Anybody here do one of these fellowships or have any firsthand experience in this area?

[tristatenontrad]

http://www.communitypsychiatry.org/pages.aspx?PageName=Public_and_Community_Psychiatry_Fellowships

Just curious to learn a little more about the career trajectory of psychiatrists who complete public psychiatry fellowships and the day-to-day work of psychiatrists who work at least part of the time in systems-level/population-based mental health. From what I've read it seems like these fellowships help train you to identify service gaps to specific populations and develop/evaluate/manage publicly-funded programs that attempt to meet these unmet needs. Anybody here actually complete one of these fellowships or do this sort of work care to share anything about the realities of working in this area and whether or not it is fulfilling as it seems?

I am very much intrigued by the idea of eventually working in both individual and 'systems-level' mental health but I was hoping to learn more about the realities of it before I let my idealism lead me too far astray. I would imagine the administrative/compliance/regulatory requirements inherent to working with public resources would leave little time for much else beyond box-checking but I could just be jaded from my brief foray into social service work. Any first-hand experience shared would be very much appreciated.

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[notdeadyet]

I have not done a public psychiatry fellowship, but I trained at a program that had one and looked closely into it.

The one question I would ask before considering any fellowship is this: do I need to do this fellowship in order to do this kind of work?

In the case of public psychiatry (and many other fellowships), I believe the answer is no. That doesn't mean that you shouldn't do it, it just means that you don't have to.

The biggest benefit of a public psychiatry fellowship is going to be for people who don't have much clinical training in their residency in working with these populations and in the settings. If you truly have a passion for public psychiatry, I would recommend that people select a residency with good exposure to this population, which decreases the need for a public psychiatry fellowship. Another circumstance in which one of these fellowships is helpful, is for folks who are transferring into an entirely new area in which they are unfamiliar with the systems. The fellowship is less important in this case, but it can be helpful to have a lot of structured training in working within a particular county. It is also helpful for making local contacts for hiring.


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[MacDonaldTriad]

Public psychiatry fellowships can be of value depending on what your training program didn’t have. If you are truly interested in serving the underserved, you can save yourself a lot of time by picking a training with this focus. No one needs a public psychiatry fellowship to open doors. If you have trouble finding a job serving the underserved, it could be argued that you haven’t found the underserved.

 

[wolfvgang22]

I concur.
You'll find in some large cities there will be a residency program that is relatively more academic, and sees more of the "worried well" or the more recently diagnosed that still have health insurance and family support, and another program across town that sees more patients without these resources that are more acutely and chronically ill.

 

[tristatenontrad]

Thanks for the responses guys. It sounds like doing residency in a large urban setting that sees a lot of patients in the public mental health system would afford one a substantial amount of exposure to this population and leave one well-prepared to provide care for them in the context of one-on-one treatment. What I was wondering is whether these fellowships are necessary to learn how to develop, organize and reform service delivery for specific populations/catchment areas. I can't remember where I found this but copied/pasted below is a description of the 'community psychiatrist of the future', sorry for no APA citation cant remember author:

“Applying a matrix method of scrutinizing services and professions prior to reform,[45] Tansella[66] distinguishes two types of psychiatrists. The 'archeologists' focus on individual psychopathology and potential for change, examining and treating the roots of disorder and distress or suffering from a psychodynamically informed viewpoint. Meanwhile the 'architects' concentrate more on groups and populations and on the development, organization and reform of services for them. The psychiatrist 'architect' particularly helps deprived populations with psychiatric disorders to live constructively without loss of respect or renouncing their identities and ideas.

Community psychiatrists often identify with this latter category. To me, no dichotomy is needed. We need both types of psychiatrists to satisfy 'met need' (treated prevalence) and deal with 'unmet need' (untreated prevalence). The 'archeologist' aspect may also provide the intervention content, whereas the 'architect' can provide the most effective vessel or vehicle and both should be evidence-based to optimize outcomes. Thornicroft[67] distinguishes between ACT as a service delivery vehicle, and actual ingredients (e.g. cognitive behavioural therapies or family intervention), which are often underemphasized and work synergistically to power a cost-effective vehicle to produce optimal outcomes. A community psychiatrist should work at both individual and population levels of complexity".

So to re-phrase I guess my question is: Are these fellowships required to learn how to be an 'architect'? Or can one learn how to be both an 'archeologist' and an 'architect' at the right residency program? My apologies if the question is naive and this sort of training is ubiquitous to psychiatry residencies I am but a mere preclinical student.

 

[thoffen]

Most residencies teach you how to take care of patients, and not necessarily how to run a business or practice psychiatry outside of an academic setting. Despite that, there are a lot of opportunities to learn, and I would hope all programs have significant mentorship from prior graduated classes on how to do these things. It's cool that these programs exist, but I would wager the large majority of people functioning in these roles have done so without a fellowship.

I'm not sure what to think of the "architect" and "archeologist" prototypes above. Firstly, real psychodynamic training is variably present and even functionally omitted at many places. Secondly, I doubt these prototypes stem directly from the training received but rather the interest of the individual and more fluidly go between roles.

At this point, you'd be better served asking how you can get involved in some community stuff where you're at and figuring out what you like and don't. Use that to inform your residency choice and repeat the process in residency. Then use that to decide on whether a fellowship is worthwhile or not.

 

[notdeadyet]

So to re-phrase I guess my question is: Are these fellowships required to learn how to be an 'architect'? Or can one learn how to be both an 'archeologist' and an 'architect' at the right residency program? My apologies if the question is naive and this sort of training is ubiquitous to psychiatry residencies I am but a mere preclinical student.

No, the fellowship is not required. You can certainly learn to be an 'archeologist' and an 'architect' at the right residency program. Frankly, I think the analogy is creating a false dichotomy, but I'm not a big thinker.

Work hard in medical school so that you have the widest range of options for residency.
1. Look for a residency with great clinical exposure to underserved communities (programs with very strong county availability fit this).
2. Look for a residency with great academics in evidence-based treatment and systems level care (good academic programs fit this).
3. Go for Chief Resident role and/or electives working in a leadership role in the public realm.

If you're able to find something that fits all 3, there is extremely little need for the fellowship.

 

[tristatenontrad]

Thanks for the responses guys. I know its a bit premature to be looking into this too in-depth but was just curious of what folks further along in training thought of these fellowships. I've done a little bit of shadowing at a local CMHC but the psychiatrist I shadowed was only there twice a week doing med checks and did not play any administrative role or do any program development/evaluation or service delivery/public health stuff, strictly meds. I'll keep an open mind going forward and hopefully eventually match into a program that affords me the opportunity to learn more. Thanks again for taking time out to respond.

 

[splik]

You certainly do not need to do a public psychiatry fellowship to take a more leadership or administrative role in public mental health. I would say the overwhelming majority of general psychiatry residency programs do not provide adequate (if any) training in leadership theory and practice, and many of the basic skills required for taking an administrative position in the public sector. That said, most people just fall into these positions are learn on the job. Physician leadership in public mental health is very much lacking (and these systems of care are overwhelmingly not run by physicians) - they are in fact DESPERATE for psychiatrists to take on such leadership roles.

Other things to consider would be to do an MPH, MPA/MPP or MBA which would provide you with many of the skills related to business operations, leadership, management, policy, politics, economics, program planning and evaluation etc.

I think it would be worthwhile doing a fellowship in public psychiatry at a place like Columbia which has an established track record in training leaders in public mental health and has a solid curriculum, and pays a more reasonable amount. I do not think it is a good idea to do a ppf as a PGY-5. Many programs will allow you to fast-track into it and complete it as a PGY-4 using your elective time, as it is an unaccredited fellowship.

UCSF allows people to audit their public psychiatry classes - so people who are just starting out working there or are doing a different fellowship for example can attend their classes.

Another reason to consider doing a public psychiatry fellowship is if you have done your residency in one area and are moving to another. This would be a good way to learn about the different models of community care, interface with different organizations, network, and have a better idea of where you might want to work as well as more smoothly land into a job. These jobs are not terribly difficult to land because the pay is generally quite poor, and often administrative positions can pay LESS than clinical ones (which is one of the reason you will find so few psychiatrists in some of these positions).

Medical students who are interested in public psychiatry should attend the IPS annual meeting which is free for them. It is a great opportunity to learn about innovative models of care in public psychiatry. This is the APA's public psychiatry meeting and there are often med students here and psych SIGN often organizes med student events. Public psychiatrists are probably the friendliest and would be very happy to talk more with you. PsychSIGN is organizing a panel of community psychiatrists (most of whom have administrative positions) to talk to med students at their annual meeting in May (which is free and I believe they will even give you a free hotel room if you sign up quickly). You can also join the AACP (american association of community psychiatrists) - it's free for med students - and they are very happy for students to attend their board meeting and socials at the APA and IPS meetings.

 

[tristatenontrad]

You certainly do not need to do a public psychiatry fellowship to take a more leadership or administrative role in public mental health. I would say the overwhelming majority of general psychiatry residency programs do not provide adequate (if any) training in leadership theory and practice, and many of the basic skills required for taking an administrative position in the public sector. That said, most people just fall into these positions are learn on the job. Physician leadership in public mental health is very much lacking (and these systems of care are overwhelmingly not run by physicians) - they are in fact DESPERATE for psychiatrists to take on such leadership roles.

Other things to consider would be to do an MPH, MPA/MPP or MBA which would provide you with many of the skills related to business operations, leadership, management, policy, politics, economics, program planning and evaluation etc.

I think it would be worthwhile doing a fellowship in public psychiatry at a place like Columbia which has an established track record in training leaders in public mental health and has a solid curriculum, and pays a more reasonable amount. I do not think it is a good idea to do a ppf as a PGY-5. Many programs will allow you to fast-track into it and complete it as a PGY-4 using your elective time, as it is an unaccredited fellowship.

UCSF allows people to audit their public psychiatry classes - so people who are just starting out working there or are doing a different fellowship for example can attend their classes.

Another reason to consider doing a public psychiatry fellowship is if you have done your residency in one area and are moving to another. This would be a good way to learn about the different models of community care, interface with different organizations, network, and have a better idea of where you might want to work as well as more smoothly land into a job. These jobs are not terribly difficult to land because the pay is generally quite poor, and often administrative positions can pay LESS than clinical ones (which is one of the reason you will find so few psychiatrists in some of these positions).

Medical students who are interested in public psychiatry should attend the IPS annual meeting which is free for them. It is a great opportunity to learn about innovative models of care in public psychiatry. This is the APA's public psychiatry meeting and there are often med students here and psych SIGN often organizes med student events. Public psychiatrists are probably the friendliest and would be very happy to talk more with you. PsychSIGN is organizing a panel of community psychiatrists (most of whom have administrative positions) to talk to med students at their annual meeting in May (which is free and I believe they will even give you a free hotel room if you sign up quickly). You can also join the AACP (american association of community psychiatrists) - it's free for med students - and they are very happy for students to attend their board meeting and socials at the APA and IPS meetings.

Thank you so much for all of this information. This is exactly the sort of thing I was looking for. I will definitely look into all the resources that you mentioned, you are truly a wealth of information. Thanks again!

 

[kagman]

I've been following this thread. And it's quite informative. I too am interested in public psychiatry. I'm an International Medical Graduate. Can you tell me what the differences are between a fellowship in public psychiatry versus a MPH in mental health ?


Psychiatry Applicant 2016.

 

[splik]

I've been following this thread. And it's quite informative. I too am interested in public psychiatry. I'm an International Medical Graduate. Can you tell me what the differences are between a fellowship in public psychiatry versus a MPH in mental health ?

a public psychiatry fellowship is residency or post-residency training in leadership, administrative, and systems based aspects of public mental health so it's a job not a degree unlike an MPH (which you or someone else pays for). I have never heard of an MPH in mental health, if it exists it's not common and none of the public health schools worth going to (harvard, hopkins, columbia, unc, berkeley, emory, uw, washu, lshtm) offer it. An MPH provides basic grounding in public health sciences (biostatistics, epidemiology, health policy and management, social and behavioral sciences, environmental health, ethics) and you would usually concentrate in one of these areas. You could certainly take mental health-related courses or do a practicum that is mental health related but i've never heard of an MPH in mental health.

bizarrely, many of the people who have MPHs do a public psychiatry fellowship.

here is the old public psychiatry syllabus from columbia, which most other programs are based on

 

[NickNaylor]

You certainly do not need to do a public psychiatry fellowship to take a more leadership or administrative role in public mental health. I would say the overwhelming majority of general psychiatry residency programs do not provide adequate (if any) training in leadership theory and practice, and many of the basic skills required for taking an administrative position in the public sector. That said, most people just fall into these positions are learn on the job. Physician leadership in public mental health is very much lacking (and these systems of care are overwhelmingly not run by physicians) - they are in fact DESPERATE for psychiatrists to take on such leadership roles.

Other things to consider would be to do an MPH, MPA/MPP or MBA which would provide you with many of the skills related to business operations, leadership, management, policy, politics, economics, program planning and evaluation etc.

I think it would be worthwhile doing a fellowship in public psychiatry at a place like Columbia which has an established track record in training leaders in public mental health and has a solid curriculum, and pays a more reasonable amount. I do not think it is a good idea to do a ppf as a PGY-5. Many programs will allow you to fast-track into it and complete it as a PGY-4 using your elective time, as it is an unaccredited fellowship.

UCSF allows people to audit their public psychiatry classes - so people who are just starting out working there or are doing a different fellowship for example can attend their classes.

Another reason to consider doing a public psychiatry fellowship is if you have done your residency in one area and are moving to another. This would be a good way to learn about the different models of community care, interface with different organizations, network, and have a better idea of where you might want to work as well as more smoothly land into a job. These jobs are not terribly difficult to land because the pay is generally quite poor, and often administrative positions can pay LESS than clinical ones (which is one of the reason you will find so few psychiatrists in some of these positions).

Medical students who are interested in public psychiatry should attend the IPS annual meeting which is free for them. It is a great opportunity to learn about innovative models of care in public psychiatry. This is the APA's public psychiatry meeting and there are often med students here and psych SIGN often organizes med student events. Public psychiatrists are probably the friendliest and would be very happy to talk more with you. PsychSIGN is organizing a panel of community psychiatrists (most of whom have administrative positions) to talk to med students at their annual meeting in May (which is free and I believe they will even give you a free hotel room if you sign up quickly). You can also join the AACP (american association of community psychiatrists) - it's free for med students - and they are very happy for students to attend their board meeting and socials at the APA and IPS meetings.

Another shout out to IPS - I went this year and found it interesting. There's some stuff for everyone if you have any interest in public psychiatry as a career or just want to learn about public psychiatry (I specifically enjoyed ethics panels related to finding information about patients online, a panel talking about emergency psych with both ER psychiatrists and EM docs, and a talk on gun rights and ownership and the interface with psychiatry - went to that one mostly for the political fires that inevitably came up). Great use of a few days in addition to having an excuse to bring the wife along to NYC...

 

[Salpingo]

I've been following this thread. And it's quite informative. I too am interested in public psychiatry. I'm an International Medical Graduate. Can you tell me what the differences are between a fellowship in public psychiatry versus a MPH in mental health ?


Psychiatry Applicant 2016.

I think it's worth noting that unless you're doing a combined MD/MPH, you're paying for the degree. Even if you're doing an MD/MBA, you have to give up a year.

My understanding of these fellowships (or at least the original one) was that the fellows are EXPECTED to be practicing in an attending level position somewhere, so there's no opportunity cost with respect to income or experience. My sense is that these programs are going to be much more attractive for that reason alone. The fellowships themselves must be motivated to train as opposed to getting cheap labor.

 

[kagman]

a public psychiatry fellowship is residency or post-residency training in leadership, administrative, and systems based aspects of public mental health so it's a job not a degree unlike an MPH (which you or someone else pays for). I have never heard of an MPH in mental health, if it exists it's not common and none of the public health schools worth going to (harvard, hopkins, columbia, unc, berkeley, emory, uw, washu, lshtm) offer it. An MPH provides basic grounding in public health sciences (biostatistics, epidemiology, health policy and management, social and behavioral sciences, environmental health, ethics) and you would usually concentrate in one of these areas. You could certainly take mental health-related courses or do a practicum that is mental health related but i've never heard of an MPH in mental health.

bizarrely, many of the people who have MPHs do a public psychiatry fellowship.

here is the old public psychiatry syllabus from columbia, which most other programs are based on

Johns Hopkins has a MPH program with concentration in Social and Behavioural Sciences. http://www.jhsph.edu/academics/degr...stomizing/social-and-behavioral-sciences.html

I checked out the course curriculum of it and compared it to the public psychiatry Columbia curriculum. To me, the mph trains you with much broader issues while the fellowship is more specific to psychiatry and is to empower clinicians with a more sound knowledge of public regulations in psychiatry or to guide policy makers about changes needed in psychiatry.




Psychiatry Applicant 2016.

 

[splik]

Johns Hopkins has a MPH program with concentration in Social and Behavioural Sciences. http://www.jhsph.edu/academics/degr...stomizing/social-and-behavioral-sciences.html

social and behavioral sciences (or something equivalent) which is what I did my MPH in, is NOT an MPH in mental health. there is no focus on mental health whatsoever. you could choose to do mental health related courses or practicum but that is true for any concentration. for someone interested in public psychiatry a concentration in health policy and management would probably be more useful.

(I won't go on my rant, but psychiatry has for many years ignored the social and behavioral sciences - the NIMH will simply not fund any research whatsoever into the psychosocial aspects of mental illness, by contrast, the National Cancer Institute, the NHLBI, and the NIAID fund lots of research into psychosocial aspects of cancer, cardiovascular disease, and HIV/AIDS and other infectious disease. The result is we know alot more about the psychosocial roots of cancer, cardiovascular disease and infectious diseases than we know about serious mental illness, and all because psychiatrists have a complex about not being real doctors and their illnesses not being "real". Well the fact that social capital of your neighborhood predicts cardiovascular mortality as well as smoking does not make cardiovascular disease any less "real" but our field has been pulled in entirely the wrong direction. sorry guess i did go on rant.)

 

[splik]

I
My understanding of these fellowships (or at least the original one) was that the fellows are EXPECTED to be practicing in an attending level position somewhere, so there's no opportunity cost with respect to income or experience. My sense is that these programs are going to be much more attractive for that reason alone. The fellowships themselves must be motivated to train as opposed to getting cheap labor.

sort of - you're still cheap labor. non-ACGME accredited fellowships tend to pay more than their ACGME ones (because you can bill as an attending and you cant in an accredited fellowship) but you still tend to make ALOT less than you would in a real job. you would count as faculty and not housestaff also. for example I'm pretty sure the columbia ppf pays <120k maybe quite a bit less than that. the UCSF one pays even worse (about 85k).

also most of the time you're not going to be seeing patients because the focus is not on clinical care - they may have different arrangements about how this is done or where they pull your salary from.

 

[Salpingo]

sort of - you're still cheap labor. non-ACGME accredited fellowships tend to pay more than their ACGME ones (because you can bill as an attending and you cant in an accredited fellowship) but you still tend to make ALOT less than you would in a real job. you would count as faculty and not housestaff also. for example I'm pretty sure the columbia ppf pays <120k maybe quite a bit less than that. the UCSF one pays even worse (about 85k).

also most of the time you're not going to be seeing patients because the focus is not on clinical care - they may have different arrangements about how this is done or where they pull your salary from.

Sure, there's no free lunch. But it's definitely a unique feature of the fellowship and says something about the ethos. For example, Columbia offers a 30k stipend if you have a full time job already, and ~90k if you don't (which you can easily double if you're a motivated moonlighted). I understand UCSF is a little different, but the fact that they have a developed auditing program suggests, again, they're MORE interested in giving something to you than getting something out of you.

The whole politics and incentives of ACGME accreditation is totally foreign to me, but I wish all fellowships followed the Columbia ppf model (it would certainly answer the complaint that psych fellowships are 100k mistakes).