Basically what the title says - what are the pros and cons of staying on at the same institution you did your residency? It seems like at least a few graduating residents from my program each year stay on as faculty. At other stages of training, I have heard that it is better to experience some institutional diversity - is it the same in this case as well? Does staying in the same system significantly ease the transition to being an attending, or does it hinder it (if for example the other faculty keep perceiving/treating you as their junior?) Is there any impact in pay or other things I might not be thinking about?
pros, cons of staying on as faculty?
- Thread starter thomasina
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Pros: colleagues you know, teaching opportunities, decent benefits
Cons: really low pay, low seniority, bureaucracy,
Cons: really low pay, low seniority, bureaucracy,
By virtue of it being an academic setting?
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If you do your own private practice you can realistically make over $300K working about 40-50 hours a week.
While I worked in a university my pay at first was over 200K, and this was about 60 hours of work a week. Despite the hard work it was stimulating rewarding, and I worked with lots of people I respected and saw them as friends and family. The respect thing was to the point where I was a name-brand in the city, Judges, lawyers, doctors and nurses knew who I was. Also the department had plans for me to move up had I stayed.
Then I moved to St. Louis (caused my wife got a professor's position in this city), and wanting to stay in academia, I worked at a place I will not name (but hey there's only 2 here so that kind of narrows it down right?) and was making $180K a year, working 70 hours a week. The latter place was a sinking ship with lots of problems. Lots of the work I put in was due to the institution not knowing what the heck it was doing. E.g. a computer was broken on the inpatient unit...FOR YEARS! and IT wouldn't fix it. While I highly respected the head of the department I could tell he couldn't fix the problems (it was an institutional thing not a department thing).
I later learned a few months into the St Louis job that the department pretty much imploded months before I joined and I could tell. Most of the attendings were new and so many things in the department were in a state of disarray.
On top of that the first job had a retirement plan where if you worked there for 25 years you got half your pay the rest of your life and free healthcare too, while the latter place didn't have either. So I said to myself I'm not getting the professional satisfaction, the pay sucks, the retirement plan is terrible and they expected me to work with a broken computer they wouldn't fix (among dozens of other serious problems).
So now I'm doing private practice, and I was recently given a medical director position at a psych/addiction center, working about 50 hours a week and making over 2x as much vs the last academic place I worked at.
Academia serves a great purpose. Teaching and learning. I recommend all new graduates to strongly consider academia because you likely will have more to learn that you didn't learn in residency, but after about 2-4 years of this you will plateau on what the department can offer you. I felt that I had gotten the system down with inpatient, outpatient, ER, and consult after a few years. So then after that if you want to further spread your wings you're going to have to either leave, get into research or have some type of plan within the department to do things other than just the above repeating itself. E.g, program director? Clinical director?
Had I stayed in my first job I might've stayed in academia cause I was part of an A-Team I was proud to be in. Unless it's highly satisfying do it for some time but then get out after you've plateaued, assuming you do. I see doctors who've practiced for over 10 years who still don't know what STAR*D is. Those doctors plateaued before even really being a competent psychiatrist.
While I worked in a university my pay at first was over 200K, and this was about 60 hours of work a week. Despite the hard work it was stimulating rewarding, and I worked with lots of people I respected and saw them as friends and family. The respect thing was to the point where I was a name-brand in the city, Judges, lawyers, doctors and nurses knew who I was. Also the department had plans for me to move up had I stayed.
Then I moved to St. Louis (caused my wife got a professor's position in this city), and wanting to stay in academia, I worked at a place I will not name (but hey there's only 2 here so that kind of narrows it down right?) and was making $180K a year, working 70 hours a week. The latter place was a sinking ship with lots of problems. Lots of the work I put in was due to the institution not knowing what the heck it was doing. E.g. a computer was broken on the inpatient unit...FOR YEARS! and IT wouldn't fix it. While I highly respected the head of the department I could tell he couldn't fix the problems (it was an institutional thing not a department thing).
I later learned a few months into the St Louis job that the department pretty much imploded months before I joined and I could tell. Most of the attendings were new and so many things in the department were in a state of disarray.
On top of that the first job had a retirement plan where if you worked there for 25 years you got half your pay the rest of your life and free healthcare too, while the latter place didn't have either. So I said to myself I'm not getting the professional satisfaction, the pay sucks, the retirement plan is terrible and they expected me to work with a broken computer they wouldn't fix (among dozens of other serious problems).
So now I'm doing private practice, and I was recently given a medical director position at a psych/addiction center, working about 50 hours a week and making over 2x as much vs the last academic place I worked at.
Academia serves a great purpose. Teaching and learning. I recommend all new graduates to strongly consider academia because you likely will have more to learn that you didn't learn in residency, but after about 2-4 years of this you will plateau on what the department can offer you. I felt that I had gotten the system down with inpatient, outpatient, ER, and consult after a few years. So then after that if you want to further spread your wings you're going to have to either leave, get into research or have some type of plan within the department to do things other than just the above repeating itself. E.g, program director? Clinical director?
Had I stayed in my first job I might've stayed in academia cause I was part of an A-Team I was proud to be in. Unless it's highly satisfying do it for some time but then get out after you've plateaued, assuming you do. I see doctors who've practiced for over 10 years who still don't know what STAR*D is. Those doctors plateaued before even really being a competent psychiatrist.
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As a senior psychiatrist, do you have any general advice about how to not plateau? I see staying in academia for 2-4 years after residency. What do you recommend after that? And then after that? etc.
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To actually answer your question which appears to be, "if you are staying in academics, what the the pros and cons of staying at your home institution vs elsewhere?"
The major pro is you are much more likely to advance in your career quickly and be promoted faster at your home institution. That is because you are already a known entity and will have used your years in training to cultivate mentoring relationships and hopefully areas of expertise. For example, if you are really interested in education you are much more likely to be appointed a clerkship director or associate residency director etc at the place you were a resident/fellow than some new institution. Similarly, if you have some clinical niche area that you developed during your training you are going to be in a much better position to become the local expert or director that program whereas it is unlikely you would be able to do that anywhere new without spending some years doing the groundwork. You will hopefully have people who are looking to advance your interests and continue to mentor and coach you at your home institution and should have some sense of the flavor of the place. Of course being a trainee and being faculty are different experiences.
It may be psychologically harder to transition into the role of faculty at a place you were resident/fellow and other people might treat you more like a trainee as well. Whether that is a problem or not is an open question as you are still going to be learning and having that backup support as long as there is mutual respect is a good thing. More so than faculty is going to be that other residents are probably not going to see you as an attending if they knew you as a resident and navigating boundaries can be complicated in that regard.
It should not impact your pay, except that people coming from elsewhere may get a moving allowance which you won't get. However you could try to negotiate to get that money for something else (though your institution will obviously be wanting that 10k or so off the table).
I do discourage residents from only looking at their training institution. Look at what is out there, and have some other offers in hand so you can negotiate a better deal even if you do want to stay at your home institution.
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Yes
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Have goals than simply just doing inpatient over and over and over. Changing up the clinical routine will make you a better clinician. E.g. do some PES, some consult, switch it up once in awhile. Doing that will also help you should you go the administration route cause you now know and have mastered all the systems so in a leadership position you'll be able to strategize better. If you've mastered all the clinical stuff move onto other stuff such as Ketamine, ECT, treatment-resistant psychosis, Buprenorphine, depression etc. (Just an an example, I did PES, outpatient, inpatient, addiction (with Buprenorphine but other stuff too), TMS, just never got around to doing ECT but had I stayed in Cincinnati I was going to get into it.
So if in academia, you master clinical practice, but then you need to master the administrative stuff. Similar to clinical practice you can then move up and become a clinical director or program director. Then there's research and publications. Some institutions that's the only way to significantly advance. Along with that comes a state-wide and national presence. Make connections at conventions, other institutions, collaborate.
If you get up in academia this possibly could lead to a lot more money if you were make a name for yourself in research or selling books, but the pure university track doesn't make much money.
Just as an example had I stayed in Cincinnati I was thinking of writing several articles on the area of ECT and forensics cause many states won't let you do involuntary ECT without the next to impossible. E.g. one patient with treatment resistant psychosis wasn't able to get ECT for over 2 years of court hearings. I was also thinking of advancing the field of psychological autopsies. The Buprenorphine thing was a major advantage in forensic evaluations for clinicians who abused opioids, cleaned up, and wanted to go back into practice.
If in a state school you could likely be set up with a great retirement plan, but if in a private university there might not be much if any of a plan at all. So when I was in U of Cincinnati, I was making over $200K but with the retirement plan assuming I lived to about 75 I would've been making the equivalent of about $300K a year, but at the newer place in St. Louis where I wasn't intellectually, professionally or even academically happy I was making $180K a year and the retirement plan was terrible so all in all it really was just about $180K. I spent more time in work not doing psychiatry vs real psychiatry. E.g. the 15th time I called IT yet again and asked them to fix the same computer that was broken before I got there and was broken the last day I left. I had to drive between the local jail and the university which was about 30 minutes each way. Simply walking from the parking lot to my office in the jail was 30 minutes cause of all the security checkpoints...
If money is a big thing for you, you will come to a point where you either have to accept academia will not make money or figure a way to monetize it that's outside the box. E.g. write a book. Being a professor this book can be used as a publication for your CV for further advancement but it might take off. If you want to make more money and not do something outside the box then go into private practice.
I'm still not against the idea of writing something (mostly a pipe-dream) such as doing a series of videos for Youtube designed to teach people about psychiatry emphasizing things that should've been told in the doctor's office but almost never is. I already did some projections on the Youtube thing and I couldn't expect it to make it for money cause it'd have to a number of hits that wouldn't make it cost-effective.
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I will add that there is nothing virtuous about academics other than it requires a lack of interest in money.
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You certainly have the heart of a saint for working so many hours for so little pay.
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I shouldn't have stayed in it as long as I did. About 1.5 years. What was going on was the head of the department is a guy I respect, and while he wouldn't say it to my face, I got the impression that even he thought the place wasn't any good (he's the head of the dept so I get it). So when I got it figured out that this place wasn't doing so well, then my attitude was to fix it so I would like working there, and then in turn I'd start liking the job cause I fixed it, I'd get more respect, and eventually so too would my pay go up.
But then the following happened, a guy above me, and right beneath the head of the dept kept nixing all my efforts to fix things. A different guy who left the job while I was there told me the person right above me's plan was to keep things going the way they were cause they let him control the puppet-strings despite that the department wasn't doing well (if I told you the entire story it'd make sense. It was like the VA where you got rewarded for mediocrity). Since the guy right above me was going to be there indefinitely, and cause he outranked me I knew if I stayed it'd be a long-term issue and I likely couldn't implement any real changes, I learned that this place didn't have any real profit-incentives for doing a better job, (At U of C you made a higher percentage if you did better work), I figured out the retirement plan was terrible, and the residents, while many of them were good, a lot of them were also terrible, while at U of C all of the residents were excellent and that kept me inspired. New place? Some did, some ticked me off, and the sum total wasn't enough for the enjoyment factor. I could only get about 1-2 weeks off an entire year cause none of my colleagues would cover for me, and if you didn't use your vacation time you lost it at the end of the year while at U of C you didn't use it, it stacked so now you could take extra weeks off or ask for that vacation time in the form of extra pay.
The final nail in the coffin was the head of the dept ran for president of the Missouri APA even while his own department was going down the tubes. That really was a sign that this guy's attitude was "eff this place, I'll put my focus into something else." If that was the case why would I want to stay on a sinking ship if the captain was going to jump-ship himself? (And I didn't blame him either because I think he came to a conclusion he couldn't fix the mess).
There some bright spots about the latter place but they weren't enough to keep me there. Another name-brand psychiatrist, not the head of the dept, who is a leader in the field of geriatric psychiatry and I would occasionally have lunch. That guy was a real lighthouse for me. He knew his stuff, was always positive, cared about people and had always something to offer whether it was knowledge, moral support, or inspiration. Had the head of the department not been a guy I knew and respected I would've been out of there at about 6 months. I gave it a longer and strong effort out of respect. Didn't work. I also kept mum about it while I was there and didn't complain about it on this forum, but about 5 years have passed so I figure that's enough time.
But then the following happened, a guy above me, and right beneath the head of the dept kept nixing all my efforts to fix things. A different guy who left the job while I was there told me the person right above me's plan was to keep things going the way they were cause they let him control the puppet-strings despite that the department wasn't doing well (if I told you the entire story it'd make sense. It was like the VA where you got rewarded for mediocrity). Since the guy right above me was going to be there indefinitely, and cause he outranked me I knew if I stayed it'd be a long-term issue and I likely couldn't implement any real changes, I learned that this place didn't have any real profit-incentives for doing a better job, (At U of C you made a higher percentage if you did better work), I figured out the retirement plan was terrible, and the residents, while many of them were good, a lot of them were also terrible, while at U of C all of the residents were excellent and that kept me inspired. New place? Some did, some ticked me off, and the sum total wasn't enough for the enjoyment factor. I could only get about 1-2 weeks off an entire year cause none of my colleagues would cover for me, and if you didn't use your vacation time you lost it at the end of the year while at U of C you didn't use it, it stacked so now you could take extra weeks off or ask for that vacation time in the form of extra pay.
The final nail in the coffin was the head of the dept ran for president of the Missouri APA even while his own department was going down the tubes. That really was a sign that this guy's attitude was "eff this place, I'll put my focus into something else." If that was the case why would I want to stay on a sinking ship if the captain was going to jump-ship himself? (And I didn't blame him either because I think he came to a conclusion he couldn't fix the mess).
There some bright spots about the latter place but they weren't enough to keep me there. Another name-brand psychiatrist, not the head of the dept, who is a leader in the field of geriatric psychiatry and I would occasionally have lunch. That guy was a real lighthouse for me. He knew his stuff, was always positive, cared about people and had always something to offer whether it was knowledge, moral support, or inspiration. Had the head of the department not been a guy I knew and respected I would've been out of there at about 6 months. I gave it a longer and strong effort out of respect. Didn't work. I also kept mum about it while I was there and didn't complain about it on this forum, but about 5 years have passed so I figure that's enough time.
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Its not just academics. This same stuff happens at any Big Box shop. Big Box also means academic Universities.
Jobs/Employers are like our patients, don't try to fix them, or improve them or make them better with any more effort than the Big Box Shop (or University) is willing to put into it themselves.
I learned this lessen the hard way. Applied a lot of energy at one Big Box shop, opening up different service lines, looking at reports for the needs of the community, tried to target those issues, etc. Honey Badger Big Box shop don't care.
Optimism persisted in thinking of going to a new Hospital start up, that shaping things from the ground up could lead to a creation of positive culture and clinical excellence. Nope suits higher up wanted widgets and only cared about widgets.
Direct positive energies towards opening one's own practice.
Jobs/Employers are like our patients, don't try to fix them, or improve them or make them better with any more effort than the Big Box Shop (or University) is willing to put into it themselves.
I learned this lessen the hard way. Applied a lot of energy at one Big Box shop, opening up different service lines, looking at reports for the needs of the community, tried to target those issues, etc. Honey Badger Big Box shop don't care.
Optimism persisted in thinking of going to a new Hospital start up, that shaping things from the ground up could lead to a creation of positive culture and clinical excellence. Nope suits higher up wanted widgets and only cared about widgets.
Direct positive energies towards opening one's own practice.
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Going to print and frame this post. I worked at Kaiser and granted my specialty is not psychiatry (PM&R), this is good advice. Applies to both employers AND patients. So glad to be a 1099 now.
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Some places will work on fixing themselves and let you orchestrate changes. While I was at U of C changes happened. Not as fast as I liked but they happened if one worked on it. At the last place I was at I was being sabotaged by a guy with his own agenda for mediocrity.
Nonetheless Sushiroll's post is very much true for many places. If the place you're at sucks, you try to do your part to fix it, but if nothing is accomplished and you gave it a fair try consider getting out.
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@whopper
Thank you for sharing about your experiences. I can tell you care a lot about psychiatry and about your patients. You are idealistic and willing to put yourself in new situations to be better. Around the wrong people, you will get burned.
Good insight about big institutions. But this applies to any group that you don't have control over, even small practices.
My personal stance is not to do extra work that I'm not compensated for. But what I am supposed to do, I do very well. And if my pay fails to meet expectations, I have no problem leaving for greener pastures. Very similar to what is done in the tech industry. This has proven to be very lucrative.
Thank you for sharing about your experiences. I can tell you care a lot about psychiatry and about your patients. You are idealistic and willing to put yourself in new situations to be better. Around the wrong people, you will get burned.
Good insight about big institutions. But this applies to any group that you don't have control over, even small practices.
My personal stance is not to do extra work that I'm not compensated for. But what I am supposed to do, I do very well. And if my pay fails to meet expectations, I have no problem leaving for greener pastures. Very similar to what is done in the tech industry. This has proven to be very lucrative.
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I actually have just made the transition to a different academic institution following residency. Here are some things that I thought of that helped me make my decision. Some of these reasons were institution specific. Both places were on paper offering about the same amount of money for approximately the same amount of work.
Pros of staying
-Familiar with the system/how services run
-Familiar with mentors, residents, and nurses (this was the hardest one for me, I was very fond of my colleagues)
-Wouldn't have to move during COVID
-I would get to do a fairly specialized area of psych
Cons of staying
-Public institution that is financially not doing well 2/2 Covid
-Poor leadership, many faculty left recently, leaving some services minimally covered
-Fewer chances for advancement over the long run
-May have been treated more like a resident than an attending
-----------------------------------------------------------------------------
Pros of leaving
-Larger, more financially sound institution
-Better leadership IMO
-More opportunities for advancement over the long run
-You have to be treated as an attending, no one knows who you are
-Develop practice patterns from two different institutions, diversity of thought = good thing probably
Cons of leaving
-Having to learn a new system/ways of doing things (especially in multiple clinical areas)
-Not being able to meet people in person due to COVID
-Having to get a new state license
-Moving during COVID
At the end of the day, it is about making it through the relative difficulties in the short term to hopefully reap those rewards after 1-3 years. We'll see if this ended up being a good decision or not. Hope this helps!
Pros of staying
-Familiar with the system/how services run
-Familiar with mentors, residents, and nurses (this was the hardest one for me, I was very fond of my colleagues)
-Wouldn't have to move during COVID
-I would get to do a fairly specialized area of psych
Cons of staying
-Public institution that is financially not doing well 2/2 Covid
-Poor leadership, many faculty left recently, leaving some services minimally covered
-Fewer chances for advancement over the long run
-May have been treated more like a resident than an attending
-----------------------------------------------------------------------------
Pros of leaving
-Larger, more financially sound institution
-Better leadership IMO
-More opportunities for advancement over the long run
-You have to be treated as an attending, no one knows who you are
-Develop practice patterns from two different institutions, diversity of thought = good thing probably
Cons of leaving
-Having to learn a new system/ways of doing things (especially in multiple clinical areas)
-Not being able to meet people in person due to COVID
-Having to get a new state license
-Moving during COVID
At the end of the day, it is about making it through the relative difficulties in the short term to hopefully reap those rewards after 1-3 years. We'll see if this ended up being a good decision or not. Hope this helps!
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IMHO earlier in your own career err on the side of learning new things. Hence why I recommend being faculty at least for a year if not more, but if you've plateaued try something else.
Schwarzenegger said one of his keys to success was once he plateaued in something he moved onto the next thing. E.g. he's already a millionaire from weight-lifting and wins the highest competition, and then sets his eye on real-estate, then on acting, then on other businesses, etc. He summed it up as "Don't be afraid to fail," saying that fear of failure is often times what prevents one from trying something new that can be better.
I noticed myself slowing down only after I had kids cause I need to spend time with them to be a good father. In a way I didn't slow down cause that too is a type of new job and does teach you more about yourself and that can apply to psychiatry.
Schwarzenegger said one of his keys to success was once he plateaued in something he moved onto the next thing. E.g. he's already a millionaire from weight-lifting and wins the highest competition, and then sets his eye on real-estate, then on acting, then on other businesses, etc. He summed it up as "Don't be afraid to fail," saying that fear of failure is often times what prevents one from trying something new that can be better.
I noticed myself slowing down only after I had kids cause I need to spend time with them to be a good father. In a way I didn't slow down cause that too is a type of new job and does teach you more about yourself and that can apply to psychiatry.
I wish there was a way to know, as a prospective job applicant to all these various institutions, whether turnover is an issue...
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I have worked with two psychiatrists who worked under my supervision (one as a resident, one as a fellow) and then took a job working in our department, in large part because of how much they liked the rotation. I treated them like any other colleague, and after a few months when they had the hang of attending life my having worked with them as trainees faded away into the realm of trivia. We also had one psychiatrist join who trained elsewhere, and I viewed working with her the same way as I viewed working with the graduating resident and fellow: I helped her get up to speed, regularly checked in on her, and tried to make sure she had a relatively lighter load for the first couple months, and now she is good to go. As long as you are good I would not worry about being seen as a trainee by those who trained you, and keep in mind you will be viewed as a kind of "junior attending" at least while getting up and running no matter where you go.
I think working where you train has the tremendous advantage of knowing the people and resources. I took a job away from where I trained, and I really miss the people I trained with. I also will never know the services at my institution the way a resident does. I might work with patients who access those services, or chat with the psychiatrists there, but I will not have the direct experience or the "inside scoop" that many residents might unless they tell me about it. If you choose to go the private practice route, it would also be wonderful to have a list of 50+ local psychiatrists you could email to start sending referrals your way.
On the other hand, I don't think any of us should stick around in a single role for decades unless we know we've struck gold! Moving to a new place was a decision I made for family/personal reasons rather than professional ones, but I shopped around and took a job that had a significantly higher salary than I would have received at my training program. I have also liked bringing a fresh perspective to the clinical work we do; the people who trained here teach me things that were particular strengths in their background (for me that has included more breadth and depth of addiction work and more specific subtypes of CBT work, for instance) and I bring areas of strength to share with them that I believe my program was stronger in (such as forensic psychiatry and psychodynamic training). Overall I have learned a lot in my current role, and I don't regret switching.
So in brief I think you should make the launch at some point, but if you like your program, shop around, and find it has something better on offer than you are finding elsewhere there is nothing wrong with sticking around and enjoying the benefits of having some roots!
I think working where you train has the tremendous advantage of knowing the people and resources. I took a job away from where I trained, and I really miss the people I trained with. I also will never know the services at my institution the way a resident does. I might work with patients who access those services, or chat with the psychiatrists there, but I will not have the direct experience or the "inside scoop" that many residents might unless they tell me about it. If you choose to go the private practice route, it would also be wonderful to have a list of 50+ local psychiatrists you could email to start sending referrals your way.
On the other hand, I don't think any of us should stick around in a single role for decades unless we know we've struck gold! Moving to a new place was a decision I made for family/personal reasons rather than professional ones, but I shopped around and took a job that had a significantly higher salary than I would have received at my training program. I have also liked bringing a fresh perspective to the clinical work we do; the people who trained here teach me things that were particular strengths in their background (for me that has included more breadth and depth of addiction work and more specific subtypes of CBT work, for instance) and I bring areas of strength to share with them that I believe my program was stronger in (such as forensic psychiatry and psychodynamic training). Overall I have learned a lot in my current role, and I don't regret switching.
So in brief I think you should make the launch at some point, but if you like your program, shop around, and find it has something better on offer than you are finding elsewhere there is nothing wrong with sticking around and enjoying the benefits of having some roots!
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I stayed on as fellow/faculty at my residency institution for 8 years, then switched to a new institution last year.
I really think the impact of knowing the system can't be underestimated. I feel so much less effective in this system. I just don't know where to refer people to get the help they need, I don't know whom to curbside, I don't know how to navigate inpatient admissions when needed.
All the other stuff is not very important. Salaries tend to be standardized within an institution. Others will respect you based on your work, not on whether they were your attendings in the past or not.
It's hard enough to be a new attending. If your home institution is a reasonable option for you as far as location, pay, etc., I'd prefer it to a new one.
I really think the impact of knowing the system can't be underestimated. I feel so much less effective in this system. I just don't know where to refer people to get the help they need, I don't know whom to curbside, I don't know how to navigate inpatient admissions when needed.
All the other stuff is not very important. Salaries tend to be standardized within an institution. Others will respect you based on your work, not on whether they were your attendings in the past or not.
It's hard enough to be a new attending. If your home institution is a reasonable option for you as far as location, pay, etc., I'd prefer it to a new one.
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Currently working as a locums at a major academic center...low pay and especially this:
-May have been treated more like a resident than an attending
Since residents/interns cant be treated as trainees with scut work anymore the admin thinks the attendings will do the work
Also admin thinks doctors who saw tons of patients years ago (because they were financially incentivized to do so) will now see high volume patient loads with no incentive...besides being employed
