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Early Career Issues

Still Searching After All These Years

By Vivian Chern Shnaidman, M.D.

This May marks the 10th anniversary of my graduation from medical school. As far as I know, my class has planned no reunion parties, celebrations, dinners. We dreamed of being doctors, and now we are. Our achievements should be rewards in themselves.

Ten years after graduation might seem like a long time to wait to write about being an early career psychiatrist. Five years after the end of training is the criterion we must meet to remain in the club. I made it just under the wire. My career path took a few detours, with a year off spent moonlighting during residency, and another year spent working between residency and fellowship. So I can say that it has been only three years since I finished my training and not feel too disappointed at what I haven't accomplished.

I feel nothing like an early career psychiatrist. I feel like I've worked enough to qualify for retirement. In the less than three years since I finished my fellowship in forensic psychiatry, I have worked in six settings, 12 if each clinic and nursing home is counted separately.

I started a private practice with an initial investment of $5,000 and gave up in disgust after less than two years, $20,000 in debt. During that time, I bought a house, had a baby, and took a good look at what I really wanted out of life. My inner search led me to a salaried academic position, with an hour-long commute, less than ideal working conditions, and low salary. My dream of being the most sought-after forensic psychiatrist in my state will have to wait. In spite of the quality of my work, the quality of my life suffered immensely when I tried being my own boss. And I finally understand why.

Nobody wants to pity a psychiatrist. In my state, it became obvious that nobody wants to pay for treatment or for forensic evaluations. An eight-page report is denigrated by the mother of the defendant in the case as "a stupid letter," unworthy of reimbursement, even after it got her son two years of parole instead of a mandatory five- to 20-year sentence. A battered woman with county Medicaid wants weekly psychotherapy, to which she routinely brings a cup of designer coffee at three bucks a pop, but isn't willing to pay her psychiatrist a dime, or even pay her the courtesy of calling if she needs to cancel.

When I started my psychiatry residency in 1989, after a med-peds internship, psychotherapy was "in" and Prozac had just been introduced. In the past nine years managed care has taken over not just how we are paid, but how our patients view us. Today we are expected to treat patients suffering from psychiatric problems quickly, cheaply, and without too much follow-up. Initially, insurance companies told consumers that psychiatrists were tricking them by seeing them weekly, or even more frequently, for psychotherapy. Over time, patients bought into the myth. Now patients have become demanding, entitled, and unappreciative.

I always wanted an academic affiliation, but I wanted to be my own boss. In the years since I left my first residency program, I have amassed enough experience to fill a five-page resume with moonlighting and part-time jobs, which were meant to support me until I could establish the career I wanted, only to find the career I wanted doesn't exist. I thought I could teach residents and medical students, write a few review articles, and see a few patients. I would win the recognition of more and more attorneys, who would send me more and more forensic cases to evaluate. I could wear nice clothes and go to all the events at my children's school. I would have flexibility-the dream of every working woman in the 1990's.

I tried. Maybe I'm just not a good businesswoman, or maybe I chose the wrong community for my efforts. But in these three years I learned that my plan wouldn't work. During residency, I was trained to treat psychiatric patients of every imaginable type. During fellowship I learned, among other things, how to evaluate the criminally insane for court purposes. In college, I learned how to do theoretical research and write a decent paper. All the bricks for my house are there, but building the house has proven to be impossible.

I don't know if I tried too much too soon or some personal characteristic stymied my best efforts. But I do know that I want to work, and somewhere in the profession I will find my niche.

I've been disappointed by these early years, but I'm encouraged by the fact that it's still early enough in my career that I could qualify to write this column. My outlook has changed rapidly since I finished training. My education continues. I remain confident that all the work I've done in my life so far has been for some greater goal, even if the specific characteristics of the goal keep shifting.

I realize that I am still in my early psychiatric career, and that I have the potential to shape the career that I want. It does not have to happen overnight. My rush to succeed led to early disappointment. Fortunately I still have the ability to make amends, changes, and plans. They just might not be the ones I anticipated when I got my diploma that sunny day 10 years ago.