What factors to determine rank list?

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microshar88

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Hi,
As interview season draws to an end, I was wondering what factors you guys are using to make your rank list?
I honestly don't know if I'm doing it right, but I'm just using where residents seem the happiest and where I got a good feeling of camaraderie amongst facutly and residents. I don't know if this is what I should be looking at as they could be brilliant actors.

The newer programs I have gone to seem to boast about not having call or having little call but I think that might be at the detriment of learning. Salary is not so much important to me. I don't care about weather or having an up&coming city either.

As I try and read through my notes, I'm wondering what things are by and large factors that you folks are considering?

Thanks for any feedback.

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location, location, location

...perhaps to the cry of program directors everywhere. There have been programs that have made me reconsider where I want to be located based on how much I enjoyed them though. Faculty is a big one for me. I've had interactions, either during formal interviews or didactics or program overviews, that have seriously swayed me. Just people that I find I have an affinity for, that I don't feel I have to put up any pretenses with. I appreciate when a PD can cut through the BS, be honest about the program and show some sign that they actually want me for their program.

Programs I don't like have been those that curtail introductions and cart me off to interviews right away like I am cattle. They have me doing 6-7 interviews, 15 minutes each with miserable people who read questions from a sheet of paper right in front of me. Or pre-interview quizzes? Vignettes? Maybe in my first few interviews I would have tolerated that but after just doing my 7th today, I would find it hard to hide my resentment.

Jamaica hospital in particular, I wish applicants would just collectively agree to boycott their program, it's the most insulting interview process I've ever heard of. A guy today told me they even go over your pre-test results in front of you and keep on pimping you throughout the interview. Ugh
 
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Hi,
As interview season draws to an end, I was wondering what factors you guys are using to make your rank list?
I honestly don't know if I'm doing it right, but I'm just using where residents seem the happiest and where I got a good feeling of camaraderie amongst facutly and residents. I don't know if this is what I should be looking at as they could be brilliant actors.
So could all of you... ;)
 
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The newer programs I have gone to seem to boast about not having call or having little call but I think that might be at the detriment of learning. Salary is not so much important to me. I don't care about weather or having an up&coming city either.

Thanks for any feedback.

What psychiatric diseases present only at night when someone is on call?

My program has little call, so many residents moonlight. This allows you to experience other systems, settings, etc while giving you more experience. Oh and you get paid for the extra work. :)
 
Things I'm considering:

-Have access to things that I'm interested in with respect to my career (i.e., in my case medical education and therapy work)

-Location; I'm bringing my soon-to-be-wife along with me, so for better or worse I have to take into account where she wants to go

-General vibe of faculty/resident interactions, i.e., how supportive the faculty are with respect to teaching and supporting the residents vs. leading an army of grunts that just needs to get work done

-Ability to moonlight

Frankly I don't care too much about call as long as it isn't onerous. While call may be a beating I see it as an advantage; during med school I always found that I learned the most when I was in the "hot seat" so to speak, so having the opportunity to work somewhat independently is tremendously advantageous from an educational standpoint for me. I also think it's something that seems to be way overblown in terms of importance here. I get that you don't want to be slaving away q4 or whatever the abhorrent call systems are, but I like the idea of flying solo to some degree and building your chops in that kind of situation.

It's going to be tough submitting the rank list, though. I'm very happy with the top 3 I currently have and would have no problem going to any of them. It'll be tough choosing which one will be #1.
 
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What psychiatric diseases present only at night when someone is on call?

My program has little call, so many residents moonlight. This allows you to experience other systems, settings, etc while giving you more experience. Oh and you get paid for the extra work. :)

I cannot emphasize this enough. The idea that ****ty call schedules get sold as "you learn so much" is one of the biggest loads of crap in modern medicine. We continue to eat it up. Whenever the idea of moonlighting comes up, people come out on their high horse about how it's "not supervised," as if the attending that you're waking up at 2 AM in a sleep stupor is actually giving you good educational pearls on your patients that they have never laid eyes on. Midway through my second year, I can honestly say that there has probably been a once or twice on call where I have felt I have learned or benefited in anyway from the attending who is on call by phone. It typically serves as a roadblock, occasionally requiring you to make clinical decisions that are inappropriate because the attending has not laid eyes on them. Then you just end up looking like "the idiot who was on call last night."

Bottom line: you could learn a lot from call. You'll reach this point rather quickly, however. I would imagine most all programs have you reaching this point rather soon.

-someone very burned out on call waiting for a checkout call to end their second 24 hour shift in 72 hours.

#NotWorthIt
 
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Things I'm considering:

-Have access to things that I'm interested in with respect to my career (i.e., in my case medical education and therapy work)

-Location; I'm bringing my soon-to-be-wife along with me, so for better or worse I have to take into account where she wants to go

-General vibe of faculty/resident interactions, i.e., how supportive the faculty are with respect to teaching and supporting the residents vs. leading an army of grunts that just needs to get work done

-Ability to moonlight

Frankly I don't care too much about call as long as it isn't onerous. While call may be a beating I see it as an advantage; during med school I always found that I learned the most when I was in the "hot seat" so to speak, so having the opportunity to work somewhat independently is tremendously advantageous from an educational standpoint for me. I also think it's something that seems to be way overblown in terms of importance here. I get that you don't want to be slaving away q4 or whatever the abhorrent call systems are, but I like the idea of flying solo to some degree and building your chops in that kind of situation.

It's going to be tough submitting the rank list, though. I'm very happy with the top 3 I currently have and would have no problem going to any of them. It'll be tough choosing which one will be #1.

You're doing great with these criteria. But you're right to think carefully about your number one...why?...because you're going to go there. I'll bet you a pitcher of beer.

I used a similar criteria set and I think it's been battle tested with internship and held up even past my doubts.

St2205's post is interesting--I've yet to make up my mind on the benefits of workload, but the moonlighting criteria is underestimated in the applicant pool. The program that facilitates that deserves a bump up in the rank list other things being equal.
 
microshar88- Go where you think you'll be happiest. That may sound like a non-answer, but people don't take it to heart enough.

Do some navel gazing and figure out what will make you happy for the next four years. If you are gunning for a high-end academic career, going to a research powerhouse might make you happiest. If you are very outdoors oriented and find a lot of satisfaction and enjoyment from spending time in a beautiful environment, that might make you happiest. If you have a partner with a very specific career who has supported you through all of this, taking his/her needs into account might make you happiest.

Do not choose based on arbitrary rankings or what a bunch of people on SDN recommend as some blanket criteria. Residency is about 90% what you put into it and you will be able to put a lot more into it if you're happy. I'd come out a much better resident at a county-focused ho-hum reputation residency in a place I love than four years in Boston at MGH. Figure out what you love and what will make you happiest for four years and rank accordingly.
 
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As for the call thing... it's just call. Psychiatrists treat call like cats treat water for some reason. It's part of training.

Can you get by without doing any call and come out a good psychiatrist? Sure. Can you go to a program with a fair bit of call with good supervision and come out a better psychiatrist. Sure.

How does it factor into choosing a program? Read my post above. If you will be happier going to a strong program with a lot of call than you would a less strong program with less call, go for the former. If not, go for the latter.

Call is just the cost of doing any residency and we have WAY less than almost any other field. The heaviest psychiatry call burden is lighter than the lightest family practice residency. The less call we have, the more we tend to fixate on it. As to how much it adds to the training, that's debatable. It's worth noting that if you apply broadly, you'll find most programs run the gamut with amount of call but if you look at the programs many people would agree are among the best, the call burden tends to be on the higher end of the scale. I wouldn't confuse causation with correlation, but there you go.

Figure out how important avoiding call is to your happiness, weigh it against your career priorities, and rank accordingly. Happy psychiatrist = better psychiatrist.
 
Call is just the cost of doing any residency and we have WAY less than almost any other field. The heaviest psychiatry call burden is lighter than the lightest family practice residency. .

Not true. You don't hear about the worst psych programs on sdn, because no one wants to attend these places. There are still places that will work you ragged.

Call is part of medicine. I have nothing against it, and I actually get paid quite well to take moonlighting call. I doubt that many places have faculty that want to do quality teaching at 3am with me awake enough to retain it.
 
I am going with my gut feelings, along with a list of not so psych related criteria that increase or decrease a program's rank. I feel like once you reach a certain level of programs, you will finish with great clinical training, excellent resources to help you go onto your career, and give you the skills necessary to do well. The things that differ between programs really comes down to things like location, which can be hugely important especially for those with families; extra-curricular activities, such as specific research areas or faculties, and program specific philosophies. I do agree that every time I hear from residents that "you learn a lot on call/night float", I think to myself "well I can learn just as well if not better during the day". However, overall it has very little if any weight on how I rank programs because it is part of the job, and most programs aren't in it to kill you, after-all we are going into one of the most supportive and caring of the medical fields.

On a totally unrelated note, it seems there are a lot more well qualified applicants this year compared to past years from my own experience and word on the interview trail. Great for the profession, though uncertain about how it will shake out for those of us applying this year. (Mainly from @Nasrudin's response to @NickNaylor).
 
Not true. You don't hear about the worst psych programs on sdn, because no one wants to attend these places.
Sorry, good point. My statement only applies to non-sweatshops. There is definitely a number of those, and the call burden is heavy. This is true for the sweatshops in psychiatry and family practice that target folks who have no opportunities elsewhere.

I'd still differentiate call from moonlighting, but I think we probably will agree to disagree on that one. Aside from the support you get if and when you call your faculty back-up, you have a much different experience doing call at a location where you are a resident vs. being a part-time employee.
 
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That may sound like a non-answer, but people don't take it to heart enough.

Right answer. You'll do your best where you are happiest. I think medical training has shoved a notion that reputation, being most-competitive, and suffering somehow means best program. It doesn't.
 
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Rank based on optimizing your support network, and your academic thirst to excel.

If that means a place with reasonable call, then great. But if that means a place being close to parents to help with your new baby with lots of call, then that trade-off is worth it in my book.
 
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It's hard to get a reliable measure of camaraderie or "gut feel" from your interview day. I go to a lot of applicant dinners, and the impression you get of the camaraderie at those dinners is based on a very small n-value... I've been to dinners where we all seemed like we'd been best friends since childhood, and I've been to others where the conversation naturally drifted to more professional topics (although we always look like good friends because we are).

When I was on the interview trail 2 years ago (wow, has it been 2 years?), I also often got the vibe that some programs were good at selectively exposing you only to the residents who were most excited about demonstrating camaraderie and selling the program. If you only meet 5-6 residents in your interview experience, suspect that those 5-6 are the ones that are most enthusiastic about recruitment (which is why they volunteered to help recruit you), and are likely to give you the most positive image about their camaraderie.

I know that this is might seem like a bit of a veiled sales pitch for my program, so I'll take away the veil and just be frank about it. If you interview here (WashU), you'll meet at least 10-15 residents (probably more like 20), they'll all know each other well and be friends/acquaintances with each other (because all 40 of us have good relationships), and they'll all tell you that they've never second-guessed their decision to come here. You'll see us joking around with faculty members and later explaining how much intellectual respect we have for the person with whom we were just exchanging witty banter.

I'm sure that plenty of other programs will offer you the same impression of their camaraderie, but remember that the n-value is critical.

I think the main thing that breeds camaraderie among residents is intellectual compatibility. I went on 17 interviews, and I always felt like I fit in better at the places where I felt like the residents were relatively smart (and there were plenty of places where I didn't get that impression) and spoke English well (which, sadly, was also often not the case). Most programs, however, did have that intellectual compatibility among residents, and therefore most programs clearly had residents that get along with one another well. If you try to compare programs by camaraderie, you're likely to be basing your impressions on just the camaraderie among the 5 residents that took you to dinner - if you average out all 40 residents in the program, I'll bet that most programs will be the same.
 
It's hard to get a reliable measure of camaraderie or "gut feel" from your interview day. I go to a lot of applicant dinners, and the impression you get of the camaraderie at those dinners is based on a very small n-value... I've been to dinners where we all seemed like we'd been best friends since childhood, and I've been to others where the conversation naturally drifted to more professional topics (although we always look like good friends because we are).

When I was on the interview trail 2 years ago (wow, has it been 2 years?), I also often got the vibe that some programs were good at selectively exposing you only to the residents who were most excited about demonstrating camaraderie and selling the program. If you only meet 5-6 residents in your interview experience, suspect that those 5-6 are the ones that are most enthusiastic about recruitment (which is why they volunteered to help recruit you), and are likely to give you the most positive image about their camaraderie.

I know that this is might seem like a bit of a veiled sales pitch for my program, so I'll take away the veil and just be frank about it. If you interview here (WashU), you'll meet at least 10-15 residents (probably more like 20), they'll all know each other well and be friends/acquaintances with each other (because all 40 of us have good relationships), and they'll all tell you that they've never second-guessed their decision to come here. You'll see us joking around with faculty members and later explaining how much intellectual respect we have for the person with whom we were just exchanging witty banter.

I'm sure that plenty of other programs will offer you the same impression of their camaraderie, but remember that the n-value is critical.

I think the main thing that breeds camaraderie among residents is intellectual compatibility. I went on 17 interviews, and I always felt like I fit in better at the places where I felt like the residents were relatively smart (and there were plenty of places where I didn't get that impression) and spoke English well (which, sadly, was also often not the case). Most programs, however, did have that intellectual compatibility among residents, and therefore most programs clearly had residents that get along with one another well. If you try to compare programs by camaraderie, you're likely to be basing your impressions on just the camaraderie among the 5 residents that took you to dinner - if you average out all 40 residents in the program, I'll bet that most programs will be the same.

I'd agree that there's a certain degree of theater going on, but the interview dinners and other interactions with residents have a high sensitivity but a low specificity. In other words, I've been surprised at what some residents will candidly say to applicants - some of which is concerning. You may not be able to judge "camaraderie" all that well, but you can certainly identify some overtly problematic things if a resident volunteers the information.
 
The whole purpose of these interviews is to detect any obvious red flags in both parties, otherwise it is unwise to consider the amount of time spent on average 7 hours enough to know if the applicant or the program is friendly or not. #Imjustsaying
 
Residency is about 90% what you put into it and you will be able to put a lot more into it if you're happy. I'd come out a much better resident at a county-focused ho-hum reputation residency in a place I love than four years in Boston at MGH. Figure out what you love and what will make you happiest for four years and rank accordingly.

I agree broadly with that statement, in that the most important factor in determining how good of a residency experience and how good a psychiatrist you will become, is dependent on YOU. That said you rank list should reflect which programs are the best FIT for you. Based on my experience through half of residency, these are questions I would try to ask myself to determine the fit and thus my rank list:

Happiness:
1. How important is having your friends and family around to you? If you away form them, how adaptable are you to a new culture ad social life? Moving to a new city and working long hours in a demanding job through intern year) is a reality, and people do leave programs because they may feel isolated and unsupported.
2. Can you still find activities in the new city that will rejuvenate you? How important is sunshine and outdoors and urban cities to you?
3. Can you find the right community to fit in?

Program:
1. Is the program director, associate program directors, mentors, supervisors, and unit directors supportive of residents?
2. Does the independence/hand-holding of the residency suitable for your clinical personality?
3. Are you seeking intellectual stimulation of academic centers, and want to immerse yourself in a culture that is open to new research ideas? How nerdy are you deep down?
4. How important is psychodyanmics? This seems to be me to be one of the biggest areas of variability between regions and even within academic programs. Does the residency have an affiliated psychoanalytic institute or a psychotherapy training program?
5. How hard do you want to work? Busy programs are stressful, but with higher clinical workloads are opportunities to see more diverse and sick patients, and to manage them more independently. How much do you want to be pushe to grow? The corollary is, how prone are you to burnout from work stress?
6. Are you set on a specific type of psychiatry career? If not, how diverse are you interests? If you are undifferentiated, do you want to exposed to be a lot of subspecialities?
7. How well do you interact with narcissists, and can get past your counter-transference and cherry pick their knowledge and wisdom?
8. How much does brand-name really matter to your self esteem? Do you want to be a big fish in a little pond, or a little fish in a big pond?
9. A good estimate of how strong a program is: how many suprevisors and how many hours of supervision a week do residents have in clinic? Is there outpatient clinic starting in PGY2? Another good estimate is: how many clinical faculty, and for academically-oriented folks, how many research faculty are there in the department?

I found the process of figuring out all these questions, and thus the right fit, was most helpful reflecting on my medical school and work experience, and spending the time to talk to people that knew me personally and professionally, as well as people I respected in the field. Reach out to your friends, family, seniors, residents, mentors and PDs at both your home program and programs you are applying to!
 
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I agree broadly with that statement, in that the most important factor in determining how good of a residency experience and how good a psychiatrist you will become, is dependent on YOU. That said you rank list should reflect which programs are the best FIT for you. Based on my experience through half of residency, these are questions I would try to ask myself to determine the fit and thus my rank list:

Happiness:
1. How important is having your friends and family around to you? If you away form them, how adaptable are you to a new culture ad social life? Moving to a new city and working long hours in a demanding job through intern year) is a reality, and people do leave programs because they may feel isolated and unsupported.
2. Can you still find activities in the new city that will rejuvenate you? How important is sunshine and outdoors and urban cities to you?
3. Can you find the right community to fit in?

Program:
1. Is the program director, associate program directors, mentors, supervisors, and unit directors supportive of residents?
2. Does the independence/hand-holding of the residency suitable for your clinical personality?
3. Are you seeking intellectual stimulation of academic centers, and want to immerse yourself in a culture that is open to new research ideas? How nerdy are you deep down?
4. How important is psychodyanmics? This seems to be me to be one of the biggest areas of variability between regions and even within academic programs. Does the residency have an affiliated psychoanalytic institute or a psychotherapy training program?
5. How hard do you want to work? Busy programs are stressful, but with higher clinical workloads are opportunities to see more diverse and sick patients, and to manage them more independently. How much do you want to be pushe to grow? The corollary is, how prone are you to burnout from work stress?
6. Are you set on a specific type of psychiatry career? If not, how diverse are you interests? If you are undifferentiated, do you want to exposed to be a lot of subspecialities?
7. How well do you interact with narcissists, and can get past your counter-transference and cherry pick their knowledge and wisdom?
8. How much does brand-name really matter to your self esteem? Do you want to be a big fish in a little pond, or a little fish in a big pond?
9. A good estimate of how strong a program is: how many suprevisors and how many hours of supervision a week do residents have in clinic? Is there outpatient clinic starting in PGY2? Another good estimate is: how many clinical faculty, and for academically-oriented folks, how many research faculty are there in the department?

I found the process of figuring out all these questions, and thus the right fit, was most helpful reflecting on my medical school and work experience, and spending the time to talk to people that knew me personally and professionally, as well as people I respected in the field. Reach out to your friends, family, seniors, residents, mentors and PDs at both your home program and programs you are applying to!
Well done
 
For pregnant moms to be out there like me, I have been factoring security on in patient units. I had someone get ridiculously close to me on the in-patient unit where I was touring during the interview and I got very worried especially when the security nurse/guard was not in a reasonable distance.

On my audition rotation, I saw someone take a fork from the plate and stab another patient in the eye. I really do not want to have to deal with this abuse while I am expecting.
 
For pregnant moms to be out there like me, I have been factoring security on in patient units. I had someone get ridiculously close to me on the in-patient unit where I was touring during the interview and I got very worried especially when the security nurse/guard was not in a reasonable distance.

On my audition rotation, I saw someone take a fork from the plate and stab another patient in the eye. I really do not want to have to deal with this abuse while I am expecting.

How do you objectively analyze that? The rate of any psych patient attacking is pretty low anyway. The worst that occurred in 4 years with all my co-residents was a geriatric lady lightly slapping a resident for getting too close.
 
The most important factor by far is to go where you want to live. Whether that be because your family is close, your spouse wants to, you love the beach or the country or a certain mountain range or whatever.....go where you want to live the next 4 years. Everything else is either pretty equivalent(salary for example), hard to gauge ahead of time(will I like my co residents), or just not that important in the long run.
 
How do you objectively analyze that? The rate of any psych patient attacking is pretty low anyway. The worst that occurred in 4 years with all my co-residents was a geriatric lady lightly slapping a resident for getting too close.


when you look at county facilities, that go on strike occasionally, you can compare the guards on the floors to private facilities. You are correct this is not objective 100% but its pretty darn close.
 
when you look at county facilities, that go on strike occasionally, you can compare the guards on the floors to private facilities. You are correct this is not objective 100% but its pretty darn close.

Comparing the guards on 1 shift based on?

Most psych facilities I've worked at have had frequent turnover of staff. Add multiple shifts, strikes, shortages, etc. and you are up against an impossible task in objectively evaluating them this far in advance in only 1 day with limited time to evaluate them.

If you really want to stay safe, I would avoid programs with extensive prison time and possibly ER. Those locations are by far more dangerous regardless of security. Some inmates can rationalize that violence couldn't worsen their lives. ER sees the most psych patients actively high on PCP or whatever.
 
when you look at county facilities, that go on strike occasionally, you can compare the guards on the floors to private facilities. You are correct this is not objective 100% but its pretty darn close.
It's 0% close. County facilities can be smelly and not nearly as pretty as private facilities, but it has little to do with safety. And the county facilities that "go on strike occasionally?" Often times it has to do with things like nurse-to-patient ratio and a slew of safety features (staff safety is pretty much the bread and butter of unions).

A unit's safety is largely the product of patient acuity and policy. Private facilities are frequently safer than county environments, but this is typically because private facilities require payment that your most acute patients will not be able to access and private facilities will often cherry pick admissions. The more acute the patients, the higher the risk of assault (to staff or peers). But policy has a lot more to do with it and I've felt safer on good county units than poor private ones. What's the nurse-to-patient ratio? What's the average length of stay? What's the use of PRNs and emergent medications like? What are the seclusion and restraints policy? How much structured activity are available during the day? How is the social work support? Etc.

And things can go bad anywhere, and when they do, you'll be much happier working at that county environment where folks react like a well-oiled machine. I do a lot of acute/inpatient work and when I reflect on situations that went south, the times I was most concerned was on the private facility where the staff do not have the mindset or practice (or often inclination) to deal with unexpected situations.

Dozens of factors are at play and you won't be able to decipher it by observation or questioning on a tour. It's experiential and the pieces don't fall into play until you've spent significant time on inpatient/acute units. Using your example of the patient that got "ridiculously close" is a great one. I've seen medical students take ridiculous precautions (to the point that they are barely practicing psychiatry) for certain patients who don't require it. I've also seen medical students get close to certain patients that I practically consider putting on a spit mask prophylactically. You learn with time, but folks who pretend it's simple are missing things.
 
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If you really want to stay safe, I would avoid programs with extensive prison time and possibly ER. Those locations are by far more dangerous regardless of security. Some inmates can rationalize that violence couldn't worsen their lives. ER sees the most psych patients actively high on PCP or whatever.
Totally agree with all of your points, but I'd quibble with the last one.

Statistically when it comes to assaults against doctors, prisons have some of the best safety records. At many prisons, you are always separated by a door and/or with a correctional officer present. You tend to work with very chronic patients who are known entities. This is far more safe than what is statistically the area that most assaults happen against doctors (the ER). Safety tends to be better at a prison than most county inpatient units.

I'm biased, because I'm more acute psychiatry focused, but I find it interesting that folks always fixate on the inpatient units for issues of safety. On a good unit, you are usually line-of-sight with staff, often have a screamer, are seconds from support if things go sour, have immediate access to IMs, etc. I've had more moments when I felt uncomfortable/unsafe doing outpatient psychiatry. Sitting in a room alone with someone as you slowly realize that their psychopathology is MUCH different than what it looked like at first glance. The hair on my neck stands up in those situations more than on inpatient.
 
Totally agree with all of your points, but I'd quibble with the last one.

Statistically when it comes to assaults against doctors, prisons have some of the best safety records. At many prisons, you are always separated by a door and/or with a correctional officer present. You tend to work with very chronic patients who are known entities. This is far more safe than what is statistically the area that most assaults happen against doctors (the ER). Safety tends to be better at a prison than most county inpatient ......

At the few prisons I've worked, there is no door between you and the prisoner. The guards are fine, but you may be dealing with someone with little or no morals. The ability and desire to demonstrate abrupt violence is the biggest danger. Prisons and ER's are the highest odds of finding these people in my opinion.

On an inpatient unit, I can sense/see the agitation developing in almost all cases. I know when to back off. I'd say the ob unit with slippery floors, family drama, airborne bodily fluids, and wide range of emotions is more dangerous. :)
 
On an inpatient unit, I can sense/see the agitation developing in almost all cases. I know when to back off. I'd say the ob unit with slippery floors, family drama, airborne bodily fluids, and wide range of emotions is more dangerous. :)
Ditto for the general medical units, where agitated patients have IV poles to swing, among other available weaponizable objects, and staff are less prepared/expectant for potential violence. A nearby hospital had 2 med-surg RNs seriously injured recently.
 
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