I was finalizing my psychiatry rank list, so I greatly appreciate your insight. I interviewed at a program with a very strong name (think like Yale/Duke/Hopkins) attached to it and the VA system. When I talked to alumni, the most significant complaint was the lack of diverse patient exposure. On interview day, we were informed that we could have up to 10 months at these big name university affiliated hospitals versus the VA each year. Last week, we received notice that this will be reduced to 2 months of non-VA exposure, meaning the majority of the year will be at the VA. We were also informed that a variety of VA elective experiences were created to make up for this. What are your thoughts? I'm very concerned and am not sure the name makes up for this. Thank you in advance.
Program I interviewed at switched from 10 Months of non-VA exposure to 2 months each year Thoughts?
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I intentionally ranked programs higher that didn't rely on VA rotations, or barley had any.
Some people consider it a positive and want VA exposure. My sampling as a medical student was more than enough.
Some people consider it a positive and want VA exposure. My sampling as a medical student was more than enough.
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Is this Harvard South Shore? If my guess is accurate then it sounds like this is a reversion to what I thought was the status quo with their residency. I'm surprised they recently had so much time not at the VA (again assuming I guessed right.)
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Tardivetrip
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Also current applicant, so I know you are talking about HSS. I am both extremely grateful and extremely disappointed. They could've been terrible and not announced this until after match. I imagine many people will be dropping them low however. They went from 10 months non-VA exposure in the first 2 years, to 8 months in FOUR years. I find this unacceptable. Every mentor I've spoken to has said something different in terms of general advice, but the one consistency has been primarily VA is not ideal for training. Personally, I found the previous curriculum to be balanced enough where I was okay ranking it highly. That is not the case anymore though :/ I am very disappointed. That being said, it still seems to have great benefits and culture. I just can't imagine doing 90% VA as my training.
I wouldn’t get hung up on the name aspect of HSS. It is not like the other names you mentioned, all of which are very strong, well-rounded programs. The reputation of HSS has always (at least for the last decade or so, probably more) been that it’s an okay program that relies heavily on the VA and may not present a very well-rounded clinical experience. If you’re hung up on the name because of how patients might view it, that’s one thing. But I would not go in thinking that the HSS name is going to open lots of doors in academia or something.
When I was interviewing for residency, I applied to HSS. Admittedly, I probably applied just because it had the Harvard name and figured it was worth a look. The place seemed fine, and I thought you could be a good psychiatrist coming from there, but even then it seemed like too much VA. It also did not seem like it had lots of well-known experts to learn from like the other places on my list did. I don’t want to bash the place or anything as I really did think it was a fine program and would be good for someone, but I ranked it pretty low in large part because it seemed like it lacked diversity of patient experience.
I ultimately wound up going to a place with more or less a polar opposite set-up to HSS, and I’m really glad I did. My residency did not have any VA experience. It did, however, involve a wide breadth of exposure through various specialty units and clinics where one worked with essentially every possible population. In residency, I think breadth of exposure is very important. At my program, the volume and breadth were such that most residents felt about ready to “fly” by halfway through PGY-3, and they probably were. I just don’t think I’d have gained that level of confidence working 90% of the time with any one population.
When I was interviewing for residency, I applied to HSS. Admittedly, I probably applied just because it had the Harvard name and figured it was worth a look. The place seemed fine, and I thought you could be a good psychiatrist coming from there, but even then it seemed like too much VA. It also did not seem like it had lots of well-known experts to learn from like the other places on my list did. I don’t want to bash the place or anything as I really did think it was a fine program and would be good for someone, but I ranked it pretty low in large part because it seemed like it lacked diversity of patient experience.
I ultimately wound up going to a place with more or less a polar opposite set-up to HSS, and I’m really glad I did. My residency did not have any VA experience. It did, however, involve a wide breadth of exposure through various specialty units and clinics where one worked with essentially every possible population. In residency, I think breadth of exposure is very important. At my program, the volume and breadth were such that most residents felt about ready to “fly” by halfway through PGY-3, and they probably were. I just don’t think I’d have gained that level of confidence working 90% of the time with any one population.
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Fwiw I'm at a big University program and majority of us at the program wish we had way less than the 12 months of va exposure we get. It was easily my least favorite day of the week during that year.
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I had the same feelings while in training, although the relaxed pace was an okay change at the time. Having looked back, I do think there's some value in a handful of months at a VA over 4 years of training. I would never have had people threaten to rape my family, see someone rip a hand sanitizer off the wall trying to get intoxicated, someone lose their mind that their heroin their friend brought to the med floor was confiscated, etc. The raw amount of character pathology, incentive to be ill, and inability to be fired definitely battle hardened me.
That said, I cannot possibly imagine doing a program that is 80% VA. Even if the name was UPMCHarvardYaleOxfordHopkins collective.
Obviously I'm pretty pro-VA. I can see this being a downside for some, but lots of programs have extreme focuses like county or academic. Heck, Kaiser runs entire programs that are ONLY Kaiser. To each their own. The VA can offer a great bread and butter experience in many different specialties, particularly psychiatry. Further, the VA has more money than other systems right now and more need for clinicians, so you're going to see more of this. I concur that you will get a great education on issues surrounding any possible secondary gain that will make handling social security disability claims a lot easier if you choose not to stay at the VA.
I don’t disagree that having some VA exposure can be a good thing, but is this really true? I think this stuff is everywhere. As I mentioned, my residency did not have a VA rotation, but all of the exact things you mentioned have happened to me. Well, I guess the one exception was that nobody threatened to rape me, but I did have multiple people who had previously served time for violent crimes and/or had active warrants for weapons charges threaten to kill me and my family.
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The big difference for me is that at my home university program, the threats and highly erratic behavior were from people who were psychotic or actively intoxicated on crack/meth/pcp and quite easy to brush off. The threats at the VA came from characterologic pathology, from patients who were sober and otherwise calm on some occasions. Someone whispering they are going to track you after your shift and assault you is such a different experience than someone being held down by 6 security guards screaming all sorts of profanities. My academic center rarely saw patients w/ active warrents/legal charges (it did happen but rarely), that may differ from program to program.
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If HSS, it does have a recognizable name for the public, but it isn’t what I would consider even top 30 for psych.
It is nowhere near Yale, Hopkins, or Duke in quality.
It is nowhere near Yale, Hopkins, or Duke in quality.
The city where my program was located is an absolute psychosocial war zone. That and the prosecutor’s office was and is run by well-intentioned social liberals who gave everyone a million chances and did things like nolle pros a person’s fifth set of second degree assault and dangerous weapon charges in as many years. Regardless of what your political opinion is about that type of policy or whether you think it is a beneficial approach on balance, one of the results was that many of the people coming to our emergency departments were people who would have been incarcerated in other jurisdictions. The city also had wildly insufficient resources to actually deal with the amount of crime that was occurring, and there were far more active arrest warrants than there were officers to actually enforce them. Because of that, we also saw lots of people with active warrants.
The police also, to their credit, seemed to be relatively good about bringing people to the hospital when they thought they had an active mental illness. Occasionally, these people would be charged and we would usually just evaluate them and send them with officers who would take them to jail. More often, though, the officers would just drop them off and leave without charging them. Often, these people either weren’t mentally ill or didn’t need to come into the hospital, but then we were stuck with a bunch of dangerous antisocial people who didn’t need to be there. Usually, the serious threats came when the emergency medicine folks either got wrapped up with trauma after trauma or simply neglected to see patients in psych and these people started getting pissed that they were still in the locked psych ED and could not go home because medicine had not seen them. As the psych provider, we were technically consultants and did not have control over where the patient was placed within the ED and we could not discharge them ourselves. Most of the serious threats occurred in such circumstances with patients who were either antisocial or really wanted to leave so they could get high.
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^^ @sloop
So glad I'm done with that goat rodeo. These days I deal with people clinging to cannabis like its the miracle cure for everything and picking a ND as primary care. Or TMS 'experts' as ARNPs giving feedback on the pharmacotherapy side of things, creating more troubles.
Thankfully I now have a physician option locally to send people to.
So glad I'm done with that goat rodeo. These days I deal with people clinging to cannabis like its the miracle cure for everything and picking a ND as primary care. Or TMS 'experts' as ARNPs giving feedback on the pharmacotherapy side of things, creating more troubles.
Thankfully I now have a physician option locally to send people to.
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So you did residency at Gotham City School of Medicine?
Haha, something like that.
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Sounds awful, would not recommend. VA is a great experience to have, but you definitely don't want to be the primary experience you have.
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I agree that some VA experience is nice, but being the majority will be very limiting. If it truly is 10 mos a year at the VA, I'd look elsewhere. Honestly if it was more than a few months a year, even just dealing with CPRS for that time would have made me crazy.
As an intern doing IM/neuro rotations and inpatient psych, I think the VA is probably fine. I was much more annoyed by outpatient VA and the lack of support and patient demands regarding travel pay and having to get billing/notes done so they could get paid for their trip to clinic. Case in point, new patient transferred in from local shrink on high dose xanax and stimulant, among various mood stabilizers for alleged bipolar disorder. NO RECORDS sent and the patient was not the best historian loaded up on all the meds. I had to personally have patient sign release and send fax for record request while the front desk "schedulers" confidently told me it was not their job, while they sat there doing absolutely nothing. They only schedule appointments. Maddening that VA employees can be so damned lazy.
I take it back the VA sucks. I also remember consulting on a delirious patient, alzheimers, admitted with hyponatremia, very low like 105. VA RN had orders to check Na hourly. Of course patient refused and VA RN thought it was ok to just document the delirious and demented patient was refusing crucial lab draws...and didn't tell anyone. The psych team found out and had to alert the medical team.
As I think back, I'm pretty sure I enjoyed VA ED psych and the psychotherapy patient experience I had. Inpatient psych was fine. Outpatient was very frustrating, and the incompetence (and/or laziness) of many staff makes it a tough place to tolerate if you're a hard worker. I also recall a particular inpatient unit night nurse always wanted on call residents to come in if someone was having low back pain. "Could you come and assess him?" It's 2 am dude, give him some tylenol and the day team will see him soon enough. Sheesh.
My program was about 30-40% VA the first 2 years.
I take it back the VA sucks. I also remember consulting on a delirious patient, alzheimers, admitted with hyponatremia, very low like 105. VA RN had orders to check Na hourly. Of course patient refused and VA RN thought it was ok to just document the delirious and demented patient was refusing crucial lab draws...and didn't tell anyone. The psych team found out and had to alert the medical team.
As I think back, I'm pretty sure I enjoyed VA ED psych and the psychotherapy patient experience I had. Inpatient psych was fine. Outpatient was very frustrating, and the incompetence (and/or laziness) of many staff makes it a tough place to tolerate if you're a hard worker. I also recall a particular inpatient unit night nurse always wanted on call residents to come in if someone was having low back pain. "Could you come and assess him?" It's 2 am dude, give him some tylenol and the day team will see him soon enough. Sheesh.
My program was about 30-40% VA the first 2 years.
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I'd like to lend my opinion that is different than the ones above about the VA experience. It really depends on which VA you are at. Not all VA's are created equally. Our outpatient VA experience had an addiction clinic where all the high dose xanax/stimulant/alcohol/opiate use patients were seen by attending who were addiction boarded. There was a methadone and buprenorphine clinic that was a wonderful experience. There was a violence team that took on any patients who made threats to staff including residents, who would not work with those patients unless wanting to as part of an elective. They were seen in a different part of the campus and made it very clear that it was legal that these patient's could be discharged from mental health care (and care all together) at that VA regardless of their service connection.
We also had a variety of electives you can do at the VA as well, including integrated primary care, a PTSD clinic, an SMI clinic (bipolar/schizophrenia), geriatrics, intensive case management, C-L including transplant and HIV, inpatient psychiatry, emergency psychiatry, forensics including the veterans treatment court, a variety of psychotherapy experiences including family/couples/group therapy, ECT, TMS & ketamine, neuropsychiatry including brain injury medicine and dementia, research opportunities in many different areas, etc.
We also had many therapists and social workers to help out with patient support for patients and it wasn't too difficult to refer a patient to be seen by one. The therapy learning experience there was great but was probably a result of dedicated supervisors. Our front desk staff was great so we had very little administrative/scheduling work. The attendings held their boundaries pretty clear so there was an appropriate division of labor where I felt like my time was mainly being used for educational or clinical purposes as a resident.
We also had a diversity of patients at our VA, from the old vietnam war veterans who were on permanent disability and 100% service connected to the afghanistan/iraq war younger veterans who were working full time. I saw the whole gamut of patients from those who were experiencing homelessness to those who were multimillionaire entrepreneurs and enjoyed being part of that VA system.
I do agree with the others that having the VA as your primary experience for more than 50% of your training could be limiting in scope of training unless you know you want to work for the VA afterwards, but not always. Although you get exposure to most things at the VA, you don't get exposure to child/adolescent which is the main drawback. Otherwise, most other learning experiences can be achieved through the VA. Is it 10 months in PGY2 that you have there or is it every year that is 10 months/year?
We also had a variety of electives you can do at the VA as well, including integrated primary care, a PTSD clinic, an SMI clinic (bipolar/schizophrenia), geriatrics, intensive case management, C-L including transplant and HIV, inpatient psychiatry, emergency psychiatry, forensics including the veterans treatment court, a variety of psychotherapy experiences including family/couples/group therapy, ECT, TMS & ketamine, neuropsychiatry including brain injury medicine and dementia, research opportunities in many different areas, etc.
We also had many therapists and social workers to help out with patient support for patients and it wasn't too difficult to refer a patient to be seen by one. The therapy learning experience there was great but was probably a result of dedicated supervisors. Our front desk staff was great so we had very little administrative/scheduling work. The attendings held their boundaries pretty clear so there was an appropriate division of labor where I felt like my time was mainly being used for educational or clinical purposes as a resident.
We also had a diversity of patients at our VA, from the old vietnam war veterans who were on permanent disability and 100% service connected to the afghanistan/iraq war younger veterans who were working full time. I saw the whole gamut of patients from those who were experiencing homelessness to those who were multimillionaire entrepreneurs and enjoyed being part of that VA system.
I do agree with the others that having the VA as your primary experience for more than 50% of your training could be limiting in scope of training unless you know you want to work for the VA afterwards, but not always. Although you get exposure to most things at the VA, you don't get exposure to child/adolescent which is the main drawback. Otherwise, most other learning experiences can be achieved through the VA. Is it 10 months in PGY2 that you have there or is it every year that is 10 months/year?
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On the topic of the VA, didn't their push to update beyond CPRS (*which they tote as amazing, like PBR does their award from a 100+ years ago) to Cerner and not Epic? That is another VA fail if I recall correctly that Cerner was picked over Epic.
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Cerner is cheaper than Epic, I suspect that's why. My residency used Cerner and it was fine but certainly less impressive than Epic. I was told it was 100% related to pricing. Bit like choosing a combustion engine over electric at this point, but I suspect that it's a $$ call.
Yes, Cerner was selected via no bid contracting... It is a bit of a disappointment, but still several years off. My disappointment is mostly because I really like CPRS and will miss it. It was also open source and not privatized in any way. There isn't another EMR in the world where you can pull up electronic records from 1996.
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I actually heard about this from a friend who is a current resident at Brigham, whose PD Margo Funk recently jumped ship from HSS to BWH (so take it with a grain of salt).
In short, yes. Unfortunately everything that OP has mentioned seems consistent with what I've heard. For years HSS seemed like a fairly solid, reputable program where residents got decent training coming out of it. They did have a quite a few shake ups in leadership (something like 3? 4? PDs in a span of under four years). I met Funk at a conference a while back and she seemed really fantastic and dedicated to residents (from my short interactions with her) so I can imagine she did a lot to advocate for the program. I think historically HSS seemed like the "underdog" of harvard psych residencies but Funk did a lot to improve the quality of the program as a whole.
Unfortunately when she left to Brigham (which has been a HUGE boon for BWH which had its own share of leadership changes for quite a while...), the VA leadership (which is separate from harvard as each "affiliated" hospital basically runs their own domain and there's no such as thing as a "harvard psych dept") decided to roll back a lot of the previous changes that Funk made. My guess is since each harvard hospital pays for its own residents salary (MGH, Brigham, BIDMC, Cambridge Hospital, Boston VA), the overall funding of HSS comes from the national dept of veteran affairs and someone higher up wanted to get their money's worth so they are significantly rolling back the number of non-VA rotations available. This is most evident in their name re-branding which is now VAB-HSS (with the primary emphasis on VA boston)
In working with HMS students in the past who are interested in psych (and interestingly I don't believe any med students from harvard have ever gone to HSS, at least in the past few years - typically they will email me telling me about matching at one of the other four), I think having 46 out of 48 months of training in the VA system is a strong disservice to trainees and would DNR until the policy gets reverted.
In short, yes. Unfortunately everything that OP has mentioned seems consistent with what I've heard. For years HSS seemed like a fairly solid, reputable program where residents got decent training coming out of it. They did have a quite a few shake ups in leadership (something like 3? 4? PDs in a span of under four years). I met Funk at a conference a while back and she seemed really fantastic and dedicated to residents (from my short interactions with her) so I can imagine she did a lot to advocate for the program. I think historically HSS seemed like the "underdog" of harvard psych residencies but Funk did a lot to improve the quality of the program as a whole.
Unfortunately when she left to Brigham (which has been a HUGE boon for BWH which had its own share of leadership changes for quite a while...), the VA leadership (which is separate from harvard as each "affiliated" hospital basically runs their own domain and there's no such as thing as a "harvard psych dept") decided to roll back a lot of the previous changes that Funk made. My guess is since each harvard hospital pays for its own residents salary (MGH, Brigham, BIDMC, Cambridge Hospital, Boston VA), the overall funding of HSS comes from the national dept of veteran affairs and someone higher up wanted to get their money's worth so they are significantly rolling back the number of non-VA rotations available. This is most evident in their name re-branding which is now VAB-HSS (with the primary emphasis on VA boston)
In working with HMS students in the past who are interested in psych (and interestingly I don't believe any med students from harvard have ever gone to HSS, at least in the past few years - typically they will email me telling me about matching at one of the other four), I think having 46 out of 48 months of training in the VA system is a strong disservice to trainees and would DNR until the policy gets reverted.
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There are some other legacy EMR systems that stretch back about that far. The ones used by BIDMC and BWH (prior to Epic upgrade) go back about that far. Integration of the legacy health information with the Epic upgrade in the case of BWH is a bit hacky though.
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I'm sad to say it but some of this is an accurate take. For the record I felt my 4 years of training at HSS were very strong, but they were also very different than what's happening now. I had great experience with a lot of variety, and the VA parts of that experience felt high quality (things like Clozapine clinic, the ECT rotation, the addictions rotations were all very very strong). My (limited) understanding from outside the current changes is that they're limiting non-VA experiences, due to higher ups in the VA (ie people outside the program but with power over it). I'm a checked out pgy4, so I only know what I'm hearing from others. It does sound like the uniquely strong experiences at VA Boston area staying, though.
I can't advise on how to rank HSS. I think you'll still get good training here but I am saddened to see some of the non-VA elements of that training disappear. You'll still get much of what made it a great program. I'm grateful for my time here and would choose it again.
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That sounds pretty extreme. I can't speak to that post as a current resident. (Again, checked out pgy4, I don't attend meetings I can avoid lol)
I think if people have questions about stuff like that they should talk to the PD and current residents to get more perspective, rather than going off a post on Reddit.
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I actually disagree. I think having that anonymous feedback on a place like reddit is very helpful for applicants. Certainly one can absorb that information and then discuss it further w/ current residents but asking the PD about that is like asking Tobacco companies about the safety of cigarettes.
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I respect the PD a great deal, and my fellow residents. I don't think any of them will lie to you if you reach out to them, and I think your comparison is really unfair to the PD. I feel like I've seen this weird paranoia over and over again in applicants, as if PDs are scheming to mislead you. They're not. They're trying to do their best job to pick the people they'll train to be psychiatrists.
Regarding the utility of a single anonymous online post:
My experience is that I've seen people both accurately and inaccurately represent programs and themselves online, and very much so for HSS. I've seen former residents who fast tracked out misrepresent themselves on these threads for example. I'm just saying, one person's perspective (which may be partly wrong) is not always super helpful information. Reach out to the PD and current residents to talk.
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I don't have a clue who the PD is nor any remote connection to the Boston area psychiatric world. I am not an applicant and have been an attending for several years. I am generally very sympathetic to PD's, but it still makes no sense what you are saying. PD's have a significant part of their identity wrapped up in their program and they have a marked power imbalance with an applicant or a resident. They are trying to have the best program in the image they imagine it, not cater to any one individual applicant or resident.
Example conversation:
Applicant - "I heard there's been significant changes to the program recently, can you tell me more about that"
PD - "Oh absolutely, we had major funding issues and have had to cleave out all of our highest rated rotations while greatly limiting diversity in training sites".
OR
Applicant - "I heard there's been significant changes to the program recently, can you tell me more about that"
PD - "There has been some restructuring going on in an effort to best maximize Harvard's ability to provide the best psychiatric training for you, we will have more details available as soon as we have them."
Guessing the conversation is going to fall much closer to the later than the first. Of course applicants should get as many data points as possible to decide, but talking to current residents in an anonymous way where they can actually express their true feelings is clearly going to be one of the most accurate ways to get good data.
The VA often gets taken advantage of by academic institutions because it can be monolithic and slow to respond to inefficiencies. I wonder if that was the case here and maybe everybody overshot trying to fix it.
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psychducky
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The reddit post is gone as of this morning.
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I feel like it's ok to share that the HSS resident group chat was discussing this topic and several people urged whoever made the post to take it down. I don't know if that was their reason for doing so but there were strongly stated opinions that it was not reflective of most people's experience. Not to diminish what that person felt, I don't want to invalidate that, but it's not anything like a consensus. And like I've said in this thread, I was very happy with my training at HSS, so I certainly agree with the discussion about taking it down.
psychducky
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Appreciate your transparency. I personally had a lovely interview day with HSS so not sure how to think about the post.
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I really encourage you to talk to as many residents as you can. I can't give advice on how to rank HSS (that's so individual), all I will say is that I'm graduating feeling exceptionally well prepared and with some very useful connections.
I share the reddit poster's frustration over higher ups at the VA ... it turns out that hospital administrators suck. Who knew. Sadly this seems to be across the board. Find me a hospital administration that doesn't suck in any other program, I'll wait 😛
That doesn't mean it's not great training. It still is. And the program (which is it's own thing within the hospital) has been an incredible home for four years. Having some frustrations over the workings of hospital administration doesn't change that.
