Several Questions on Residencies

[Darkskies]

Hi Everyone,

Well, application season is almost here and I have a few questions regarding Psychiatry overall. First of all, I am a 4th year DO student who only took COMLEX and scored a 500+ on the Level 1. I also took the Level 2 and am awaiting my scores. I know not taking the USMLE is a detractor on my application but seeing as that Psychiatry is not yet too competitive I hope I still have opportunities to be accepted into a good University program. I remember Splik mentioning in one thread that the nature of Psychiatry makes it so that in most programs residents can become competent and, dare I say it, even superb Psychiatrists provided they are motivated to seek out and fill the gaps in their education. Conversely, I remember in another of his postings, he remarked that most psychiatry residencies are horrible. So, which is true?

The most important factor for me in the residency search would be a supportive faculty, PD, and co-residents in a friendly environment where there is a lot of input on training, constructive criticism, and support for motivated, hard-working individuals. I want to absolutely avoid a malignant atmosphere and avoid any programs that terminate residents(the thread by koikisi really frightened me). The next most important aspects are good training at a university program with a wide breadth and depth of exposure to all aspects of Psychiatry. Although I don't have much of a research background, I would like to have some research experience during residency. Ideally I would like to stay in the northeast near a major city(NYC, Boston, Philadelphia, D.C.) but will be applying all over the country and am not completely opposed to moving. Are there any such programs that fit my criteria(most importantly having a benign, supportive atmosphere) in the northeast that would accept someone with my stats?

I actually was able to speak with the PD of a program at length about applying and I was informed to include my MCAT and SAT scores(both of which were high), after he heard what they were, on my application to that particular program. This seems like it would be a faux pas to me but he stated that the scores would help give me leverage since I did not take the USMLE. His tone was not facetious when he mentioned this to me. What does everyone here think?

Lastly, I wanted to ask about the practice of Psychiatry in general. It seems there have been numerous comments on this forum about how bad psychiatrists out in the community put patients on random drug cocktails and such with nary a thought and how others like yourselves have to fix the poor job bad psychiatrists have done. However, I remember there was a comment on how it's not that there are just all these lazy psychiatrists happy to be doing the bare minimum and not caring about their patients enough so they put them on whatever drugs they please, but that the practice of Psychiatry itself is so varied and problematic at times that there are no 'real' rules so that what one Psychiatrist may think is a good treatment or drug regimen, another would see as egregiously wrong or piss-poor work. That can't be true, right? How do I make sure that I become a great Psychiatrist and not a bad one?

I appreciate the time you took to reading and any and all advice that comes my way regarding these topics! Thanks!

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[notdeadyet]

I remember Splik mentioning in one thread that the nature of Psychiatry makes it so that in most programs residents can become competent and, dare I say it, even superb Psychiatrists provided they are motivated to seek out and fill the gaps in their education. Conversely, I remember in another of his postings, he remarked that most psychiatry residencies are horrible. So, which is true?

Both are somewhat true, but only to a point...

Can residents become superb in any program? No, probably not. Yes if you'r some kind of protegy, but for most of us, we depend on the guidance of teachers and the opportunity for diverse clinical experience. Both of these can be lacking in bad programs. Motivation will get you so far. Takeaway: 80% or so of the kind of psychiatrist you'll become depends on you, the other 20% depends on training.

Are most psychiatry residencies horrible? Well, I've only been to one, but I've worked in whole lot of settings, including many out a ways in the community. I've worked with folks from a whole slew of different residencies and many of them were very good psychiatrists, even those from programs whose reputation no one would really right home about. Takeaway: your average psychiatry residency is fine. There are couple dozen truly great ones and likely a couple dozen truly horrible ones. If you go to the ones in the middle, you'll have the capacity to be a great psychiatrist if you work hard. (Caveat: I'm talking allopathic residencies, never met one who did an osteopathic psych residency).

The most important factor for me in the residency search would be a supportive faculty, PD, and co-residents in a friendly environment where there is a lot of input on training, constructive criticism, and support for motivated, hard-working individuals. I want to absolutely avoid a malignant atmosphere and avoid any programs that terminate residents(the thread by koikisi really frightened me).

These factors might be contradictory. If you look at the (very small) number of terminated residents, the majority seem to be let go for reasons that conflict with the first. You can have very malignant residencies because programs do not care enough to protect their residents from the occasional sociopath that sneaks their way in. I would not avoid a program that has terminated a resident in the past. But I wouldn't go to one that does it frequently.

The next most important aspects are good training at a university program with a wide breadth and depth of exposure to all aspects of Psychiatry. Although I don't have much of a research background, I would like to have some research experience during residency. Ideally I would like to stay in the northeast near a major city(NYC, Boston, Philadelphia, D.C.) but will be applying all over the country and am not completely opposed to moving. Are there any such programs that fit my criteria(most importantly having a benign, supportive atmosphere) in the northeast that would accept someone with my stats?

I can't comment on programs that fit your stats, because I have no idea what they are (I'm not familiar with COMLEX scores). You can certainly inquire about research opportunities, but do keep in mind that all psychiatry residencies struggle with what I call "research hobbyists." These are folks that didn't really do research in medical school but would like to scratch that itch in residency. The challenge is that meaningful research experience takes a whole lot of time. Many program have tracks, but these can be a bigger time commitment than you want or you may not have the qualifications. I'd ask about opportunities, if nothing else, to do as electives or during PGY-4 year. What I'm getting at is that if programs don't have a great answer for you, I wouldn't judge too harshly. When you peak under the hood at some of the residencies that do have options, a lot of them are fairly minimal in impact and potentially of questionable utility.

I actually was able to speak with the PD of a program at length about applying and I was informed to include my MCAT and SAT scores(both of which were high), after he heard what they were, on my application to that particular program. This seems like it would be a faux pas to me but he stated that the scores would help give me leverage since I did not take the USMLE. His tone was not facetious when he mentioned this to me. What does everyone here think?

If he thinks that would be helpful at his program, go for it, but I certainly wouldn't include things like MCAT or SAT on my application anywhere else. It will generate a lot of eye rolling.

Lastly, I wanted to ask about the practice of Psychiatry in general. It seems there have been numerous comments on this forum about how bad psychiatrists out in the community put patients on random drug cocktails and such with nary a thought and how others like yourselves have to fix the poor job bad psychiatrists have done. However, I remember there was a comment on how it's not that there are just all these lazy psychiatrists happy to be doing the bare minimum and not caring about their patients enough so they put them on whatever drugs they please, but that the practice of Psychiatry itself is so varied and problematic at times that there are no 'real' rules so that what one Psychiatrist may think is a good treatment or drug regimen, another would see as egregiously wrong or piss-poor work. That can't be true, right? How do I make sure that I become a great Psychiatrist and not a bad one?

Go to a good program, listen to your instructors, read a lot, model behavior on role models, and practice, practice, practice. There are a lot of bad doctors out there and there is a lot of bad judgment. This is more apparent in psychiatry because a lot of what we do relies on judgment.

 

[SmallBird]

I can't comment on programs that fit your stats, because I have no idea what they are (I'm not familiar with COMLEX scores). You can certainly inquire about research opportunities, but do keep in mind that all psychiatry residencies struggle with what I call "research hobbyists." These are folks that didn't really do research in medical school but would like to scratch that itch in residency. The challenge is that meaningful research experience takes a whole lot of time. Many program have tracks, but these can be a bigger time commitment than you want or you may not have the qualifications. I'd ask about opportunities, if nothing else, to do as electives or during PGY-4 year. What I'm getting at is that if programs don't have a great answer for you, I wouldn't judge too harshly. When you peak under the hood at some of the residencies that do have options, a lot of them are fairly minimal in impact and potentially of questionable utility.

I think I disagree - scholarly engagement can be very meaningful to residents, regardless of the extent to which they wish to become independent researchers. Good residencies should particularly provide opportunities for eager residents who want to gain some type of research experience - like including them in some clinical capacity on ongoing studies, pulling them into salient review articles, providing awareness of more easily obtainable funding mechanisms, have both career mentors and methodological supervisors, and offer opportunities for protected time. I agree that not every residency is likely to have this, but it should be seen as an important feature and I believe the impact can be transformative.

 

[OldPsychDoc]

...First of all, I am a 4th year DO student who only took COMLEX and scored a 500+ on the Level 1. I also took the Level 2 and am awaiting my scores. I know not taking the USMLE is a detractor on my application but seeing as that Psychiatry is not yet too competitive I hope I still have opportunities to be accepted into a good University program. ...

I actually was able to speak with the PD of a program at length about applying and I was informed to include my MCAT and SAT scores(both of which were high), after he heard what they were, on my application to that particular program. This seems like it would be a faux pas to me but he stated that the scores would help give me leverage since I did not take the USMLE. His tone was not facetious when he mentioned this to me. What does everyone here think?

Why do we as PDs care about test scores? Because they correlate with success on future test scores!
They don't tell us whether you are a compassionate, ethical, or competent physician--but they will give us an indication of whether we will be biting our nails waiting for Step III results to come in on a resident in danger of contract non-renewal when they don't pass, or whether they will end up being that one resident who repeatedly fails to pass Boards and makes our Board Certification rate look bad.
Some PDs are just not comfortable with COMLEX, since there's never been a table of equivalencies published so we know whether a 500 is more like a 200 or a 250, and they haven't interviewed enough DO students to get a sense for it. I suppose this PD above is suggesting that you offer those scores as evidence of your testing prowess, to alleviate anxieties on the selection committee.

 

[nitemagi]

Medicine, including psychiatry, is very much still built on an apprenticeship model. Therefore you can easily become as good as the models you have available. If your models are just kinda OK, that's how far you'll get without taking your education into your own hands. To be "superb" you have to be able to recognize where the gaps are, which many of your models will not have recognized (many don't know what they don't know), and look beyond much of the "tribal lore" that is taught. And work with many and varied attendings in a variety of settings. You can raise the bar in your training through moonlighting experiences in settings you're not getting through residency, other electives, workshop training in different psychotherapies, online seminars, and reading (a lot).

 

[MacDonaldTriad]

As far as MCAT and SATs, it has been many years since I have been involved in undergraduate medical school admissions. I'm fairly certain most PDs would have no idea what the numbers mean. I hear they keep adding and subtracting parts of the test. This would create some eye rolling. I have never seen this included.

 

[Darkskies]

Thanks for the replies so far, guys. I wanted to quote the following piece to see if you could elaborate on it. When you say there are a lot of bad doctors out there, why is that? If a lot of what Psychiatrists do relies on judgment, does that mean you have to have a certain knack at it to be good at it?Is there much nebulousness in the practice of Psychiatry with regards to patient appraisal and care in comparison to other medical specialties? I am fine with not having any hard and fast rules but I keep getting dejected when I think there won't be any real rules or guidelines as that would constantly make me wonder whether what I'm doing is helping the patient. I would also worry about if other doctors will think poorly of my decisions when they see the same patients. Nitemagi, If it is important to look past much of the tribal lore that is taught, does that mean a good portion of what is standard teachings may be bad practice?

Go to a good program, listen to your instructors, read a lot, model behavior on role models, and practice, practice, practice. There are a lot of bad doctors out there and there is a lot of bad judgment. This is more apparent in psychiatry because a lot of what we do relies on judgment.

I know having only COMLEX scores makes it difficult to assess my competitiveness but even so, I would appreciate it if anyone who was familiar with many programs could advise me on what residencies I would have a good shot at(that also provide a good education and a supportive environment)? What are ways to gauge programs come interview time vis-a-vis malignancy especially considering everyone is on their best behavior on Interview day? Thanks!

 

[Doctor Bagel]

Thanks for the replies so far, guys. I wanted to quote the following piece to see if you could elaborate on it. When you say there are a lot of bad doctors out there, why is that? If a lot of what Psychiatrists do relies on judgment, does that mean you have to have a certain knack at it to be good at it?Is there much nebulousness in the practice of Psychiatry with regards to patient appraisal and care in comparison to other medical specialties? I am fine with not having any hard and fast rules but I keep getting dejected when I think there won't be any real rules or guidelines as that would constantly make me wonder whether what I'm doing is helping the patient. I would also worry about if other doctors will think poorly of my decisions when they see the same patients. Nitemagi, If it is important to look past much of the tribal lore that is taught, does that mean a good portion of what is standard teachings may be bad practice?

I think it's pretty easy to be judgmental of doctors who are actually OK and doing their best in limited systems. I just started a job in community MH, and the medication regimens people are on are certainly not textbook and likely eye roll inducing by other providers. But these patients are passed along from provider to provider and are really sick (and yeah, our medications used in textbook ways really aren't good enough to eradicate true severe mental illness). Couple that with multiple psychosocial stressors and limited time with each patient, you continue things that sound not too great for on paper.

 

[notdeadyet]

I think I disagree - scholarly engagement can be very meaningful to residents, regardless of the extent to which they wish to become independent researchers. Good residencies should particularly provide opportunities for eager residents who want to gain some type of research experience - like including them in some clinical capacity on ongoing studies, pulling them into salient review articles, providing awareness of more easily obtainable funding mechanisms, have both career mentors and methodological supervisors, and offer opportunities for protected time. I agree that not every residency is likely to have this, but it should be seen as an important feature and I believe the impact can be transformative.

Great point. But what you are describing is exactly what I mean by the hobbyist. Journal club, mentoring, additional involvement in projects and studied. I caution that more detailed involvement in research requires more time than applicants expect, hence research tracks. These tracks tend to require more commitment than they are prepared to give (which is why they don't have much experience coming in to residency).

Good point about making sure residents can be involved. I just want to caution residents that if sub-track research opportunities sound soft, it's because they are.

 

[Dharma]

Your COMLEX score is good man. Couple that w solid clinical grades and LOR and you will have a good shot at many solid programs. You are most definitely NOT limited to some hole in the wall IMG sweatshop. Apply far and wide and you have nothing to worry about.

I'm sure you've seen the stickies for DOs. Check them out... Add those "friendly" programs to your list and apply. I wouldn't worry man.

And don't mention SAT or MCAT. That sounds ridiculous IMO. You really think that will change the perception of a PD who doesn't realize your COMLEX score is above average?

Many many folks with COMLEX only applications have matched at solid programs. MANY. Stay confident!

 

[rkaz]

Comlex scores between 500 to 550 are 50th percentile (a score of 400 is passing). You might occasionally see a score of 700 to 900, but that is a home run kind of score, and much less common with most in the 400 to 600 range.

I applied with Comlex only, my score being slightly lower than the OP. I interviewed at some solid programs and matched at an excellent one, which I couldn't be more thankful for.

Assuming you don't have too many other red flags, you will have many opportunities at quality 'mid-tier' programs (though no one really knows what 'mid tier' means). Maybe not the 'ivy league' type programs but programs that are well regarded and can give you good training.

I realize this is all vague as there are no official rankings on programs to stratify tiers or the like. You can look at where other DO posters applied to and interviewed at, but don't sell yourself short. My program isn't advertised to be DO friendly but it definitely is. So look at resident lists at specific programs as well.

 

[clausewitz2]

I think it's pretty easy to be judgmental of doctors who are actually OK and doing their best in limited systems. I just started a job in community MH, and the medication regimens people are on are certainly not textbook and likely eye roll inducing by other providers. But these patients are passed along from provider to provider and are really sick (and yeah, our medications used in textbook ways really aren't good enough to eradicate true severe mental illness). Couple that with multiple psychosocial stressors and limited time with each patient, you continue things that sound not too great for on paper.

Working with an ACT team currently who services someone who spent literally decades homeless and in the past few months has actually maintained a fixed residence for the first time as an adult. This individual is currently on two depot antipsychotics in addition to oral Abilify. No one really wants to be the one to remove the leg that is propping up the most functional state this person has known in a very long time, and no significant side effects presently, so there are no plans to change a blessed thing.

 

[nitemagi]

...Nitemagi, If it is important to look past much of the tribal lore that is taught, does that mean a good portion of what is standard teachings may be bad practice?

Not necessarily. I guess there's two aspects I think about --
1. Teachings that aren't researched/evidence based. I take less issue with things that haven't been researched. That's different than things that have been disproven through research.
2. Someone teaching "THE" way to do something (or dismiss a case as impossible) is teaching really their way of approaching it. It doesn't mean that's the only way. Do your own research on cases, look for other data and other approaches.

 

[notdeadyet]

No one really wants to be the one to remove the leg that is propping up the most functional state this person has known in a very long time, and no significant side effects presently, so there are no plans to change a blessed thing.

Amen to that. You run into people who have a legitimate need for three antipsychotics. It's the docs who prescribe three benzodiazepines for their patient that I sometimes have issues with.


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