How important is it to match at a residency with a forensic fellowship?

[whopper]

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Someone PM'd me and I figure this is something that can benefit everyone.

There is no specific yes or no answer I can give. It's a spectrum based on many factors.

1) If a residency program is attached to a forensic fellowship, it's a signal that the program is of higher quality. This is true of any program and any fellowship. The people in the department will be more on top of data that is specialized field specific thanks to the faculty in the fellowship.

2) If a program is attached to a forensic fellowship, expect the program to be able to do their forensic stuff with a higher level of competency. Where I did general residency several doctors did not know why they did several things other than it was the law. If you had a forensic psychiatrist there, that doctor could actually explain why those laws were put into place.

I have noticed that in a program without an attached forensic program, the lack of crossing the Ts and dotting the Is can happen with regards to forensic psychiatry. I knew several attendings where my level of forensic psychiatric knowledge by 3rd year exceeded their own just because I read up on it on my spare time. I knew some doctors for example that regularly petitioned for involuntary committment but never even bothered to read the laws on it. Some of those doctors despite years of practice never once did forced medications on their patient. In fact some of them wouldn't do it, even if it was clinically warranted because of their fear of appearing in court. They just let the patient linger and stay psychotic. This could happen even in a program with a forensic psychiatric program but don't expect it to happen as much.

3) A program attached to a fellowship will likely be able to offer you better source of electives and residency experiences with forensic psychiatry. For example at U. of Cincinnati, all the medstudents and residents can rotate with the fellowship where they literally are exposed to some of the top forensic psychiatrists and psychologists in the country as well as work at a forensic psychiatric institution of extremely high quality (the place I work). The state of Ohio regularly consults top people in the field and incorporated their recommendations into the state system that are not available in many other states such as 1) a mental health court 2) psychological testing is actually common in Ohio to rule out malingering where as in other states its on the order of "I never heard of the SIRS" and those doctors use clinical opinion that in studies is no better than a layman 3) criminal ACT teams 4) outpatient commitment (though it is not on the order of NY's outpatient commitment). In Ohio, a patient can be involuntarily assigned to a case manager and that case manager can at any time have the patient evaluated in a crisis center. 5) Offender specific facilities in the community.

4) You can very well still get into a forensic psychiatry fellowship if you don't go to a residency program attached to a fellowship. I will say that forensic fellowships are becoming more competitive.

5) During interviews for fellowship, you may get pimped. I for example was asked about a few landmark cases. Don't expect a non-forensically trained psychiatrist to be able to teach you these things.

While you may think that it was unfair to get pimped guess what? The cases I was pimped on are cases that are the basic backbone of involuntary commitment. They are things that any psychiatrist that ever petitioned for involuntary commitment ought to know. So in hindsight I don't think the questions were unfair though at the same time only one of the doctors I had in residency was able to teach me these things and all the other attendings wouldn't have known WTF these cases were.

6) If you attend a residency attached to a fellowship, it may give you an idea of what the better programs are. You'll have more opportunities to see that forensic psychiatry is like and it's not a big world. My PD mentioned other programs all the time because he was involved with their research or had to contact them because they had experts in fields he did not specialize.

7) If the program is not attached to a fellowship, it is still possible to get a good forensic experience if there are enough faculty members with forensic training. My own program that I graduated had two. One left my fourth year and the other rarely saw the residents.

But if no one has forensic training, don't expect get a lot of advice in this area. Hardly any of the attendings knew what to say when I told them I had a forensic psychiatry interest. In fact one attending erronesouly told me and another resident that the forensic psychiatry application process was on the MATCH. This was witnessed by several and when we looked into it, not only was she wrong, several programs had already stopped taking applications (and we looked into it at a time frame that would've been considered very very early to start worrying about MATCH applications). Well it just added salt into the wound when she denied she ever made that mention......

If you are in a program without a forensic fellowship, and no one is guiding you in this process, you may want to call up forensic psychiatry programs starting 3rd year and ask them that you're interested and ask what you can do to help the process of getting in. Ask to see if you can do an elective.

In short, you do not have to get into a program attached to a fellowship but it helps. If you're not in a program that is attached, it's not the end of the world though you may be on your own without much correct guidance from people in your department (and that is what happened to me). You should be in a position where even being on your own you can get what you need done so long as you start looking into things in your third year.

 

[nitemagi]

Whopper makes great points. I entered residency with an interest in child forensics, and am finishing a program without a forensics fellowship. You definitely have to be proactive in learning about it. I started going to the AAPL conference during 2nd year, which is a great opportunity because program directors will want to talk with you and recruit you, and there you're getting the real inside story.

Sadly, like Whopper, as a resident I had more forensics knowledge by 3rd year than many attendings. Not all of course. Most likely there are some forensic psychiatrists locally that may do teaching, and the trick is to tap them for guidance as well. We have them, they're just not a prominent feature of the program so took more work to get to know.

 

[whopper]

Working with a forensic psychiatrist (FP) as an elective that is not involved in academics will help but they may not be able to answer many of your questions.

There are still several FPs that never did fellowship because back in the day you could still be forensic psychiatry board certified without it. Ask a private FP on advice to get in and they'll likely say they do not know what to tell you.

They might be able to give you clinical exposure but don't expect much more. Many of them may have good expertise on the landmark cases and may have very limited and highly specialized focus on their forensic practice. E.g. one guy may only do disability evaluations but have never done a competency, sanity, or workplace evaluation.

Something I did not mention: FP is a very young field and as a result you can get some terrible FPs getting good gigs private and in academia. I know of some in name-brand institutions as professors, even PDs that I did not think were of good quality, but what's an institution supposed to do when there are literally only a handful in an area? If you got a bunch of PDs in FP and all asked them if they ever did a SIRS, few would be able to say they did so and only relied on clinical judgment to see if someone was malingering. As I mentioned, studies show that has no more reliability than a layman making the judgment yet these people are not willing to tell the court that.

The shortage of psychiatrists leads to interesting things such as bad doctors not getting fired for doing bad work. The extremes are much more in forensic psychiatry. I could for example move out to some areas and possibly be one of only 10 in an entire state. If I chose to do a terrible job at it, the place that hired me would have to take it or not have an FP at all.

More people are applying into this field and I believe with time, things will even out. As of now,

 

[TexasPhysician]

2) If a program is attached to a forensic fellowship, expect the program to be able to do their forensic stuff with a higher level of competency. Where I did fellowship several doctors did not know why they did several things other than it was the law. If you had a forensic psychiatrist there, that doctor could actually explain why those laws were put into place.

Competency or capacity? 😀

 

[whopper]

I don't mean the legal versions of those terms! 😉

Correction

Many of them may have good expertise on the landmark cases

I meant the opposite. Lack of good expertise. The landmark cases are often heavily emphasized in a good forensic psychiatry program. Those that became board-certified in forensic psychiatry before the fellowship requirment usually learned those cases to the degree where they just wanted to pass the exam.

and I didn't finish the sentence...

More people are applying into this field and I believe with time, things will even out. As of now,

As of now, we're still having plenty of specific areas where even name-brand places may have terrible forensic psychiatrists in the faculty. A notable forensic psychiatrist that I will not name has been on several news programs and making statements that are incorrect. The guy still gets people willing to pay him big bucks. It's one of those things where if a general psychiatrist were asked if that specific FP was legitimate or full of it, the general psychiatrist would not be able to tell.

 

[Cinnameg]

Hey Whopper -- What do you think of going to a place that is just starting a forensics fellowship, or has only had a forensics fellowship for a year? Do these fellowships often disappear/lose funding after they have begun?

 

[whopper]

Make sure the program is accredited. Some places have fellowships that are not.

To answer your question, it's a spectrum where on one end you see a program expecting to be there indefinitely, and on the other end, expect a program to be there only a few years tops if not dissolved in a matter of months.

Forensic psychiatry is more on the latter end of the spectrum. Why? It all boils down to faculty numbers. As I mentioned, FPs are rare. A place may hire one, even a bad FP to be on faculty, perhaps even as a PD, because there is no one else in the area.

So suppose a psychiatric dept only has 2 forensic psychiatrists and one of them is the fellowship PD? It's a situation where if the PD decides to leave the fellowship, the fellowship could tank. You'd have to find a replacement right? What if that other FP doesn't want to take it up? That is usually not the case with general psychiatry. If the PD leaves, the program usually has someone else willing to take up the position. Even if no one in the department is willing to do so, they are in a much better position to recruit someone outside the area.

In general, when I was applying, I noticed a few programs dissolved that were up and running just the year prior. The fellowship where I graduated, right before I started, the former PD (an AAPL award winning teacher) left to take a job running one of the top psychiatric facilities in the country. While he loved being a PD, he couldn't turn the offer down. Luckily for me, the guy who took over actually had even more experience, respect, credentials in the field, was a top person in the field, and he was a good teacher. The program, however, could've folded. There wouldn't have been anyone else who could've done it IMHO in the area that was willing to do so.