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[Celexa]

Somewhere between 1 and all of them.

You gotta give us more than that if you want useful answers. It's not at all hard to match in general.

 

[swamzi]

CL ain't that competitive, most people want to make attending salaries sooner than later and just learn on the job.

 

[FlowRate]

If you're planning to apply to a "top" fellowship then probably more than one. At least one "top" CL fellowship that I'm very familiar with ends up really being about how many internal candidates are applying and, of those, how many they like.

 

[Celexa]

If you're planning to apply to a "top" fellowship then probably more than one. At least one "top" CL fellowship that I'm very familiar with ends up really being about how many internal candidates are applying and, of those, how many they like.

This is true of all programs. Most programs have only one or two spots. A program that went unfilled two years in a row might be unobtainable in a given year if they're keeping their internal candidate or candidates. That's just the nature of a small subspecialty.

There's really no exclusionary criteria from "top" CL programs broadly defined--nearly all have taken DOs and/or IMGs recently if I'm remembering my own research two cycles ago accurately--but without the OP providing even basic demographic info or geographic preferences there's really no useful advice that can be given.

 

[comp1]

This is so hard to say. This is NOT a competitive fellowship. So much of matching will be knowing the right people. Many programs (and applicants) likely have their selections already made internally. It's not exactly like residency. If you know the right people, you only need to apply to one. If you don't know anyone at the "top" program you want to go to, then you probably need to be applying to several.

 

[Sushirolls]

If you aren't going to in C/L for transplant psychiatry and intend to work for a transplant center as their psychiatrist.... just don't do it.

Complete waste of time, and marginal gain. Unless you trained at weak program with tiny hospitals, then perhaps going somewhere like CCF / 1000+ bed hospital could be a knowledge gain. But seriously, just don't.

The only medical specialty that conjured up a fellowship year to do "consults."

 

[Sushirolls]

And the liaison part? There is no liaison. It's "thank God psychiatry is here" and then the primary service walk away and admin walks away ands says you deal with it. But yet they still might hold meetings, you know, to waste time, virtue signaling ritual, but really, they just want you to step up and solve the mess.

Nursing staff liaison? That's like trying build a sand castle on a beach. Looks pretty for an hour or so, got the mission accomplished, perfect spires and sand shell gate. But new waves of new nurses come crashing in or they forget and behavioral interventions you pushed for all just washed away.

C/L may as well call it Rapid Delirium Team.
Your second home will be the ED.

 

[Merovinge]

If you aren't going to in C/L for transplant psychiatry and intend to work for a transplant center as their psychiatrist.... just don't do it.

Complete waste of time, and marginal gain. Unless you trained at weak program with tiny hospitals, then perhaps going somewhere like CCF / 1000+ bed hospital could be a knowledge gain. But seriously, just don't.

The only medical specialty that conjured up a fellowship year to do "consults."

This feels like 50% of the folks going into CL fellowships. Plain ole fellowship washing of the resume. Why look at University of Albuquerque certificate when you can spend a year and then just tell everyone you trained at Harvard (no offense to any real or imaginary programs in Albuquerque).

 

[Stagg737]

This feels like 50% of the folks going into CL fellowships. Plain ole fellowship washing of the resume. Why look at University of Albuquerque certificate when you can spend a year and then just tell everyone you trained at Harvard (no offense to any real or imaginary programs in Albuquerque).

Was about to say that some of the foremost research in the world on psychopathy is at UNM. Sounds like a stellar place to get a deep understanding of all our Cluster B C/L and ER patients, lol.

 

[Celexa]

And the liaison part? There is no liaison. It's "thank God psychiatry is here" and then the primary service walk away and admin walks away ands says you deal with it. But yet they still might hold meetings, you know, to waste time, virtue signaling ritual, but really, they just want you to step up and solve the mess.

Nursing staff liaison? That's like trying build a sand castle on a beach. Looks pretty for an hour or so, got the mission accomplished, perfect spires and sand shell gate. But new waves of new nurses come crashing in or they forget and behavioral interventions you pushed for all just washed away.

C/L may as well call it Rapid Delirium Team.
Your second home will be the ED.

Aw c'mom now Sushi I already knew I made bad life decisions you don't have to rub it in

Jk. Despite the opportunity costs I'm glad I did fellowship because it does matter for my very specific current interests (namely, teaching) and without it I wouldn't have been in the position to negotiate as aggressively regarding my faculty position. And my experiences on big academic CL services, while full of frustration, don't particularly resemble this miserable portrait. We don't actually spend much time in the ED bc we only see people who are actually admitted to the hospital. Anyone being dispo'd from the ED is seen by a separate service. I get to see the full range of absolute bat**** cases on a regular basis. Most of the time either the patients or the teams (sometimes even both!) are genuinely grateful for my help. I spend a lot of my day pretty active and not trapped at my desk/in my office.

That being said, if I leave academics it won't be for a non-academic CL job, it'll be for full time private practice. Ive talked to enough people about experiences elsewhere to know that outside my academic bubbles your description is frequently apt.

Any psych fellowship other than child really only makes sense for a very narrow, specific set of career goals. I see a lot of hesitance and anxiety about making the leap to the big bad real world and fellowship-seeking-as-safety-behavior.... I strongly discourage that and try to push residents to really think about what they want from their job, and not just do the easiest next step.

That being said, the OP didn't ask if they SHOULD do fellowship, only about how many programs to apply to, but we still don't have any information from which to advise on that point...

 

[G Sheb]

Aw c'mom now Sushi I already knew I made bad life decisions you don't have to rub it in

Jk. Despite the opportunity costs I'm glad I did fellowship because it does matter for my very specific current interests (namely, teaching) and without it I wouldn't have been in the position to negotiate as aggressively regarding my faculty position. And my experiences on big academic CL services, while full of frustration, don't particularly resemble this miserable portrait. We don't actually spend much time in the ED bc we only see people who are actually admitted to the hospital. Anyone being dispo'd from the ED is seen by a separate service. I get to see the full range of absolute bat**** cases on a regular basis. Most of the time either the patients or the teams (sometimes even both!) are genuinely grateful for my help. I spend a lot of my day pretty active and not trapped at my desk/in my office.

Totally.
I'd push back a bit against CL fellowship being useless if you're interested in academics.
The most interesting cases are on CL and the bit of extra training absolutely helps. You can learn on the job I guess but there will be a learning curve. CL in some of the academic places can be heavy on teaching and some can be quite chill as well. In my residency, it was where we learned the most and spent the most time with patients.

 

[swamzi]

If you aren't going to in C/L for transplant psychiatry and intend to work for a transplant center as their psychiatrist.... just don't do it.

Complete waste of time, and marginal gain. Unless you trained at weak program with tiny hospitals, then perhaps going somewhere like CCF / 1000+ bed hospital could be a knowledge gain. But seriously, just don't.

The only medical specialty that conjured up a fellowship year to do "consults."

 

[Merovinge]

Was about to say that some of the foremost research in the world on psychopathy is at UNM. Sounds like a stellar place to get a deep understanding of all our Cluster B C/L and ER patients, lol.

Dang, I didn't even realize it was a real program. Just finished Better Call Saul so it was the most remote place that sprang to mind.

 

[Stagg737]

Totally.
I'd push back a bit against CL fellowship being useless if you're interested in academics.
The most interesting cases are on CL and the bit of extra training absolutely helps. You can learn on the job I guess but there will be a learning curve. CL in some of the academic places can be heavy on teaching and some can be quite chill as well. In my residency, it was where we learned the most and spent the most time with patients.

I don't think it's useless, but if someone knows they want to do C/L work, I think it's one of the few times when doing a dual Med/Psych program is actually a good choice. It's a lot easier to stay up to date on medical issues when you're addressing them regularly in residency instead of having to go back and relearn a lot of medicine after PGY-4 of a general psych residency.

Dang, I didn't even realize it was a real program. Just finished Better Call Saul so it was the most remote place that sprang to mind.

It's real, but I honestly have no idea if their psychiatry residency is good. I just know that Kent Kiehl and his giant mobile fMRI machine that he takes to jails to scan all the psychopaths is part of their psychology department.

 

[reca]

I don't know how good of a program it is but my residency interview there (years ago) was the weirdest interview I've been on. Got pimped on dosing of lamictal and lithium by the inpatient attending. Only one of the current residents showed up to the lunch so it was literally just all the applicants eating lunch with the sole resident who was responsible for paying. We got a short tour of the VA hospital and then the faculty member thought it would be more useful to have us pile into her minivan and show us all the places around the city that they filmed Breaking Bad.

 

[splik]

I don't think it's useless, but if someone knows they want to do C/L work, I think it's one of the few times when doing a dual Med/Psych program is actually a good choice. It's a lot easier to stay up to date on medical issues when you're addressing them regularly in residency instead of having to go back and relearn a lot of medicine after PGY-4 of a general psych residency.


It's real, but I honestly have no idea if their psychiatry residency is good. I just know that Kent Kiehl and his giant mobile fMRI machine that he takes to jails to scan all the psychopaths is part of their psychology department.

Some years ago I attended a round table discussion (or something) with Kent Kiehl where in addition to some very sensible points, he claimed he could diagnose schizophrenia based on neuroimaging. And that is when I lost interested in what he had to say.

 

[Stagg737]

I don't know how good of a program it is but my residency interview there (years ago) was the weirdest interview I've been on. Got pimped on dosing of lamictal and lithium by the inpatient attending. Only one of the current residents showed up to the lunch so it was literally just all the applicants eating lunch with the sole resident who was responsible for paying. We got a short tour of the VA hospital and then the faculty member thought it would be more useful to have us pile into her minivan and show us all the places around the city that they filmed Breaking Bad.

I had one like that as well, but it wasn't UNM. I also had a PD pimp me on why risperidone was the most likely 2nd gen to cause prolactin abnormalities. He was actually really nice and the question wasn't malicious at all, but still. Was funny to talk to the residents and hear their subsequent groanswhen they asked how the interviews with the PD went.

Some years ago I attended a round table discussion (or something) with Kent Kiehl where in addition to some very sensible points, he claimed he could diagnose schizophrenia based on neuroimaging. And that is when I lost interested in what he had to say.

Some of his stuff is really fascinating, I'm still looking for sources on the "weird P wave" he talks about on EEGs of psychopaths. Disappointing to hear that, but not that surprising considering how much he's invested into his fMRI research.

 

[Celexa]

I don't think it's useless, but if someone knows they want to do C/L work, I think it's one of the few times when doing a dual Med/Psych program is actually a good choice. It's a lot easier to stay up to date on medical issues when you're addressing them regularly in residency instead of having to go back and relearn a lot of medicine after PGY-4 of a general psych residency.


It's real, but I honestly have no idea if their psychiatry residency is good. I just know that Kent Kiehl and his giant mobile fMRI machine that he takes to jails to scan all the psychopaths is part of their psychology department.

I actually disagree that med-psych is a particularly good path for someone wanting to do CL. Med-psych programs have much less time for electives and focus very heavily on inpatient, so you miss out on critical psychotherapy skill development that is a core part of the specialty--both in terms of patient interactions and team dynamics. Yes, as a CL doc you need to stay more up on medical and surgical topics than the avergage psychiatrist, but a big part of that comes naturally from continuing to live and breath it in the hospital and getting a mini refresher every time you read an h&p. The level of detail you would need to actually manage the medical problems vs what you need to manage complex differential diagnosis and understand the emotional and logistical impacts on patients lives is quite different. Plus, the med part of med-psych is just internal medicine. It won't help you much in understanding the surgical or obstetric or neurology etc sides of things. You'll just spend more time being an order monkey on inpatient medicine, and you'll be waaaaay more exhausted and burned out than a psych resident.

My advice for someone considering CL is to join the ACLP, pick clinics third year with more medically complex patients when possible (ie geri), don't neglect your psychotherapy training, moonlight a bit to gain general experience and confidence, and pursue some off service electives fourth year.

 

[Celexa]

Duplicate post

 

[Stagg737]

I actually disagree that med-psych is a particularly good path for someone wanting to do CL. Med-psych programs have much less time for electives and focus very heavily on inpatient, so you miss out on critical psychotherapy skill development that is a core part of the specialty--both in terms of patient interactions and team dynamics. Yes, as a CL doc you need to stay more up on medical and surgical topics than the avergage psychiatrist, but a big part of that comes naturally from continuing to live and breath it in the hospital and getting a mini refresher every time you read an h&p. The level of detail you would need to actually manage the medical problems vs what you need to manage complex differential diagnosis and understand the emotional and logistical impacts on patients lives is quite different. Plus, the med part of med-psych is just internal medicine. It won't help you much in understanding the surgical or obstetric or neurology etc sides of things. You'll just spend more time being an order monkey on inpatient medicine, and you'll be waaaaay more exhausted and burned out than a psych resident.

My advice for someone considering CL is to join the ACLP, pick clinics third year with more medically complex patients when possible (ie geri), don't neglect your psychotherapy training, moonlight a bit to gain general experience and confidence, and pursue some off service electives fourth year.

Idk that the psychotherapy aspect here is as essential as you're describing. Med/psych programs still require a full 12 continuous months of outpatient clinic which is where the bulk of psychotherapy training is going to occur in most programs. Depending on the C/L service, it may not be necessary for treatment either. My team as therapists dedicated to doing brief psychotherapy with medical patients and we refer to them as a separate consult. I may do some minimal brief interventions on initial consult, but ongoing therapy is deferred to them. Rotations will also vary. Where I trained, the med/psych residents did rotations with services like neuro ICU, the ER, and I think OB/gyn (would have to check on the last one).

Imo, the biggest advantage to doing med psych over a C/L fellowship is familiarity with non-psych meds. The med/psych docs I've worked with just have a better grasp of side effects and interactions between meds leading to issues that the general psychiatrists do (myself included). It's not so much about us assisting with the managing medical problems as it is understanding how our meds and other meds are interacting and when it's appropriate to adjust one of our meds vs one of theirs.

ETA: I'm not really an advocate of doing med/psych residency as a necessary part of training unless you want to do outpatient medicine and manage all their psych meds too. I just think there's an argument to be made if one knows they want to do C/L psych vs circling back to do a C/L fellowship later.

 

[Celexa]

Idk that the psychotherapy aspect here is as essential as you're describing. Med/psych programs still require a full 12 continuous months of outpatient clinic which is where the bulk of psychotherapy training is going to occur in most programs. Depending on the C/L service, it may not be necessary for treatment either. My team as therapists dedicated to doing brief psychotherapy with medical patients and we refer to them as a separate consult. I may do some minimal brief interventions on initial consult, but ongoing therapy is deferred to them. Rotations will also vary. Where I trained, the med/psych residents did rotations with services like neuro ICU, the ER, and I think OB/gyn (would have to check on the last one).

Imo, the biggest advantage to doing med psych over a C/L fellowship is familiarity with non-psych meds. The med/psych docs I've worked with just have a better grasp of side effects and interactions between meds leading to issues that the general psychiatrists do (myself included). It's not so much about us assisting with the managing medical problems as it is understanding how our meds and other meds are interacting and when it's appropriate to adjust one of our meds vs one of theirs.

ETA: I'm not really an advocate of doing med/psych residency as a necessary part of training unless you want to do outpatient medicine and manage all their psych meds too. I just think there's an argument to be made if one knows they want to do C/L psych vs circling back to do a C/L fellowship later.

While I started my psychotherapy training pgy3 as you say, it was the pgy4 year when I really found my footing and started (in my opinion) really making headway into being a fluent in psychotherapy applications. I since have come to understand that pgy4 genuinely is a very empty/lackadaisical year in some programs; I certainly agree that doing actual medicine during that time rather than a whole lot of nothing would be better preparation. But I still think a dedicated psychiatry residency with diverse therapy training is the best background for CL. I don't do ongoing therapy either, but I don't think I would be anywhere near as adept at pulling out brief or one-time bedside interventions without both years of my training. Its not unlike having to spend time building the whole car to be able to hear a problem with the engine, pop the hood, and immediately reach for the thing that will keep the car running for the next several miles even if it's not the long term fix (apologies for the extended metaphor).

I actually see zero reasons for anyone at all to do med-psych these days (I can squint and see potentially valid reasons in the past, when the knowledge base of both fields was smaller), but that's a long conversation for somewhere else lol.

 

[Dantes]

Not to further derail, but from the outside looking in, it seems like every other specialty has an inpatient consult service without further need for a fellowship. Is the extra year really necessary when psych is already four years with lots of room for electives?

 

[Celexa]

Not to further derail, but from the outside looking in, it seems like every other specialty has an inpatient consult service without further need for a fellowship. Is the extra year really necessary when psych is already four years with lots of room for electives?

There is an active internal debate about whether psychiatry residents should be a able to fast track and do the fellowship their fourth year. Initially I thought that was bonkers mainly because pgy4 year at my program was quite robust. I understand more now why some people argue for it after getting more of a sense of the variety among programs. I definitely think you can be a competent CL psychiatrist without the fellowship if you choose to devote effort to it. The same is true in psychiatry for geri and addiction and even child, although you'd probably have more legal exposure.

That doesn't mean it's not a distinct subspecialty knowledge base, though.

Thats why I advise people mainly to do CL fellowship if they want to stay in academia, because the credential and the networking do matter there.

 

[Stagg737]

Not to further derail, but from the outside looking in, it seems like every other specialty has an inpatient consult service without further need for a fellowship. Is the extra year really necessary when psych is already four years with lots of room for electives?

Not at all imo. I applied for a few C/L positions in the Midwest and everyone was interested in me, I’m just gen psych trained.

There is an active internal debate about whether psychiatry residents should be a able to fast track and do the fellowship their fourth year. Initially I thought that was bonkers mainly because pgy4 year at my program was quite robust. I understand more now why some people argue for it after getting more of a sense of the variety among programs. I definitely think you can be a competent CL psychiatrist without the fellowship if you choose to devote effort to it. The same is true in psychiatry for geri and addiction and even child, although you'd probably have more legal exposure.

That doesn't mean it's not a distinct subspecialty knowledge base, though.

Thats why I advise people mainly to do CL fellowship if they want to stay in academia, because the credential and the networking do matter there.

I can see that for academia. I’ve mentioned it before, but my residency had a very heavy med/psych presence and this was just naturally built into our expectations (we managed all medical meds on inpatient psych and only consulted for urgent issues). More than a few of the docs I trained with are or will be C/L psychiatrists and none of them did fellowships, and a few of us are at major academic programs.

 

[Celexa]

Not at all imo. I applied for a few C/L positions in the Midwest and everyone was interested in me, I’m just gen psych trained.


I can see that for academia. I’ve mentioned it before, but my residency had a very heavy med/psych presence and this was just naturally built into our expectations (we managed all medical meds on inpatient psych and only consulted for urgent issues). More than a few of the docs I trained with are or will be C/L psychiatrists and none of them did fellowships, and a few of us are at major academic programs.

Yeah it's still very possible to practice academic CL without the fellowship, but the field has reached the point where it may end up being limiting (for example, if somewhere wants to start a CL fellowship, or has one, you need a certain number of boarded CL faculty). So within academia even though you certainly can get CL positions you might find yourself more limited in job choice than a colleague who has done the fellowship. Whether that will actually matter over the course of a career is a very individual question.

The fellowship also can offer some protection against being randomly reassigned to cover other coverage gaps--it's harder to argue for taking a boarded subspecialist off their specialty than it is someone who is a generalist on paper. I've definitely seen some departmental shenanigans in that vein.

I've worked with plenty of excellent CL docs who didn't have the fellowship.

 

[Ellomate]

What are some top CL fellowship in the east coast? (preferably from Virginia to NE)
Thank you!