PGYII all Outpatient?

[Lucy May]

I was excited with a program that has the entire year as all outpatient. The PD stated it was a strength because it exposes and trains residents a year earlier than most programs how to do psychotherapy and gives residents the chance to follow patients long term.

I was then warned by a resident that when a program does outpatient the entire second year it was because they are trying to get the "most for their buck," by placing the resident in that position.

Anyone agree/disagree?

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[Chrismander]

I was excited with a program that has the entire year as all outpatient. The PD stated it was a strength because it exposes and trains residents a year earlier than most programs how to do psychotherapy and gives residents the chance to follow patients long term.

I was then warned by a resident that when a program does outpatient the entire second year it was because they are trying to get the "most for their buck," by placing the resident in that position.

Anyone agree/disagree?

My program does PGY-2 all outpatient. I don't see any real financial incentive for the program to do it this way. If anything it's a bigger pain in the neck for them in terms of scheduling because we have 2 years of continuity clinic in the 3rd and 4th years, which means other rotations in those years lose us for a half day a week.

Really whether they use you for outpatient 2nd or 3rd year, they're getting 1 year of labor out of you. If you're into psychotherapy and want the experience of treating a few patients for 3 years (we take about 4 cases into our 3rd and 4th years), then the 2nd year thing makes sense. If not, it's just going to be that much more painful for you seeing outpatient psychotherapy cases for 2 continuity years instead of 1, and it's going to be painful coming back onto more intensive 3rd year rotations after living an 8-5 lifestyle for a year.

Feel free to PM me if you have any other questions about this sort of program.

 

[Doc Samson]

The only thing I'd be concerned about is if by making all of PGY2 outpatient, the program is deferring requirements (e.g., CL or inpatient months) to PGY4, thus preventing residents from fast-tracking into child after PGY3. That's the only financial incentive I can see.

 

[whopper]

In the program where I trained, programs were getting the most bang for the buck by having residents do inpatient.

So on the surface, I would suspect they aren't trying to exploit residents. I of course do not know how the dynamics work for that other program.

IMHO the hospital skills one attains as a first year aren't yet plateaued in the learning curve, and since hospital psychiatry at least IMHO shows you the more dramatic and intensive clinical situations, that should be firmly developed before one were to do a complete year of only outpatient. I believe by the time I finished PGY-1, my gutt check barometer said I had a decent idea of how to do inpatient, but I still had more I needed to learn, and wanted to start tinkering with new ideas I accumulated that I had not done yet.

Another factor for consideration is at least for several residents, they don't pass USMLE step III until their 2nd year or later. When you only do outpatient, medical concerns though still important are much less important v. inpatient. In inpatient you have more direct responsibility over a patient's medical problems, while in outpatient, the PCP is supposed to pretty much handle almost everything, and you're just making sure what you do does not conflict with the PCP.

This can affect a resident's medical knowledge, and if that resident still has not yet passed step III, it could be a bad thing. I remember while in inpatient, I had to spend a lot more time making sure the BP, blood sugars and any medical issues. In outpatient if a patient's blood sugar isn't being well controlled, yes I do tell the patient to do more to control it, but I pretty much always end the sentence with "you really need to talk to your PCP about this."

I have also noticed that in general an inpatient psychiatrist's medical knowledge tends to be better than a outpatient only psychiatrist. Just my anectdotal experience.

The opinions I've stated are my opinions, they aren't evidenced based, and a lot is based on personal preference. I wouldn't be surprised to see a psychiatrist countered my opinion with good reasons.

 

[Doctor Bagel]

I was then warned by a resident that when a program does outpatient the entire second year it was because they are trying to get the "most for their buck," by placing the resident in that position.

Anyone agree/disagree?

As mentioned above, I don't see how programs profit financially by moving the outpatient year into PGY-2. My home program follows this model, and I think they're very sincere in their rationale for it (giving you more time to hone psychotherapy skills and have longer continuity). 4th year is still all electives here, so there's no loss there either. Also, my home program is the exact opposite of a malignant, workhorse type of place, so, no, I don't think you should be automatically suspicious of places with this structure.

 

[DebDynamite]

My program has all of the second year outpatient, and we have only two months that are not elective fourth year ( 10 months of electives). The University really is not benefiting financially from longer continuity, as we cherry pick the patients (they are not forced on us) we keep and it is a very small number. Residents who love therapy tend to pick as many as they can (6-8) and keep them. Residents who don't enjoy OP/ therapy pick the patients that they sense won't stick around (brief therapy, etc) and keep the minimal number of patients (3-4).
It's a win- win situation.

We still have six months of med- management clinic third year (outpatient) and six months of community MH during third year. We are required by the program to pass step III by the end of PGY2, so moving into an outpatient setting tends to give us the time needed to study for and pass it ( as my entire second year class has done by now, mid- way through second year - yay!). I like this set up, because when I do three months of consults next year and more inpatient my fourth year- I will be looking at medicine issues more from the vantage of of who has passed step three and is reviewing concepts for the sake of staying up to date, not passing an exam (ie what I will be doing for the rest of my professional life). I think Whopper is right in that inpatient psychiatrists tend to "do" more medicine. But when one does their outpatient year, in the long run, I think matters very little.

I tend to question if the person who made the comment to you is a resident in a program that scuts out it's residents, and/or they have outpatient in the third year and are just trying to recruit you. Just my 2 cents.

 

[Chrismander]

The only thing I'd be concerned about is if by making all of PGY2 outpatient, the program is deferring requirements (e.g., CL or inpatient months) to PGY4, thus preventing residents from fast-tracking into child after PGY3. That's the only financial incentive I can see.

Nope, at my program they just moved the traditional PGY 2 requirements into PGY-3. People fast track into child like normal.

 

[Wednesday]

We start seeing therapy patients for a half day a week during second year while we are doing our inpatient rotations. Most people in my program have two patients that they then take into third year. I liked having only 1 or 2 pts at first for therapy since you can really focus on what you're doing. I started as a PGY2, so starting with outpatient so early would have been a bad idea for me. I'm not sure even the people who started as PGY1s would have been ready since at our program attendings don't see our outpatients and we staff them much later. I liked having the inpatient under my belt before moving to an office all by myself. Of course, if programs are doing this it must work out for them!