6 Ways for Psychiatry Residents to Find Their Niche

When Dr Howard Forman invited me to write an essay for the Masters Series, he sent me the first contribution in the series, “Twenty Meditations For Residents,” by Drs James Knoll, IV, and James Knoll, III, as an example. My initial response was to wonder what I could possibly add to the Knolls’ masterful list. I agreed with everything they said. Therefore, my first recommendation to residents is to reread the first article in this series, and take it very seriously. It is a wonderful list.

I must admit that I did not follow the same track to an illustrious academic career, as did other Masters Series authors. I admire their achievements, and I read their journal articles voraciously-but I never attempted that feat. Going by statistics, I predict that most residents will also go in other directions.

Although I have enjoyed peripheral roles as an Assistant Clinical Professor at Albert Einstein College of Medicine and elsewhere and genuinely delight in mentoring residents and teaching medical students, I do not have an “authentic” academic career. My “claim to fame,” so to speak, is as an author of “atypical” (aka non-clinical) books that revolve around psychiatry and cinema; psychiatry and superheroes; and psychiatry and the arts and religion.

My most recent book is about Cinema’s Sinister Psychiatrists. It was in “previews” for 5 years, and was presented in workshop form at the APA Institute of Psychiatric Services.

My first book, Dreams in Myth, Medicine, and Movies, evolved out of several years of online classes that I taught at a local college, at the inception of the Internet era. Those classes had catchy names, such as “Different Approaches to Dreams;” “Meanings of Madness;” and “Insanity, Psychiatry, and Society.” Those topics attracted university students, but not medical students. Since then, the concept of “medical humanities” was coined, and the marriage of medical science and humanistic studies is now celebrated.

During that time, my private practice began to attract patients who were not necessarily wealthy or famous. Instead, they were interesting, creative people who believed that they could benefit from treatment with a psychiatrist who knew something extra about their college majors or their chosen careers. Even when appointment times became shorter in duration and psychopharmacology grew more and more prominent, having this self-selected patient population made psychiatric practice a rich experience to me.

There are a few morals to this story, as outlined by the following recommendations:

1. Find your niche. That niche may not necessarily be the same one that your supervisor or your first employer or your parents think you should pursue, but it will be yours. Choosing a position simply because it is safe and guarantees continuing employment opportunities may simply result in years of unfulfilling and frustrating work.

2. Distinguish yourself from the next doctor. Almost any psychiatrist can prescribe Prozac, or whatever the drug du jour is. Instead, seek a position that is uniquely “you.” If you are lucky, you will find a like-minded mentor, often by accident, maybe by synchronicity.

3. Carve out a career in an area that interests you. Responsibilities for some people, especially for those who rise high in academia, will revolve around clinical care or bench research. If you’re drawn to specialized topics, such as atypical bipolar disorder, club drugs, glutamate transporters, or genetic links to autism-and if you’re intrigued enough to work long hours on such projects without being paid well or paid at all-then pursue those avenues. You owe it to yourself and to society to fulfill your destiny.

4. Develop activities beyond medicine and psychiatry. Psychiatry is remarkably versatile when it comes to blending with other pursuits. Perhaps you are as enthusiastic about sports, antique cars, horses, international politics, or religion, as you are about psychiatry. By cultivating those extracurricular activities and linking them to psychiatry, you can develop your niche, and have fun in the process. There is a “psychiatric angle” to just about anything, and people with specialized interests will seek out a psychiatrist who understands their interests. Often, writing a short article or blog can reach those people.

5. Read, write, or teach. For me, writing on topics I am interested in is not only fun, but also it is also relaxing, especially after a challenging day of seeing patients. Of course, writing books is not like writing letters home from summer camp. It requires time, effort, and dedication. Luckily, research has become exponentially easier because of the Internet.

In my case, writing allows guilt-free time to contemplate a character’s psychopathology and the cultural context, albeit in a fictional setting. There is no need to worry about how to fix the character’s problems or about adverse effects of medications that you did not prescribe. I don’t have to wonder if I should (or should not) follow Tarasoff’s Duty to Warn and inform the intended victim.

6. Remain flexible. Avoid the temptation to scoff at new ideas. One never knows how the world will change-or how your situation will change. Ambulation problems might develop in the energetic consultation-liaison psychiatrist, who might switch to a more sedentary subspecialty. The dedicated emergency psychiatrist who relishes unexpected occurrences and unscheduled events may find himself coping with a child with special needs at some time in the future. That physician may decide that his family is more compelling than exciting cases seen on rotating shifts. Your spouse may win a coveted professorship in a distant locale that needs psychiatric generalists more than child subspecialists, even though you just completed your own coveted child psychiatry or forensic fellowship.

Conclusion
The good news is that there are many ways to practice psychiatry today, and there will probably be even more ways in the future. Mental illness, with all of its many manifestations, is unlikely to disappear any time soon. The bad news is that we do not know exactly what is in store at this time, because mental health care delivery systems and mental health care staffing are undergoing tumultuous changes. The extra-good news is that psychiatry is too culturally sensitive to be off-shored (like radiology or pathology), and robots-like the ones that perform surgery remotely-cannot replace psychiatrists. In effect, psychiatric residents may face fewer challenges in the near future than some of our medical colleagues who once seemed to be so secure, even though the trend to expand prescribing privileges to non-physicians increases uncertainty.

Today, more psychiatrists are employed than self-employed. The lucky ones find jobs that are next to Nirvana, but many find themselves frustrated because they feel they have no control over their work setting. That is when your special niche holds even more meaning-and when cultivating out-of-work interests can carry you through a difficult day.