Community vs. University Psych Training

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Osminog

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I'm starting to think about how to assemble my psychiatry ROL, and I'm wondering about the relative advantages/disadvantages of training at a community program vs. a university program.

I skimmed through old SDN threads on this subject within this subforum, and opinions seemed to widely vary. Some users were saying that the difference is largely inconsequential - that most of residency training is based on individual motivation rather than program quality; someone also said that psychiatry is a very community-based specialty in general, so going to a university program still entails a great deal of the community experience. Others said that university programs are generally superior because academic attendings (as compared to community ones) are more likely to use a more evidence-based approach and are more familiar with the latest research, and that university programs offer a more comprehensive, rigorous foundation for one's psychiatry career.

Of course, there are other important factors that I'll consider (geography, residency culture, work-life balance, etc.) — but how should the community vs. university question fit into the equation?

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I think that the difference is more specific to one program versus the other than lumping community and academic.

Plenty of community programs like Cleveland Clinic Akron General, Michigan State, etc have excellent academic components/connections with research opportunities that are just as readily available as more academic programs, just like you said.

What matters the most is what your interests are and how they align with the program, bearing in mind that interests change throughout training and your career after training.

There's nothing wrong with making the decision on whatever factors feel important to you. Imo it's not important whether the program is community versus academic. I went to a community program with a lot of connections to research but absolutely no university, college, or other academic affiliation, so bear that in mind when considering my opinion.
 
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Is your intention to try to break into research in a serious way? Then 100% go academic, as prestigious as possible. Do you just want to be involved in academic psychiatry long-term? Then academic will make it easier, but not strictly required. Do you want to set up a high-end private practice in a saturated city? Then the more fancy names you can associate yourself with the better.

Once you descend from the Olympian heights, it makes very little difference to your career prospects.

I am biased in favor of academic programs provided they are real-deal tertiary referral centers just because you get a chance to see weirder stuff and more complicated cases, but this is a question of being better at dealing with maybe 5% of the patients you will encounter in the real world, not the vast majority.
 
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Is your intention to try to break into research in a serious way? Then 100% go academic, as prestigious as possible. Do you just want to be involved in academic psychiatry long-term? Then academic will make it easier, but not strictly required. Do you want to set up a high-end private practice in a saturated city? Then the more fancy names you can associated yourself with the better.

Once you descend from the Olympian heights, it makes very little difference to your career prospects.

I am biased in favor of academic programs provided they are real-deal tertiary referral centers just because you get a chance to see weirder stuff and more complicated cases, but this is a question of being better at dealing with maybe 5% of the patients you will encounter in the real world, not the vast majority.
I really like the way you're breaking it down, and agree with the importance of ensuring an academic program has a really robust tertiary referral center if you're planning on practicing in the community. High-end practices in a saturated city are in some respects a tougher market to break into / require more diligent advertising and referral management compared to an underserved urban, suburban, or rural setting.

I will say though that it depends on what the experience is. Please, if I'm wrong on any of this CW or others, call it out because I think a discussion point-counterpoint from us and other members would be helpful for Osminog and other medical students trying to come to a similar decision.

I imagine CW had a great experience with some of the rarer or more complex cases where they trained, though I am venturing to guess that there were still fewer and/or less severely treatment-refractory psychosis cases than, for example, my training that involved 12 months of state hospital level care (a different form of tertiary referral center).

CW's program probably was rather academic in the approach and systematically applied very good algorithms and very up-to-date treatments. The patients were still probably not as violent, agitated, and profoundly ill as the ones I trained with. It probably leads to me being very comfortable in a state hospital, correctional, or underfunded community program whereas I imagine CW might occasionally miss the highly structured specialty center when it comes to managing those patients and I don't know what I'm missing out on in regards to that.

This being said, my program may have been unique among non-affiliated programs in the fascinating breadth of opportunities. 12 months of state hospital care, 4 months of private-for-profit inpatient, 3 months of VA, then a combination of outpatient clinics with medicaid patients, cash-only patients, private insurance patients, student health center patients, and 2 years of child/adolescent outpatient clinic. At least one resident per year was doing research at the NIMH throughout training and fast-tracked into a fellowship through the NIH. Of course, we would have had to do an elective to have HIV specialty clinic (though with the rate of HIV so high in our population, it might not have really mattered), bipolar specialty clinics, etc.

Adding to my previous post, if a prospective trainee wants a particular experience that a program doesn't currently offer, it's important to look into what it would be like to gain that experience at a given program. For example, if one wants to learn psychedelic psychotherapy or work in an IV ketamine clinic for 2-3 months while in residency, it might be a different process at an academic program that is currently conducting psychedelic research and has an IV ketamine clinic than it would be at a program that offers neither but is open to residents forging the path for an elective in those fields. There are merits to putting some of that onus onto the resident, as it offers a practical experience in managing negotiations between bodies, developing a training curriculum, and searching through clinics to determine which would be the most beneficial / easier / harder to work with. There are, of course, all the frustrations associated with that which might not be desirable if someone intends to simply sign a contract to work with GreenBrook or a similar company, working in an academic ketamine clinic, partnering with an anesthesiologist, joining a group, or going into it as a solo provider when they graduate. It can be a lot to juggle while in training, but there's no time like training for getting your feet wet with something that complex (again, this is showing my own biases).
 
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I'm starting to think about how to assemble my psychiatry ROL, and I'm wondering about the relative advantages/disadvantages of training at a community program vs. a university program.

I skimmed through old SDN threads on this subject within this subforum, and opinions seemed to widely vary. Some users were saying that the difference is largely inconsequential - that most of residency training is based on individual motivation rather than program quality; someone also said that psychiatry is a very community-based specialty in general, so going to a university program still entails a great deal of the community experience. Others said that university programs are generally superior because academic attendings (as compared to community ones) are more likely to use a more evidence-based approach and are more familiar with the latest research, and that university programs offer a more comprehensive, rigorous foundation for one's psychiatry career.

Of course, there are other important factors that I'll consider (geography, residency culture, work-life balance, etc.) — but how should the community vs. university question fit into the equation?
I started my training in a university one then switched to a community residency. More independence in community programs. It has very limited potential regarding your future jobwise or fellowship potential.
 
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I go to a university program. There are some heavyweights coming through for grand rounds at times, so if you're inclined to network you get to rub elbows with the biggest names in the field. Otherwise, it feels like there are more superfluous requirements placed on us that friends at community programs don't have.
 
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I go to a university program. There are some heavyweights coming through for grand rounds at times, so if you're inclined to network you get to rub elbows with the biggest names in the field. Otherwise, it feels like there are more superfluous requirements placed on us that friends at community programs don't have.
Curious do you talk psych with your friends at community programs? Wondering how you feel their knowledge of the literature base is compared to your peers at the university program.
 
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I imagine CW had a great experience with some of the rarer or more complex cases where they trained, though I am venturing to guess that there were still fewer and/or less severely treatment-refractory psychosis cases than, for example, my training that involved 12 months of state hospital level care (a different form of tertiary referral center).

CW's program probably was rather academic in the approach and systematically applied very good algorithms and very up-to-date treatments. The patients were still probably not as violent, agitated, and profoundly ill as the ones I trained with. It probably leads to me being very comfortable in a state hospital, correctional, or underfunded community program whereas I imagine CW might occasionally miss the highly structured specialty center when it comes to managing those patients and I don't know what I'm missing out on in regards to that.
I don't think this is necessarily a common difference. I went to residency at a large academic center, and we could rotate at the state hospitals (though it wasn't required). I did interview at 2 academic programs that had required rotations through the state hospitals and one was at a forensic psych facility. I also don't know that academic programs would miss out on the SPMI. A large percentage of my CMHC patients had been admitted to the state facilities multiple times and I've seen multiple physical altercations on inpatient units. I think this will vary significantly between programs, but I don't think whether a program is academic vs community makes much of a difference.
 
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I don't think this is necessarily a common difference. I went to residency at a large academic center, and we could rotate at the state hospitals (though it wasn't required). I did interview at 2 academic programs that had required rotations through the state hospitals and one was at a forensic psych facility. I also don't know that academic programs would miss out on the SPMI. A large percentage of my CMHC patients had been admitted to the state facilities multiple times and I've seen multiple physical altercations on inpatient units. I think this will vary significantly between programs, but I don't think whether a program is academic vs community makes much of a difference.

So what proportion of those patients you treated had documented failure of 12 antipsychotics of heroic dose and adequate duration in various combination with every conceivable augmentation strategy? There's a difference between 2 months on a unit and seeing a patient multiple times throughout four years of their commitment while they go from 4-5 codes per day down to stable for discharge. Same thing with all the forensic admissions, evals, and chronic NGRIs.

I definitely got excessively comfortable with things like Thorazine 200 mg IM with Ativan 4 mg for the right patient (and would never recommend someone do that outside of very narrow circumstances) as well as talking down without meds people who have extensive homicide histories (and would also never recommend someone try that for the first time unless they are in the right environment).

To put it in other terms, all of our non-forensic patients were referred to us by the types of hospital settings that academic programs work in and they had failed to stabilize them after 20+ admissions or 6+ admissions in a 3 month period. In fact, none of the academic programs in that city saw ANY involuntary patients.

I also imagine you might not have had much experience filling out / testifying for year-long civil commitments as well as semi-annual renewals. Not that it's relevant outside of jobs that require that.

In turn I did only around 6 total months of the standard 3-5 day admission units and 0 months of the 2-3 day admission units because I have zero interest in practicing in those settings.
 
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So what proportion of those patients you treated had documented failure of 12 antipsychotics of heroic dose and adequate duration in various combination with every conceivable augmentation strategy? There's a difference between 2 months on a unit and seeing a patient multiple times throughout four years of their commitment while they go from 4-5 codes per day down to stable for discharge. Same thing with all the forensic admissions, evals, and chronic NGRIs.
Not a huge proportion, but I've seen enough of them to feel comfortable working with them. Though I didn't see them for the course of 4 years. I don't have the forensic experience with NGRI or true forensic aspects that I'd like, but have certainly treated people who have had major legal issues associated with their illness (or just their sociopathy) including pedophiles, rapists, and murderers. I have treated patients who were admitted for several months and over a year in a few situations, though this was only in 1 month stints (2 months on one occasion) where I'd have them for a month and come back and have them in the same admission 4-6 months later. I've testified in involuntary hearings including emergency guardianship hearings or continuances.

I've worked with patients who had been on regimens like Thorazine 1g daily or depakote 3,500mg daily + Lithium 1800 daily + Haldol 20mg. Yes, these were uncommon, but I've seen enough regimens that initially appear outrageous to have learned not to make an assumption until I talk to the patient and ideally review their med history to understand how they arrived there.

So yes, I've had that experience at my program, though it certainly does not sound as intensive with those kinds of patients as yours was and it sounds like I would have enjoyed your program. As an aside, the other academic program in our city had a forensic unit with several patients who had been admitted for 10+ years and apparently one who had been there nearly 30 years. One of the academic programs I interviewed at had an associated program where 100% of inpatient was at the state hospital. Yes, those are atypical for academic programs, but if we're talking about programs where there majority of time is spent at state hospitals or forensic hospitals I think that's fairly uncommon for both academic and community programs.

Eta: I could be completely off, but from my experience interviewing at multiple academic and community programs I did not feel there was a major difference overall other than the community programs had better benefits.
 
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Not a huge proportion, but I've seen enough of them to feel comfortable working with them. Though I didn't see them for the course of 4 years. I don't have the forensic experience with NGRI or true forensic aspects that I'd like, but have certainly treated people who have had major legal issues associated with their illness (or just their sociopathy) including pedophiles, rapists, and murderers. I have treated patients who were admitted for several months and over a year in a few situations, though this was only in 1 month stints (2 months on one occasion) where I'd have them for a month and come back and have them in the same admission 4-6 months later. I've testified in involuntary hearings including emergency guardianship hearings or continuances.

I've worked with patients who had been on regimens like Thorazine 1g daily or depakote 3,500mg daily + Lithium 1800 daily + Haldol 20mg. Yes, these were uncommon, but I've seen enough regimens that initially appear outrageous to have learned not to make an assumption until I talk to the patient and ideally review their med history to understand how they arrived there.

So yes, I've had that experience at my program, though it certainly does not sound as intensive with those kinds of patients as yours was and it sounds like I would have enjoyed your program. As an aside, the other academic program in our city had a forensic unit with several patients who had been admitted for 10+ years and apparently one who had been there nearly 30 years. One of the academic programs I interviewed at had an associated program where 100% of inpatient was at the state hospital. Yes, those are atypical for academic programs, but if we're talking about programs where there majority of time is spent at state hospitals or forensic hospitals I think that's fairly uncommon for both academic and community programs.

Eta: I could be completely off, but from my experience interviewing at multiple academic and community programs I did not feel there was a major difference overall other than the community programs had better benefits.
From what I recall, the community programs had better benefits and in some situations either had better pay or pay was better when compared to the cost of living (the same pay goes further in Akron Ohio vs Cleveland, and Charleston vs DC).

One of my biggest gripes when I was in medical school was when residents would decide to admit someone who was taking fluphenazine LAI and had been discharged two days ago from a 6 month stay in a state hospital because of mild disorganization and "to try Invega instead of that neurotoxic first gen" without obtaining any records or communication to see why Prolixin was the choice or what the baseline was for that patient. Granted, that resident was at a community program.

So as long as the trainee is interested in learning from the populations treated by the program and the benefits and culture of the program are a good fit, I don't see why academic versus community is a good line to draw in the sand.
 
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There are many community programs with strong university ties, and many university programs that are heavily involved in the community. The distinction is propagated by establishments that make programs declarer which one they are, but it isn't black and white at all. You can generalize about which is better training, but there is plenty of overlap.
 
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Curious do you talk psych with your friends at community programs? Wondering how you feel their knowledge of the literature base is compared to your peers at the university program.

Honestly I feel that my friends at academic programs just know what their facility does and not multiple perspectives like the community residents as a general rule, though of course it's probably like only around 30% of residents at both types of programs whether they know what they're talking about vs 70% that do not.
 
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Curious do you talk psych with your friends at community programs? Wondering how you feel their knowledge of the literature base is compared to your peers at the university program.
I've wondered this myself when we talk. I do feel like I am better prepared than they are when we talk. I feel like there's more discussion, etc into why a certain med at rounds for example. Some of them do their training at for profit hospitals where the goal is to get in and out as fast as possible while maximizing the number of patients seen.
 
This issue is very program dependent. I trained at a large academic tertiary referral center, and I felt like I had a great breadth of training. A friend trained at a relatively laid back community program and has struggled with aspects of CL and SMI that were commonplace to me, but he spent much more time studying and knows far more from a details/textbook standpoint than me, because my program did not afford a lot of free time. The residents I'm with now in a community psych setting are very good and have extensive experience with SMI, and are very comfortable with it, but struggle even more than me from the book standpoint, because although I didn't study as much, my didactics where better than what they have.

Every program is going to have strengths and weaknesses. My recommendation would be to go somewhere that has a broad range of training opportunities, but also has plenty of what you want to do long-term.
 
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Most important question: 1. Do you want to do research in your career at all? If so, you need to be at an academic institution. Doubly/triply so if you are looking to transition to a T or K grant.

Other than that, it really is program by program. I'm at an academic position, and I found that I had not come across any program that had the breadth and depth of expertise in different sectors of psychiatry built into the residency program. Early autism, eating disorders, reproductive psych, transgender psych, ECT, TMS, geriatrics, addictions, pain, new interventions (neurosteroid, ketamine is not so new...), forensics, C/L. or transplant... among others. Learning these from the "experts" in the field. Not needing to do a fellowship to get real exposure to those domains. Not saying community programs can't do that, just that community programs frankly don't always need those services for the populations you serve.

I definitely find that outside of the different clinical experiences, my coverage of the actual research and knowledge in the field has grown immensely, but more importantly, learning how to learn from the science, and how to criticize it appropriately- understand the limitations. I'm sure many community programs do a great job of EBM as well, but who better to teach you to criticize science than actual scientists?

My 2 cents
 
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Community rotations expose you to doctors in the "real world." They are working to make money and not coupled to the academic mothership for whatever reason. I think the real world experience is valuable to at least see what a normal job is like, talk about compensation, how you get paid, some insight into negotiation, what to look for in a job, workload, etc.

Ideally, an academic program that has community-based rotations available, like an inpatient or CL elective in 3rd or 4th year would be useful for the exposure to those physicians and a taste of normal doctor job.
 
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Academic vs community are indirect proxies for what you actually really care about in training:
  1. The quality of teaching from attendings who know the literature, have lots of experience, and know how to take a history and deliver recommendations with empathy and nuance. I've found that it really depends on the individual how evidence-based they want to be. I find in academic settings, off-label treatments are trialed much more readily than in community settings, which may be a pro or a con.
  2. The volume of patients that give you a diverse set of psychopathology. Academic centers tend to have outpatient specialty clinics and tertiary referrals for C-L for things that are less bread and butter in psychiatry such as transplant, HIV, LGBT, OCD, Tourette's, Geriatrics, Addiction (including suboxone/methadone although this is more common in community), Autism, Eating Disorders, Interventional (TMS, ECT, ketamine, DBS, VNS), neuropsychiatry, early psychosis, pain center, perinatal, sleep medicine, bariatrics, executive health, psycho-oncology, integrative medicine, and more. Community hospitals and clinics tend to have the more severe schizophrenia, bipolar, addiction, personality disorders although not necessarily.
  3. As you go through your residency, the way that the program is set up is best if they give you a graduated level of autonomy. If you get too much independence early on this can be bad because it isn't good for patient care, you might not feel supported, and bad habits can set in. Too little independence later on can impede a successful transition after residency. Community programs often throw you headfirst into too much volume with too little support. Academic programs can be much too protective of their patients to let you make any kind of meaningful clinical decision throughout residency.
  4. You also want access to good training in a diverse set of tools and techniques to practice psychiatry and individualize care. This includes different modes of psychotherapy including CBT, CBT-I IPT, DBT, psychodynamic, PE/CPT for PTSD, MBCT, MBT, couple's therapy, ERP, CBIT, family therapy, group therapy, MI, PMT, etc. This is often found in academic centers rather than community programs.
    • Community programs will often allow you to learn how to use LAIs not just antipsychotics, mood stabilizers, and MAT more than academic ones.
    • At either place, you'll need to have attendings who are comfortable with using and teaching you how to use a variety of medications. It's really a shame that people come out of residency never prescribing TCAs, MAO-Is, benzos, Z-drugs, first gen antipsychotics other than haloperidol, MAT for alcohol/opiate/tobacco use disorders, starting clozapine and managing the side effects beyond the hematological ones, stimulants although this has changed dramatically lately, or even supplements.
    • It's also helpful to have exposure to ECT, TMS, and ketamine as these are tools to know how to refer to or utilize yourself in practice. This is often not found in CMHCs but can be found in outpatient private/group practices if you consider that "community." Definitely they can be found in academic centers.
    • Finally, it's really important to be taught the evidence-based lifestyle changes that can help with different psychiatric conditions and how to deliver these recommendations to the patient. How do you use bright light therapy for depression, especially seasonal depression? How much exercise should a person get to help with depression, particularly cognitive symptoms of depression? How can sleep restriction help with a patient's insomnia?
If you want to be a well rounded psychiatrist, the best programs have a mix of academic + community (both Medicaid and private/group practice) + VA in terms of inpatient + outpatient + IOP/PHP/RTC. If you want to just treat depression/anxiety in the community, it doesn't matter where you go.
 
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Is your intention to try to break into research in a serious way? Then 100% go academic, as prestigious as possible. Do you just want to be involved in academic psychiatry long-term? Then academic will make it easier, but not strictly required. Do you want to set up a high-end private practice in a saturated city? Then the more fancy names you can associate yourself with the better.

Once you descend from the Olympian heights, it makes very little difference to your career prospects.

I am biased in favor of academic programs provided they are real-deal tertiary referral centers just because you get a chance to see weirder stuff and more complicated cases, but this is a question of being better at dealing with maybe 5% of the patients you will encounter in the real world, not the vast majority.
I just want to be the town shrink somewhere, or failing that Local Shrink #4910 at the local hospital.
 
I just want to be the town shrink somewhere, or failing that Local Shrink #4910 at the local hospital.
Then it matters very little where you train. All programs (in any specialty) should be tailored enough to help someone be the busy bee worker. A community program may be more likely to give experience related to being "the" town shrink, though an academic program may expose you more to the newer literature or practices that may be commonplace in rural settings several years out.

It's important to look at if programs expose you to mentors like that. While my program is located in a major city, one of my mentors and psychotherapy supervisors in residency is a psychiatrist (and child analyst) who practices in a rural area several hundred miles away. This meant that I got exposure to a city system and a rural system. Some of the major academic centers may have excellent rural rotations. Some of the vaguely academic branches of programs (like the non-cleveland residencies that are part of the Cleveland Clinic) would probably be pretty ideal for this type of exposure while also being able to send you to the tertiary academic sites for electives.
 
So much of learning can be and is self directed. If there is a specialty or niche you are interested in, read, listen to podcasts, network, take CME/online learning, and find mentors who practice in the way/field you want to practice in. You don’t need to necessarily get niche training from a residency and while it’s nice if you can, not necessary. People put too much focus on where you get trained but once you’re out and practicing, you realize that it doesn’t matter as much as you thought it did.
 
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So much of learning can be and is self directed. If there is a specialty or niche you are interested in, read, listen to podcasts, network, take CME/online learning, and find mentors who practice in the way/field you want to practice in. You don’t need to necessarily get niche training from a residency and while it’s nice if you can, not necessary. People put too much focus on where you get trained but once you’re out and practicing, you realize that it doesn’t matter as much as you thought it did.
I think that depends on the person. I am very good at listening to podcasts/absorbing new information but very bad at self-directed learning where there is no structure. Had I not had the exceptional journal clubs and attendings with encyclopedic knowledge of the literature, I know for certain I would be a far worse attending.

If you are someone who will seek out pubmed, cochrane, podcasts, peer discussion/supervision, big conferences, and really go after the knowledge you need to do the best you can for your patients then I would agree it matters less where you train.
 
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So what proportion of those patients you treated had documented failure of 12 antipsychotics of heroic dose and adequate duration in various combination with every conceivable augmentation strategy? There's a difference between 2 months on a unit and seeing a patient multiple times throughout four years of their commitment while they go from 4-5 codes per day down to stable for discharge. Same thing with all the forensic admissions, evals, and chronic NGRIs.

I definitely got excessively comfortable with things like Thorazine 200 mg IM with Ativan 4 mg for the right patient (and would never recommend someone do that outside of very narrow circumstances) as well as talking down without meds people who have extensive homicide histories (and would also never recommend someone try that for the first time unless they are in the right environment).

To put it in other terms, all of our non-forensic patients were referred to us by the types of hospital settings that academic programs work in and they had failed to stabilize them after 20+ admissions or 6+ admissions in a 3 month period. In fact, none of the academic programs in that city saw ANY involuntary patients.

I also imagine you might not have had much experience filling out / testifying for year-long civil commitments as well as semi-annual renewals. Not that it's relevant outside of jobs that require that.

In turn I did only around 6 total months of the standard 3-5 day admission units and 0 months of the 2-3 day admission units because I have zero interest in practicing in those settings.
Where did you work bc this sounds exactly what I’m looking for
 
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