Is the Training of a Psychiatrist More Like That of a Neurologist or a Psychologist?

Psychiatrist, Neurologist, Psychologist: Which Clinicians Are Most Similar?

Posted May 17, 2010

Recently, one of us was asked about the differences between a psychiatrist and a neurologist. This was an interesting question because over the years, many people have asked us about the differences between a psychiatrist and a psychologist. Some might be surprised to learn that there are many more similarities between a psychiatrist and a neurologist than between a psychiatrist and psychologist. Let us explain:

Psychiatrists and neurologists are medical doctors. People choosing these professions attend medical school after graduating from college. Psychologists do not go to medical school and are not physicians. Instead, after completing their college educations, they enter a graduate school training program in psychology. This type of training is totally different from medical school.

Medical schools must fulfill rigorous requirements in order to be accredited by the Liaison Committee on Medical Education (LCME). This organization continues to monitor medical schools after they receive accreditation, and every school is inspected on a routine basis. Although some flexibility is allowed in the curriculum, broad-based training in the basic and clinical sciences and extensive clinical experiences in medical disciplines like internal medicine, surgery, pediatrics, psychiatry, and obstetrics/gynecology are required.

Graduate training in psychology is rigorous but does not require broad training in basic sciences (anatomy, physiology, neuroscience, and biochemistry, for example), clinical sciences (such as pathology and pharmacology), or intense clinical training in the medical disciplines mentioned above.

Medical school training is usually 4 years long. At our medical school (Washington University in St Louis), the first two years involve rigorous classroom and laboratory-based courses dealing with the structure and function of the various organs in the human body, including the brain. Students are also exposed to fundamental clinical techniques like physical examination of a patient and interpretation of laboratory results.

The third year of medical school usually consists of intensive clinical rotations that include hands-on experience in the fields of internal medicine, pediatrics, surgery, obstetrics & gynecology, psychiatry, and neurology. Medical students are part of the medical team evaluating and treating patients, including very ill patients in a hospital setting. Students also gain experience with outpatient management. The clinical team usually consists of an attending physician (usually a senior physician with specialty certification), one or more residents (trainees who have completed medical school and are at some stage of further training in a specific specialty), and medical students. Other healthcare professionals including nurses, social workers, and pharmacists frequently interact with the team. The fourth year of medical school usually consists of elective rotations that provide students with experience in various subspecialty areas such as cardiology or geriatrics.

By the middle of the third year of medical school, most students have a fairly good idea about the field of medicine they wish to focus on for their careers. Often, students don't make final decisions about the field they wish to enter until early in their 4th year. This 4th year offers students opportunities to take electives that often help them decide what best fits their interests and personalities.

During medical school, students must pass the first two parts of the United States Medical Licensing Exam (USMLE). Usually, students take part 1 at the end of the 2nd year and part 2 during their 4th year. Part 2 includes exams of simulated patients.

All medical students follow the course we just described. Nothing differentiates the training of those interested in psychiatry, neurology, surgery, or pediatrics other than the choice of 4th year medical school electives. In contrast, the training of psychologists is very different. As we stated before, psychologists do not attend medical school and are not physicians. Their training varies depending on their graduate program. Research experience is often central to their training. Coursework focuses on various aspects of behavior. However, the curriculum does not cover the same information that is required and monitored in medical school. For example, it would be unusual for a graduate program in psychology to require intensive training in basic sciences like genetics, anatomy, pharmacology, cell biology, and physiology. It would also be unusual for a graduate program in psychology to have intensive coursework dealing with the lung, heart, liver, kidney, brain, endocrine system, reproductive system, etc.

Learning how to utilize medications safely requires a strong background in understanding how the various organs of the body handle and react to different drugs. Persons with medical illnesses may react quite differently to drugs than healthy persons. Also, drugs have the potential to interact with each other. Gaining experience in the use of medications is a process that incorporates much of the information that is learned during the years of medical school and residency training. Medical training is not the focus of psychology graduate programs, and these programs generally aren't designed to provide psychologists with the basic and clinical scientific background and broad-based clinical experiences that are so important if one is to prescribe medications.

Once a medical student decides on a field of interest, he or she applies to residency training programs in that field. Residency training varies in length depending on the specialty. For example, family medicine training is 3 years. Both psychiatry and neurology training programs are 4 years. The first year of psychiatry residency includes at least 4 months of clinical training in either internal medicine and/or pediatrics and at least 2 months of neurology training. The first year of a neurology residency includes 8 months of training in internal medicine.

The final three years of psychiatry and neurology residency training differ with regard to the illnesses residents learn to treat and the special techniques they are taught to perform. Certain illnesses are of interest to both psychiatrists and neurologists, for example, dementias, delirium, certain seizure disorders, certain movement disorders, etc. Other disorders tend to be of more interest to either neurology or psychiatry. For example, neurology residents may be very interested in muscle disorders, peripheral nerve disorders, infectious diseases of the brain, stroke, brain tumors, etc., and psychiatry residents may be very interested in schizophrenia, mood disorders, anxiety disorders, substance abuse disorders, personality disorders, etc. Neurologists learn techniques like performing lumbar punctures, reading EEGs, and performing procedures to investigate problems with muscles and peripheral nerves; psychiatrists learn techniques related to evaluating a person's behavior, performing certain forms of psychotherapies, administering procedures such as electroconvulsive therapy, and prescribing specific groups of medications. Although traditionally neurology residents have been more interested in brain imaging techniques than psychiatry residents, this is beginning to change as these techniques are becoming clinically relevant to psychiatry. Both psychiatry residents and neurology residents gain extensive experience in the ways illnesses in their specialty area may interact with other medical and surgical disorders.

Over time, there has been an increasing overlap in the core knowledge expected of psychiatrists and neurologists, especially in areas involving brain structure and function, imaging techniques, genetic techniques, and various branches of clinical neurosciences including molecular and cellular neurosciences.

Psychologists receive specialized training in various psychological techniques and procedures during an internship. They also learn about the nature of mental disorders, but they do not usually receive extensive training in the interface among psychiatric, neurological, surgical, and medical illnesses. Their training is very different from that of physicians in residency programs.

Like medical schools, residency programs are nationally accredited (in this case by the Accreditation Council for Graduate Medical Education - ACGME) and monitored by site visits every 1-5 years. Each specialty must fulfill educational requirements that are determined by its national Residency Review Committee (RRC). All RRCs meet regularly and update clinical requirements in response to changes in the field.

During the end of the first year or the beginning of the second year of residency, most residents take the third part of the USMLE. This test is the same for all residents training in any medical field. Licensing of physicians is handled at the state level, and states require that a physician pass all three parts of the USMLE in order to obtain an unrestricted medical license. States also require a certain amount of residency training before they will review an application for a medical license. A permanent medical license can be obtained before completing a residency program; however, it would be rare for a physician to practice medicine without completing a full residency program and becoming board certified in the field in which they trained.

Once psychiatry and neurology residents successfully complete their 4 years of specialty training, they can apply to the American Board of Psychiatry and Neurology (ABPN) for "board certification." ABPN verifies that applicants have fulfilled the qualification criteria to take the specialty board examinations in their field. Once a physician passes the specialty exams, he or she becomes "board certified." This certification is limited to a specified period of time - usually 10 years. During those 10 years, the specialist must fulfill ongoing "maintenance of certification" (MOC) requirements, including continued medical education and various peer and self evaluations. At the end of the 10-year period, physicians who successfully complete the MOC requirements are eligible to take a recertification exam. This 10-year cycle of recertification continues throughout the physician's career.

This discussion highlights the fact that there are many similarities in the educational backgrounds and extent and length of training of neurologists and psychiatrists. Their rigorous medical training distinguishes them from psychologists. Psychology is an extremely interesting and important field. Psychologists have unique skills and training and are very important members of the mental health team. Their training prepares them to provide a variety of services that psychiatrists and neurologists are not trained to perform. Psychologists, however, are not trained to be physicians.

Thus, in terms of background, training, certification, and approach to patients, psychiatrists are much more closely related to neurologists than to psychologists. Psychiatrists and psychologists do share a strong desire to work with and help persons suffering from mental disorders. The complementary skills of internists, psychiatrists, psychologists, social workers, and various types of counselors are all essential if we are to have an efficient and effective system of health care delivery for the mentally ill. More about this in a subsequent posting.

This column was co-written by Eugene Rubin MD, PhD and Charles Zorumski MD