How to get the best CLINICAL training?

[neopsych12]

I entering my fourth year of medical school and will be applying to psychiatry residencies in the upcoming year. I am at the top of my class at a non-top 40 medical school with great scores (250+), mostly honors in clinicals, leadership & research exp. I am interested in psychiatric research but I do not think I would be as happy working primarily as a researcher with minimal patient contact for 30+ years.

It seems that most of the well-known/competitive residency programs emphasize research careers more than encouraging their graduates to go into private practice. So my question is, what are some "top" programs that train residents to become excellent clinicians/ private practitioners? Would I be better off training at a smaller more clinical/less research oriented state program or a big name research powerhouse like MGH/Columbia? I am assuming that these top programs also have great clinical training but it seems that their research is what creates their prestige.

Thanks for your time.

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[Sneezing]

Look for programs that aren't overly dependent on the VA to fund their program. In other words they have enough money to form rotations for educational purposes beyond just service. These types of programs will also have more specialty clinics/focuses that are representative of their size, catch basin, and distant referrals. These programs will provide name, clinical, and research opportunites.

Look at many programs, go on many interviews, and by the time you put your rank list together it will be more clear. Also, remember, even with a superstar academic pedigree in cash only, if you are a ... less than savory person ... it won't matter.

 

[billypilgrim37]

Your training is much more about you than the place. You simply want to find a place that has all the opportunities you want (something you have to personally figure out) and doesn't work you so hard in things that aren't educational that it gets in the way of your education. I'm not so sure about Sneezing's mention of the VA, as places like Washington, Michigan, Duke, Cincinnati and Stanford all spend a good time at the VA, and it's a good thing. At some programs this might be a bit of a red flag, maybe he could elaborate.

It's silly to separate the academic powerhouse programs from the clinic powerhouse programs, as the former will always qualify as part of the latter. There are good programs clinically that don't do a lot of research, but there aren't really programs that do a lot research that aren't good clinically.

Psych is a buyer's market, and you're a good applicant. Only a few places might hold the uncompetitive medical school against you, very few.

Decide where you want to live first, then go from there. There are too many good programs in too many places to split hairs about them this generally.

 

[loveoforganic]

pain medicine, bp?

 

[billypilgrim37]

I don't know much about pain medicine. But MasterofMonkeys I think knows that world really well, you might want to pm him.

 

[whopper]

This is a hard thing to measure because no one's figured out a formula of what makes better clinical training, while also tallying several programs head-to-head.

The only advice I can give you is don't go to a place that's malignant, and has a wide-array of different clinical settings. E.g. emergency, C&L, inpatient (voluntary and involuntary), inpatient long-term, inpatient short-term, (P)ACT teams, etc.

E.g. one program I know of didn't have an involuntary unit, and the overwhelming majority of the work was doing consults, and most of those consults were BS. You don't want that.

 

[loveoforganic]

I don't know much about pain medicine. But MasterofMonkeys I think knows that world really well, you might want to pm him.

Sorry, I was getting you two mixed up, so that was unclear. Was just asking what you chose to fellowship in

 

[billypilgrim37]

Sorry, I was getting you two mixed up, so that was unclear.

I am very hairy like a monkey. So that's understandable.

I'm a child fellow, and I'm thinking about doing an addiction fellowship after that. Why is a question for my analyst.

 

[BobA]

First, I'm not sure I agree with the VA statement. Some VAs are more educationally oriented than others.

Personally, I find my clinical training happens from my upper level residents as much as from my attendings. I would recommend going to a place where you think you'll have good upper level residents (and attendings) to model yourself after.

All things being equal, it would seem that training at a "brand name" program would provide some advantage when getting the highest-of-the-high-paying private practice jobs.

HOWEVER, all things are not equal. For instance, if you wanted to get the highest of the high paying jobs in Phoenix, I would think that training in phoenix and being chief resident and getting good recs from your department would be much more useful than training at MGH. Now if you want a super elite clientele in Manchester-by-the-sea, MA, you should probably go for MGH.

Additionally, you have to consider cost-of-living. In NY, LA, SF, Boston, etc the places where "top" programs are located and where their names carry cache the cost of living is so high that the purchasing power of your salary might actually be lower that it would be in lower-cost places such as Arizona, North Carolina or Texas, etc., where being chief resident at the local U might convey equal (or more) cache.

 

[Sneezing]

My VA comments stem from these personal observations. Take them with a grain of salt.
-I'm not fond of the VA CPRS chartings system. I find it antiquated, numerous redundancies, and not user friendly.
-Simply doing anything with the VA requires paperwork. These are not normal tension headache inducing paperwork stacks but migraine severity.
-Patient population is not homogenous to the community at large. We are getting trained to see as much pathology as possible from different backgrounds. This is fine if you plan to practice in the VA, but considering non-VA and non-academic centers are still the bulk of future practice opportunities it can be argued its less preparation. Mind you different programs have different levels of dependance on the VA. Some VA exposure is good to round off training, but not if it is the main educational venue for a residency program.
-It has been my experience the VA is like a massive HMO, but unlike an HMO like Kaiser they don't readily accept transfers. This is especially frustrating when the patient actually wants to be treated at the VA.
-I personally dislike the resource availability of the VA and how veterans will have to travel 2.5hrs to one location for this service, then 5hrs to this location for that service, etc. when right down the street is a hospital with the same specialist. Why not just give Veterans additional money for private insurance or some sort of other voucher to use community resources in lieu of the whole VA system? I have a hard time believing the unique attributes of veteran disease exposures are enough to warrant an entire seperate national health system.
-VA work ethic is a government work ethic. 8-5. Not 5:05PM or 5:07PM, but 5:00PM on the dot is check out time. I can't work in that type of setting.

+The VA does do well for PTSD resources and treatment. I applaud the institution for this.

 

[whopper]

First, I'm not sure I agree with the VA statement

An issue with the VA is that you see a type of patient population in a specific type of system. This is not a bad thing unless this is all you see. It's good to get a flavor of as many systems and patient populations as you can.

Getting VA experience is not a bad thing but I'd recommend it be in concert with several other types of clinical experiences.

The paradigms and treatment strategies I employ are highly variable depending on the treatment setting.

and as bad as the problems are in the VA, this too can be a good learning experience. Every clinical setting has it's pros and cons. The good thing about working in multiple settings is that you have an out and will likely leave the setting you're in once you've figured out the problems with it.

If you're in a residency where you're in limited settings, you'll spend more time trapped in a setting where you've already learned what you can from it.

 

[neopsych12]

Thanks for the responses. I really appreciate your input and time.

 

[notdeadyet]

1. There is no "The VA." Since it's federal, it's easy to make the mistake that one is exactly like the other, particularly since they have the same architecture, signage, and EMR. But one is as different from the next one as are neighboring hospitals. They have different cultures, emphasis and offerings. I've worked closely at three and they were very different experiences. Some of the criticisms above sound very foreign to me. Particularly the gripe that the VA is all-white/all-male. It definitely skews heavily male (in the older population) but the all-white thing probably is as much a reflection as the geographic areas the VAs are located as the VA system itself.

2. Diversity of experiences is key. My personal ideal for a residency training program would be one that had a county experience, a VA experience, a private practice model, and a tertiary care academic experience. I wouldn't want a program that didn't have experience offerings in any of these.

 

[whopper]

Agree with the above. Not every VA is the same.

I'd also add start reading up on topics not taught in psychiatry residencies. For example, learn DBT for real. Do an H&P that tracks the patient's history from birth. I'd recommend the Kaplan and Sadock guidelines on doing this. Doing this will yield plenty of relevant information on truly understanding a patient well. Read up on psychotherapy.