRISTS WORK
PSY CHI ATRISTS HAVE A DI VERSE VARIETY OF SETTINGS IN WHICH THEY CAN
work. Most psychiatrists work in urban areas where medical and educational institutions are established. It would be very rare to find a psychiatrist in private practice or even in a hospital in a small town. Psychiatrists can work in rural settings where a residential treatment center is located, or a prison has been established. They can also work around the world for the Foreign Service taking care of government employees and their families at embassies. The US military employs psychiatrists at military bases and some are even on Navy ships. But for the most part, psychiatrists work in institutions or private practice in larger population areas. While some psychiatrists work totally in private practice, many combine several types of work activities. Those in private practice may also work for general and psychiatric hospitals where they screen and assess hospital admissions
and provide crisis intervention therapy. Or they may add teaching at a university medical center. Psychiatrists may have a particular specialization, including geriatrics, child and adolescent psychiatry, forensics, addiction, research and clinical neurophysiology. The particular specialty will then determine where they work. The addiction psychiatrist can work at a rehab or treatment center which treats substance abuse and eating disorders such as anorexia. The geriatric psychiatrist works at a rehab center which treats older patients, or at convalescent homes, or at hospice sites with terminally ill patients. The child and adolescent psychiatrist works at an isolated treatment center for children and adolescents, or for a foster care agency. The psychiatrist with training in neurophysiology can work in university or government research centers. There are a variety of ways psychiatrists work within the corrections system. The forensic psychiatrist works with attorneys, courts and other individuals to determine the competency of individuals involved in the legal system, treats those who are mentally ill, helps victims of crimes, and helps attorneys and judges understand the psychological aspects of the cases. Other psychiatrists work within the prison system to treat and hopefully rehabilitate those convicted of crimes. Those individuals who are alleged to have committed crimes but are found not fit to stand trial due to severe mental illness are sent to government mental institutions where they receive therapy and treatment by psychiatrists. Hospital emergency rooms employ psychiatrists to treat cases such as attempted suicide, or drug problems, and they are also available to counsel the families of victims. Larger colleges and universities employ psychiatrists in their health services centers to treat students, in medical schools to teach, and in research positions. Psychiatrists work in a variety of settings from small individual offices to large medical centers and universities. They work with needy individuals in distress from small children in the early developmental stages, to elderly individuals coping with issues at the end of life. They work with populations ranging from students to deranged murderers. As there is now a shortage of psychiatrists, they have virtually an unlimited array of work environments from which to choose.
DESCRIPTION OF WORK DUTIES
PSYCHIATRISTS WORK IN SUCH A VARIETY OF ENVIRONMENTS THAT THEIR duties
may vary considerably. Research psychiatrists may be working in a laboratory on mice instead of humans. They may be doing research on the biological, anatomical, and chemical properties of the brain and nervous system. Monkeys may be the patients. But for the most part, psychiatrists interact with human beings to help them cope with and conquer a variety of mental illnesses. The main activities and duties are:
Diagnose Being a medical doctor, the psychiatrist can prescribe
medicines. The psychiatrist diagnoses the illness and designates a classification or label for the condition. A variety of psychological tests may be used for this purpose. The psychiatrist then uses a classification system which is the same for everyone in the field. The DSM-IV is the diagnostic manual used and lists all mental illnesses and disorders. If one psychiatrist lists a specific personality disorder or syndrome, all other professionals involved know what it entails. The psychiatrist listens to the patient, and in some cases the parents. A full medical history is taken and more information may be sought from schools, co-workers, a primary physician, social worker or other important individuals in the person’s life. The psychiatrist may order some laboratory tests or refer the patient to a specialist like a neurologist or allergist for additional evaluation. The psychiatrist then works with the other physicians and healthcare professionals to coordinate treatment.
Prescribe Psychiatrists prescribe medications. There have been so
many recent advances in medications, that many more individuals can be treated on an out patient basis as long as they take their medications. The psychiatrist usually discusses the medications with the patient before they are started. Psychiatrists who work in private practice and those who are working in hospitals and treatment centers do periodic medication reviews. The psychiatrist works with the patient, nurses and staff, and others to assess whether the medication is beneficial or needs to be adjusted.
Treatment The psychiatrist develops a comprehensive treatment
plan. If there is insurance the plan might have to be submitted for approval and subsequent reimbursement. Treatment plans include a course of action for the individual. This will be discussed with the
patient, and others involved in the life and care of the individual. Treatment plans include goals for the patient, and methods to be used in obtaining those goals such as form of therapy, medications, activities, restrictions and monitoring. It usually includes an estimation of the length of therapy such as six months, 12 sessions or ongoing.
Review Cases Psychiatrists work in concert with many other
professionals. In residential treatment centers, correctional facilities, and mental hospitals, periodic case reviews are conducted. All individuals who are involved in the care and treatment of the individual are in the meeting to discuss the behavior, progress, and treatment of the individual. This may include nurses, staff, social workers, rehab therapists, teachers, and any number of other individuals. In a child and adolescent treatment center, the children are typically housed in cottages with a house parent who works closely with the psychiatrist in reporting incidents and carrying out the treatment and recommendations. The case review allows for exchange of information, and ensures that all involved will use the same type of response, treatment, or reward for the patient.
Individual and Group Therapy In private practice, prisons,
mental hospitals and treatment centers, psychiatrists conduct individual therapy. The traditional therapeutic hour may exist only in private practice. Even psychiatrists in private practice may see up to 15 patients a day. A check or report on how the medications are working does not take very long. The psychiatrist in a hospital environment may be seeing 25 to 30 patients a day. The number of patients seen daily may be an indication of the shortage of psychiatrists today, or a result of budget cuts, but the daily case load does not allot a lot of time per patient. Psychiatrists also lead groups. Group therapy involves a number of individuals who are coping with the same challenge. The psychiatrist encourages group members to share their feelings and their attempts at change. The idea is for the group members to help each other. The psychiatrist also functions to make sure none of the interchanges become destructive for any of the members. There may be group therapy for anger management, addiction issues, abuse, or many other issues. There are many different types of psychotherapy and many different theories. Not all psychiatrists use psychoanalysis or follow the teachings of Freud. Psychiatrists use what they feel is the best therapy
for their patients. Generally, individual sessions involve encouraging the patient to bring to consciousness some of the issues and background which have led to present day behaviors and problems. The psychiatrist is not judgmental but rather offers interpretation of the events, and suggestions for positive change. Most psychiatrists feel that the past must be explored thoroughly to result in lasting change. Therapy may involve just the individual or it may include sessions with family members. Therapy with an individual may range from a few sessions to many sessions over several years. There are some conditions which require monitoring over the entire life time. Just some of the conditions treated are: stress, addictive behaviors, family dysfunction, manic-depression or bipolar disorder, obsessive-compulsive behavior, anger management, pain management, panic disorder, anorexia, and anxiety disorder. Treatment usually includes a combination of medication and therapy. Some psychiatrists work with first responders or law enforcement, EMTs, and firefighters. They provide support and therapy for those involved in particularly traumatic events such as a shooting. PTSD or post traumatic stress disorder happens to some individuals involved in events like war, or the 9/11 World Trade Center attack. Many of those involved in 9/11 were helped afterwards by psychiatrists.
Psychiatrists in virtually all work environments may be called on for crisis intervention. Crisis intervention is when an immediate intervention is needed for the person. In hospitals, all persons who attempt suicide are evaluated by a psychiatrist. When persons are brought to the hospital with delusions such as hearing voices which command the person to do some violent act, the psychiatrist makes a tentative diagnosis based on the situation and prescribes medications and decides what further treatment should be obtained. Generally crisis intervention is required when the person either intends to do harm to the self, or inflict harm on others. A patient may describe plans to kill someone else. This type of situation can occur in colleges when students get depressed by bad grades, or a love relationship gone sour. It can be in a residential treatment center. Or it can be a patient who comes in for a weekly session. Crisis intervention can also be needed after a critical natural event. Counselors, psychologists and psychiatrists all assist now in areas where there have been floods, tornadoes, or other disasters which have left people shocked and confused by tragic losses. The Red Cross
and FEMA (Federal Emergency Management Agency) have rosters of psychiatrists and other mental health professionals who help out in such situations.
It is mostly forensic psychiatrists who testify in court. However, any psychiatrist with expertise in a specific area may be called upon. Forensic psychiatrists examine, evaluate and diagnose patients or clients for attorneys and courts. They answer questions like: is this person competent to stand trial, is the client competent enough to have child custody, what was the client’s state of mind during some behavior or action and so on. Testimony and competency evaluations are a minor part of work duties even for forensic psychiatrists.
Paperwork, Paperwork, and More Paperwork Psychiatrists
take notes on all clinical sessions. These are usually abbreviated notations of significant topics covered in a session. In residential treatment or hospital environments the psychiatrist must make notations on the patient’s chart. The forms of paperwork are as varied as the situations. Patient information is considered confidential and is covered by client/patient privilege. Psychiatrists are pledged not to divulge patient information except to others involved in the treatment, or if the patient is threatening to do harm to another individual. Notes must be kept for all sessions. Forensic psychiatrists write reports for courts and attorneys. The residential treatment psychiatrist reviews incident reports and writes recommendations. The private practitioner must do paperwork for insurance reimbursement. The research doctor must keep careful track of all data collected and write reports on the statistical information. Paperwork is a significant part of this occupation.
Teaching and Learning Some psychiatrists combine teaching with
a private practice. Psychiatrists teach in university hospitals which train psychiatrists. Some hold workshops or seminars in the community. The variety of issues which can be covered is endless. These medical specialists, like any other healthcare professionals, must continually be learning about new developments in their field. Psychiatry is a field which is evolving rapidly due to new advances in neurology and medication. Psychiatrists go to seminars and conferences to learn more about new therapies and new medications.
Psychiatrists must also spend time reading a variety of journals and written texts to keep up on their field. Usually they attend several conferences a year to meet, converse, and share information with their colleagues. There is a tremendous amount of variety in what psychiatrists do. Psychiatrists say they are never bored because there is always something new in human behavior, and there are certainly many different environments, situations, and interesting groups of people. Young and old, meek or mean, rich or poor, they are all patients needing the help of these trained professionals.
PSYCHIATRISTS TELL THEIR OWN STORIES It’s the Complexity That Interests Me “I was intrigued by the complexity of
psychiatry. Originally I was interested in being a surgeon, but once I sampled psychiatry I was hooked. Psychiatry looks at the relationship between the mind and the body. Surgeons are like mechanics. Laboratory tests or cat scans reveal something. It’s broken and they fix it. It can be a very black and white situation. Psychiatry deals more in grays. There is always a variation, another influence, perhaps a genetic link. It just continues to be a fascinating field. This field is advancing so rapidly with new discoveries in neurochemistry. I predict that as we find out more about the mind body connection, there will be less surgery and more psychotherapy. This is a field where you never will be bored. This is a pioneering field. I am not bored and I have been doing this since 1974. I majored in biology and went to a state university. Then I went to medical school. The surgeons are the fixers and generally don’t have good communication skills. In psychiatry you have to have great communication skills. You have to be endlessly curious about human nature. Of course you have to be smart. But you also have to be very compassionate and humane. This is a cognitive field meaning you have to think and make decisions. The answers for psychiatry are not on some chart with milliliters, pounds or inches. A computer will never do psychiatry. You have to take all the information and data and combine it in your own mind to come out with a diagnosis, a good guess and a treatment plan. The intensive mind work necessary can be fatiguing. I live in a semi-rural area. Our city is growing fast but the population is still only 50,000. I work with the local hospital and also have a private practice. In the morning I do my hospital rounds. I see those new admits who have what appear to be severe mental problems. They may have attempted suicide, have delusions or have disorganized thought processes. They may not know who they are or where they are. One drawback is you really
see the underside of life. You encounter tragic situations and that can be draining. I also am active in our professional organizations and I go to the national conferences. This field is wide open now. There is a shortage of psychiatrists. I would recommend students pursue activities which will let them know if they really are fascinated by human nature. Any activity where you have in depth conversations will help. You could get some of this by tutoring or mentoring. Volunteer at a hospital, a homeless shelter, a group home, or a convalescent home. Be a camp counselor. Also read everything you can on psychology, biology and science. After hospital rounds, I see my own patients. Generally I charge anywhere from $150 to $300 per hour. This specialty is not as lucrative as some others. I would have made more money if I did become a surgeon. But then in this job, I am always eager to go to work and see what each day brings. I work with thought problems, relationships, addiction problems, depression, schizophrenia, anxiety, and the variation is endless. As a doctor, I can prescribe medicines. There are now wonderful new medicines which are very effective and do not have the toxic side effects like the old medicines. This is a very exciting time in this field. I would recommend psychiatry as a career to anyone who is fascinated by human behavior, loves a challenge, and sees complexity as a positive attribute.”
I Work With Children and Adolescents “I came from a small town in the
South. I was the local nerd and graduated from high school early at the age of 16. Then I went to the local community college. There were several doctors in our family but my family thought I should be a ‘real doctor’ instead of a psychiatrist. I was the first woman in our family to become a doctor. Anyway, my high school counselor encouraged me to go to pharmacy school instead of medical school. I finished pharmacy school, did that for one year and then applied and went to medical school.
I decided on psychiatry because I was curious. I wanted to know more. The pediatricians prescribed medicine and that was it. I wanted to know about the variables behind the illness. I wanted to have time to explore what was going on. I also got MS or multiple sclerosis while I was in medical school and I was encouraged to quit right there. A wonderful neurologist encouraged me to stay. My MS is now in remission and I am doing great. I certainly have had some barriers to climb over to get to where I am now. I have had a blast. I love going to work each day. I work with children and adolescents, and my patients are young and lively, not dying. My husband is a neurologist and he comes home depressed about a patient dying. I don’t have to deal with that. I work in a residential treatment facility for children and adolescents. I worked at another one before but I felt like I was a prescription pad. Just prescribe medicines more and more. Here I have a huge influence on the patients. I do medication reviews daily. I am responsible for 32 patients, 16 are in day treatment and 16 are residential. I lead groups on anything from grief and loss to anger management. We have treatment teams, case reviews, staff meetings, and medical staff meetings, so I have one or two meetings per day. We always review major incidents, occasional fights and keep closely in touch. If I change a medication I need to talk to the patient, and the nurse. I love the multidisciplinary approach. We work with the schools, with occupational therapists, physical therapists, the cottage parents. Working in a residential treatment center does not pay as well as some private practices. Psychiatrists here earn between $100,000 and $150,000 a year. But I have a very rich professional life. For young people, I would recommend getting involved with helping people. The Y has mentor programs, or be a Candy Striper in a hospital, work with children at the Boys and Girls Clubs, or volunteer at a clinic with kids. Learn about social issues and what affects families and children. Volunteer at Planned Parenthood or with the Special Olympics. Just get involved intensely with people and see if it is your thing. If you want to know about people, you
enjoy being a helper, and you are curious about human nature, this is a great field. There is a tremendous shortage of child and adolescent psychiatrists, so the field is wide open.”
Financial Aid Made My Career Possible “If I hadn’t received financial aid, I never
would have made it through school. I had financial help and grants for my undergraduate work, then my master’s degree and in medical school. My parents weren’t poor, but they certainly could not afford the quality of schools I attended. My field is forensic psychiatry. I am head of my own organization. We specialize in psychiatric consultations. A good forensic psychiatrist is also a good clinician. We have the same type of interview and evaluation process, just forensic psychiatrists are involved in cases which are connected to the legal system at some point. I see patients, examine their medical records, and make recommendations. Sometimes I have to testify in court. If you have to testify in court you have to have a good appearance, and be able to communicate with the judge and jury in a clear, understandable manner. Just the physical characteristics of the psychiatrist may make the difference with a jury. In other words, while you can get away with a great degree of individualism and a bit of eccentricity in private practice, when you work with the courts and legal system, you pretty much have to be on the straight and narrow. Men wearing earrings, ponytails, and tie dye shirts just aren’t going to be effective. Being knowledgeable about our society and culture is an absolute must for this type of work. A psychiatrist who doesn’t understand different cultures can easily offend or misinterpret behaviors. Most psychiatrists do a combination of things. You don’t limit yourself to forensic psychiatry or any other specialty and do just that. While the work with my firm is full time now, over the years I have taught in medical school and am very proud that I received a Teacher of the Year Award. I have evaluated NGRI’s – those found Not Guilty by Reason of Insanity. I worked in a large prison in
Texas. I also worked with the Veterans Hospital, provided emergency psychiatric evaluations at another hospital and provided psychiatric services for the elderly in nursing homes. So I have done a lot of different things. Some were for practical purposes, in order words, income. Most have been related to forensics at some level, and all have combined to build my career as a forensic psychiatrist. This is a career that suits me well. I still love it and find it fascinating. I would suggest to someone who wants to enter this specialty, that you must be very good at what you do. Some psychiatrists whose case loads have been impacted negatively by managed health care, are now spreading out to include forensic psychiatry. Some are good; some aren’t. But there is increased competition in the field. And with all the TV shows featuring an enhanced picture of this field, I expect more and more people will be interested in it. So if you want to do this, you can, but there will be more competition than in other specialties.”
PERSONAL QUALIFICATIONS REQUIRED
BE COM ING A PSY CHI ATRIST IS A TWO-PART SE RIES. FIRST YOU BE COME A
medical doctor, and then you complete a residency in psychiatry. All those who enter medical school have to be bright and have the personal ability to work hard and endure long hours to reach the goal. But the specialties require unique and specific qualities. The anesthesiologist or dermatologist needs different qualities from the psychiatrist. The pathologist and surgeon are again very specific personality types. While you can say all medical doctors are smart, you can’t say all medical doctors have the qualities to be good psychiatrists. Here are some specific traits that may make for success:
Curiosity A good psychiatrist finds people to be puzzles to be solved. There is a delight and infinite curiosity about the wide range of human behavior. The psychiatrist wants to know the “why” of behavior. The complexity of behavior is a challenge. What variables caused this person to act in this way? That is the question which consistently pops up for the psychiatrist. The psychiatrist lives comfortably with ambiguity. At times, treatment is more of an art than a science. Human behavior doesn’t always fit in tidy categories and there needs to be acceptance of the gray areas which still exist. Compassion and Caring Some other medical specialties can get away with coldness, and a lack of caring, the psychiatrist can’t. Caring and concern about human beings are mandatory. Depending on the subspecialty, these patients can be the homeless and mentally ill who live on the streets, a serial killer, a teenager who can’t control his rage, or an elderly and cantankerous lady. Along with this is the genuine desire to help others. Patience It takes patience, long hours, and sometimes years to elicit important information and experiences from an individual. Delving into the self, and facing repressed feelings or experiences can’t be pushed or accelerated. Life-long problems cannot be solved in an hour. Psychiatrists must be comfortable with allowing patients to
proceed forward at a pace which is good for that patient and not feel the need to rush the process. Communication and Social Skills All subspecialties of psychiatry require good communication skills. The psychiatrist must be able to communicate clearly and accurately with the patients, the families or guardians, and other involved professionals and staff. The forensic psychiatrist is communicating with law enforcement, judges, and juries. The child and adolescent psychiatrist must communicate with children, adolescents and families. The geriatric specialist must talk with elderly patients and their caregivers. The addiction specialist is communicating with another specific part of the population. The clinical psychiatrist may see patients from any of the groups. Good communication and social skills are necessary for all these doctors. Psychiatrists must also be alert and able to read body language. Body cues can many times be a more valid indicator of mood, or behavior than words. Body language is an important source of information for the psychiatrist. Psychiatrists must have good intellectual abilities. But they also need to have all the “C” words: curiosity, compassion, caring, and communication skills.
PSYCHIATRISTS REALLY ENJOY GOING TO WORK. THAT IS A DEFINITE PLUS. THEY
get up eager to face another day. This field is never boring. Individuals are unique and each personal story is different. Anticipating another work day with a sense of excitement is a very attractive feature of this field. Those who have worked 20 or more years still have that sense of eagerness. This is a cognitive field which means it takes a lot of hard intellectual work. It is not rote or mechanical. Each new human challenge involves the psychiatrist eliciting as much information as possible and then using both sides of the brain to come to a tentative conclusion. This process is exciting for those who practice. Psychiatry is also now on the cutting edge of science. As research uncovers more about the chemistry and neurotransmitters, new information is gained on the connection between the mind and the body. There are now new medications which can help those who couldn’t be helped even a few years ago. It is exciting to see those who would have been confined to mental institutions get medicine which allows them to function in the real world. Rapid advancement brings many more options to those who suffer from mental illness. The psychiatrist who practices now realizes how the field has expanded and finds it all energizing. This is not a stagnant area but one which is rapidly evolving and changing which makes it more interesting and lively for practitioners. Psychiatry does not pay as well as some other medical fields but earnings are excellent. Since there is a need for more psychiatrists there is security that jobs will be available for the foreseeable future. There is tremendous variety in this field. Psychiatrists help everyone from young people to elderly people. They help those who are addicted, depressed, bipolar, suffering from phobias, or just plain suffering. Psychiatrists can work in a private practice, work for hospitals or HMOs, work in government agencies, teach, write, consult and the list goes on. There is just a tremendous latitude and choice of what to do with training in this field. Imagine the gratification obtained from helping others. To help someone recover from or conquer personal challenges is very rewarding.
THERE IS A DARKER SIDE TO THIS OCCUPATION. LIKE ALL OCCUPATIONS, THERE
are some negative features. Psychiatrists see the worst of people. They encounter the underside of life. They are asked to help in horrible, tragic situations. This can be emotionally draining and physically exhausting. Hopefully there are positive situations to balance out the negative ones, but especially if one is working with a population as in corrections, one can get a very biased view of humanity. Listening intently to dozens of persons with problems daily can be fatiguing and is quite simply stressful. Add to this, the fact that psychiatrists can receive threats of harm or physical violence from patients, and you have some negative factors to be considered in this field. To put this in perspective, in our violent world, teachers, lawyers, social workers and many others receive death threats from those they work with. Managed care has also had an effect on this part of medicine. Managed care means that insurance of the health organization decides how many sessions should be reimbursed for a specific diagnosis. Whereas the psychiatrist may feel that 12 sessions are reasonable for the patient, the managed care organization decides on three or five sessions. The psychiatrist feels a loss of control over the situation. Some organizations put pressure on psychiatrists to use medications over therapy as treatment. As one psychiatrist said, “I felt like I was a prescription pad.” The managed care problems extend throughout the medical profession, it is not only psychiatrists who feel these demands. For psychiatrists, all the types of paperwork and record keeping are real negatives. Whether one is working in a hospital, residential treatment center or private practice there is a lot of record keeping. Medical charts must be complete. If the psychiatrist is in private practice, there are insurance forms to complete for reimbursement. In private practice, like any other business, there is the rent to be paid, maybe a receptionist, or a bookkeeper, computer systems, and all the other parts of a small business to be taken care of. Psychiatrists are very satisfied with what they do, but the reality is that dealing with individuals in dire situations can be exhausting. It takes a lot from the self. It takes a special person to be able and want to give this much to others.
EDUCATION AND TRAINING
THE TRAINING AND EDUCATION REQUIRED TO BE A PSYCHIATRIST IS LENGTHY AND
arduous. After the bachelor’s degree it can take up to 10 years of medical and psychiatric education to become certified in a subspecialty of psychiatry like child and adolescence, or forensic psychiatry. It is really a personal choice which has to be carefully thought about. If you go into medical school straight from your undergraduate work, you won’t be ready for your first real job until at least your early 30s. Medical school for this many years is also expensive. The average doctor starts practice with about $90,000 worth of government loans to pay off. This field takes a time and monetary commitment beyond most occupations. While there are some programs where you can complete three years of college and apply to medical school, most students complete the standard four-year bachelor’s degree. There is no required pre-med major. Students are admitted to medical school with majors ranging from engineering to anthropology. However, there are pre-med courses which must be taken regardless of major. Most medical schools require one year of biology, one year each of organic and inorganic chemistry with lab, one year of English, and sometimes calculus and biochemistry. To have a good chance of being accepted in a medical school, students generally must have a grade point average of 3.5 to 4.0. The average of those accepted in one recent year was 3.6. Besides good grades, most medical schools require prospective students to take the MCAT or Medical College Admission Test. The test includes physical and biological sciences, verbal reasoning and essay writing. Most medical schools require a combination of personal interview, essays, and recommendations. Some include assessment of character, personality, leadership and extracurricular activities. Students apply to many medical schools just in case. There are 125 medical schools in the United States. Medical school requires four years after graduation from college. The first two years are like undergraduate work – they follow the classroom model. The courses include anatomy, physiology, histology, biochemistry, embryology, pathology, pharmacology, microbiology and immunology.
After the first two years, medical students take the first part of the US Medical Licensing Exam. They take another part of the exam in their last year of medical school, and yet another part during residency. Beginning with the class of 2005 there is also a Clinical Skills Exam. During this test, students spend the day examining 10 standardized patients in a clinical setting. This test was developed because while some medical students do well on written exams their clinical skills are not at an acceptable level, and this issue is now being addressed. During the last two years of medical school students rotate through areas such as psychiatry, neurology, emergency medicine, pediatrics and so on. By the fourth year the students must select their specialty, such as psychiatry. For psychiatry, after medical school, the student must take one year of general medical practice in an approved residency program. Then there are two or three years of supervised residency in general psychiatry. Then, if the student wants certification in any of the subspecialties such as child and adolescent, addiction, or forensic psychiatry, additional years of training are required. The residency portion of training is when medical students really start working with patients. This training in the particular specialty includes doing the rounds to check on patients. A group of students with a supervising doctor or resident does the rounds and exchanges suggestions and information. Students still attend lectures. And they now do physical exams and hospital admissions. If residents are on call, they stay at the hospital overnight to take care of patients. For the psychiatrist this would include emergency admissions, suicides, psychiatric cases. During the residency, students are finally paid for their work. There are still more tests to be passed. All states require doctors to pass a licensing exam. Each state is different but some have reciprocity. After completion of residency, students can take more exams to become certified in general psychiatry, and after more training there are certification tests for the subspecialties like forensic, geriatric and so on. The certification exams include both a written exam and oral questions posed by a board of psychiatrists. The training is extensive and expensive, but if you are a person interested in the inner workings of the human mind, it’s not too high an entrance fee.
WHAT PSYCHIATRISTS EARN DEPENDS ON THE TYPE OF PRACTICE, HOW MANY
hours they work, the region or location, and whether it is private practice or a public or private institution. Psychiatrists earn on average about $150,000 annually, which is similar to primary physicians or pediatricians. The average for all physicians is about $200,000. The top earnings for a psychiatrist would be unlimited. A psychiatrist with a lucrative practice in New York or Beverly Hills charging $300 or more an hour would make a tremendous amount of money. Psychiatrists who work in residential facilities make $100,000 to $150,000 a year. A psychiatrist who works for the state of New York will make up to $125,000. The psychiatrist who works with the Foreign Service earns about $75,000 to $85,000 but gets to live in a foreign land and receives other excellent benefits. A psychiatrist who lives and works in South Dakota will earn under $120,000. There is a wide range of earnings for psychiatrists. A psychiatrist who works with an HMO, hospital, or in government entities would also receive medical, retirement benefits and paid vacations which can amount to several thousands in benefits. Private practitioners must pay for their own benefits and when they aren’t working, they aren’t earning. When considering salaries, also consider the cost of living in the specific area. Most psychiatrists are in larger population areas. While the New York psychiatrist makes more money than one in Sioux Falls, the cost of living in New York will eat up most of the difference. Psychiatrists do have the options to put together several jobs to increase their income. Psychiatrists at a facility can do private practice at night, or teach. Psychiatrists in private practice can work part time at a treatment center. Another may have the private practice but be a consultant to the local hospital. There is a lot of leeway to putting together a combination of assignments to increase compensation. Psychiatrists after a number of years may go into management, such as the director of a treatment center, and this would increase earnings. Many positions for psychiatrists have gone unfilled in the past couple of years, so unless the shortage disappears, psychiatrists will have some bargaining power over their salaries in the future.
Those who go into this field do not generally consider monetary compensation as the primary factor. Instead, it’s connection with their patients, the in depth complex nature of the therapeutic relationship, the gratification from helping others, and satisfying their own needs for knowing. The overall average compensation is more than sufficient to raise a family or have a satisfactory lifestyle. This is still a well-paying occupation. It just is not as lucrative as some other medical specialties.
GROWTH IN THIS OCCUPATION WILL BE ABOUT AVERAGE FOR THE NEXT COUPLE OF
decades. But that overall statement is really too simplistic to reflect the reality of this occupation. Psychiatrists of today and those of the future are being impacted by two competing variables. On the negative side, managed care has impacted all those who work in medicine or give therapy. Not just psychiatrists but psychologists and family counselors have been affected negatively by the limitations on sessions of therapy dictated by managed care or the insurance industry. Some find they must diversify their activities to keep their level of income stable. More and more psychiatrists are working in hospitals or treatment centers where the compensation is stable and secure, rather than private practice situations. On the positive side, as the boomer generation hits retirement age, the entire field of geriatric psychiatry is rapidly expanding. This specialty did not even exist a decade ago. The rapidly increasing elderly population has issues of retirement, health, and mortality which were never dealt with before. This has created a need for geriatric psychiatrists. Since most psychiatrists are located in urban areas, there is a severe shortage of psychiatric services in rural areas. If a psychiatrist does not limit employment to the cities, there is a great need to be filled in those areas. In the subspecialty of child and adolescent psychiatry, experts predict that by 2020 some 12,000 more psychiatrists will be needed to meet demand, but if funding and recruitment remain the same only about 8,000 more will be trained. More than 20% of child and
adolescent psychiatry residencies were unfilled in one recent year. This subspecialty needs more doctors. After spending so many years in medical training, and incurring large educational debts, many doctors feel they need to pursue other medical specialties which are higher paying. Also families sometimes pressure the student to be a “real” doctor, meaning surgeon or primary physician. This has led to fewer students specializing in psychiatry. The mental illnesses are just as great, the population is growing, there will always be a need for psychiatrists. The need will be greatest for specialties like child and adolescent, and geriatric psychiatrists. And the need will be greatest in areas or regions which have not been served, or served adequately. For those who want to work in this field, and are flexible enough to relocate or investigate some nontraditional career paths, there will be many opportunities available for a long time to come. Mental illnesses and personal crises are not going to disappear anytime soon.
IT TAKES MANY YEARS TO BECOME A PSYCHIATRIST. IT WILL TAKE EVEN MORE
years to establish yourself in this field. By the time you are in your residency, you will have some idea of what your long term goal is. Like any career, there is a career path to be traveled. Your first step will be to secure a job to give you more experience, to establish yourself, and to develop contacts and a professional identity. The traditional psychiatrist shown on television or in the movies has an established private practice. Actually this is not very realistic. Fewer psychiatrists are going into private practice because of the managed care issue. You rarely start out in private practice today. Most start working in a clinic, treatment center, or other full-time employment. The position may create referrals for private practice, and a private practice may be started in the evenings while maintaining a full-time position. A private practice is actually a small business. It involves advertising, or networking, or even giving free seminars or speeches to become known in the area. There is office rent, employees, insurance, and furnishing the office. If you are considering this option, talk to clinicians in private practice about how they started out and what they would recommend. Read books on establishing a private practice, and business startup books. Do your homework before you start on this path.
More than likely you will start out working for a hospital or other organization. In order to get your first position, get your job hunting papers in order. You will need a résumé or need to update your résumé. Help can be obtained at your school’s career center. You need to have a file established in your career placement center which has your résumé, and up to date references. This can then be sent to any place where you want to apply. Your school’s career center can also help you with job openings. Make a list of references. Inform those who may be contacted. Now you have your tools ready for the job search. In this occupation your professional organizations will be your lifeline to jobs. All the professional organizations have job boards. No matter your specialty, as a psychiatrist you will need to join the American Psychiatric Association. They have student memberships and they have a job board. For subspecialties, you can join the American Academy of Child and Adolescent Psychiatry, the American Academy of Addiction Psychiatry, or the American Association for Geriatric Psychiatry. Attend their conferences before you graduate. They will have information and most often possibilities for interviews. Conferences also offer the opportunity to network, and many job opportunities still come from networking resources. Two additional resources to check out online are: www.psychiatristsjobs.com www.medhunters.com/jobs/ There are many unfilled positions in psychiatry. If you get your career information together and spend appropriate time doing your searches, you should be able to get a position which affords good compensation, good experience, and the opportunity to really do what you are trained to do.
n American Academy of Addiction Psychiatry www.aaap.org n American Academy of Child and Adolescent Psychiatry www.aacap.org n American Association of Emergency Psychiatry www.emergencysychiatry.org n American Association for Geriatric Psychiatry www.aagpgpa.org n American Board of Psychiatry and Neurology www.abpn.com n American Psychiatric Association www.psych.org n Association for Academic Psychiatry www.hsc.wvu.edu/aap/ n Association for Women Psychiatrists www.womenpsych.org n Association of Gay and Lesbian Psychiatrists www.aglb.org n Society of Biological Psychiatry www.sobp.org
n American Journal of Psychiatry n Journal of the American Academy of Child and Adolescent Psychiatry www.jaacap.com n Nature www.nature.com n Psychiatric News http://pn.psychiatryonline.org n Science www.sciencemag.org
n Association of American Medical Colleges www.aamc.org n Medical School Links www-net.com/univ/list/medical.html n National Institute of Mental Health www.nimh.nih.gov n U.S. Medical Licensing Exam www.usmle.org
COYRIGHT 2007 Institute For Career Research CHICAGO CAREERS INTERNET DATABASE www.careers-internet.org
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