rkaz

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Hi folks. I'm just wondering how much weight to give to various residency selling points when it comes to making my rank order list (as I'm currently starting to pre-order them based on each interview I go to). My present favorite choice program is across the country from where I live, as I really like all of its elective opportunities and the fact that it offers all fellowships in-house. It also has certain specialty clinics which are of interest to me, as they are not widely available.

I'm wondering how much weight to give to such factors. People say that it really helps to go to residency in the same place that you want to train. There are 2 community psych residency programs in my city, with the nearest academic psychiatry program being 2 hours away. I could stay in-state (as I like my in-state programs a lot), or I could decide to rank first to a 'best fit' program across the country in a cold environment. (The program itself is a best fit, not the cold weather or distance from home.)

Anyway, here are some selling points I've encountered at programs (especially at my favorite program thus far) and I wonder the weight you'd give them in terms of making ranking decisions:

1. having all fellowships in-house (vs. having no fellowships, or only 1-2, especially if we are undecided) - does it really matter since most psychiatry fellowships are considered to be uncompetitive?
2. elective rotations prior to 4th year
3. specialty clinics in your area of interest
4. elective rotations in your area of interest that are less commonly available at other institutions
5. opportunities to watch psychotherapy (between attending physician and patient) behind a screen
6. night float vs. no night float system

Thanks so much!
 
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rkaz

rkaz

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I was recently interviewing with the PD at one of my in-state programs, and I did mention that I had interviewed at another program (didn't mention name) who had very interesting elective rotation options. I asked if it was possible to get those same experiences at the program (where I was interviewing). The PD told me, "Don't assume that you can't get those experiences here, just because we don't advertise them." She then proceeded to tell me that there may be opportunities for electives in my areas of interest. Her response made me wonder if there is much leeway in tailoring a residency experience to one's interests to bridge the gap between attending one program versus another. I realize that in residency we are there as an employee first and foremost, but I'd like to know also how much it's possible for programs to try to create a 'custom-fit' for their residents personal interests as well. I don't want to get my hopes up beforehand, and then after starting residency find out that I'm just there to work and know that the residency does not care about my specific interests.... and then wish I had chosen the best-fit program in the first place, since it already had all my interests tailored for me without needing much custom-fitting. (Sorry if this doesn't make sense. I'm travelling right now and really exhausted and rambling.)
 

SmallBird

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Hi folks. I'm just wondering how much weight to give to various residency selling points when it comes to making my rank order list (as I'm currently starting to pre-order them based on each interview I go to). My present favorite choice program is across the country from where I live, as I really like all of its elective opportunities and the fact that it offers all fellowships in-house. It also has certain specialty clinics which are of interest to me, as they are not widely available.

I'm wondering how much weight to give to such factors. People say that it really helps to go to residency in the same place that you want to train. There are 2 community psych residency programs in my city, with the nearest academic psychiatry program being 2 hours away. I could stay in-state (as I like my in-state programs a lot), or I could decide to rank first to a 'best fit' program across the country in a cold environment. (The program itself is a best fit, not the cold weather or distance from home.)

Anyway, here are some selling points I've encountered at programs (especially at my favorite program thus far) and I wonder the weight you'd give them in terms of making ranking decisions:

1. having all fellowships in-house (vs. having no fellowships, or only 1-2, especially if we are undecided) - does it really matter since most psychiatry fellowships are considered to be uncompetitive?
2. elective rotations prior to 4th year
3. specialty clinics in your area of interest
4. elective rotations in your area of interest that are less commonly available at other institutions
5. opportunities to watch psychotherapy (between attending physician and patient) behind a screen
6. night float vs. no night float system

Thanks so much!
Good question!

I guess I'm a little atypical in that I valued a good educational experience above being in a specific area, and certainly felt that having the research and educational opportunities I wanted was worth considerable disruption to my personal life. And so if it were
me I would definitely move across country to go to a better program, although I realize that is not how everyone views these things.

Regarding your points:

1. Having all fellowships in-house: I think this is a small advantage, as long as it doesn't reflect a lack of depth within the program (for example, Duke only has a few fellowships but I think its still a great program). So if you feel a program offers you everything you want
in terms of education and research opportunities, but doesn't have a specific fellowship, I would not weight this too heavily.

2. I think this is vital - I'm currently on a 3 month research elective where I can do pretty much whatever I want and it is helping me make enormous progress with research in my specific interests.

3. I think this is a nice bonus but not vital. For example, I'm excited that next year I will likely be able to work with undergraduates for the entire year, but I don't think this is crucial to having good training. Not so sure about how important this is, will defer to those with more outpatient
exposure.

4. I think this will depend on the specifics - If there is just one elective that you find interesting I probably wouldn't think it too important, but if for example you really want to work with eating disorders and there is a program where you can do a lot of this during your elective time, that
would probably be important then.

5. I don't think this is that important, it may be a cool educational adjunct but people can learn psychotherapy very well without this and I don't think it is particularly enriching?

6. I don't think this is important at all.

I don't know about your career goals, but things that I think are very important that you haven't mentioned:

1. Good benefits

2. Dedicated research time, and accessible research faculty (neither of which are the same as being at a research heavy institution)

3. Diversity of clinical experiences

Hope thats helpful, and I am sure others will have different ideas!
 

SmallBird

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May 3, 2010
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I was recently interviewing with the PD at one of my in-state programs, and I did mention that I had interviewed at another program (didn't mention name) who had very interesting elective rotation options. I asked if it was possible to get those same experiences at the program (where I was interviewing). The PD told me, "Don't assume that you can't get those experiences here, just because we don't advertise them." She then proceeded to tell me that there may be opportunities for electives in my areas of interest. Her response made me wonder if there is much leeway in tailoring a residency experience to one's interests to bridge the gap between attending one program versus another. I realize that in residency we are there as an employee first and foremost, but I'd like to know also how much it's possible for programs to try to create a 'custom-fit' for their residents personal interests as well. I don't want to get my hopes up beforehand, and then after starting residency find out that I'm just there to work and know that the residency does not care about my specific interests.... and then wish I had chosen the best-fit program in the first place, since it already had all my interests tailored for me without needing much custom-fitting. (Sorry if this doesn't make sense. I'm travelling right now and really exhausted and rambling.)
That makes sense, and what you need to find out is: How much funded time do they have for residents to do such custom experiences? It may be true that the PD will be able to connect you with people in your specific area of interest, but unless he is able to also help you carve out time to do this, it doesn't help all that much.
 

notdeadyet

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I think that the final ranking will fall more on the place, or the community, than on program minutiae. I have spent the last couple of years poring over SDN interview reviews, and I am frankly overloaded at this point. The way I see it, I already made the first ranking cuts when I created my app list - I only applied to programs that sounded good on paper, in places that I was interested in living in. The second cut came when I had more interview offers than available time and money, and I had to cut down the list further. So I had pretty high expectations for the programs where I am interviewing, and I am finding that the programs are at least as good if not better than I had hoped for, so it really feels like it will boil down to the place - what does the city offer in terms of housing, and diversions, and climate, and hassle factors like traffic / car needs vs public transit.
I think that's an awesome strategy, Psychotic. When I was applying, I made spreadsheets and all the rest. But ultimately, it comes down to gut. It really looks like you're going about this in a way that you'll end up happy and well-trained.
 

twright

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Agree with going with your gut. Most programs will provide you with good training. Once you feel like you have identified the minimum 'quality' or 'prestige' threshold that you are comfortable with, at that point I strongly believe your decision should be primarily driven by non-residency factors, e.g., where do you want to live, do you have family nearby, etc.

In terms of your specific questions:

1. Fellowships -- A lot can change between 4th year of medical school and 3rd year of residency. Many people go into residency wanting to do child, and then they realize they can't stomach it. Many people want to do consults and then realize they can't stomach it. etc. Plus, having a diversity of fellowships in house can be good because (a) fellowships tend to like hiring their own residents, and (b) by the time you finish residency you may not want to leave the city (e.g., family, friends, etc).

2. Early electives -- I think this is important, but clearly not all psychiatric educators would agree. Some programs firmly believe that all residents should have a well-rounded education and, to enforce it, have all residents rotate through subspecialty clinics and discourage short-tracking.

6. I hate night float, but that's just me.
 

notdeadyet

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1. Fellowships -- A lot can change between 4th year of medical school and 3rd year of residency. Many people go into residency wanting to do child, and then they realize they can't stomach it. Many people want to do consults and then realize they can't stomach it. etc. Plus, having a diversity of fellowships in house can be good because (a) fellowships tend to like hiring their own residents, and (b) by the time you finish residency you may not want to leave the city (e.g., family, friends, etc).
Good points. I'd also like to add one more plug for a psych program with lots of good fellowships: programs that have their own fellowships in a particular field tend to have those fields better emphasized in their training throughout residency. For example, psych programs with a forensics fellowship often have their forensics people teaching didactics and attending on inpatient units, which give you more exposure to forensic issues on those rotations. I think this makes for better general residency training.
 

whopper

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Diversity of the patient population
Fairness (non-malginancy) of the attendings
Reasonable work schedule
Diversity of clinical scenarios: e.g. involuntary unit, eating disorder exposure, VA population, emergency psychiatry, PACT teams, private patients, forensic, geriatric, psychotherapy
Location of the residency: will you like where you live?
 

shan564

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Good question!

I guess I'm a little atypical in that I valued a good educational experience above being in a specific area, and certainly felt that having the research and educational opportunities I wanted was worth considerable disruption to my personal life. And so if it were
me I would definitely move across country to go to a better program, although I realize that is not how everyone views these things.

Regarding your points:

1. Having all fellowships in-house: I think this is a small advantage, as long as it doesn't reflect a lack of depth within the program (for example, Duke only has a few fellowships but I think its still a great program). So if you feel a program offers you everything you want
in terms of education and research opportunities, but doesn't have a specific fellowship, I would not weight this too heavily.

2. I think this is vital - I'm currently on a 3 month research elective where I can do pretty much whatever I want and it is helping me make enormous progress with research in my specific interests.

3. I think this is a nice bonus but not vital. For example, I'm excited that next year I will likely be able to work with undergraduates for the entire year, but I don't think this is crucial to having good training. Not so sure about how important this is, will defer to those with more outpatient
exposure.

4. I think this will depend on the specifics - If there is just one elective that you find interesting I probably wouldn't think it too important, but if for example you really want to work with eating disorders and there is a program where you can do a lot of this during your elective time, that
would probably be important then.

5. I don't think this is that important, it may be a cool educational adjunct but people can learn psychotherapy very well without this and I don't think it is particularly enriching?

6. I don't think this is important at all.

I don't know about your career goals, but things that I think are very important that you haven't mentioned:

1. Good benefits

2. Dedicated research time, and accessible research faculty (neither of which are the same as being at a research heavy institution)

3. Diversity of clinical experiences

Hope thats helpful, and I am sure others will have different ideas!
When I saw the initial post, I thought "well, I have a lot of opinions about every question that the OP has asked, but I'm way too lazy to type it all out." Luckily, SmallBird managed to explain my thoughts in a nutshell without me having to do it.

One thing I want to add (and emphasize) is that the importance of these factors will depend MASSIVELY on what you want to do with your career. Since I want to be an academic, it is very important to have early electives (to start building a research portfolio), presence of opportunities in my areas of interest, etc. If you want to be a community psychotherapist, you might be more interested in observing attendings doing psychotherapy. If you tell us a bit more about your interests, we could probably give you a more specific answer. There is no generic answer about what is "best" - if there were, then we'd be able to rank programs based on their overall "quality."

The single most important thing to good training, in my opinion, is to have the opportunity to manage lots of different kinds of patients (i.e. "diversity of clinical experience," as SmallBird mentioned). That means having specialty exposure in lots of different subspecialties, like C/L, eating disorders, geriatrics, ECT, addictions, outpatient, academics, etc. A good program should give you exposure to each of those things without making you work in any of those areas for so long that you start to have diminishing returns in terms of learning. For instance, if they make you do inpatient psych during PGY2, you probably won't be learning too much more than you already knew from PGY1... but if PGY2 is distributed with a different rotation every month, you'll always be learning.

And the second part of that is to be in a geographic area that has people across all socioeconomic groups, including rich WASPs, farmers, hardened criminals, refugees from war zones, heroin addicts from the ghetto, cocaine addicts from the "elite" suburbs, etc. Managing bipolar disorder in a Cuban refugee is very different from managing it in a successful lawyer or in a rural stay-at-home mom or in a kid who is caught up in gangs, etc. That would require you to be in a city that has a reasonably large impoverished population, a reasonably large rich population, a reasonably large refugee population, and a "major" academic hospital with a wide catchment area that includes a large rural area. Places like that include St. Louis, Kansas City, Indianapolis, Minneapolis, and probably most cities in Texas... and maybe a few others.
 

OldPsychDoc

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....

And the second part of that is to be in a geographic area that has people across all socioeconomic groups, including rich WASPs, farmers, hardened criminals, refugees from war zones, heroin addicts from the ghetto, cocaine addicts from the "elite" suburbs, etc. Managing bipolar disorder in a Cuban refugee is very different from managing it in a successful lawyer or in a rural stay-at-home mom or in a kid who is caught up in gangs, etc. That would require you to be in a city that has a reasonably large impoverished population, a reasonably large rich population, a reasonably large refugee population, and a "major" academic hospital with a wide catchment area that includes a large rural area. Places like that include St. Louis, Kansas City, Indianapolis, Minneapolis, and probably most cities in Texas... and maybe a few others.
Around here it's actually more heroin addicts from the "elite" suburbs (and exurbs) and (crack) cocaine addicts from the ghetto...but I get your point. (Just felt a need to address the changing demographics of opiates...)
 

OldPsychDoc

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The rich people in my area can usually get prescriptions for opioids and get it paid for by their insurance so that they can stay rich instead of letting the drug habit make them poor...
Right now the heroin's cheaper and more available and doesn't require keeping track of what symptoms you've told them about at which doctor's office. (And heroin doesn't get reported to the state Pharmacy Board database--those pesky bureaucrats are keeping track now!)
 

notdeadyet

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Yeah, a state pharmacy board database would certainly make it much harder to get opioid scripts. But that would be Communism. Missouri might adopt that around the same time that we allow medical marijuana and free healthcare and change the name of St. Louis to St. Petersburg.
The databases are typically run as an extension of law enforcement. Not so much communism as War on Drugs, which I have a hunch Missouri is a bit more likely to get behind.
 

Shikima

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My favorite conundrum has been to negotiate with patients after they've seen others who play candyman and give everyone xanax.
 
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rkaz

rkaz

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Thank you all so very much for your insightful and thoughtful comments. I'm sorry for the late reply, but I just got back home last night after a 12 day overseas trip in which I had limited internet access. Then I see your awesome responses, and I remember how much I love this group here. :love: You all give me lots of things to think about.
 

OldPsychDoc

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