Utility of 2nd year outpatient exposure?

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Just looking for what people's thoughts on this are based on some statements I've heard about from people at my program expressing skepticism about our 2nd year clinic. From what I remember when I interviewed, most programs did have outpatient exposure in the 2nd year and some programs had more extensive exposure (Northwestern, Harbor), which people generally felt positive about. Some old school programs I guess don't have 2nd year outpatient work (Hopkins?).

Here, we have a half day clinic starting 2nd year but unfortunately not as much support for the clinic as would be ideal on inpatient rotations (which is where the criticisms of us having clinic might be coming from?). Apparently some people have claimed that building more therapeutic exposure into the inpatient experience could potentially obviate the need for a 2nd year outpatient clinic, which to me sounds like a horrible idea. As a person who just plain doesn't love inpatient psychiatry (although I like parts of it), not having any outpatient exposure at all until 3rd year would be painful. I also feel like outpatient exposure has actually enriched my inpatient exposure. And, of course, the possibility of gaining good cases (unfortunately more difficult than I'd like) that you can follow for 3 years seems good to me.

Just wondering how other people feel about 2nd year clinics? Valuable, a waste of time? Also, how much support do you get for your clinics? Do you get help finding good patients? Do you get support for absence from other clinical duties -- here when you're on inpatient psych, you don't get any help with your daily workload in spite of being in clinic for up to 4 hours.

My favorite solution is when programs do outpatient 2nd year instead of 3rd.

As an applicant, I'd also love to hear other thoughts. Soon, please!

We have therapy cases second year on our "own time" and no clinic. That's fine with me.

Originally Posted by billypilgrim37

We have therapy cases second year on our "own time" and no clinic. That's fine with me.

So are you supposed to take on a certain number of cases, scheduling them wherever fits, or do you only take on cases if interested?

Originally Posted by Doctor Bagel

So are you supposed to take on a certain number of cases, scheduling them wherever fits, or do you only take on cases if interested?

We have a very paltry minimum requirement but are encouraged to take on more. I think I had two dynamic cases for 2nd year and one interpersonal case lasting a few months, probably all seen 5pm or later. Some of my friends had more, some of them didn't do any therapy until 3rd year. In 4 years, I've had 5 adult dynamic cases, only one currently still active around 60 sessions, two cbt cases, and one ipt case. I'll have another long-term adolescent case, a parent management case, and some dbt cases next year before I finish up child fellowship. The dbt is entirely optional and something I'm arranging myself. We can graduate with only 1 dynamic case, 1 cbt case, and 1 ipt case from general adult. We also have a pretty intense MI curriculum but it's inpatient based.

I have few friends who have done much more, but most have done much less. I spend a lot of time on research, and have taken on too many leadership roles, so I'm pretty sure one way or another I'm logging many more hours of work than any of my colleagues. And I still have time to make bad jokes on SDN.

Here we have a 1/2 day a week as a second year to see outpatients. The afternoon is structured for 2nd years to see one 1hr psychodynamic psychotherapy case and psychopharm patients with 90min new evals and 45min follow up appointments. It's a great learning situation. The psychopharm supervision is built in, and we have to make time on our own for the 1hr of required psychotherapy supervision.

I think it takes a long time to learn psychodynamic psychotherapy well - and that's only if you're motivated. I'm a much better therapist having had that case under my belt with the 1hr patient case: 1hr supverision ration before moving on to a more demanding psychotherapy load as a third year.

Also, it's nice to have a year with more time for psychopharm patients during that year.

The inpatient folks with always give push back about this - anytime you take from one pot and give to another there's going to be that reaction. We get it here too - but doesn't mean it's founded.

Originally Posted by BobA

Here we have a 1/2 day a week as a second year to see outpatients. The afternoon is structured for 2nd years to see one 1hr psychodynamic psychotherapy case and psychopharm patients with 90min new evals and 45min follow up appointments. It's a great learning situation. The psychopharm supervision is built in, and we have to make time on our own for the 1hr of required psychotherapy supervision.

I think it takes a long time to learn psychodynamic psychotherapy well - and that's only if you're motivated. I'm a much better therapist having had that case under my belt with the 1hr patient case: 1hr supverision ration before moving on to a more demanding psychotherapy load as a third year.

Also, it's nice to have a year with more time for psychopharm patients during that year.

The inpatient folks with always give push back about this - anytime you take from one pot and give to another there's going to be that reaction. We get it here too - but doesn't mean it's founded.

That sounds like a good setup. How do you get the one hour psychodynamic cases? My primary goal this year is to pick up good psychodynamic cases that I carry with me for the next two years, but it's been harder than I would like. Does someone do an intake to make sure they're a good case for a 2nd year?

I think someone else here mentioned doing two psychodynamic cases in the 2nd year as their whole outpatient experience, which also sounds good provided you get good psychodynamic cases.

Good point about the inpatient people, too.

Originally Posted by billypilgrim37

We have a very paltry minimum requirement but are encouraged to take on more. I think I had two dynamic cases for 2nd year and one interpersonal case lasting a few months, probably all seen 5pm or later. Some of my friends had more, some of them didn't do any therapy until 3rd year. In 4 years, I've had 5 adult dynamic cases, only one currently still active around 60 sessions, two cbt cases, and one ipt case. I'll have another long-term adolescent case, a parent management case, and some dbt cases next year before I finish up child fellowship. The dbt is entirely optional and something I'm arranging myself. We can graduate with only 1 dynamic case, 1 cbt case, and 1 ipt case from general adult. We also have a pretty intense MI curriculum but it's inpatient based.

I have few friends who have done much more, but most have done much less. I spend a lot of time on research, and have taken on too many leadership roles, so I'm pretty sure one way or another I'm logging many more hours of work than any of my colleagues. And I still have time to make bad jokes on SDN.

Hmm, I would not be a huge fan of this setup. It sounds like it gives you lots of flexibility, though, which could be a positive for lots of people.

Originally Posted by digitlnoize

My favorite solution is when programs do outpatient 2nd year instead of 3rd.

As an applicant, I'd also love to hear other thoughts. Soon, please!

My medical school had this type of schedule, and I was a fan. The residents seemed pretty happy with it, too, and felt that it aided their psychotherapy training. I think the main downside would be that going back into an intensive inpatient/CL type of schedule 3rd year after doing an outpatient year could be a little demoralizing. My medical school's program was pretty relaxed overall, so that maybe wasn't as much of an issue. Here, however, it could be a little miserable.

Personally knowing that I will no longer do regular calls unless I choose to for moonlighting after about 4.5 months is pretty awesome.

we get referrals for our cases - they usually come from faculty.

Originally Posted by Doctor Bagel

Hmm, I would not be a huge fan of this setup. It sounds like it gives you lots of flexibility, though, which could be a positive for lots of people.

I don't know that I'm necessarily a fan of it either. The flexibility is nice, but a little bit of structure wouldn't be such a bad thing either (since I'm somebody who valued my therapy experiences).

One thing I definitively asked about at programs was 2nd year o/p load AND difficulty of scheduling. I know at some places (I think maybe Cornell residents said this, correct me if I'm wrong) that it's nice to have a number of 2nd year patients but you aren't really given any time to see them and it ends up really becoming difficult to get time to see them or get time for supervision or anything like that.

What are everyone's thoughts on programs that used the PGY2 year as the outpt year? As an applicant, I personally like it. I also have a preference for inpt psych, so I like the idea of a PGY3 dedicated to inpt work. I think 3 of the 13 programs I interviewed at did the outpt year PGY2.

Originally Posted by psychphan

What are everyone's thoughts on programs that used the PGY2 year as the outpt year? As an applicant, I personally like it. I also have a preference for inpt psych, so I like the idea of a PGY3 dedicated to inpt work. I think 3 of the 13 programs I interviewed at did the outpt year PGY2.

I don't like the idea for myself, but then again, I don't like inpatient psych...

I also think the flow from medicine to inpatient psych to gradually more outpatient psych and then electives just makes sense (at least from the perspective of someone "looking forward" to outpatient work - both in general and in terms of a lighter schedule).

But I can see wanting to do outpatient first in that it would give you more "tools" to use on inpatient, particularly if you're interested in that venue.

At most programs, I would expect that the inpt rotations are more rigorous or at least time intensive than the outpt year. The idea of having an easier 2nd year and then a tougher 3rd year sounds like a nightmare to me.

Originally Posted by billypilgrim37

At most programs, I would expect that the inpt rotations are more rigorous or at least time intensive than the outpt year. The idea of having an easier 2nd year and then a tougher 3rd year sounds like a nightmare to me.

I figured that would be most people's gripe with it. But to me, a whole extra year of psychiatry experience under your belt should make you more efficient when you go back to the inpt wards. That may curb some of the 'intensivness' of the inpt rotations.

I actually hate inpatient psychiatry - if that was all psychiatry was I would never do it. Even with that viewpoint I would still concede that inpatient units are where you start to learn psychiatry - it is where you see the sickest patients, it is where you have the closest supervision (hopefully), it is where you get observe your patients closely, it is where you get to see the effects of your interventions in real time, it is where you deal with emergencies, where you manage the medical and the psychiatric, where you work in a more multidisciplinary way, where others can directly observe you, where you can really learn descriptive psychopathology, begin to understand group dynamics, and understand your role as a physician and psychiatrist. This is all great preparation for working in an outpatient setting where you have less supervision, should have a stronger grasp of psychopharmacology, can begin to work more psychotherapeutically having enhanced your clinical interviewing, and have a stronger sense of your identity.

There is, I think a very good rationale for having an inpatient 2nd year for those reasons. Ideally, we would all begin learning psychiatry in one of the old asylums where you saw everything from malignant catatonia to delirious mania, neurosyphilis, stupourous depression, the effects of institutionalization, and the patients stayed around long enough for you to become a strong descriptive psychopathologist, to make meaninful relationships, to see the effects of your interventions, to understand the limits of psychiatry... Sadly, as inpatient units dwindle in size and number, as admissions increase and duration shrinks, the inpatient experience is becoming less educationally valuable - more a lesson in containment of frank psychopathology, the psychiatist relegated from medical expert to risk assessor...

Originally Posted by psychphan

I figured that would be most people's gripe with it. But to me, a whole extra year of psychiatry experience under your belt should make you more efficient when you go back to the inpt wards. That may curb some of the 'intensivness' of the inpt rotations.

This was my take. All the residents I talked to said that their outpatient experience helped a ton when going back to C-L, Forensics, etc during 3rd year.

I think both systems are fine, but I would like to see a few more places do the 2nd year outpatient schedule, just to have some variety, if nothing else. I doubt that one is better or worse than the other...

Originally Posted by NoNoNoNo

One thing I definitively asked about at programs was 2nd year o/p load AND difficulty of scheduling. I know at some places (I think maybe Cornell residents said this, correct me if I'm wrong) that it's nice to have a number of 2nd year patients but you aren't really given any time to see them and it ends up really becoming difficult to get time to see them or get time for supervision or anything like that.

I remember hearing something about this at MGH/McLean, especially with the traveling back and forth between the two sites.

Originally Posted by digitlnoize

This was my take. All the residents I talked to said that their outpatient experience helped a ton when going back to C-L, Forensics, etc during 3rd year.

I think both systems are fine, but I would like to see a few more places do the 2nd year outpatient schedule, just to have some variety, if nothing else. I doubt that one is better or worse than the other...

I agree with this. My program has 6 months of full-time outpatient psychiatry in PGY-2.

From the interview trail, a trend I noticed is that the programs that had more of a psychodynamic/psychoanalytic focus and training had earlier outpatient experience. Granted, that's an N of about 12...

Starting with hard-core inpatient and acute care psychiatry is great, but I do like the idea of PGY-2 having devoted outpatient experience so that when you return to the inpatient environment, you actually bring back some non-pharmacologic approaches. You pick up some of these with didactics in PGY-1, but you'll learn how to do them properly with practice in an outpatient set-up.

To each their own. I'm much more inpatient focused, so I'd've been fine with more inpatient exposure early and less outpatient as a whole.

So 6 months of full time outpt in PGY2. Does that mean you have some inpt in PGY3, or does your program just have more outpt time than most places?

Originally Posted by psychphan

So 6 months of full time outpt in PGY2. Does that mean you have some inpt in PGY3, or does your program just have more outpt time than most places?

Nope, entirely inpatient in PGY-3. PGY-4 is all elective, so you can go back heavy on inpatient in that year.

Whereas UCSF is 6 months outpatient in 2nd year, and entirely outpatient 3rd year, too.

I came across a couple programs that had 6 months outpt second year and then a full year of outpt PGY3. However, notdeadyet's program is the first I have heard about that does it the other way, with more time spent inpt. Care to share what program you are at?

Originally Posted by notdeadyet

Nope, entirely inpatient in PGY-3. PGY-4 is all elective, so you can go back heavy on inpatient in that year.

How do you get your 12 consecutive outpatient months with this schedule?

Originally Posted by Doctor Bagel

How do you get your 12 consecutive outpatient months with this schedule?

My bad. Slightly bad typo. Meant to say that PGY-3 is entirely OUTpatient. Sorry...

That makes more sense. I think that's relatively common, at least based on my sample size of 13 interviews, 3 of them had that extra 6 months of outpt at the expensive of inpt. I was not a fan, at all.

Originally Posted by psychphan

That makes more sense. I think that's relatively common, at least based on my sample size of 13 interviews, 3 of them had that extra 6 months of outpt at the expensive of inpt. I was not a fan, at all.

Ditto. I much prefer inpatient. But what I'm discovering is that the learning curve is a lot steeper on the tools you build on outpatient than the tools you build on inpatient. I prefer the inpatient environment personally, but professionally I think I've come around that more time in residency spent on longitudinal psychodynamics is probably more worthwhile than more time in residency spent on acute care largely psychopharm. Might be sweet lemons at play, but I'm down with that.

Originally Posted by psychphan

That makes more sense. I think that's relatively common, at least based on my sample size of 13 interviews, 3 of them had that extra 6 months of outpt at the expensive of inpt. I was not a fan, at all.

I would have loved that. I'm overall happy with where I'm at, but I'd definitely prefer less inpatient work. I'm really glad we get outpatient exposure in 2nd year, but I feel like I don't focus on it as much as I would like to because of all my other clinical duties. I guess that talk about getting rid of clinic in 2nd year was especially annoying since we do a lot of inpatient work as it is.

Didn't think about it much but our program is all IP first year and then in 2nd year all OP except that little detail of the in-house overnight call. 3rd year we do consults 40% time for 6/12 months but the rest is outpatient stuff.

I think I will be glad to have had the extended psychotherapy and OP experience. IP is IP is IP if you ask me much more about the systems then the actual medicine for my taste but then again, I don't have much interest in doing IP except for with call.

I like the idea of really focusing on the psychodynamic modality starting in 2nd year, our program doesn't do that.

And to address Bagel, we never have that pull of the IP being pissed about us going to OP clinic. Once we are done with IP our intern year we are done. I think that is a good thing. Getting out of the hospital is always tough.