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Many of my students did not get their 1st choice (or even 2nd choice) program. There is this myth that everyone will get their top choice in psychiatry, and while the odds are good clearly that isn't true. I did not match at my first choice and know a lot of people who didn't (in fact they didn't even rank me despite telling my mentor who worked there that I had a good chance). But there's a stigma about it. People don't talk about. It's just assumed. When applicants asked me "why did you choose this program", I was just thinking "I didn't". After the initial shock and 4 years later I have to say it worked out very, very well and I think I would not have been well suited to my no.1. Remember, you are about to become a physician and begin your training in the most fascinating field of medicine and you can live where you want and practice where you want once you've finished. The outlook is very good because of how ridiculously uncompetitive fellowships are and the job market is very good compared to most other fields of medicine. You will likely enjoy a satisfying career that allows you to privilege lifestyle and be in at least the top 5% of earners.
Here are my thoughts:
1. It's open season on psychiatrists
Psychiatrists have long fallen from grace in the eyes of the public. Always the ugly step-child of medicine, psychiatrists were once the most respected medical specialtists by the general public. Today psychiatrists are seen as preaching pseudoscience, pathologizing all of mental life, peddling quack treatments, often under coercion or control and beholden to the pharmaceutical companies, ready to label and medicate anything that moves. The unholy alliance of psychiatry and the pharmaceutical industry has severely undermined the credibility of the profession.
2. Good enough is NOT good enough
As a result, it is no longer acceptable to simply want to be a "good-enough" psychiatrist in the Winnicottian sense. You should be aspiring to be the best psychiatrist you can - you owe to your chosen profession and your patients.
3. Learn the language of psychiatry
Descriptive psychopathology is the language of psychiatry and yet the vast majority of American psychiatrists lack fluency in it. If you don't know the difference between hallucinations and pseudohallucinations, pallilalia and verbigeration, word salad and transcortical sensory aphasia, ultradian cycling and emotional lability, then you will be diagnosing everyone with borderline personality disorder and schizoaffective disorder, and missing real brain disease like fronto-temporal dementia, stroke, epilepsy, and failing to distinguish psychosis from neurosis, and character disorder from neurosis. Potentially with disastrous consequences.
Fish's Clinical Psychopathology is a good place to start (though I prefer to older edition by Max Hamilton). Symptoms in the Mind by Sims is another.
For the adventurous:
Kraepelin E. Manic-Depressive Insanity and Paranoia. Edinburgh: Livingstone, 1921
Jaspers J. General Psychopathology. Chicago: University of Chicago Press, 1953
Bleuler E. Dementia Praecox: Or, the Group of Schizophrenias. New York: International Universities Press, 1950
Schneider K. Clinical Psychopathology. New York: Grune & Stratton, 1959
4. You can't make a diagnosis you haven't heard of before
Not heard of Ganser's syndrome, De Clerembault Syndrome, Othello Syndrome, Capgras syndrome, or Cotard syndrome? Then how will you ever identify them? (I have seen several cases of each of these)
Check out:
Enoch MD, Trethowan WH. Uncommon psychiatric syndromes. Bristol: John Wright & Sons, 1979
Friedmann CTH, Fauget RA. (Eds.) Extraordinary disorders of human behavior. New York: Plenum Press, 1982
5. Don't forget about the Brain!
While learning about the neurobiological basis of psychiatric syndromes is all well and good some of this is pseudoscience and the rest does not have any clinical relevance. But having a working knowledge of the neuroanatomy of emotion is a must for the 21st century psychiatrist.
Also being able to recognize when your patient actually has brain disease is the most important thing you can do as a psychiatrist! But it requires suspicious, curiosity, and the last point, for you to have heard of the diagnosis. I have seen patients with VGKC antibody limbic encephalitis presenting with catatonia, SLE presenting with schizophreniform psychosis, frontal-variant Alzheimer's presenting as mania, temporal lobe epilepsy presenting as intermittent explosive disorder , bvFTD presenting as psychotic depression, semantic dementia presenting as depression etc... sadly neuropsychiatry is not part of the skillset of the general psychiatrists and many patients are being misdiagnosed.
Check out:
Lishman's Organic Psychiatry
Texbook of Clinical Neuropsychiatry
6. Step out of your comfort zone
We learn the most when we step out of our comfort zone. in fact there are probalby only a few months of your entire residency where most of your learning happens. Adapted from Donald Light's sociological calendar - these are probably your first month of medicine, first month of inpatient psych, first nightfloat/night call block, first therapy patient, starting outpatient. If you are averse to psychotherapy then learn as much as you can and get as much experience in this. If you are not keen on psychopharm, master this and take on complex psychopharm cases. If you don't like child psychiatry, push yourself to get the most out of it or even do extra rotations.
7. You can't learn it all
General psychiatrists are notoriously woeful at group therapy, family therapy, couples therapy, psychosexual medicine, sleep medicine, managing eating disorders, paraphilias, dissociative disorders, somatization, intellectual disability and autistic spectrum disorders. You may have to use your elective time, attend conferneces, do parallel additional training (especially for the psychotherapies) or learning after residency to get comfortable with some of these other areas. This does not necessarily mean doing a fellowship however. Medicine really is about lifelong learning
8. Explore what excites you and run with it
Intern year can be a drag. PGY-2 year can suck even more. You will enjoy your experience better if you can remember what it was that excited you about the specialty if the first place. If there wasn't anything - find it. Maybe its bioethics, palliative medicine, public psychiatry, forensics, addictions, psychodynamics, clinical neuroscience, administration, teaching, clinical interviewing, public engagement, technology ... whatever it is tell everyone what you're interests are. Try and make your rotations relevant to this. Meet with people early to see how to cultivate these interests. Identify kindred spirits (cointerns, residents, or psychiatrists in practice) who will support these interests and provide mentorship.
9. Find a mentor...or 10
Mentoring is extremely important for personal and professional development. Mentors don't have to be senior psychiatrists (or even psychiatrists at all). You may find that actually junior faculty and more available to help with that. Peer mentors (fellow residents) may also be invaluable. Look outside your program too - only a tiny minority of programs have "everything". Although it's better to have a connection put you in touch with someone, or use databases (for example AAAP has a mentoring database to identify psychiatrists) you can just ask people whether they would. Be gracious, you need to put in most of the effort, make the time for it, don't take your mentors for granted. Most of my mentors were not at my residency program. If you're interested in psychodynamics but don't have anyone at your program the AAPDP has a mentoring program (you can use skype etc).
And pay it forward...mentor medical students and undergrads etc - you have more to offer than you think!
10. Take advantage of opportunities outside of your program
If you're interested in global mental health but your program doesn't have opportunities other programs do! If you're interested in psychoanalytic training then you can do this with a local analytic institute. This can sometimes be done remotely if you aren't near one. There are training on a whole bunch of other therapies like hypnosis, EMDR, IPT, ISTDP, mentalization based treatment - it's usually much cheaper to do this as a resident.
There are also various national opportunities - for example the APA has a number of fellowship programs (public psych, minority, child psych, leadership) that provide leadership training, networking and mentoring opportunities. The NNCI has a scholarship program for residents interested in neuroscience education. the ACP has a PRITE Fellowship if you fancy writing the questions! the GAP has a fellowship program if you fancy writing on a taskforce and hob-knobbing with the great and good of American Psychiatry. There are usually travel awards to attend conferences such as the APM (psychosomatic), AAGP (geriatrics), AAAP (addictions), ASAM (addictions) meetings (or if you volunteer it will be free). These opportunities also allow you to meet with residents etc outside of your training program and develop your professional network and make friends etc. You will also be enthusiastically welcome if you wish to get involved with the subspecialty organizations or with your state psychiatric association/district branch.
11. Residency is supposed to suck
People who whine about how awful residency is typically do so from a vantage point of thinking that is supposed to be some wonderful utopia where they don't have to do any work and will be so much better than med school etc. Hate to break it to you but it is supposed to suck. Look at the facts: you don't have much autonomy or control, you are trapped because you can't afford to quit and it's hard to move around, likely crushed with six-figure debt, you are underpaid and at the mercy of people who could end your career if they so wished. It has all the hallmarks of what sociologists would call high job strain: a recipe for poor health.
Over 50% of psychiatry residents experience burn out. One of the reasons IMGs have much lower burnout rates is because they don't have a sense of entitlement or expectation of how wonderful it will be - they are grateful to have gotten a residency position and know that at the end of it they will enjoy significant autonomy and command a handsome salary.
If you remember it's supposed to suck you will enjoy it more because it's not as bad as that.
12. ...Remember you get to have a life!
Though the first year or two of residency can be hard, it's not surgery or one of those other dreadful specialties where the departrments own you and would begrudge you having a life. Enjoy your family, friends, old hobbies, new ones, traveling, etc etc.
Many of my students did not get their 1st choice (or even 2nd choice) program. There is this myth that everyone will get their top choice in psychiatry, and while the odds are good clearly that isn't true. I did not match at my first choice and know a lot of people who didn't (in fact they didn't even rank me despite telling my mentor who worked there that I had a good chance). But there's a stigma about it. People don't talk about. It's just assumed. When applicants asked me "why did you choose this program", I was just thinking "I didn't". After the initial shock and 4 years later I have to say it worked out very, very well and I think I would not have been well suited to my no.1. Remember, you are about to become a physician and begin your training in the most fascinating field of medicine and you can live where you want and practice where you want once you've finished. The outlook is very good because of how ridiculously uncompetitive fellowships are and the job market is very good compared to most other fields of medicine. You will likely enjoy a satisfying career that allows you to privilege lifestyle and be in at least the top 5% of earners.
Here are my thoughts:
1. It's open season on psychiatrists
Psychiatrists have long fallen from grace in the eyes of the public. Always the ugly step-child of medicine, psychiatrists were once the most respected medical specialtists by the general public. Today psychiatrists are seen as preaching pseudoscience, pathologizing all of mental life, peddling quack treatments, often under coercion or control and beholden to the pharmaceutical companies, ready to label and medicate anything that moves. The unholy alliance of psychiatry and the pharmaceutical industry has severely undermined the credibility of the profession.
2. Good enough is NOT good enough
As a result, it is no longer acceptable to simply want to be a "good-enough" psychiatrist in the Winnicottian sense. You should be aspiring to be the best psychiatrist you can - you owe to your chosen profession and your patients.
3. Learn the language of psychiatry
Descriptive psychopathology is the language of psychiatry and yet the vast majority of American psychiatrists lack fluency in it. If you don't know the difference between hallucinations and pseudohallucinations, pallilalia and verbigeration, word salad and transcortical sensory aphasia, ultradian cycling and emotional lability, then you will be diagnosing everyone with borderline personality disorder and schizoaffective disorder, and missing real brain disease like fronto-temporal dementia, stroke, epilepsy, and failing to distinguish psychosis from neurosis, and character disorder from neurosis. Potentially with disastrous consequences.
Fish's Clinical Psychopathology is a good place to start (though I prefer to older edition by Max Hamilton). Symptoms in the Mind by Sims is another.
For the adventurous:
Kraepelin E. Manic-Depressive Insanity and Paranoia. Edinburgh: Livingstone, 1921
Jaspers J. General Psychopathology. Chicago: University of Chicago Press, 1953
Bleuler E. Dementia Praecox: Or, the Group of Schizophrenias. New York: International Universities Press, 1950
Schneider K. Clinical Psychopathology. New York: Grune & Stratton, 1959
4. You can't make a diagnosis you haven't heard of before
Not heard of Ganser's syndrome, De Clerembault Syndrome, Othello Syndrome, Capgras syndrome, or Cotard syndrome? Then how will you ever identify them? (I have seen several cases of each of these)
Check out:
Enoch MD, Trethowan WH. Uncommon psychiatric syndromes. Bristol: John Wright & Sons, 1979
Friedmann CTH, Fauget RA. (Eds.) Extraordinary disorders of human behavior. New York: Plenum Press, 1982
5. Don't forget about the Brain!
While learning about the neurobiological basis of psychiatric syndromes is all well and good some of this is pseudoscience and the rest does not have any clinical relevance. But having a working knowledge of the neuroanatomy of emotion is a must for the 21st century psychiatrist.
Also being able to recognize when your patient actually has brain disease is the most important thing you can do as a psychiatrist! But it requires suspicious, curiosity, and the last point, for you to have heard of the diagnosis. I have seen patients with VGKC antibody limbic encephalitis presenting with catatonia, SLE presenting with schizophreniform psychosis, frontal-variant Alzheimer's presenting as mania, temporal lobe epilepsy presenting as intermittent explosive disorder , bvFTD presenting as psychotic depression, semantic dementia presenting as depression etc... sadly neuropsychiatry is not part of the skillset of the general psychiatrists and many patients are being misdiagnosed.
Check out:
Lishman's Organic Psychiatry
Texbook of Clinical Neuropsychiatry
6. Step out of your comfort zone
We learn the most when we step out of our comfort zone. in fact there are probalby only a few months of your entire residency where most of your learning happens. Adapted from Donald Light's sociological calendar - these are probably your first month of medicine, first month of inpatient psych, first nightfloat/night call block, first therapy patient, starting outpatient. If you are averse to psychotherapy then learn as much as you can and get as much experience in this. If you are not keen on psychopharm, master this and take on complex psychopharm cases. If you don't like child psychiatry, push yourself to get the most out of it or even do extra rotations.
7. You can't learn it all
General psychiatrists are notoriously woeful at group therapy, family therapy, couples therapy, psychosexual medicine, sleep medicine, managing eating disorders, paraphilias, dissociative disorders, somatization, intellectual disability and autistic spectrum disorders. You may have to use your elective time, attend conferneces, do parallel additional training (especially for the psychotherapies) or learning after residency to get comfortable with some of these other areas. This does not necessarily mean doing a fellowship however. Medicine really is about lifelong learning
8. Explore what excites you and run with it
Intern year can be a drag. PGY-2 year can suck even more. You will enjoy your experience better if you can remember what it was that excited you about the specialty if the first place. If there wasn't anything - find it. Maybe its bioethics, palliative medicine, public psychiatry, forensics, addictions, psychodynamics, clinical neuroscience, administration, teaching, clinical interviewing, public engagement, technology ... whatever it is tell everyone what you're interests are. Try and make your rotations relevant to this. Meet with people early to see how to cultivate these interests. Identify kindred spirits (cointerns, residents, or psychiatrists in practice) who will support these interests and provide mentorship.
9. Find a mentor...or 10
Mentoring is extremely important for personal and professional development. Mentors don't have to be senior psychiatrists (or even psychiatrists at all). You may find that actually junior faculty and more available to help with that. Peer mentors (fellow residents) may also be invaluable. Look outside your program too - only a tiny minority of programs have "everything". Although it's better to have a connection put you in touch with someone, or use databases (for example AAAP has a mentoring database to identify psychiatrists) you can just ask people whether they would. Be gracious, you need to put in most of the effort, make the time for it, don't take your mentors for granted. Most of my mentors were not at my residency program. If you're interested in psychodynamics but don't have anyone at your program the AAPDP has a mentoring program (you can use skype etc).
And pay it forward...mentor medical students and undergrads etc - you have more to offer than you think!
10. Take advantage of opportunities outside of your program
If you're interested in global mental health but your program doesn't have opportunities other programs do! If you're interested in psychoanalytic training then you can do this with a local analytic institute. This can sometimes be done remotely if you aren't near one. There are training on a whole bunch of other therapies like hypnosis, EMDR, IPT, ISTDP, mentalization based treatment - it's usually much cheaper to do this as a resident.
There are also various national opportunities - for example the APA has a number of fellowship programs (public psych, minority, child psych, leadership) that provide leadership training, networking and mentoring opportunities. The NNCI has a scholarship program for residents interested in neuroscience education. the ACP has a PRITE Fellowship if you fancy writing the questions! the GAP has a fellowship program if you fancy writing on a taskforce and hob-knobbing with the great and good of American Psychiatry. There are usually travel awards to attend conferences such as the APM (psychosomatic), AAGP (geriatrics), AAAP (addictions), ASAM (addictions) meetings (or if you volunteer it will be free). These opportunities also allow you to meet with residents etc outside of your training program and develop your professional network and make friends etc. You will also be enthusiastically welcome if you wish to get involved with the subspecialty organizations or with your state psychiatric association/district branch.
11. Residency is supposed to suck
People who whine about how awful residency is typically do so from a vantage point of thinking that is supposed to be some wonderful utopia where they don't have to do any work and will be so much better than med school etc. Hate to break it to you but it is supposed to suck. Look at the facts: you don't have much autonomy or control, you are trapped because you can't afford to quit and it's hard to move around, likely crushed with six-figure debt, you are underpaid and at the mercy of people who could end your career if they so wished. It has all the hallmarks of what sociologists would call high job strain: a recipe for poor health.
Over 50% of psychiatry residents experience burn out. One of the reasons IMGs have much lower burnout rates is because they don't have a sense of entitlement or expectation of how wonderful it will be - they are grateful to have gotten a residency position and know that at the end of it they will enjoy significant autonomy and command a handsome salary.
If you remember it's supposed to suck you will enjoy it more because it's not as bad as that.
12. ...Remember you get to have a life!
Though the first year or two of residency can be hard, it's not surgery or one of those other dreadful specialties where the departrments own you and would begrudge you having a life. Enjoy your family, friends, old hobbies, new ones, traveling, etc etc.
