40 Hour Weeks

[Psychczar]

Long time lurker here applying in the fall for psychiatry residency. I've realized on the current rotation I am on that my ideal schedule is 8-4p, no weekends. I know that this is probably not possible till I'm an attending, but I'd like to have something close during residency. I am fine with short night call to 9-10 pm once every week or two, but having two day weekends every week makes a huge difference in my well-being. Ideally I would also like to be in a diverse city where we could live comfortably (my wife and I could not adjust to living in a 500 sq ft studio, and we'd like to have a child during residency).

I have looked through most of the program review threads on the forum that have pointed out which are "lifestyle friendly", but I was hoping for more specifics when making my list of where to apply based on what I have described (40 hr weeks, occasional short call, few weekends, time to sit with patients instead of standing for three hour bedside rounds). I am open to either coast up and down, and some midsize-big cities in the Midwest. I would like to avoid the South, but Texas and Florida are fine. I'm at a top 25 school, >240 Step 1, all HPs in third year rotations.

It would be helpful to get some input on programs that fit (or don't fit!) well with me based on your experience, and the living situation with respect to rent/mortgage, large enough space for two plus possibly a child. I'm concerned that there is a dissonance between what I want out of a program and a city and my program list, which currently looks like a smattering of several more competitive programs. I don't want to be in a situation where I don't apply to enough of the right programs. A "brand name" would be a great plus, but not at the expense of fit.

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[MacDonaldTriad]

There are good programs that work you hard. There are bad programs that work you hard. But there are no truly excellent trainings that are easy trainings. Your grades will get you in most of these places, but keep anonymous; your post would not be seen as attractive by most training directors.

 

[slappy]

Defo keep the chilled out programs like San Mateo, MCW, etc on your "to apply" list. They're some of the excellent programs with a (relatively) relaxed training schedule.

 

[Bartelby]

I don't believe any programs that cush exist (no call, 8-4 M to F with no weekends). If you are looking for prestigious programs that gravitate toward the better end of the work-life balance spectrum I recall Cambridge Health Alliance and Yale as being excellent programs with lighter than expected call.

 

[shan564]

Another thing to keep in mind is that as a student, you tend to look at the intern year as a gauge of how difficult a program is, since that's the closest step to you. Different programs are very different in my regard. My program has a heavier-than-average workload in PGY1, probably average-ish in PGY2, and then you can have the schedule that you're describing in PGY3/4.

 

[SteinUmStein]

Fighting for a cush intern year and even PGY2 year seems both futile and counterproductive to me. There's a lot to learn. I can understand wanting to avoid malignant programs though.

 

[Jester25]

Fighting for a cush intern year and even PGY2 year seems both futile and counterproductive to me. There's a lot to learn. I can understand wanting to avoid malignant programs though.

Guys, this is your career here. Put solid work in during your training years and reap the benefits throughout your career. You can't see every possible case in residency, but the more you see, the better (in a non-malignant/ minimal scut work sort of environment).

 

[digitlnoize]

Guys, this is your career here. Put solid work in during your training years and reap the benefits throughout your career. You can't see every possible case in residency, but the more you see, the better (in a non-malignant/ minimal scut work sort of environment).

Agreed. There are happy mediums. I feel that my program, while not being particularly good at didactics, excels at having us see a fairly high volume of patients in a relatively low stress environment.

I work occasional weekends. These are kind of important because it's when you're more without a net. Do I hate it? Yes. Does it help me? For sure. Nights are the same way. I am MUCH more confident after a year of flying solo on night ER call (our interns cover inpatient call and PGY2's cover ER call). I've never come close to breaking duty hours, but also haven't spent much time in my preferred 30-40 hours per week window.

Still, I've seen great clinicians come out of programs who had very cushy schedules, so I'm not sure how much it matters or whether it's all in our heads.

 

[slappy]

Still, I've seen great clinicians come out of programs who had very cushy schedules, so I'm not sure how much it matters or whether it's all in our heads.

+1

I'm also a proponent for reasonably cushy schedules that allows for residents to develop their own interests within the field rather than have it busy throughout, moulding them all into one cast.

 

[notdeadyet]

I'm also a proponent for reasonably cushy schedules that allows for residents to develop their own interests within the field rather than have it busy throughout, moulding them all into one cast.

This can be done at programs with lots of elective time. Really light programs are great for the down time, but there is a very finite amount of learning you get from reading a bunch in all your downtime.

At the end of the day, I don't think Psychiatry is all that different from other fields of medicine, in that you get better at it by doing the work.



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[Jorje286]

This can be done at programs with lots of elective time. Really light programs are great for the down time, but there is a very finite amount of learning you get from reading a bunch in all your downtime.

At the end of the day, I don't think Psychiatry is all that different from other fields of medicine, in that you get better at it by doing the work.



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My hunch though is that the quality of the patient encounter will matter more than the number of patients. And the first things that go away when one is a little overworked are communication skills/empathy. You could probably get away with being overworked in other fields of medicine and still do an excellent job, but I don't think that's the case in psych.

 

[notdeadyet]

My hunch though is that the quality of the patient encounter will matter more than the number of patients.

We'll have to disagree. The "quality" of a patient encounter comes from experience, which you gain with the more patient encounters you have. It also comes from having enough background to try new approaches and techniques, which doesn't come until you have some mastery over the first line techniques, which also requires experience.

There's a point at which I think this no longer applies. This comes when programs are so busy that you have far more patient encounters than you can practice decent psychiatry. This the problem with malignant/exploitive programs, but not busy quality ones.

The whole topic gets kind of loaded. Folks who want to do the least amount of work in residency will have a vested interest in believing that this is a plus. Folks who attend busy programs have a vested interest in believing that this is beneficial so that they don't learn that they've made a four year sacrifice for naught. I'm probably in the latter camp. But objectively, it means something that the programs regarded as having the best training also almost to a one are know for being busy programs. There is just no shortcut to learning how to practice medicine. Any field.

And the first things that go away when one is a little overworked are communication skills/empathy.

True. And you overcome this problem with training and practice. You learn what works for you to maintain your empathy, compassion, and composure in times of stress in the company of supportive colleagues and mentors who have managed to maintain this ability and passion for what they do after long careers. You learn it in residency, If you wait to learn this on the job, when you will likely be PAID to be busy, you will be learning this in an environment where no one is being paid to teach you. This is where folks are prone to burn out. We've all seen it happen.

You could probably get away with being overworked in other fields of medicine and still do an excellent job, but I don't think that's the case in psych.

I don't think it's the case for any medical field. We focus on rapport because it's our bread and butter, but all fielded need to be cautious about what happens with overworked staff.

Anyway, everyone finds a residency home and makes the best of it. I would just caution folks from trying to look to hard to find the easiest residency possible if they are serious about becoming psychiatrists. The work you did in med school was mostly for the sake of getting into residency. Residency is where you actually learn to be a psychiatrist. Investing the time to learn how to do it right will pay off in dividends for the rest of your career. And it will retire hard work if you want to learn as much as you can. It's worth it.

 

[slappy]

But objectively, it means something that the programs regarded as having the best training also almost to a one are know for being busy programs.

But there are no truly excellent trainings that are easy trainings.

Cambridge.

 

[Nasrudin]

We'll have to disagree. The "quality" of a patient encounter comes from experience, which you gain with the more patient encounters you have. It also comes from having enough background to try new approaches and techniques, which doesn't come until you have some mastery over the first line techniques, which also requires experience.

There's a point at which I think this no longer applies. This comes when programs are so busy that you have far more patient encounters than you can practice decent psychiatry. This the problem with malignant/exploitive programs, but not busy quality ones.

The whole topic gets kind of loaded. Folks who want to do the least amount of work in residency will have a vested interest in believing that this is a plus. Folks who attend busy programs have a vested interest in believing that this is beneficial so that they don't learn that they've made a four year sacrifice for naught. I'm probably in the latter camp. But objectively, it means something that the programs regarded as having the best training also almost to a one are know for being busy programs. There is just no shortcut to learning how to practice medicine. Any field.


True. And you overcome this problem with training and practice. You learn what works for you to maintain your empathy, compassion, and composure in times of stress in the company of supportive colleagues and mentors who have managed to maintain this ability and passion for what they do after long careers. You learn it in residency, If you wait to learn this on the job, when you will likely be PAID to be busy, you will be learning this in an environment where no one is being paid to teach you. This is where folks are prone to burn out. We've all seen it happen.

I don't think it's the case for any medical field. We focus on rapport because it's our bread and butter, but all fielded need to be cautious about what happens with overworked staff.

Anyway, everyone finds a residency home and makes the best of it. I would just caution folks from trying to look to hard to find the easiest residency possible if they are serious about becoming psychiatrists. The work you did in med school was mostly for the sake of getting into residency. Residency is where you actually learn to be a psychiatrist. Investing the time to learn how to do it right will pay off in dividends for the rest of your career. And it will retire hard work if you want to learn as much as you can. It's worth it.

I have come to agree with this perspective even as one who values enough personal time to maintain good physical fitness, rest, and respite. I agree particularly with the loadedness of the issue. I think, as an applicant you should weigh all these things in total. I would've ranked San Mateo highly if interviewed and not worried once about being paid to take call. I ranked AE-monte highly and it was by all accounts quite cushy but with excellent therapy supervision and academics.

As is it is I'm headed to a busy program with tough call and not the most impressive academics. It was still my number 1. I liked the leadership. And am happy to learn by doing. Though am not wedded to that as a maxim. It's not one or the other emphasis that will make me what I am to be in this field.

I think also we should be aware enough to realize that our brethren in surgery and the like will be working long after we've had a hot bath and are sleeping soundly and therefore should not worry too much about how Cush we are on the scale of cushiness.

 

[Nasrudin]

Cambridge.

. Actually I agree with you as well. There are great training programs that are not as rigorous. And by what evidence could we say otherwise. I think good academics could cover a lot of ground that repetition and clinical experience could not. And vice versa. Both perhaps is ideal. And perhaps that's what the best programs have.

But a step down from best to acquire something beneficial to the applicant, whatever that means to them, would trump, in my opinion, whatever is to be gained by best-ness. You should definitely go where you will be happy as an applicant.

 

[MacDonaldTriad]

Most other specialties would laugh at us for using “overworked” and “psychiatry” in the same sentence. It is all relative I guess, but becoming immersed in your development as a fine psychiatrist involves spending a majority of time being a psychiatrist. Less is more in interior decorating, but less is less in most cases.

 

[michaelrack]

As long as you work at least 30 hours a week, you will learn enough; just make sure you are at a program with good psychotherapy exposure/experience. And do spend some time after work reading.

 

[cookymonster]

If you want to "learn by doing," you might as well develop your autonomy, improve your efficiency, and get paid more than $20 an hour in the process. The best mix is to coast through a very cush residency program with good didactics and good clinical instruction and save all of your clinical volume, money, and stress for moonlighting work.

With a month left of my training, I still like psychiatry, but I've concluded that residency is for the birds and have no qualms with gaming the living crap out of it.

 

[notdeadyet]

If you want to "learn by doing," you might as well develop your autonomy, improve your efficiency, and get paid more than $20 an hour in the process. The best mix is to coast through a very cush residency program with good didactics and good clinical instruction and save all of your clinical volume, money, and stress for moonlighting work.

There's something to this. I actually moonlight a ton and it's definitely helped my skills.

But the problem is that the value of quality busy programs is that you're not just toiling away, you're working hard in an environment with good supervision and the service component is a thoughtful part of the training process. At every (external) moonlighting gig I have, I'm expected to operate independently. You can get confident doing this, but if you don't have good chops you're building on (from a lot of exposure and good training), you're running a risk of false confidence. You just don't know what you don't know.

I'd opt for investing time in decent training. And as MacDonaldTriad mentions, it's a psychiatry residency. If you average out the hours over four years of the top busy psych residencies (which feels redundant to say), you're still working less than 50 hours/week. This is less than professionals work in most professional fields. And much less than the most cush residencies in most specialties. It's really not bad.

 

[Jester25]

There's something to this. I actually moonlight a ton and it's definitely helped my skills.

But the problem is that the value of quality busy programs is that you're not just toiling away, you're working hard in an environment with good supervision and the service component is a thoughtful part of the training process. At every (external) moonlighting gig I have, I'm expected to operate independently. You can get confident doing this, but if you don't have good chops you're building on (from a lot of exposure and good training), you're running a risk of false confidence. You just don't know what you don't know.

I'd opt for investing time in decent training. And as MacDonaldTriad mentions, it's a psychiatry residency. If you average out the hours over four years of the top busy psych residencies (which feels redundant to say), you're still working less than 50 hours/week. This is less than professionals work in most professional fields. And much less than the most cush residencies in most specialties. It's really not bad.

Yeah. I would say my program went..

PGY-1: 55-60 hrs
PGY-2: 50-55 hrs
PGY-3: 45 hrs

Not bad at all. Plus got to see a TON of cases. No scutwork.

 

[Psychczar]

Thanks for the constructive input. It seems there is a mix of very valid opinions. I am not convinced a lighter schedule automatically means poorer training, but at this stage what do I really know.

What are your thoughts on whether a future career in academia vs community or private hospital vs private practice factor into these opinions? I imagine rigorous training might be more relevant in academia, perhaps brand in PP, etc.? Does going to a less intense program really make a difference outside of academic medicine?

 

[shan564]

I think that a lot of the above discussions center on the idea that "working hard" = "overworked" and "busy" = "narrow focus." I think that my program definitely does not fit this idea. We work more hours than most programs, but we also have more didactics than most programs, and most of our didactics are quite resident-centered. We stay busy, but we probably have one of the widest array of required clinical rotations. If you give a trainee too much freedom to do what they want to do, then they are likely to miss out on a lot of the things that they need in order to be well-trained... by definition, a trainee is in training, and is therefore not yet qualified to know what he/she needs to learn in order to be well-trained.

One of my biggest complaints about the med school associated with my current program is that they give too much flexibility for MS4 electives, so everybody just does whatever interests them and/or is relevant to their fields. Psych was my last MS3 rotation, so if I had to choose my electives before that, I might have ended up going into pathology. And I never would have chosen to do rotations in primary care, pediatric surgery, pediatric ED, ICU, neonatal ICU, acute surgery, etc... having required rotations in those fields made me better at considering issues relevant to those fields when dealing with psychiatric patients. If I had a year of electives, I would have done most of them in psychiatry... which wouldn't really have helped my overall education all that much, since it would have been a drop in the bucket compared to the ensuing 4 years of psychiatry.

If you want to pursue your own interests, you can do it in elective time and/or after residency. Residency is when you're supposed to learn how to be a good general psychiatrist by seeing a ton of cases.

Of course, if the program is wasting your time with scutwork, then that's different. My program probably makes us take care of a higher-than-average patient load, but we are NEVER expected to do anything that could be done by somebody without a medical degree. I know that a lot of programs make you waste a lot of time doing things that could be done just as effectively by a nurse or a social worker, and that's definitely a situation in which more work doesn't necessarily make you a better clinician.

Thanks for the constructive input. It seems there is a mix of very valid opinions. I am not convinced a lighter schedule automatically means poorer training, but at this stage what do I really know.

Medical school is for reading and learning stuff that can be learned from books. Residency is for seeing thousands of cases with supervision... more cases = more training, as long as you're not exhausted to the point of being unable to learn, which is a rarity in psychiatry. Post-residency is for doing whatever you want.

What are your thoughts on whether a future career in academia vs community or private hospital vs private practice factor into these opinions? I imagine rigorous training might be more relevant in academia, perhaps brand in PP, etc.? Does going to a less intense program really make a difference outside of academic medicine?

This question seems to imply that "better" means "more marketable" and/or "better career prospects." The purpose of most of the above comments is that "better" means "better clinical acumen." Rigorous training will make you a better psychiatrist.[/quote][/QUOTE]

 

[cookymonster]

There's something to this. I actually moonlight a ton and it's definitely helped my skills.

But the problem is that the value of quality busy programs is that you're not just toiling away, you're working hard in an environment with good supervision and the service component is a thoughtful part of the training process. At every (external) moonlighting gig I have, I'm expected to operate independently. You can get confident doing this, but if you don't have good chops you're building on (from a lot of exposure and good training), you're running a risk of false confidence. You just don't know what you don't know.

I'd opt for investing time in decent training. And as MacDonaldTriad mentions, it's a psychiatry residency. If you average out the hours over four years of the top busy psych residencies (which feels redundant to say), you're still working less than 50 hours/week. This is less than professionals work in most professional fields. And much less than the most cush residencies in most specialties. It's really not bad.

I think it depends highly on the type of moonlighting opportunity that you choose. I've worked in one hospital in which I primarily did admissions during the day at a rural institution and had very collegial relationships with the attendings. I went to many of the meetings and discussed difficult cases, M&M's, etc. They were also involved in teaching medical students, and hence eager to share their clinical acumen with me. They weren't nearly as influential as the practices I learned where I've trained, but it was good to get exposed to different paradigms. I've also done a lot more overnight, isolating work in which I've never seen another doctor. I've tried to learn more from those experiences by uncoupling the case itself from the supervisory environment (i.e. I'll present that case to one of my attendings at my program when I get back and ask him/her what s/he thinks). My attendings may not have actually been on site to see these patients, but the same could be said for all of the patients I discharge on call in residency and check out to them the next morning.

I guess if I thought the training were inherently that good, I'd be more in line with your point of view. But I don't think it is, and I don't think it's dependent on the structure of any particular program. As residents, we spend a high percentage of our time seeing very similar cases we feel fairly comfortable managing (drunkicidals at 3AM, nonadherent schizophrenics, an intake to restart Zoloft, etc), and the amount of learning compared to service that takes place makes four years of residency a very hard sell.. If you have a specialized sub-interest within psychiatry that dazzles you, it may be different, but for the generalist, it's too much cheap labor and insufficient teaching and learning. You should find other things that are worth your time and skill set.

 

[Nasrudin]

This discussion is very interesting. It seems everyone of the residents from different programs has very different but very good points.

 

[notdeadyet]

Great suggestion on ways to make moonlighting experiences more learning-oriented by tying it directly into your residency experiences. I like that....

I guess if I thought the training were inherently that good, I'd be more in line with your point of view. But I don't think it is, and I don't think it's dependent on the structure of any particular program. As residents, we spend a high percentage of our time seeing very similar cases we feel fairly comfortable managing (drunkicidals at 3AM, nonadherent schizophrenics, an intake to restart Zoloft, etc), and the amount of learning compared to service that takes place makes four years of residency a very hard sell.

I'd disagree with this. I think there is a fair bit of variation by program in this. While I think a certain amount of the call experience is going to be risk assessment and the like, the core experiences may vary.

It depends on the reputation of the psych program within an institution (and it's power as a department), funding, availability of and relationship with community providers, and diversity of training locations. At some places, you may have a huge part of your experience made up of doing intakes on,y to restart SSRIs. But at other places, you will find that your program acts as largely tertiary care and most of your outpatient experience is focused on dealing with zebras and refractory/complex psych cases. At some places, your inpatient experience may be mostly a "move the meat" vibe. But at others, you will have more (but never enough) modalities and dispo offers for your patients and collaboration with their care post hospitalization. At some places, your experiences will be mostly "core." At others, there will be a lot of ways you will be encouraged to customize your training to reflect interests, research, teaching, and the like.

I think that this is why I'm hoping folks won't shy away from the great programs that ask you to put in the hours. Because many of those programs have the long hours BECAUSE they have a lot of rotation sites and hospitals to cover. Some places are busy and heavy hours because they are malignant. But others are busy and heavy hours because there is a lot going on, the learning curve is steep, and boredom isn't a complaint you hear a lot.

I think there is a good bit of variance amongst programs. At least from the way I've heard lots of folks described theirs. And I love the fact that there is. Everyone will find their balance of learning and free time represented in a program if they look with an open mind.

 

[Sporadicus]

Thanks for the constructive input. It seems there is a mix of very valid opinions. I am not convinced a lighter schedule automatically means poorer training, but at this stage what do I really know.

What are your thoughts on whether a future career in academia vs community or private hospital vs private practice factor into these opinions? I imagine rigorous training might be more relevant in academia, perhaps brand in PP, etc.? Does going to a less intense program really make a difference outside of academic medicine?

These are my thoughts regarding NYC programs:

Not very chill - NYU, St Lukes, Columbia
Good work/life balance - Cornell, Mt Sinai, Beth Israel
Way too chill for me - Montefiore, LIJ

Based on your 'ideal' situation I would recommend Montefiore.

If you eventually want academia, any of these places gives you a good 'brand' for your CV - academic psych in NYC is a very small world - they all know each other and most of them trained at each other's programs.