PGY-4 Electives

[trixter888]

Hello, I am currently a rising PGY-4. My psychiatry residency is quite flexible in that we can design many of our own electives. I was wondering if anyone could comment on any electives they did during 4th year that they found extremely helpful. Particularly I am looking for any electives that are outside the normal scope of traditional inpatient work/consult work.

Professionally I want to enter private practice after I graduate. So far these are the electives I have chosen: Sports Psychiatry (able to obtain a certificate online), Integrative Psychiatry, MAT (suboxone waiver) and TMS (certifications).

1) What electives do you recommend?

2) Are there any other "certifications" I can work towards during 4th year that don't require a fellowship?

 

[splik]

Forget about “certifications” and just try to get as much in the way of different experiences you can before you graduate especially things you e we not easily get later. Consider doing psychotherapy electives if that way inclined.

Sleep medicine may be a good one. Is there an advanced psychopharmacology elective? Are there any opportunities for you to learn about the business of medicine or nuts and bolts of private practice? Regardless of any formal electives you should seek out mentor ship from psychiatrists in private practice if you are thinking about going into solo private practice upon graduation. Think about whether you have particular areas of interest you can carve out a niche in during training that you could market later on.

there is definitely huge variation in what electives are available or possible depending on where you are. Think about not only what your interests lie but what you’re afraid of or dislike and embrace that.

 

[Sushirolls]

Certifications mean nothing. No one cares, nor should they, and nor do we want them to. You are a physician and soon psychiatrist. That is the be all end all.

Do sleep medicine.

Do hypnosis CME with ASCH.

Go knock on the door of your dept chair, and the suit equivalent to your hospital chair. Outline a 1 month admin elective with them. You shadow them for a month, and possible any other high up suit you can get to agree to it. Lots and lots of meetings. Ask as many questions as you can. Get their spreadsheets for the meetings. It will be quite insightful. Maybe even have 1 week be with a midmanagement, like the office manager or the Sleep Medicine clinic after you do that rotation.

Eating disorder clinic if you haven't already. Month with whoever is doing the mental health evals for the bariatric surgeries.

Find a rotation that does share medical appointments (SMA). Granted with Covid-19 who knows what these look like right now. My residency had them in women's health. I created them for Suboxone management in a Big Box Shop job I had. The patients loved the SMA.

 

[trixter888]

Thank you for the replies thus far!

In regards to certifications, I guess I meant just being able to get qualified for certain procedures or medications. Ex: TMS, being able to prescribe suboxone, etc. I will have a lot of down time during PGY-4 year. I will look into the Hypnosis CME, but welcome any other ideas that you may have wanted to get in hindsight. Another attending recommended getting certified to do ECT, but I don't ever see myself practicing that in the future, so I am going to pass on that experience.

Sleep Medicine seems like a great elective too. I think I will incorporate that into my electives. We have a dedicated pharmacy team for psychiatry, so pairing up with them may seem the closes to an advanced psychopharmacology elective.

I just met with my program director and expressed wanting to do an "business in psychiatry elective" but didn't seem to get much traction. I guess he wanted more objectives that would "qualify under the ACGME." Basically, I want a mentor to ask all of these questions to, but in the small community I practice in there is only one private practitioner affiliated already with our university and she politely declined an opportunity to work with her (focuses more on private pay clients, which I am sure don't want another provider during the session). This doesn't however mean it's impossible, I will keep on looking in the community to see if anyone would be able to host an elective or observer ship with me. I basically am hungry for more knowledge of private practice because I feel we get so little exposure to it during residency.

I appreciate everyone's responses thus far! It's giving me a lot of ideas to look into this next year. Please keep them coming!

 

[Sushirolls]

There is no ECT certification certificate. You can get certificates from programs like ISEN-ECT.org, or other mini-clinics with some universities. However, none of this mean a thing. The only thing that matters is the hospital you are seeking privileges at and what their credential card has. Some can be as simple as being incorporated into the general privileges a Psychiatrist. Others can be more of a pain, with like 200 procedures per year, and other random stuff. I've set up privilege cards before for 10/per year with other random details.

The push that some residencies have had to incorporate pharmacists onto the rounding teams is a joke and sad in my opinion. Our pharmacology knowledge exceeds theirs in the real world practical sense. The times I've been on these types of services they would simply be like "uh... I don't know" "I'll get back to you on that" and they never actually did, or on drug interactions they whipped out their phone and reviewed the epocrates drug/drug interaction checkers. I can do that too... Pharmacists also don't know the real world side effects and the real world feed back patients give on them. I do not see pharmacists as value added to any clinical rounding service and wonder why they are there? What do they do? What do they offer? Consistently the psychiatrists knew their pharmacology more, and simply tolerated them there because some admin above them told them to accept it.

Part of my clinical headaches are dealing with pharmacists calling to delay or say they won't fill a prescription. To then call them and say, no, gabapentin is perfectly acceptable to prescribed for PRN anxiety, and the patient is already aware that it is off label. Or to call and tell me they have concerns about dual overlapping therapy (trazodone / SSRI) or (SSRI / SNRI).

I feel a sense of disappoint that somewhere out there a resident is considering a rotation with pharmacists as advanced pharmacology.

 

[Sushirolls]

Reach out to the private doc again. This time offer to take the person out for lunch, dinner, whatever. Make it clear up front you want to get as much information about running a practice as you can. Including ability to see their books if willing. Make it clear you won't be staying and practicing in that area (yes/no?). Hopefully the person is willing to open up and share the nuances of their practice.

This request is not for a month long rotation but instead a weekend day, or clinic half day, evening, whatever time block you can get. Come prepared with a notebook and pen. Save these notes for later.

Your Chair/PD are fools to not see the merits of a business elective in residency. A more palatable name to them would have been 'administration' elective, "to better prepare us for the emerging role of medical directorship as this will be physician level while there is an emerging need for physician oversight/management of midlevels in the rising health system sector that is delivering an ever increasing share of the healthcare market. This is a deficiency that we as residents aren't getting, but will be expected to perform in future employment."

They won't assist because of their short sightedness, then dive in and create your own with trial by fire. If you are a PGY-IV in a few days, you could actually start the leg work to open your own private practice now. Why wait? Even if it is in a different location city. There are things you can get started now, so July 1 of 2021 you are ready to have, and even see already scheduled patients. Or, you could even be creating your own telemedicine practice now and 'moonlighting' for yourself on the weekends/weeknights with patients.

 

[clozareal]

It's a little unclear what your goals are for private practice. Is it going to be cash only or insurance-based? If the latter, are you going to take Medicare? Because that will determine what types of patients will be coming to you (e.g., you probably won't get a lot of private pay patients with schizophrenia).

Are you trying to market to the most people available with these certifications? If so, then you can market whatever the latest popular fad is in psychiatry. At this time, it would probably be intranasal esketamine, psychedelic assisted psychotherapy, TMS.

Are you trying to get as many clinical experiences as possible to treat a broad range of clients? Then take inventory on what you haven't had much experience with yet, particularly with diagnosis and pharmacology. Sleep medicine including the sleep meds outside of benzos/z-drugs, eating disorders, dementia, getting comfortable using clozapine and managing both hematological and non-hematological side effects of it, using long-acting injectables including non-antipsychotics such as vivitrol and sublocade, using MAT for alcohol/tobacco/opiates minus methadone, treating eating disorders,

Do you want to set up a therapy practice too? Then get extra training that you might not have already had in residency, such as trauma-informed therapy (CPT, PE, EMDR), DBT, ACT, couples therapy (Gottman, EFT), hypnosis for dissociative and somatic symptom and related disorders, MBCT, biofeedback, ERP for OCD, CBIT for tic disorders.

Are you interested in forensic work? This can be a good supplement to your future private practice that you can get experience in during an elective in residency. See if there are any faculty doing IME/forensic work and ask if you can help them with a case.

Regardless, I agree with sushirolls that getting business experience when setting up a practice is something that residency programs are woefully terrible at. Reach out to your APA district branch to see if there are private practice psychiatrists that are willing to chat with you about how they set up a practice. Meet with those who are a few years in, 10-15 years in, and nearing the end of their career in private practice. Read the APA Starting a Practice reference guide. Watch videos online about how to set up a private psychiatry practice. There are also some good articles you can search through PubMed. Meet with a CPA who works with doctors who've set up private practices. Learn the pros and cons of forming an LLC vs other business entity structures. Collect referral resources in your area where you can send people to. If you're going to take insurance then start getting credentialed with them and start negotiating rates. Consider joining one or two group practices part time while building up your private practice so you can learn the lessons from those structures. In terms of what you can make into an elective, see if you can be part of a group practice that your university or hospital is affiliated with for an elective.

 

[J ROD]

Do you plan to go into an established private practice so you can learn the ropes, etc? Or just go out there and learn the hard way?

 

[J ROD]

There is no ECT certification certificate. You can get certificates from programs like ISEN-ECT.org, or other mini-clinics with some universities. However, none of this mean a thing. The only thing that matters is the hospital you are seeking privileges at and what their credential card has. Some can be as simple as being incorporated into the general privileges a Psychiatrist. Others can be more of a pain, with like 200 procedures per year, and other random stuff. I've set up privilege cards before for 10/per year with other random details.

The push that some residencies have had to incorporate pharmacists onto the rounding teams is a joke and sad in my opinion. Our pharmacology knowledge exceeds theirs in the real world practical sense. The times I've been on these types of services they would simply be like "uh... I don't know" "I'll get back to you on that" and they never actually did, or on drug interactions they whipped out their phone and reviewed the epocrates drug/drug interaction checkers. I can do that too... Pharmacists also don't know the real world side effects and the real world feed back patients give on them. I do not see pharmacists as value added to any clinical rounding service and wonder why they are there? What do they do? What do they offer? Consistently the psychiatrists knew their pharmacology more, and simply tolerated them there because some admin above them told them to accept it.

Part of my clinical headaches are dealing with pharmacists calling to delay or say they won't fill a prescription. To then call them and say, no, gabapentin is perfectly acceptable to prescribed for PRN anxiety, and the patient is already aware that it is off label. Or to call and tell me they have concerns about dual overlapping therapy (trazodone / SSRI) or (SSRI / SNRI).

I feel a sense of disappoint that somewhere out there a resident is considering a rotation with pharmacists as advanced pharmacology.

Have you worked with pharmacists that are trained in psych specifically and did a 2 year fellowship? Also, at VA, they see patients and get a better understanding of patients and what we as physicians look for and plan. I use those trained psych pharmacist all the time because they can add some value. And not all folks are created equal. Some are better than others. I worked with one at VA I rather ask than other physicians. She knows her stuff.

 

[trixter888]

Thanks for all the advice. As of right now, I am hoping to start a private practice with cash paying only clients. I am fortunate to have a significant other who will be able to supplement my income in addition to the moonlighting money I have been saving up. Assuming I take no patients the first year, based off my estimates I should be able to run a practice for about a year.

I have been on the APA website and read through the handbook on how to start a private practice. I agree with the people above in that finding a mentor could in fact save me years of learning "the hard way." I think I will try to focus on this during PGY-4 year. I have electives set up this year to understand TMS and esketamine in further detail (with aim of potentially of incorporating this into my own practice one day). Additionally I am doing a lot of electives to help with certification in sports psychiatry and integrative psychiatry which may help set me apart from others. I am going to reproach the private practice doctor in my community who is cash paying only, and although not being able to offer a formal elective, perhaps she could be a mentor in helping me understand the "business" behind psychiatry.

At our institution we have pharmacists who sub-specialize in psychiatric medications, each completing a 1-2 year fellowship in the department of psychiatry after their schooling. I have a lot of faith in them, and perhaps doing an elective with them, I will be able to gather more detailed information on medications.

What complicates the situation is that I will be moving to a different state, so I want to try to understand the laws better in that state.

Electives I have set up so far:
- Inpatient Unit (required)
- Inpatient Consults (required)
- Partial Hospitalization Program for substance abuse and mood
- Sleep Medicine
- Neuromodulation (with emphasis on Ketamine and TMS)
- Neuropsychology (hopefully better able to understand the nuances of standardized testing).
- Advanced Psychopharmacology (I like the idea and will ask if this is a possibility)
- Sports psychiatry (certification)
- Integrative Medicine
- Integrative Psychiatry

I still have 1-2 blocks of 4 weeks I need to set up for.

Thanks everyone again for the suggestions!