Is a psychiatry residency too hard or too laid back?

[appac1010]

I am looking at psych residency programs, and I see there is a lot of variation in how many hours/wk different programs do. Some programs boast about working you hard (near 80h/wk) in residency so you can be "prepared to see anything", while others advertise a more comfortable 40h work week. I was hoping to get some input about the pros and cons of a programs workload.

It seems that the benefit to working very intensely in residency is that it prepares you to handle the rigor and patient load seen as a practicing physician. The philosophy I've seen among PD's who run these program is that a physicians skill is directly correlated to the quantity of patients he/she has managed. It would therefore make sense to simply see as many pts as possible during training. Additionally, you are exposed to a wide range of pathologies throughout your training, which should prepare you to be comfortable managing a variety of disease processes. The downside to working excessive hours is that you reach the point of diminishing returns, which essentially means that the extra hours that you are putting in are coming at a greater cost. If a program were working you 120h/wk, the extra hours in which you see patients may not compensate for the loss of quality of care. In addition, fatigue and loss of concentration from sleep deprivation would worsen your ability to learn, and hence not be worth it.

It is also worth questioning how much of your work time is educational versus noneducational "scutwork". Two programs that each work 50h/wk may differ significantly if one of the programs have a greater emphasis on education, while the other one is repetitive poor quality work.

So what about the 40h/wk programs? The benefit to this is obvious: work life balance with a strong life outside of the office. But is that really the point of residency training? Working less hours will allow you to put more time towards education if that is what you'd like. In addition, having a fulfilling life outside of work can help to get the most out of being at work. But is 40h/wk sufficient to learn how to manage patients independently?

Ultimately what I am getting at is what is your philosophy for what a psych residency program should be in terms of workload? Is heavy and intense call with many hours/wk justified? Or is that just being taken advantage of?

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[OldPsychDoc]

Yes.

 

[Stagg737]

Ultimately what I am getting at is what is your philosophy for what a psych residency program should be in terms of workload? Is heavy and intense call with many hours/wk justified? Or is that just being taken advantage of?

You want a happy medium of the two. If a program can legitimately offer you the full spectrum in terms of pathology, offer significant supervision/teaching time, and still provide a reasonable workload (not too much, not too little) in 40 hrs, then that's great. Realistically that's very unlikely t0 happen though. On the other end of the spectrum, I don't think "heavy and intense call" will add a lot to your education other than just experiencing what a crappy schedule feels like. It's pretty rare when you have a great teaching moment during overnight call and most of the time it's just admitting the patient and stabilizing them until the team gets there in the morning. Necessary for the unit to function but doesn't add much to your education other than forcing your to be more independent in your decisions (which may or may not be a good thing).

Volume is also important, but greater volume does not necessarily equate to better training and as you stated variety matters. You want to have enough patients that you feel comfortable developing and enacting a plan for them in as many fields as possible. It's great if you see 1,000 patients with MDD, but if you only see 20 with schizophrenia at the same program all that volume will not make you a well-trained and well-rounded doc. I interviewed at a program that claimed their docs were well trained because they saw a lot of the "sickest of the sick" patients. Which is great when you're managing really sick patients, but not great when you don't know how to treat patients with mild to moderate symptoms or adjustment disorders (have stories from interview day that I even knew as a M4 were completely inappropriate).

Imo, I think averaging 50-65 hrs/wk is a reasonable amount of time in which you can see a variety of cases and have a solid case volume and still maintain a healthy balance to your life. Keep in mind, rotations may vary significantly and that the "average" number of hours can be misleading (I averaged ~75 hrs/wk on my last rotation and this rotation I'm averaging ~45). I was weary in general about any program that bragged about the number of hours their residents worked instead of focusing on what their curriculum was actually like and what residents actually learned.

 

[appac1010]

Hey thanks for the input, just wanted to ask a bit more on what you said.

I don't think "heavy and intense call" will add a lot to your education other than just experiencing what a crappy schedule feels like

Totally agree. My only experience with work schedules was through M3 rotations, and I felt like overnight shifts or shifts >12h didn't add very much benefit to my overall education. It taught me how to work while tired, but I feel like i could have developed that skill at any time, and it is not really necessary for residency.

It's great if you see 1,000 patients with MDD, but if you only see 20 with schizophrenia at the same program all that volume will not make you a well-trained and well-rounded doc. I interviewed at a program that claimed their docs were well trained because they saw a lot of the "sickest of the sick" patients.

great point, i didn't think of that. I do hear lots of programs boasting about seeing the worst of the worst, but I didn't think to ask about the variety of pts rather than just the extremes.

weary in general about any program that bragged about the number of hours their residents worked instead of focusing on what their curriculum was actually like and what residents actually learned

I've definitely seen this in some programs now that you mention it.

On a side note, any thoughts on programs that are "resident independent"? Some programs don't require residents, so they really try to focus on the educational part of training. In addition, night float and calls are minimal. But the con seems to be that you are sort of a glorified medical student with slightly more responsibility. Hospital staff may not know if they can depend on you to come into work, and this may cause some autonomy and decision making issues. It also seems like there is lots of hand holding in these programs. On the same token, hand holding can be seen as supportive so I'm not sure what to make of it.

 

[bashir]

I'm a cynical PGY-4, so bear that in mind, but in my view 4 years is more than enough time to develop basic competency to practice psychiatry, even at lighter hours programs. There will be a pretty serious learning curve once you get out into practice, even if you went to a heavier program. There is a wide variation in the quality of supervision you will receive at different programs, which I think is a bigger factor in training than is volume of patients seen and is not necessarily correlated with the latter. And much of your learning will be self-directed, so it's pretty important to actually have time, energy, and motivation to read, which require not being burnt out by clinical duties.

I may be rationalizing, as I'm graduating from a relatively light program in a few months. Learning doesn't stop when you finish training-- you just make more money while you continue to develop your skills and knowledge base.

 

[Shufflin]

Being on call q2 working 4am to 10pm in neurosurgery residency with demeaning superiors is too hard. That's too hard.

 

[Stagg737]

I felt like overnight shifts or shifts >12h didn't add very much benefit to my overall education.

I agree with the overnight shifts not adding much, I think 12 hour shifts can be very beneficial though unless you're just getting worked to the bone. On busier days I get to make decisions more independently with less supervision, but I also know that all the attendings I've worked with so far have been really supportive when I needed it. Plus if you get luck and have a really slow day, you get plenty of time to study or read articles (or just mess around, but I like to try and be productive when I get a lot of downtime at work).

On a side note, any thoughts on programs that are "resident independent"? Some programs don't require residents, so they really try to focus on the educational part of training. In addition, night float and calls are minimal. But the con seems to be that you are sort of a glorified medical student with slightly more responsibility. Hospital staff may not know if they can depend on you to come into work, and this may cause some autonomy and decision making issues. It also seems like there is lots of hand holding in these programs. On the same token, hand holding can be seen as supportive so I'm not sure what to make of it.

Depends. If you're basically just a glorified med student then that's not a good thing. If being "resident independent" allows residents more autonomy in the patients they get to work with and the teaching/education they receive then that's a good thing. At the other end, you don't want to be at a program that falls apart when a resident takes a sick day or goes on vacation because they're too dependent on residents. I'm not at a resident independent program (I mean, it could function without residents but it would be a major struggle) and I like the balance. What I do matters, but I also think that on most rotations I have time to learn and have good supervision.

In terms of hand holding, you want that to a certain extent early on with more autonomy as you move along. Being an intern in July can be insane if you're completely on your own. At the same time, if it's May of PGY-2 and your attendings are managing your patients then that's not good either. It's a balancing act and you have to kind of judge how much supervision you think you need compared to what residents get.

There is a wide variation in the quality of supervision you will receive at different programs, which I think is a bigger factor in training than is volume of patients seen and is not necessarily correlated with the latter.

Agree that quality of supervision play s a huge role, oftentimes more than volume. Volume is important, but as long as a program isn't at the extremes it's probably fine at most places as once you hit a certain volume of patients I think you start seeing some diminishing returns (other than truly unique cases and zebras). Like I said before, if your volume is so low and variety is so poor that you only see 10-15 schizophrenic patients while in residency, that's not good. At the same time, if you're regularly carrying 15 patients on the inpt unit then how much time do you actually have for real learning? For volume, I think there's an acceptable range that the majority of programs probably fall into that range, but I've certainly heard of/interviewed at a couple where volume seemed less than ideal.

And much of your learning will be self-directed, so it's pretty important to actually have time, energy, and motivation to read, which require not being burnt out by clinical duties.

+3 to this. I try and make a goal to do an hour of reading a day. Sometimes I can do this, sometimes I can't. At the very least I know I'm trying to keep up on my independent learning and I have the opportunity to do this on most days.

 

[deleted736562]

Overnight shifts in my program tend to be lighter in supervision and you get to have more independence, particularly on the administrative side (running the psychED, communicating with nurses and emergency doctors) so they have been helpful in developing competency on that level. The biggest advantage though is that you get to tolerate working long hours when you're tired; our brains can pretty much get used to anything, so it would be much easier to take call for extra $$ when you're out of residency.

I agree though the quality of supervision is far more important than the clinical volume.

 

[shaosoldier]

As noted in the many posts above. Psychiatry overall is a more laid back residency compared to most others. Our patients due tend to be more taxing from an emotional perspective but this still doesn't make it too difficult of a residency still. The good part is that with that extra time, you can dive deep into pharmacology theory, psychopathology theory and even psychotherapy allowing you to become,truly, a specialist.