Country/Community vs. Academic Medical Center vs. VA

[jfksenior]

Hello All!

I was wonder if some of the more experienced residents here could help a younger student understand the unique assets and liabilities of doing psychiatry in each of these three different kinds of environments:

For County Hospital/Community vs. Academic Medical Center vs. VA

1. What is especially rewarding about this context? What kind of a person would enjoy it/not enjoy it?
County-
Academic-
VA-

2. What is especially frustrating about this context? What kind of a person would enjoy it/not enjoy it?
County-
Academic-
VA-

Thanks for any help! I hope this would be informative for others who are deciding on different contexts to train in and work.

---

Members don't see this ad.

 

[peppy]

You should ideally be at a program where you get exposed to a little of each type of setting.
Some general comments from my experience:
County - often will see the most severe pathology at this sort of setting so in that sense it is good educational experience. Depending on the setting it might be frustrating due to the lack of resources available and you may or may not have good social workers to help you make sense of "the system". The county site I had experience with had rather low morale and was kind of a depressing place.

Academic - it's probably most important to have a CL rotation at a major academic medical center, since that's where you would see most of the odd zebras. Otherwise, I'm not really sure that it's quite as important in psych as it is in specialties like IM.

VA Psych - I actually like the VA best. Partially because of their great electronic record system. Their electronic charting makes life a lot easier. You also don't really have to worry much about issues like insurance in the VA system, although you are restricted in some ways by the bureaucracy at the VA.
At the VA you will get a lot of exposure to PTSD and (probably in part due to the high prevalance of PTSD among vets) substance abuse issues. At a good VA you should also learn about suicide screening as well, since the vets are a high risk group.
I personally like working with vets because I think they're an interesting group of people
and I have a lot of respect/empathy for them after hearing about what some of the guys with combat PTSD went through (although you should be prepared that there are some who malinger trying to get benefits from the VA, there are definitely others who are legitimate). I also find the vets to TYPICALLY be more respectful of us and appreciative for the care they receive than the average psych patient.
One thing that some people don't like about the VA is that the majority of VA patients are older males...although contrary to popular belief, yes, you do see SOME female patients (increasingly so, due to the higher number of females in the military nowadays). In my location, while a lot of our patients are from the Vietnam era, it's not at all uncommon to see young Operation Enduring Freedom/Iraqi Freedom vets coming in for psych care.

 

[nitemagi]

1. What is especially rewarding about this context? What kind of a person would enjoy it/not enjoy it?
County- A lot of dual dx, homeless, and malingering, sadly. Many with few resources. Good for learning and seeing the most extreme state of individuals, and figuring out how to work with that. Good as a learning experience to practice boundaries and recognize how many we can only help so much -- practice at letting go and maximizing the resources you have.
Academic- Agree with Peppy. Good for seeing the most diversity of pathology, including the rarities.
VA- An ok mix - some diversity of conditions, a lot of PTSD, substances, malingering. I think of the diversity as similar to county, maybe a little better in the pathology, mostly men, with more resources to offer them.

2. What is especially frustrating about this context? What kind of a person would enjoy it/not enjoy it?
County- Lack of resources is always frustrating. There's only so much available.
Academic- Politics often play into how academic centers are run, rather than evidence based practice per se (across medical specialties).
VA- Federal government bureaucracy means a lot of rules that make no sense, and little ability to change them. Why does a qday prn need a not to exceed order?

 

[jfksenior]

Many thanks, Peppy and Nitemagi, your comments are much appreciated.
Anyone else have some expertise in these domains and how they vary? Thanks in advance!


If you had to rank county, academic vs. VA – where are the psychiatrists the happiest? Where is best quality of life? Why do you think that is the case? I think one could be very happy at a county/community hospital since one is helping those most in need, right? I have no experience here…

-Is it generally agreed that one sees the most severe pathology at public/county hospitals? Or is that just for schizophrenia?


Summarizing a bit here:

County
-many homeless, malingering
-most severe pathology
-lots of dual diagnoses
-lack of resources means you do more social work?
-low morale?

Academic
-most important for people interested in CL
-see diversity of pathology

VA
-great electronic medical records
-no insurance problems
-see lots of PTSD, Substance abuse
-more respectful/thankful patients?
-mostly older males
-government bureaucracy

Thanks, and any others who feel they can contribute would be awesome, thanks!