Does it matter where you do your residency?

[mymembernames]

Does name/prestige/where you train make any difference once you finish residency?

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[OldPsychDoc]

Not really/no/yes
You are far more likely to practice where you trained than elsewhere.

 

[TexasPhysician]

It matters to some degree if your primary goal is to become faculty at a prestigious academic center or open a cash practice in a saturated city. If not, no.

 

[DisorderedDoc417]

Yes it does matter. It will influence how and where you practice most likely.

 

[Shufflin]

It will help you land your first job. After that your reputation and how good you are will quickly take center stage.

 

[tortuga87]

It matters to some degree if your primary goal is to become faculty at a prestigious academic center or open a cash practice in a saturated city. If not, no.

I remember someone told me essentially the same thing for college. I didn't listen and just went to the highest ranked place. Unfortunately I was wrong and they were right. Ppl also told me the same thing for medical school, and I still didn't listen. They were right. Maybe I should listen this time...

 

[Merely]

Are we gonna ignore the fact that if you go to a top tier academic place you’ll be surrounded by intellectuals and will probably graduate as a more competent and thoughtful psychiatrist compared to a student that goes to a random community program?

 

[OldPsychDoc]

 

[OldPsychDoc]

Are we gonna ignore the fact that if you go to a top tier academic place you’ll be surrounded by intellectuals and will probably graduate as a more competent and thoughtful psychiatrist compared to a student that goes to a random community program?

Don't confuse mental masturbation with clinical acumen.
I keep returning to the comment made by a colleague working in an underserved state who encountered an "intellectual" Ivy League-trained psychiatrist who "wasn't comfortable with" long acting injectables or clozapine.

 

[TexasPhysician]

Are we gonna ignore the fact that if you go to a top tier academic place you’ll be surrounded by intellectuals and will probably graduate as a more competent and thoughtful psychiatrist compared to a student that goes to a random community program?

While this may occasionally be true (some workhorse programs with poor teaching), this is generally false. Residency is often chosen based on location, family, and future goals. The end result is that intellectuals will be spread out broadly.

You can similarly find good teachers at many programs.

 

[TexasPhysician]

I remember someone told me essentially the same thing for college. I didn't listen and just went to the highest ranked place. Unfortunately I was wrong and they were right. Ppl also told me the same thing for medical school, and I still didn't listen. They were right. Maybe I should listen this time...

Keep in mind that residency is the end goal of competition (fellowship outside of pain is not competitive), Everything you have done puts you in a place to allow you to choose a residency of your liking. A prestigious residency will not earn you more money or help with the 95% of jobs outside of academics. If you decide during residency that you want to teach at somewhere like Yale, do a fellowship at a prestigious location. There are fellowships at good places that sometimes go without a single completed application (I’ve seen it).

 

[Merely]

Just to be clear, are we saying that the residents at a top 10 program will not on average be more equipped, sharper, have a deeper, richer, and more nuanced understanding of both the clinical and theoretical basis of psychiatry and its applications compared to say a community program graduate? I am asking as I am merely a student going off what I have heard from many attendings who understandably have their biases

 

[Stagg737]

Just to be clear, are we saying that the residents at a top 10 program will not on average be more equipped, sharper, have a deeper, richer, and more nuanced understanding of both the clinical and theoretical basis of psychiatry and its applications compared to say a community program graduate? I am asking as I am merely a student going off what I have heard from many attendings who understandably have their biases

If they are it's more likely because they're the kind of residents who, as a whole, will actively seek out learning opportunities and will be more driven to learn. Not necessarily because the staff are far superior (though staff may also be more driven to contribute to the academic community through research and conferences as well).

Anecdote: Mercy in Iowa is a new community program which took their first class of residents this past cycle. The PD there (and primary inpt attending) trained and was previously faculty at Wash U and their other main attending was trained at another solid academic program (I think Iowa? Can't remember). While it's a new community program that most would likely consider a "weak" program, I didn't have questions in terms of the kind of education that the faculty would be providing to their residents.

 

[TexasPhysician]

Just to be clear, are we saying that the residents at a top 10 program will not on average be more equipped, sharper, have a deeper, richer, and more nuanced understanding of both the clinical and theoretical basis of psychiatry and its applications compared to say a community program graduate? I am asking as I am merely a student going off what I have heard from many attendings who understandably have their biases

There are some excellent community programs that likely draw stronger applicants than some Ivy programs. I don’t keep up as much with competition as I did a few years back, but I recall the San Mateo community program being incredibly competitive 7-10 years ago.

If you are only comparing Top 10 academic programs to bottom 10 community programs, then odds would lean in your favor.

 

[Animal Mother]

anecdotally, you’re going to work with better doctors and see more variety working at a large teaching hospital rather than at a small community program, DO program, one that does all its rotations at the local VA/jail, etc. not saying that there aren’t some good doctors at smaller places, but there are a lot of really, really bad psychiatrists out there. It’s harder probably for the bad ones to sneak into more prestigious university positions than it is for them to find undesirable VA spots or community jobs in rural Tennessee.

 

[Shufflin]

There are some excellent community programs that likely draw stronger applicants than some Ivy programs. I don’t keep up as much with competition as I did a few years back, but I recall the San Mateo community program being incredibly competitive 7-10 years ago.

If you are only comparing Top 10 academic programs to bottom 10 community programs, then odds would lean in your favor.

Harbor-UCLA and Harvard's Cambridge Health Alliance come to mind as top community programs that have the advantage of being connected to top academic programs and draw impressive applicants.

 

[Blackdogue]

Are we gonna ignore the fact that if you go to a top tier academic place you’ll be surrounded by intellectuals and will probably graduate as a more competent and thoughtful psychiatrist compared to a student that goes to a random community program?

I read something interesting on that topic. It can pull you up, but it's even more likely to push you down. The one statistic that was interesting was that the top 25% of graduates of mid and low tier colleges have more publications than the bottom 75% of ivy league graduates. The author hypothesized that being in a smaller pond with lower competition can build your confidence. On the other hand, in an ivy league school, a person with above average intelligence can easily feel inadequate. Of course the top 25% percent of ivy league graduates had the most publications.

 

[OldPsychDoc]

I read something interesting on that topic. It can pull you up, but it's even more likely to push you down. The one statistic that was interesting was that the top 25% of graduates of mid and low tier colleges have more publications than the bottom 75% of ivy league graduates. The author hypothesized that being in a smaller pond with lower competition can build your confidence. On the other hand, in an ivy league school, a person with above average intelligence can easily feel inadequate. Of course the top 25% percent of ivy league graduates had the most publications.

Again, publications only matter in academia. Having a ton of publications is no guarantee that a resident is going to be a great clinician (and certainly in many cases, it may represent exactly the opposite!)

 

[nitemagi]

I would argue that the higher prestige programs generally don't have as a baseline better training, but that they have the availability of resources that can make you excel. It does require you to find all the hidden pearls and maximize them because typically they're not well built into the curriculum.

 

[Blackdogue]

Again, publications only matter in academia. Having a ton of publications is no guarantee that a resident is going to be a great clinician (and certainly in many cases, it may represent exactly the opposite!)

Of course. It was just a general indication of success and it wasn't even about medicine specifically. But I still think there is something to be learned from this. That competing against the best of the best can make one feel inadequate and end up negatively affecting his career. Maybe I'm just trying to come to terms with the fact that I didn't go to a prestigious med school, but it certainly felt good to be one of the best ones there (while being nothing special really) and gave me more confidence to pursue my goals.

 

[splik]

Of course it matters where you do your residency. Of course, you will be a psychiatrist regardless, the notion that there is some minimum standard that all programs provide is just fantasy. A large proportion of residency programs are garbage and part of the reason our field is a race to the bottom. Things to consider:

1. Location matters. For several reasons. As mentioned above - you are more likely to end up where you train, and more likely to turbo charge your career by staying in the area where you trained because you will have the upper hand in terms of knowing the opportunities available, the people involved, and a better ability to set up shop from the get go. The kind of patients you will see, the psychopathology you will be exposed to, and the specific geographic challenges of practice will be quite different.
2. Residency programs differ in the level they prefer their graduates for private practice. While people who go to name-brand programs like to tout their credentials, the most important factor that helps these people establish themselves early on is they are provided access to a network of people in private practice to are able to mentor them and help them establish (cash-based) private practices. While you can certainly do this from any program, going to a program where they provide you the training and mentorship to be able to do this (and where a decent proportion of recent graduates have carved out this path) makes a huge difference. Some programs even allow residents to begin private practice as a PGY-4 (or look the other way).
3. Residency programs differ in psychotherapy training. Some programs do not provide any training at all in one or more modalities of psychotherapy. Others still may be much stronger in particular modalities or provide unique opportunities. If you want psychotherapy to be a part of your career, it makes a big difference where you train. Geography plays a part too, as many parts of the country do not have patients who are suitable psychotherapy candidates. While there are some opportunities (especially for analytic training) after residency, it is much easier to get a solid foundation and supervision (and for free) if you attend a program that does this.
4. Not all programs provide the minimum ACGME requirements. The ACGME very loosely applies its criteria for programs. There are programs out there that do not provide geriatric psychiatry, addiction psychiatry, community psychiatry, forensic psychiatry, emergency psychiatry, or psychotherapy training. I know of several programs that count inpatient months as "community psychiatry" (including top programs) which is ridiculous. Others still count C/L for geriatrics etc. Many smaller programs do not provide therapy training, particularly psychodynamic psychotherapy.
5. Moonlighting. Moonlighting is a great way to supplement your income as well as gain further experience and exposure to different settings with greater autonomy while in training. Some programs prohibit any moonlighting. Others have no internal moonlighting. Others still have little call and plenty of internal and external moonlighting opportunities allowing residents to triple their pay. Something to bear in mind.
6. Elective time. There are wide variations in elective time and offerings between programs. Some programs allow for away rotations at other programs or even international electives. Others allow elective time as early as the PGY-1 and -2 years. Others still have no elective time at all, and the claimed electives are just repeating service-heavy months. Elective time can be some of the most nourishing and useful to your overall career development by allowing you to carve out a niche for yourself.
7. Specialty training/services. Some programs will provide training in eating disorders, others in neuropsychiatry, others still in sexual medicine, transgender health, paraphilias, palliative care, sleep medicine, global health, reproductive psychiatry etc etc. Something to bear in mind if you have a particular niche interest.
8. Research. If you want to have an academic/research oriented career, or even have research be a small part of your career, it would make sense to train somewhere that affords such opportunities.
9. Workload and call. There are huge variations between the workload and call of programs. Some programs have no call and light rotations. Others have a higher workload than internal medicine residencies. Balance is the key.
10. Connections. There will be a big difference in terms of the connections you make within your program, community, in the psychiatric and medical community at large. This can be a big thing in terms of finding jobs and other opportunities, and having a strong social network to rely upon in your career.

Frame of reference is they key thing here. if you are an uncompetitive applicant and the choice is between not matching and a not-so-hot program, than the choice is a no-brainer. However, if you do have many options open, you would do well to consider the above, and counterbalance that with your personal wishes, your family's needs and wants, and identify what would be the best fit for you. It is not the superficiality of "name"/prestige that matters, but often those programs are able to provide opportunities that allow you to kick start your career and open to doors to different options more readily.

 

[clausewitz2]

I would argue that the higher prestige programs generally don't have as a baseline better training, but that they have the availability of resources that can make you excel. It does require you to find all the hidden pearls and maximize them because typically they're not well built into the curriculum.

So much this. I think you could go through my program with relatively unremarkable training if you just did the things you were required to do and nothing else. There'd be volume and definitely more zebra cases than at a really small place, and probably better C&L exposure than I think is the norm but nothing super exciting or distinct.

If you do take even a little bit of initiative, though, there is a fantastic array of specialized clinics and services and huge opportunity to piece together your own electives and trainings. Like, we are not the only place that has an IOP program dedicated to OCD in children, but it is also not like most psychiatrists out there have any experience with a setting like that.

 

[liyaz]

A large proportion of residency programs are garbage and part of the reason our field is a race to the bottom.

Can you expound on this a little bit? What parts of a psychiatry residency are not useful? And what do you mean by race to the bottom?

 

[MedMan80]

Of course it matters where you do your residency. Of course, you will be a psychiatrist regardless, the notion that there is some minimum standard that all programs provide is just fantasy. A large proportion of residency programs are garbage and part of the reason our field is a race to the bottom. Things to consider:

1. Location matters. For several reasons. As mentioned above - you are more likely to end up where you train, and more likely to turbo charge your career by staying in the area where you trained because you will have the upper hand in terms of knowing the opportunities available, the people involved, and a better ability to set up shop from the get go. The kind of patients you will see, the psychopathology you will be exposed to, and the specific geographic challenges of practice will be quite different.
2. Residency programs differ in the level they prefer their graduates for private practice. While people who go to name-brand programs like to tout their credentials, the most important factor that helps these people establish themselves early on is they are provided access to a network of people in private practice to are able to mentor them and help them establish (cash-based) private practices. While you can certainly do this from any program, going to a program where they provide you the training and mentorship to be able to do this (and where a decent proportion of recent graduates have carved out this path) makes a huge difference. Some programs even allow residents to begin private practice as a PGY-4 (or look the other way).
3. Residency programs differ in psychotherapy training. Some programs do not provide any training at all in one or more modalities of psychotherapy. Others still may be much stronger in particular modalities or provide unique opportunities. If you want psychotherapy to be a part of your career, it makes a big difference where you train. Geography plays a part too, as many parts of the country do not have patients who are suitable psychotherapy candidates. While there are some opportunities (especially for analytic training) after residency, it is much easier to get a solid foundation and supervision (and for free) if you attend a program that does this.
4. Not all programs provide the minimum ACGME requirements. The ACGME very loosely applies its criteria for programs. There are programs out there that do not provide geriatric psychiatry, addiction psychiatry, community psychiatry, forensic psychiatry, emergency psychiatry, or psychotherapy training. I know of several programs that count inpatient months as "community psychiatry" (including top programs) which is ridiculous. Others still count C/L for geriatrics etc. Many smaller programs do not provide therapy training, particularly psychodynamic psychotherapy.
5. Moonlighting. Moonlighting is a great way to supplement your income as well as gain further experience and exposure to different settings with greater autonomy while in training. Some programs prohibit any moonlighting. Others have no internal moonlighting. Others still have little call and plenty of internal and external moonlighting opportunities allowing residents to triple their pay. Something to bear in mind.
6. Elective time. There are wide variations in elective time and offerings between programs. Some programs allow for away rotations at other programs or even international electives. Others allow elective time as early as the PGY-1 and -2 years. Others still have no elective time at all, and the claimed electives are just repeating service-heavy months. Elective time can be some of the most nourishing and useful to your overall career development by allowing you to carve out a niche for yourself.
7. Specialty training/services. Some programs will provide training in eating disorders, others in neuropsychiatry, others still in sexual medicine, transgender health, paraphilias, palliative care, sleep medicine, global health, reproductive psychiatry etc etc. Something to bear in mind if you have a particular niche interest.
8. Research. If you want to have an academic/research oriented career, or even have research be a small part of your career, it would make sense to train somewhere that affords such opportunities.
9. Workload and call. There are huge variations between the workload and call of programs. Some programs have no call and light rotations. Others have a higher workload than internal medicine residencies. Balance is the key.
10. Connections. There will be a big difference in terms of the connections you make within your program, community, in the psychiatric and medical community at large. This can be a big thing in terms of finding jobs and other opportunities, and having a strong social network to rely upon in your career.

Frame of reference is they key thing here. if you are an uncompetitive applicant and the choice is between not matching and a not-so-hot program, than the choice is a no-brainer. However, if you do have many options open, you would do well to consider the above, and counterbalance that with your personal wishes, your family's needs and wants, and identify what would be the best fit for you. It is not the superficiality of "name"/prestige that matters, but often those programs are able to provide opportunities that allow you to kick start your career and open to doors to different options more readily.

Splik your posts are so well thought out and well written my man, thanks for taking the time!!

 

[deleted736562]

Frankly I think geography makes the biggest difference. From my experience the biggest variation in training is in therapy and research. It's kind of sad how the field is pushing psychiatrists away more and more from therapy when it's really as much of a science as pharmacology and is equally important in our treatment arsenal. In the right geographical area, though, you can easily seek outside training in therapy and research if that's what you want.

Careerwise (i.e $$ or whatever), I really don't think it makes the slightest difference. If you want to work in an academic setting (why would anyone do that is a different subject), you can seek one of many noncompetitive fellowships and get a leg there.

Bottom point: by far the most important limiting factor is yourself; how motivated you are to seek opportunities, to learn...etc. Nothing else will stop you.

 

[ziggyhope]

I think most people are right, you can be a good psychiatrist in many different residencies. However, in my limited experience, it matters because you (hopefully) learn why the institution is prestigious, what do they do that others places do not. Also, the institution may attract patients with uncommon/rare presentations. You have access to a lot of very niche expertise, subspeciality clinics, etc. In the end though, the resident needs to be motivated to utilize those opportunities, and whether it's training or employment, the most immediate previous experience will be the most important.
Also, connections matter whether we like it or not.

 

[MacDonaldTriad]

It has been proven over and over again, brand name places are capable of producing weak clinicians. The learner has to keep up their end of the equation no matter how much talent they are surrounded by.

 

[whopper]

I agree with the above comments and were way better clarified than I could've stated.

Something to add, most people fresh out of residency still will not have enough clinical experience to be a very good psychiatrist. You're still learning. You will always be learning if you're a good physician but IMHO you still need to be in an environment that actively encourages your growth for at least a few years after graduation.

Buprenorphine, malingering, important legal issues, end-of-life issues, dynamics of private practice...these were things where I didn't feel I got enough training from my own residency program.

Even though my forensic fellowship was headed by one of the top guys in the field and he was an absolutely great teacher he only got me started in that field to the degree where I had the tools to become something much better. This is not a criticism of him. In fact that's really all the best teachers can do cause real learning is life-long. He was one of the best teachers I ever had. Even the best programs (I'm not talking about prestige, I'm talking programs that will train you well and reputation and this don't correlate close to 100%) will only get you to that point. I was going to go into forensic psychiatry as a main thing but life threw me some curve balls (not in a bad way, heck I'm earning way more than I would've had I stayed on the academic forensic track), but I knew that for me to be even half as good as my former director I'd have to stay active in the field at least another 10 years.

The best programs get you to toddler stage where you can walk on your own. There's still so much more to learn. I've noticed the really bad psychiatrists managed to graduate and from there choose to not make it an active and important priority to continue to learn and expand their skills. Even as residents these people often times did just what they could to be safe and pass on but really not thrive as physicians.

 

[mymembernames]

From looking at some of the top name places it looks like all the faculty are from top name places...

 

[mymembernames]

Plus heard if planning on going into PP in a saturated area it can make a difference...