What's It Like Being a Pediatric Psychiatrist?

How Dr. Brooke Weindarden introduces her career to new friends can alter the course of a conversation. "I usually try to stick with 'pediatric psychiatry,' because it reminds people that it’s more of a medical subspecialty," the Michigan-based doctor told ValuePenguin. "Because when I say 'child psychiatry,' people then get confused with psychology, and I get a lot of, 'Whoa, that’s intense.'" While her work is often of the serious nature, there's a lot more to it. We asked her to break it down for us.

This interview was condensed for clarity. To contribute to ValuePenguin’s coverage on careers, follow us on Twitter @VP_Careers.

Are there a lot of misconceptions about psychiatrists?

The biggest misconception is just what we do. I think a lot of people — and I remember even when I was growing up — didn’t know the difference between a psychiatrist and a psychologist, and still didn’t understand that a psychiatrist was a physician, somebody that went to medical school. So it’s confusing; they feel as though I’m just a person that is providing medication, and sees them for X amount of time.

Now, versus when I was growing up, it’s more well-understood; and maybe it’s because the stigma is somewhat less, and people are a lot more open to discuss mental illness in general. It’s not as hush-hush of an issue.

Still, every day, I get patients that come in and I have to explain to them, “This is what I am, and this is what I do, and this is how the clinic works. A therapist does something different, and let’s talk about how that adds to the big picture." It’s very similar to if you went to an orthopedist for a surgery on your leg, or something musculoskeletal, and they treated one particular thing, but then still recommended physical therapy, which is equally important, but works in a different way to achieve the same thing.”

Brooke Weingarden

As for your own career path, why psychiatry?

Originally, I wanted to do pediatrics. My dad’s a pediatrician; I have many physicians in the family, I have an uncle who’s in neurology. I was discouraged from pediatrics because it’s a very difficult specialty, and it’s somewhat thankless in a lot of ways. They work very, very hard. It’s very different than it used to be. I was encouraged to sub-specialize if I wanted to pursue something in pediatrics.

Psychiatry was always something that I felt that -- I don’t know that I’d say I understood it -- but it was like the elephant in the room in every single specialty, but nobody really addressed it. I wanted to be able to focus on this one thing that could really make such an impact on people. I felt that it was just something that I got a feel for people. While it was still practicing medicine, it was a little bit more than that. I have, certainly, family members that have suffered from different mental illnesses, which maybe made me more keyed to being in tune to that. I just thought it was such a good opportunity to really address those things that every single specialist has to deal with, but doesn’t directly address.

What was your education path like?

It was in the middle of my rotation years. As I started medical school, which was always the path that I was going on, I was planning to do pediatrics; but as I was exploring more rotations during my third and fourth year of medical school, I had done a couple of different psychiatry rotations, some inpatient, and I was encouraged to do some outpatient rotations, which really solidified my decision to go that path. It was a really good experience, especially seeing the different areas of psychiatry.

Sometimes an inpatient rotation is very different, and that was not my area of interest; but the outpatient setting really was very rewarding. I found especially with kids it was very nice to be able to provide a voice for kids that may not even know how to really express or explain the things that they’re experiencing, and really get to address that for them, and give them a voice.

When during medical school did you start to focus on psychiatry?

The way that it works in medical school: your first two years everybody is doing the same thing. You take the same basic courses, the same clinical training. Everybody is on the same path. Your third year is a year of core rotations, where everybody does internal medicine, and everybody does surgery, and orthopedics… every specialty, because they really want to expose everyone to every opportunity that there is.

Because some people are undecided of their desired field, but also they want people to have had a taste of every specialty. When I’m working in psychiatry and somebody comes in with an endocrine issue, a lot of times that can affect their psychiatric presentation a lot, so I need to have that background. So third year is something that everybody does the same. And then fourth year there’s a lot of room for electives. So if there are things that people want to try again; or if they say, “I might be interested in cardiology,” they can do an extra elective in cardiology. Or if they say, “I know that I want to do psychiatry, and I’m really wanting to go to this particular program,” they’ll try to get a couple of rotations in psychiatry in different areas at that specific hospital, to get their face seen and to get some more experience with those physicians and the teachers that are at that hospital. So usually the fourth year is when people will then take extra rotations in the field that they’re interested in. And then after they graduate, once you’ve applied to a residency program, that will be specific to the field. So, after medical school, then I applied and was accepted to my residency program. It was three years of adult psychiatry, and then a two-year fellowship after that for child and adolescent psychiatry; and that’s all psychiatry.

Is that a pretty standard path for people who want to get into pediatric psychiatry?

Yes. If you do adult psychiatry, it’s actually just a four-year residency. If you choose to expand to the child and adolescent route, then many people certainly could do the full four years, but it’s not necessary, as that fourth year is more of an elective year. So many people will then leave after the third year and start their fellowship, which is two years. Which I definitely would recommend for anyone, even if they just want to do adult psychiatry.

What was your residency experience like?

I think that any residency that somebody does is going to be difficult. It’s daunting, because we’re essentially trying to help the mechanics of a hospital. So there are long shifts in the emergency room, and there are long shifts in the in-patient hospital. And I think that while it’s hard, I enjoyed it. I found it to be very interesting, and it just fascinated me. Each year, I would see the year above me, as each year sort of teaches the year below. So the residents in the year ahead of us helped to guide us, in different classes and different clinical experiences. I would always wonder how they knew so much more than us. And then, each year, we would sort of gain that amount of knowledge.

If the program tends to work, by the end everybody gets to where they need to be. There definitely were rotations that I found to be more fun, or more interesting to me, than others. The emergency room is something that a lot of people didn’t really love, because you get a lot of acute issues where people would come in and you really have to triage what the best thing to do was. I spent a little extra time there, and I found that I had a very positive experience with it. It’s not something I’d want to do as my career path, but some people loved it. It helped me to really understand the resources in the community, and the different things, as far as guiding my own patients in my outpatient practice.

And for the child fellowship, I have to say that… I enjoyed the whole thing, although I’m somebody who enjoys even the difficult tasks. But I found it to be very educational in a way where we spent a lot of time learning about normal development, which is not focused on as much in the adult fellowship. I think that was probably the best thing that we could have learned. Learning about normal development, and all of the different physicians and psychologists who study normal development, and all of the developmental theories, really gave me a good perspective on looking at the normal child that comes in, and any child with any disorders or pathological issues, and how to put it in perspective. A lot of times, the way we treat things is going to be adjusted based on their developmental stage. It really helps to understand where they fit in their own development, and within their family structure. I think that that, specifically, is something that was an invaluable lesson that we learned. We got to spend a lot of time working in an outpatient setting, and that was great. A lot of the patients that I had in outpatient actually followed me to my practice, so that was really nice, to have that continuity.

What was your clinical experience like?

The program that I was in — I was at Henry Ford Hospital for my residency, and they had an outpatient clinic, which was a resident-run clinic. And then in fellowship we had an outpatient clinic, which was through Wayne State University, so it was the Wayne State Physician Group. So that would also be a resident/fellow-run clinic. There was an attending physician who oversees all of the residents and the fellows that are working at the clinic. At that point, since we were already graduated from our adult program, technically we were board-certified psychiatrists. They really only had to minimally monitor what we were doing; but we would touch base about different cases. It gave us an opportunity to really be seeing some very interesting and challenging cases, but have support, and have somebody to go over the cases, and make sure we’re not forgetting any vital decision-making process, or making sure we’re considering all of the important factors. There were a lot of things where one day a week everybody would see a case together, and it would be a group discussion. It was a really nice learning facility. I still refer patients; if I have any referrals that are very tough cases that have a lot of multi-factorial issues going on, a lot of times I’ll refer them back to that clinic, because I feel that they would be good learning experiences for the fellows.

Was there any point on your path where you questioned the process of becoming a psychiatrist?

The whole time I felt as though my education was very good. I was very happy with everybody that trained me, and I feel that along the way I really was learning and I was right where I needed to be. I think that going through the process of medical school and residency, probably everybody that I’ve spoken to in every field has a moment every now and then, and oftentimes as they’re nearing the end of their training, where they kind of freak out and say, “Oh my god, do I know what I’m doing? Is this really what I want to do? I’ve been doing this for 11 years now. What if this is not what I want to do?” I think everyone has kind of a moment. It’s oftentimes more having to do with the amount of time and effort; time meaning years and hours and emotional time, everything that we’ve put into it. Everybody’s afraid that, what if I made the wrong choice? But really, that passes quickly. I think it was a great choice, and a great pathway for me.

What was the process like of gaining licensure and passing your board exams?

You’re eligible to take the boards a year after you are completed with training. After I finished my fourth year of training for residency, I was then eligible to take my adult psychiatry boards. So I did that in the middle of my child fellowship. Everybody who was in the same year did that; we all took it then. It’s very regulated; everybody does it on the same day, it’s once a year. Most of us signed up for similar “beat the boards” courses, and we studied together, and that was maybe four months’ worth of really hard-core studying. And so then the year after our fourth year we took the boards that September, and then the year after we graduated, like the September after graduation from fellowship, we were able to take our child/adolescent boards, which was that same September. So then we did that “beat the boards” course that I took. We just did it. It’s very regimented; which is nice, because after all the training that we’ve done, we’re sort of used to people telling us, “This is when you’re taking this exam, and this is how you’re going to do it.” And that’s great; it works for us. You add it into your calendar, and it works nicely.

How difficult were your exams?

It’s sort of par for the course. In medical school, you take three sets of boards anyway: after your second year, after your third year, and after your fourth year. So there’s three sets of boards just to graduate and become a doctor. For each of those you spend a certain amount of months studying for that. There’s some people that studied the month before, and some people that studied longer than that. It just depends on your own personal study schedule. But certainly if you don’t pass, you can’t take it again until the next year, so everyone wants to make sure that they are getting as much time as they possibly can. It sort of kills the summer before, but that’s fine. Nobody really questions that this is particularly hard or not hard; it really is just par for the course, and you do it, and you move forward, and it’s OK.

And about getting the job you have now...

Right after I graduated — or actually, right before I graduated from my fellowship — I started at the clinic that I’m at right now. I was doing a couple of hours a week, just moonlighting there, to ease the transition and to get used to the way that they do things there. So I really went straight into it, and I filled up very quickly, because there aren’t many child and adolescent psychiatrists, so it’s very much a need. I’m there four days a week, and then one day a month I work at a boys’ residential facility in Detroit, which is also very cool. It just is something totally different, to spice things up a little bit.

At your outpatient clinic now, what’s the routine that you go through with a new patient?

Every patient is different, so it’s going to depend a lot on what their main concerns are. Similar to any medical field, you’re going to want to know their chief complaint. For me, it ranges anywhere from anxiety, behavioral issues, attentional issues, obsessive-compulsive concerns, anger, developmental issues, neurological issues, depression… very wide spectrum of things. Depending on what their chief complaint is, I’m going to explore that a little bit more. You want to first find out the history of their illness: how long things have been going on for, what associated symptoms might be going on. You really look at all the different psychiatric disorders and run through some of the gamut of criteria to rule in and out different kinds of things. Certainly in training you do it a lot more methodically, a checklist kind of way. But as you gain some more experience into presentation, you take the patient’s lead on what the different things are that they’re experiencing. And then you want to find out about their past psychiatric history. Have they been seen before? Who have they been working with? Who’s their therapist? Have they been in the hospital? Family history of psychiatric illness, and what’s worked for their family, and what’s not worked. You want to find out about medical history. Substance abuse — that’s usually a big factor for a lot of kids. You want to find out about social history, educational, any issues in school, any issues with learning, because those oftentimes will affect things. I like to spend a lot of time on developmental history, because I find that it really is important to their presentation. I like to spend a lot of time on what people enjoy doing: what their strengths are, what makes them feel happy, where they excel. And then really taking the time to look at the big picture: look at the patient as a whole, look at what they need psychologically and biologically and socially in order to help them to function at their best and to really succeed, and give them the best possible prognosis.

Then we do a little bit of education as far as diagnosis. If medication is indicated, what does that mean? What’s the family of medication? We talk a little bit about that, and I like handouts, so I like to print them out a little bit of information about the medication and diagnosis. And if they’re a younger kid, I like to observe them in their play while at the same time I’m talking with their mother, because you want to see the types of play, and the types of behavior that they’re having. How does that rank, as far as where they should be developmentally? What’s their attachment like to their parent, or guardian, or whoever they’re with? How are they behaving in an office kind of setting? What do they look like when they walk? What are their facial features? What is their voice like? Really that all is included in the mental status exam for any age. That gives us a lot of information. Just like if you were going to listen to somebody’s heart and lungs, to check them physically, we’re going to get a lot of similar types of data looking at their gaze, their eye contact, their fluency of their speech, the way that they use their thought process, and the types of content that they use in their thoughts. Are they hyper-focused on one particular thing? Are they able to reciprocate conversation? Are they touching every single thing in the entire room and rolling on the floor? It gives us a lot of information about them. A lot of times I will provide rating scales.

A lot of times, if they’ve seen a therapist ahead of time, I’ll have the therapist send me a little summary of some of their main concerns, or things that they’ve observed and they’re working on, especially somebody that’s seeing them very regularly. I like to look at report cards, I like to look at any reports from the teachers, because you want to look at things that are happening in multiple settings. If you’re only seeing a problem in the home setting, and nowhere else, that’s telling you something; if you’re seeing a problem at Girl Scouts and nowhere else, there’s something else going on. So really getting a look at the big picture of what’s happening in the entire life of the person.

Is it that problem-solving or something else about being a pediatric psychiatrist that, on a daily basis, you find especially stimulating or rewarding?

I think that it is very rewarding to be able to understand, based on non-verbal and verbal cues that a child will provide, to be able to give them words for the things that they’re trying to convey. That may be acting out, and screaming and breaking things, but really being able to help them understand where that’s coming from, and to be able to help them address it. Especially if they’re somebody that has a lot of biological and genetic loading for mental illness, and we’re addressing this at such a young age for them, they don’t have to go their entire life having to struggle with these feelings. That may affect their self-esteem, and their schooling, and their learning, and their social interactions and friends, and just their quality of life. When we can address that as a much younger age, having them come in the next time, and smile, and bring in a picture that they made, or tell you about their day. It really is very rewarding to see that they’re able to function and make friends and be happy at a much younger age, where maybe their family member that suffered with something similar may not have addressed it quite as young, or early. So really getting to address those things at the appropriate time, and seeing kids that do well, is very rewarding. And when they come in, and they’re smiling and they’re proud of themselves, and they feel good, that’s always a very rewarding thing. And really understanding, and trying to help other people understand. Getting a lot of education about psychiatry, and how psychiatry and neurology are so related, and overlap in so many areas. There will be a child that will be acting a certain way, and the family may be getting impatient or frustrated or upset, and really trying to help them understand, biologically and neurologically, the basis of where this condition is coming from, and why. If somebody has a broken leg, you’re not going to yell at them for not running on the track, because clearly you can see that they can’t do it. But when it’s something internal, it’s a lot harder to really comprehend how that works. It’s really positive to able to provide that kind of education, and really explain the organic and biological causes behind a lot of the psychiatric disorders. 

What are other challenges of being a pediatric psychiatrist?

Some of the challenges would definitely include — and this would probably be in any pediatric specialty — is that you don’t just have one person as your patient; you have the entire family. And so sometimes that’s a family that functions as a really nice family unit; sometimes that’s a family that is not a traditional family; sometimes that’s a family where the parents don’t speak to each other. Any of the different family dynamics are certainly all out on the table at that point. First of all, that can affect the presentation of the child, and can affect the treatment of the child, and consistency of compliance with medication, and compliance with therapy, and inconsistent environment. So the family, all of the different experiences and pathologies that the family may have, are then also coming into play for the child. Similarly, if there are any genetic predispositions, if mom or dad has different psychiatric illnesses, a lot of times that makes it easier for us to diagnose and treat the child. But it also may make it harder for the parent… if they’re struggling with their own disorder, it may make it harder for them to support their child. So the family dynamic is definitely a big issue. There’s also the issue in kids where a lot of disorders, or a lot of diagnoses, present similarly. Like, attentional issues. If someone comes in and they’re having trouble with attention and focus, that could be attention deficit disorder, that could be an anxiety disorder, that could be a depressive disorder, that could be a learning disorder. Or, that could be something particular happening at home that happens to be on their mind, some sort of an adjustment reaction, or something that’s purely psychological. Or maybe they’re having trouble seeing, their glasses need to be adjusted. Or hearing. There’s a number of different things that can contribute to a basic symptom, like attention and focus. To really weed out all those different possibilities, and get a lot of collaborative information and really investigate, is important.

It sounds like challenging work that you have to engross yourself in, at least to do it well. How do you get away from it all once in a while?

Most physicians in any field find that they have to learn real early on to compartmentalize. Certainly at first it’s much harder, and it’s something that you have to learn as you go through all the years of training, to pull yourself back a little bit. Because otherwise it would really be all-consuming, and there are so many intensely emotional cases, and so many sad, overwhelming things that we’re dealing with, that it really could consume you. And certainly that does happen to some people. But really, it’s so important to learn to compartmentalize, and to be in the moment there, and be supportive there, without letting it completely take you over. And I think that a lot of that has to do with experience, and I think just when they immerse you at first in the hospital, with the most acute cases — in any field, really, the most acute and the saddest and the most difficult cases — on the one hand they’re good learning experiences, but I think emotionally, also, to some extent… they don’t really desensitize you, but they help you to be able to be empathetic, but also compartmentalize it a little bit. And I think at the beginning everybody comes home and takes it home with you, and it’s difficult.

To me that’s why I chose outpatient, because it was slightly less intense. But you still get very difficult cases, and you think about them sometimes, but you have to find things that help you to change your focus. For some people, they stay at work, and when they’re done with work, they don’t bring anything home with them; they just finish their charting and then they leave. I like to exercise; I like to do yoga and ride my bike, and some days I like to finish with enough time to pick my daughter up from school, and do mom stuff, and take her to dance, and immerse myself in some of those things. Having to change focus is always a positive thing. But I really think experience helps people to compartmentalize, and that’s the most important thing that people have to learn to do. And it doesn’t mean being insensitive; because certainly we care very much, and we want to be empathic, and we want to be supportive, and we truly care about the wellbeing of our patients. But we also have to focus on self-care as well.

Is there any advice you would give your younger self?

I think that it’s just important to remember that it’s OK to ask for help. I do have a partner that works in my office, and he has been in the field for many more years than I have. If I have a case that’s particularly difficult, I’ll run it by him. On the opposite, he’ll come to me, and say, “I just had this case, what are your thoughts about it?” I think it’s so important to have peer collaboration, and to be involved in different peer groups, where people can bounce off ideas. Then you feel like you’re not alone in that, and you remember that sometimes cases are hard, and it’s good to have outside perspective. And it doesn’t mean you don’t know the material, it just means it’s good to have external support. Peer support, I think, is vital. Having a mentor, at least at the beginning, to run things by and to gain confidence. And continued education: it’s certainly required, but it’s also very good in peer networking, but also just being up on whatever the new medications are, and the new studies and practices. I’m a member of a group on Facebook, the Physician Moms group. There’s like 50,000 members of Physician Moms. While it’s not something that’s very clinical, because of HIPAA regulations, but it’s a very nice support group for physicians that are also moms. Just to say, “I had a caseload, and then I took my kid to do this and this and this, and I totally forgot to pack their lunch.” It’s an amazing group of women. Having external support, I think, is huge. Not many people truly understand the pathway to get to the point that we are, and even the types of careers, and the things that we do, unless you’ve been there.

Ting is a ValuePenguin Co-Founder. She previously evaluated corporate mergers and acquisitions as a Financial Analyst at Citigroup.