SS 18 : A Look at Private-Practice Child and Adolescent Psychiatry

Session 18

If you're a medical student, we are about to launch a new podcast called Board Rounds Podcast, where we focus on the USMLE and COMLEX Step 1 and Level 1. Check us out at MedEdMedia.com. It's going to be a co-branded podcast with MedQuest so stay tuned!

Today's guest is Dr. Jacqueline Hubbard, a private-practice Child and Adolescent Psychiatrist. Hear her thoughts on the specialty, what you can do to get involved, and see if this is something you might take interest in.

[01:55] Choosing Her Specialty

Jacqueline knew she wanted to go to medical school when she was a sophomore in college. Then in medical school, she narrowed down her choices. Having interest in both Pediatrics and Psychiatry, she ended up picking psychiatry and decided on the Child and Adolescent Fellowship.

When she was on Pediatrics, she felt like she was being rushed as she wanted to talk more to the patients instead of just doing the physical exam. She wanted to always have more time to sit down and get to know the patients on a deeper level.

Just like in Pediatrics, there is a lot of parent involvement in her specialty, education is one. She talks a lot about parenting skills, behavior modification, and positive reinforcement.

[03:22] Traits of a Good Child and Adolescent Psychiatrist

Some of the traits that lead to being a good child and adolescent psychiatrist include being a good listener, empathetic, caring about the patient and looking at the patient as a whole, patient, inquisitive, and making sure you're looking at the big picture and ruling all the other things that may not just be your specialty like vitamin deficiencies or thyroid, etc.

[04:05] Private-Practice And Patient Types

After graduating, Jacqueline took a job working at a community mental health center where she ran an in-patient unit while doing some outpatient work. They had a residency program there and knowing she wanted to teach residents and medical students, she felt rushed working at the outpatient and thought she could provide better care if she worked for a private-practice model. Consequently, she took a job doing a group private-practice and ended up leaving it because she wanted to just do it on her own and made it exactly the way she wanted or if she were the patient, it's how she would want to go in and see someone.

As a Child and Adolescent Psychiatrist, Jacqueline treats patients with ADHD, depression, anxiety, OCD, autism spectrum disorders as well as those with bipolars, oppositional defiant kids, and for substance-use. She also sees some adults for binge eating disorder.

She is actually more particular about who she takes. She sees a lot of severe anxiety, OCD, depression in adults as well as some childhood issues. Kids with autism end up being adults with autism so she finds that Child and Adolescent Psychiatrists are good providers for those types of issues since they're used to treating them.

Jacqueline is double-board certified, with a board certification in General Psychiatry and another board certification in Child and Adolescent Psychiatry. She tries to focus her practice mostly on Child and Adolescent Psychiatry because of the huge demand considering that there is not that many Child and Adolescent Psychiatrists. She further explains that there are not many fellowship spots and a lot of medical students are not exposed to it as often as they could. Where she trained at University of South Florida, they only had two spots.

A general psychiatrist can technically see child and adolescent patients, basically depending on their comfort level. However, a lot of times during the general psychiatry training, they only had a month of child psychiatry and half a day in outpatient per week so you only got limited exposure to treating kids especially when you pick up autism,, for example, which is something that is picked up most of the time in the pediatric populations so you don't really get the training and experience treating those kinds of patients as well as those with ADHD.

[08:38] A Typical Day

Jacqueline would describe her typical day as everyday being different, something she likes about her job. Because it is private practice, she can typically decide when the day starts. If she chooses to, she can see patients early and fit somebody at 7 am since she likes to come in early instead or working late. So she would start anywhere from seven to nine or ten, depending on the day and gets done by five.

For kid evaluation, she would see them for 90 minutes while for adults, she would typically give herself 75 minutes. She would also do half-hour follow ups and one-hour therapy for some patients on a more regular basis.

Having a lot of variety, she basically doesn't know what she's going to get for that day especially when she's seeing new patients, making it more interesting and fun for her.

[09:43] Follow-Up, New Patient Consults, & Therapy

For a new patient, a full clinical interview is done. If it's a child, she would sit down and talk with the family. If the parents want to talk alone and not in front of the child, she will talk with the parents and find out their concerns.

For all kids, she would try to meet with the child alone only if they're willing to or if the parents allow her to. They will then all sit down and talk together, the parents, the patient, and herself, and then come up with a treatment plan which she has written down while talking with them so they can walk away and not try to remember things. This is the typical procedure whether she's recommending a specific type of therapy or exposure and response prevention, or lab work or order, medications and supplements, or other referrals for other things like an occupational therapy or speech language referral, or neuro-psych testing. She would also try to get them to sign a release for their primary care provider. She feels that part of her job is working with an interdisciplinary team consisting of their primary care provider and any specialist. So they cover all of this and she books them for a follow-up.

For follow-up appointments, they will go over the treatment plan again and see what's been done in between appointments, if they've established with a therapist, an occupational therapist or speech therapist. They will talk about their medications and make sure they're not having side effects and find out what's been going on in between the appointments, how school is going, how family life is going. She will also refill their medications.

For therapy, Jacqueline is trained in cognitive behavior therapy, which is a therapy approved for anxiety and depression. She is also trained in exposure and response prevention, an excellent therapy for OCD and social anxiety. It involves doing exposures for kids and adults, where they are put in an anxiety-causing situation starting at the bottom of the hierarchy. This lasts for about an hour. Sometimes, they will use work books tailored for young kids for example. She basically sees therapy patients on a more regular basis, for one hour weekly or every other week. She loves getting to know the patients at a different level as well as the families as you're able to see them more often.

She also has patients that will see an outside therapist like a counselor or social worker, at which she will have the patients sign a release so they can work all together and they'll see her more for medications and managing the treatment team while they see the therapist for therapy.

[14:20] On-Call, Out-of-Network Provider, and Work-Life Balance

Jacqueline explains that the extent upon which they do calls depends on the state you're in or if you take insurance. As for her, she does not directly accept insurance but she's an out-of-network psychiatrist, which means patients can see her and they pay out of pocket to see them and they can request reimbursement from their insurance. Insurances require that you have some type of call system in place. Her policy as an out-of-network psychiatry states that if in case of emergency, they can call 911 or go to an ER. With her  practice, she does have a secure portal where patients can send in a secure email which they can do anytime so she gets messages which she encourages. She also gets calls after hours that go to voicemail, but if it's an urgent voicemail, they can press the number four and she'd be alerted that's it's an urgent voice message. However, during their first appointment, Jacqueline actually explains to her patients that she doesn't have an on-call service or emergency service after hours.

Being an out-of-network provider is common in her area, both geographically and specialty-wise, because it's easier to run the practice that way and they won't have to hire any staff so the overhead expense is a lot lower. Not having any office staff, Jacqueline basically does everything from the patient's first phone call to taking their payment.

Being her own boss, Jacqueline can say she has definitely a good work-life balance as she enjoys the flexibility of it, blocking her schedule whenever she chooses for her personal or family life.

[17:10] Residency, Fellowship. and Matching

After medical school, the General Psychiatry residency program takes four years and the Child and Adolescent Fellowship Program is an additional two years. However, most programs allow you to enter into the two-year fellowship after three years of the General Psychiatry residency, cutting out a year. Overall, it's a total of five years after medical school.

Fourth year is residency is usually a lot of electives so you're doing different rotations and you basically have gotten everything required during the first three years. Moreover, they know you're going to be doing inpatient and outpatient work and consultation work in doing the fellowship.

In terms of the competitiveness of residency matching, it varies year to year and according to where you're going. However, it's not as competitive as when you're doing plastic surgery or dermatology. However, Jacqueline found matching for fellowship to be very competitive with only two spots available and there were four of them in their class of eight that wanted to go to their fellowship program and they only applied to their program so obviously only half of them got it.

In order to stand out for Fellowship, get to know the Child Faculty if you're considering going into Child and Adolescent Psychiatry Fellowship. During her second year, they had electives and they applied during third year so her Child and Adolescent rotation was by the end of second year for which she wasn't sure of because they haven't had any exposure to it. So she scheduled her electives earlier in the year for Child and Adolescent Psychiatry to get to know the Child and Adolescent faculty in order to make sure and confirm that she really wanted to do it.

If you show an interest in it, it's important to get to know the faculty so that you can get great recommendation letters from the faculty. Jacqueline also encourages joining AACAP (American Academy of Child and Adolescent Psychiatrists), a national organization that accepts medical students for free. They hold a yearly conference where medical students can attend and residents can also participate in at discounted rates.

[21:06] MDs and DOs

Jacqueline did not see any bias towards DO's. In fact, the other Fellow she graduated with was a DO. She also thinks a lot of DO's gravitate towards Psychiatry probably because of their training where they take a holistic approach to taking cases.

[21:53] Other Subspecialty Opportunities

As a Child and Adolescent Psychiatrist, you can pursue more fellowships such as Forensic Fellowship and focus on the juvenile justice system or an Addiction Fellowship where you add an additional year. You may also choose a diagnosis that you really enjoy treating and just focus your practice on that. There are autism private-practice psychiatrists where they treat mainly autism.

[23:00] Primary Care and Other Specialties

Jacqueline believes it is important for everyone to work together. She tries to make it easy for pediatricians or IM's for them to work together. She would coordinate with them with regards to the diagnosis along with the lab work. A lot of times, primary care doctors order lab work before the psychiatrists do so if they're referring to a specific psychiatrist and the patient agrees in the office, Jacqueline thinks it would be great to have them sign a release through a little form sent over indicating the patient referral and lab work. If they're concerned about depression, it's important for them to be thinking of psychiatric diagnosis and screen for safety concerns, and if there is any, it's definitely good to have a referral relationship with the psychiatrist they trust where they can call them and run cases by them.

Specialties she works the closest with are therapists, GI doctor for stomach pains, Neurologists for headaches, but mostly primary care from a medical standpoint as well Endocrinologists and OB/GYNEs.

What she wished she knew before going into her current specialty is to have more exposure to the different areas one could practice. If she had done so, she would have explored the justice system and community mental health. She thinks it's important to be aware that where you do your training can be different elsewhere as well as to seek out mentors outside of where you train.

[27:15] Most and Least Liked Things & The Future of Child Psychiatry

Jacqueline thinks it's a great privilege to work with families and getting to know the patients and working with families and how rewarding and exciting it is to see patients get better. When you treat kids, you really get to see kids make a lot of strides and you can make a huge difference in the trajectory of their lives in general.

What she likes the least about her job is the administrative side of things compounded by the fact that she is in private practice.

In terms of the future of her specialty, it's important to stay on top of what's happening in their field with all the cool things coming out like telepsychiatry where you get to see patients remotely.

[29:22] Special Opportunities Outside of Medicine

There are opportunities to get involved with the education system especially in educating parents, as well as do talks in the community for mental health issues in general like the importance of sleep. You may also work with the school systems to educate, not only parents, but also, teachers and guidance counselors on mental health issues and advocacy issues children face.

[30:18] Final Words of Wisdom

Jacqueline says that if she had to do it all over again, she would have definitely chosen the same specialty. Lastly, Jacqueline encourages students interested in this specialty to look into it and to reach out to a Child and Adolescent Psychiatrist and learn more about it because there is a demand for this specialty so you will always have a job, not to mention the huge difference you can make in the lives of kids and young adults. Learn more about it to make sure you want to do it!

Links:

MedEdMedia Network

MedQuest

Board Rounds Podcast

AACAP (American Academy of Child and Adolescent Psychiatrists)

Transcript

Introduction

Dr. Ryan Gray: The Specialty Stories Podcast is part of the Med Ed Media network at www.MedEdMedia.com. Now you may be interested, if you're a medical student listening to this, especially an early medical student, we are about to launch a new podcast called Board Rounds where focus on the USMLE and COMLEX Step 1 and Level 1. Go check us out at www.MedEdMedia.com.
This is Specialty Stories, session number 18.

Whether you’re a premed or a medical student, you've answered the calling to become a physician. Soon you'll have to start deciding what type of medicine you will want to practice. This podcast will tell you the stories of specialists from every field to give you the information you need to make sure you make the most informed decision possible when it comes to choosing your specialty.
Now welcome to the Specialty Stories Podcast, my name is Dr. Ryan Gray, and I am the host here at this podcast as well as many others including a new one that I mentioned at the beginning, Board Rounds: Level 1 and Step 1 for your board prep needs. It's going to be a co-branded podcast with MedQuest. And yeah, I'm excited to launch that in the next couple weeks.
So today we have an awesome guest that is going to share her story and her specialty of Child and Adolescent Psychiatry. So let's go ahead and jump right in and meet Jacqueline.

Meeting Dr. Jacqueline Hubbard

Dr. Hubbard: I'm Jacqueline Hubbard, Child and Adolescent Psychiatry.

Dr. Ryan Gray: And how long have you been practicing?

Dr. Hubbard: Almost two years.

Dr. Ryan Gray: When did you know- so you're a child and adolescent trained psychiatrist. When did you know you wanted to do that for a living?

Dr. Hubbard: I knew probably sophomore year of college that I wanted to go to medical school, and then when I went to medical school I kind of narrowed down my choices and I really liked pediatrics, and I really liked psychiatry, and I ended up picking psychiatry, and then decided on the child and adolescent fellowship.

Dr. Ryan Gray: How did you- as you got to that decision point between peds and psychiatry, how did you go down the psychiatry path?

Dr. Hubbard: I felt like when I was on peds I was somewhat rushed, and I wanted to talk more to the patients instead of just doing the physical exam, and listening to the heart- I felt like I was being rushed. So I wanted to always have more time to sit down and get to know the patients on a deeper level.

Dr. Ryan Gray: Just because I love peds, and the joke is always well you're not dealing with the patients, you're dealing with the parents. I'm assuming from the psychiatry standpoint there's less parent involvement.

Dr. Hubbard: There is a lot of parent involvement. A lot of what I do is educating parents, and we talk a lot about different parenting skills, and we do a lot of behavior modification, teaching parents about positive reinforcement, so I do deal a lot with the parents just like in peds too.

Traits of a Good Child & Adolescent Psychiatrist

Dr. Ryan Gray: Okay, interesting. What traits do you think lead to being a good child and adolescent psychiatrist?

Dr. Hubbard: Someone that is a good listener, someone who's empathetic, cares a lot about the patients and looking at the patient as a whole. Someone who has a lot of patience since you do deal a lot with families. Someone who's inquisitive and making sure that you're looking at the big picture and ruling out other things that may not just be your specialty like vitamin deficiencies, or thyroid, and that kind of thing.

Dr. Ryan Gray: Okay. And you're in a private practice setting. What led you down the path into private practice?

Dr. Hubbard: After I graduated I took a job working at a community mental health center where I ran an inpatient unit and did some outpatient work, and they had a residency program there. I knew I wanted to teach residents and medical students, and I felt the outpatient was- it was fifteen minute appointments, and there was overbooking, and I felt just very rushed and like I could provide better care working for more of a private practice model. So I took a job doing a group private practice, and then I ended up leaving that and wanting to just do it on my own, and making it the way- exactly the way that I would want it, and if I were a patient, exactly kind of how I would want to go in and see someone.

Types of Patients for Child & Adolescent Psychiatry

Dr. Ryan Gray: Nice, okay. Describe what types of patients are you treating?

Dr. Hubbard: I treat ADHD, depression, a lot of anxiety, OCD, autism spectrum disorders, some bipolar, a lot of oppositional defiant kids, some substance use, and then I also see some adults for binge eating disorder.

Dr. Ryan Gray: Interesting. Why the extra adult side of things too?

Dr. Hubbard: I don't see that diagnosis as much in kids, so in adults I'm a little more particular about who I take, so I will see a lot of severe anxiety, OCD, depression in adults, as well as some childhood issues that kids with autism and being adults with autism. So I find that child and adolescent psychiatrists are good providers for those types of issues since we're used to treating them.

Dr. Ryan Gray: Interesting. So just for educational purposes, the fellowship training of child and adolescent psychiatry doesn't limit you once you're out in practice to only see child and adolescent patients?

Dr. Hubbard: No I'm double board certified so I have a board certification in general psychiatry, and then I have a board certification in child and adolescent psychiatry. My board certification number is actually in the 9,000s so there's really not that many child and adolescent psychiatrists, which is why I try to focus my practice mostly on that because there's a big need for it.

Dr. Ryan Gray: Interesting. Why do you think there aren't that many?

Dr. Hubbard: There are not that many fellowship spots, and I think a lot of medical students are not exposed to it as often as they could be. So some people just aren't aware that it's something that they can go into, and then the limit of the fellowship spots. So where I trained at the University of South Florida, we only had two spots my year, so it was me and one other fellow.

Dr. Ryan Gray: Okay. Now I'm kind of going off into the weeds because this is interesting. So kind of flipping the previous question I asked, can a general psychiatrist see the child and adolescent patients?

Dr. Hubbard: They technically can, there are definitely general psychiatrists who will see most of the time older adolescents. So it depends on their comfort level. They technically can but a lot of times during the general psychiatry training, when I was in the general program we only had a month of child psychiatry, and then a half a day in outpatient per week. So it's very limited, so you really don't get the exposure to treat a lot of kids, especially for some of the more- when you pick up autism for example, that's something that's picked up most of the time in the pediatric population. So you don't really get the training and experience treating those types of things, and ADHD as well.

Dr. Ryan Gray: Yeah so very needed physicians.

Dr. Hubbard: Yes.

A Day in the Life

Dr. Ryan Gray: Okay. Describe a typical day for you.

Dr. Hubbard: Every day is different which is what I like about the job. So my day typically starts anywhere- because it's a private practice I can decide when the day starts. So if I choose to, I have some patients that I come in early to see. So like tomorrow I fit somebody in at 7:00 AM because personally I like coming in early and not working too late. So I'll start anywhere from 7:00 to 9:00 or 10:00 depending on the day, and then I typically try to be done by 5:00.

Dr. Ryan Gray: Okay.

Dr. Hubbard: My patients- so for a kid evaluation I'll see them for 90 minutes, for an adult I typically leave myself 75 minutes, and then I do half hour follow-ups. I do have some patients that will come for therapy on a more regular basis, weekly or every other week, who I see for an hour at a time. So there's a lot of variety, I never know what I'm going to get that day, especially when I'm seeing new patients which makes it more interesting and fun.

Dr. Ryan Gray: Yeah. So a far cry from 15 minute appointments.

Dr. Hubbard: Definitely.

Dr. Ryan Gray: Describe the difference between a follow-up and the consult, or the new patient, and therapy as you called it.

Dr. Hubbard: So for a new patient I do a full clinical interview. If it's a child patient I will typically sit down and talk with the family. If the parents want to talk alone and not in front of the child, I'll talk with the parents and find out what their concerns are. And then for all kids I will try to meet with the child alone if they're willing to. I won't push it if they don't want to or the parents don't want to, but I like to talk to the kid alone. And then we will all sit down and talk together, the parents and the patient and myself, and I come up with a treatment plan which I usually write down for them while I'm talking to them so they can walk away and not have to try to remember things and everything is kind of written down. And so typically that will be going over whether I'm recommending a specific type of therapy like cognitive behavior therapy, or exposure and response prevention, we'll talk about any lab work that I recommend or order, we'll talk about medications, we'll talk about different supplements like Omega-3s, and then if there's any other referrals that the patient might need like an occupational therapy referral, or speech language referral, or neuropsych testing, we'll talk about that and we'll go over what that means. And then I try to get them to sign a release for their primary care provider, because part of my job I feel like is working with an interdisciplinary team of their primary care provider, any specialists like a pediatric neurologist, or a gastroenterologist, or even cardiologist for clearance of any of the medications. So we cover all of that, and then I'll book their follow-up, and then for their follow-up appointments we will go over their treatment plan again, see what's been done in between appointments, if they've established with a therapist, or an occupational therapist, or speech therapist. We'll talk about their medications, make sure they're not having side effects, and find out what's been going on in between the appointments, how school is going if it's during the school year, how family life is going, those kinds of things, and then refill their medication if they're on medications. And then for therapy I am trained in cognitive behavior therapy, which is the therapy that is approved for anxiety and depression. I'm also trained in exposure and response prevention which is an excellent therapy for OCD and social anxiety; it involves doing exposures for kids and adults where you put them in a situation that causes them anxiety but you start- it's a hierarchy where you start at the bottom of the hierarchy, something that may cause one out of ten anxiety instead of a ten out of ten anxiety. And so it lasts for about an hour, and sometimes we'll use workbooks. Like for young kids they have really good workbooks that are tailored to young kids like a Coping Cat workbook where it breaks it down and puts it into language that the child is familiar with in teaching about recognizing emotions, and naming emotions, and what those might mean. So the therapy patients I will see on a more regular basis, weekly or every other week, very rarely they'll come twice a week. And it's for an hour so it's really neat because you really get to know the patients at a different level and you're really getting to know the families because you're seeing them so often. Now I do have patients that will see an outside therapist like a licensed mental health counselor, or a psychologist, or a social worker or clinical social worker for therapy, and at that time I will have the patients if they're willing sign a release so that we can all kind of work together and they'll see me more for medications and sort of managing the treatment team, and then the therapist they will see for therapy.

What Call Looks Like

Dr. Ryan Gray: As a private practice physician, how does call- what does call look like for you?

Dr. Hubbard: Well it all depends on the state that you're in, and whether or not you take insurance. So I do not accept insurance directly, but I'm an out of network psychiatrist, as in patients can see me and they pay out of pocket to see me, and then they can request reimbursement from their insurance. Insurance is required that you have some type of call system in place where as when you're out of my network, I have in my policies that if it's an emergency they can call 911 or go to an ER, but with my practice I do also have a secure portal that they can send me a message in, like secure email, and they can do that anytime. So I have patients that will send me messages after hours which I encourage because I think it's good to know what's going on, and then I also have patients that will call me after hours. It goes to voicemail but if they feel that it's an urgent voicemail they can press the number four and then it comes and alerts me that it's an urgent voice message. But I tell them that when they call me for their first appointment and during their first appointment, we kind of go over how I do not have an on call service or an emergency service after hours.

Dr. Ryan Gray: Is that a common setup for private practice psychiatrists to not take call and to be an out of network provider?

Dr. Hubbard: It is in my area. In my area most of the private practice psychiatrists are out of because it's much easier to run a practice that way and not have to hire any staff, so the overhead is a lot lower. I don't have any office staff so I do everything from the patient's first phone call to taking their payment.

Dr. Ryan Gray: And when you say for your area, you're talking geographic area or area of specialty?

Dr. Hubbard: Probably both.

Dr. Ryan Gray: Okay.

Dr. Hubbard: Now I worked at a group before doing this, and the call- technically I was not on call but the psychologists that worked for the group answered the phone after hours.

Work Life Balance

Dr. Ryan Gray: Do you feel like your current setup, you being the boss, you have good work life balance?

Dr. Hubbard: Definitely. Definitely it's very flexible. I can block my schedule whenever I choose, for my child's events at school, or birthday, or trip, I just block my schedule and we're good to go.

The Residency and Fellowship Path

Dr. Ryan Gray: Nice. Talk about the path to becoming a child and adolescent psychiatrist, the residency and fellowship training.

Dr. Hubbard: After medical school it's a- the general psychiatry residency program is four years, and then the child and adolescent fellowship program is an additional two years. But most programs will allow you after three years- so three years of the general psychiatry residency, they allow you to enter into the two year fellowship, so that would cut out a year. So then overall it would be a total of five years after medical school.

Dr. Ryan Gray: Interesting. What's the thought process behind that?

Dr. Hubbard: Well because fourth year is usually a lot of electives, and so you're doing different rotations, you've basically gotten everything that's required during the first three years, plus they know that you're going to be doing more inpatient and outpatient work and consultation work doing the fellowship.

Dr. Ryan Gray: Okay. So it's kind of like medical schools going down to three years if you know you're going into family practice. It's about the same.

Dr. Hubbard: I guess so.

Competitiveness of Programs

Dr. Ryan Gray: Yeah, okay. Is child and adolescent psychiatry- and I guess psychiatry in general, how competitive is it to match?

Dr. Hubbard: I would say it's residency- it varies year to year. Residency for me, I stayed where I went to medical school, so that made it pretty easy on me. I think if you go- it depends on if you're trying to go to an Ivy League type place, it's definitely more competitive. Probably not as competitive as doing something like plastic surgery or dermatology. The fellowship program was very competitive from my experience. We only had two spots and there were four of us in my class of eight that wanted to go to our fellowship program, and we only applied to ours, so only half of us got it. So it was pretty competitive to get into the fellowship program.

Dr. Ryan Gray: Okay. So you did- it sounds like you did all of your training at USF then?

Dr. Hubbard: I did my medical school and residency and fellowship at USF.

Dr. Ryan Gray: Okay, great. So for fellowship, with that being so competitive because there are so few spots, what does a resident have to do to stand out for fellowship?

Dr. Hubbard: Get to know the child faculty. I think if you're considering going into child and adolescent it's important to- during my second year we had electives, and we apply during third year, so my child and adolescent rotation was actually the end of second year, which I wasn't completely sure yet and I hadn't had exposure, so I scheduled my electives which were earlier in the year for child and adolescent psychiatry to get to know the child and adolescent faculty, and to also make sure and confirm my choice that I wanted to do it. So I think if you show an interest in it, it's important to get to know the faculty so that you can get great recommendation letters from the faculty. And another great thing to do would be to join AACAP which is American Academy of Child and Adolescent Psychiatrists. They are our national organization for child and adolescent psychiatrists and they accept medical students for free. So if you were considering doing it, it's a great conference- we have a yearly conference, and there's medical students there, and residents can also participate, and at discounted rates I believe too.

Bias Towards DOs

Dr. Ryan Gray: Awesome. That's great. You're an MD obviously having trained at USF. Do you see any bias towards DOs?

Dr. Hubbard: Not at my program, we did not have bias towards DOs. Actually the other fellow that I graduated with was a DO from Lake Erie. So no, I think there's a lot of DOs that gravitate towards psychiatry, I believe maybe because of their training and taking a holistic approach to the way they look at approaching cases.

Opportunities to Sub-Specialize

Dr. Ryan Gray: Okay. Once you are fellowship trained in child and adolescent psychiatry, are there any other opportunities to further sub-specialize?

Dr. Hubbard: Definitely, definitely you can pursue more fellowships. So if you wanted to do a forensic fellowship and focus on the juvenile justice system, you can do that. You can also do- the fellow that's graduating this year also did an addiction fellowship, so he added an additional year of that as well. Plus if you don't do an additional fellowship you can also choose a diagnosis that you really enjoy treating like autism, and focus just your practice on that. There are autism private practices out there where the psychiatrist mainly treats autism. So you can pick a particular diagnosis that you enjoy, and that you find very rewarding to treat, and focus your practice on that.

Working with Other Physicians

Dr. Ryan Gray: Okay. Now some students listening to this are going to go into primary care and be pediatricians or internal medicine docs. What would you want to tell them so that they can help you do your job, so that their job is easier?

Dr. Hubbard: I think it's important for all of us to work together, and I try to make it easy for pediatricians or internal medicine doctors, for us to work together. I will send a letter to them letting them know the diagnosis along with any lab work. I think if- a lot of times the primary care doctors are ordering lab work before the psychiatrists are, so if they know- if they're referring to a specific psychiatrist and the patient agrees in the office, I think it would be great to have them go ahead and sign a release, and send over a little form saying that they're referring the patient, and that here's some lab work. I have some of the primary care doctors that do that. So if they're concerned about depression, it's important for them to be thinking of psychiatric diagnoses and screen for definitely safety concerns, and if there are any safety concerns- it's good to have a referral relationship with a psychiatrist that they trust where they can call them and run cases by them and let them know, ‘I'm very concerned about this patient. What should I do? Should I send them to the hospital?' Kind of like curbside consultations like that.

Dr. Ryan Gray: Okay. What other specialties do you work the closest with?

Dr. Hubbard: I work the closest with therapists because they're seeing the patients more frequently than I am a lot of times. So the therapists will send me messages with updates on how they're doing. I also work a lot with neurologists. A lot of the patients, for example autism, they should have a baseline [Inaudible 00:24:53] seizures. So I work with the neurologists, and then for kids a lot of times they might have vague somatic complaints like stomach pain or headaches. You know if they're complaining a lot about stomach pain they might end up seeing a GI doctor, and then the neurologists for headaches and things like that. I would say it's mostly primary care in terms of from a medical standpoint, but then also neurologists and gastroenterologists. And also endocrinologists and OBGYNs. So a lot of OBGYNs, they're doing a great job of screening for postpartum anxiety, or depression, and they'll refer me their patients as well.

What Dr. Hubbard Wishes She Knew Then

Dr. Ryan Gray: What do you wish you knew before going into your current specialty?

Dr. Hubbard: Well I wish I had more exposure to the different areas that you could practice. I think I probably- if I had had more experience in- basically with my training, we trained mostly at the VA and at the university academic center. I wish that I had more exposure to other places like the justice system, and like community mental health for example where I took that job.

Dr. Ryan Gray: Is that something that students and residents can be looking for in a program? Or do you think because there are so few programs that it's just something you need to know that you need to seek out while you're in a program?

Dr. Hubbard: I think it's important to be aware that where you do your training, things could be different elsewhere, and to seek out mentors outside of where you train. I think that's important.

Dr. Ryan Gray: Well that's what this podcast is here for too, to give people that insight to know that there's other things out there.

Dr. Hubbard: Yeah.

Best and Worst of Child & Adolescent Psychiatry

Dr. Ryan Gray: What do you like the most about being a child and adolescent psychiatrist?

Dr. Hubbard: I think that it's a great privilege to work with families. I love getting to know the patients and getting to work with families, and it's really exciting seeing patients get better. And when you treat kids, you really get to see kids make a lot of strides, and you can make a huge difference in the trajectory of their lives in general. And so that's really what I love most about my job, is getting to work with families and seeing the progress that they make. It's very rewarding.

Dr. Ryan Gray: What do you like the least?

Dr. Hubbard: The administrative stuff that I have to do, I probably like the least, like prior authorizations for medications, and just administrative tasks like writing 504 letters and things like that.

Dr. Ryan Gray: Yeah and it's compounded by the fact that you're in private practice as well.

Dr. Hubbard: Yes, exactly. Returning phone calls and that kind of thing.

What the Future Looks Like for the Specialty

Dr. Ryan Gray: Do you see any major changes whether it's technology, or new diagnoses, or anything coming down the road for child and adolescent psychiatry that will make big changes in how you practice?

Dr. Hubbard: I think it's important for us to stay on top of what's happening in our field. There are so many cool things that are coming out like the ability to do telepsychiatry, where you can see patients that are not necessarily in your city, but in your state. So I see college kids who will go off to Gainesville or to Florida State and will still be able to do [Inaudible 00:29:03] meds because they're still in the state of Florida where I'm licensed. And so that's really neat, and I'm sure it's only going to get better from there.

Opportunities Outside of Clinical Practice

Dr. Ryan Gray: That's interesting. Are there any unique opportunities outside of clinical medicine for child and adolescent psychiatrists?

Dr. Hubbard: Oh definitely. There's opportunities to get involved with the education system, educating parents, there's a lot of education involved. So if you like teaching, and mentoring, you can get involved and do talks for the community on just mental health issues in general like the importance of sleep. You can work with the school systems to not just educate parents but to also educate teachers, and guidance counselors on mental health issues and advocacy issues that children face. So there's lots of opportunities to be involved in non-clinical work.

Dr. Ryan Gray: Okay. So you're only two years into this, so still pretty new, but if you had to do it all over again would you still choose child and adolescent psychiatry?

Dr. Hubbard: Definitely, I love my job.

Dr. Ryan Gray: Awesome. Now for premeds or medical students or internal medicine residents maybe that are interested in psychiatry, or even the general psychiatry residents looking at child and adolescent psychiatry, what words of wisdom- final words of wisdom do you have to tell them to take a look into it?

Words of Wisdom

Dr. Hubbard: I would encourage them to look into it, and to reach out to a child and adolescent psychiatrist and learn more about it because we are so needed, and you will always have a job, and you can really make a difference in kids and young adults' lives. So I would highly encourage anyone considering it to do it or to learn more about it to make sure that you want to do it.

Final Thoughts

Dr. Ryan Gray: Alright there you have it, Jacqueline Hubbard with child and adolescent psychiatry. It sounds like an awesome and much needed specialty, so if you're interested in psychiatry, if you're interested in working with kids, and if you're going down this path like Jacqueline did of liking to work with children but not wanting to be as rushed as pediatricians are, then take a look at child and adolescent psychiatry. It looks like you can make a huge difference in kids' lives and their families which is an awesome thing. So again, thank you Jacqueline for joining us here on the Specialty Stories Podcast. If you have a specialty you want covered, let me know. Ryan@medicalschoolhq.net. If you know a physician that you think would make a great guest for this podcast, let me know. Ryan@medicalschoolhq.net.

If you like this podcast, I'd love a rating and review in iTunes. You can go check us out, just go to iTunes, search for Specialty Stories, and leave a rating and review right there. Or if you're on your phone right now, your iPhone specifically, go leave a rating and review in the podcast app. But more importantly I would love for you to share this with your school, with your classmates, with everybody. I don't charge you for the podcast so that's my ask for you, go share this with somebody.
I hope you have a great week, and come back, check us out next week here at the Specialty Stories Podcast.

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