Some thoughts on why NOT to freak out over your program or ROL

[nitemagi]

So as usual around this time of year I notice the threads deconstructing every aspect of training and choices, from the free food to whether the PD is fuzzy enough for you.

So I thought I'd share some brief thoughts I have about the whole process and a bigger picture aspect to keep in mind. These are in no particular order, and they all overlap, but hell I'll number them anyway

1. Your program is not YOU. As much as we would like to imagine that everyone that comes out of X medical school or X medical school and Y residency must be a good doctor or a good psychiatrist, there is more to what you get out of it than what the environment is. An outstanding environment is a great pre-condition to coming out to be a good clinician, but I wouldn't say it's sufficient. There is the element of YOU, namely the many factors of your aptitude, language ability, openness to new experiences, ability to discern science from propaganda and that no single perspective is an actual Truth. Even in the best residency (which there isn't) no one will force you to learn information. You may be forced to learn enough to be sufficient or adequate. Getting beyond that is a different matter. So be content with whatever program you get, because that is just the backdrop upon which you develop who you are as a clinician.

2. We are meant, especially in the modern era of ever-increasing information and new data, to be lifelong learners. This means what you learn in residency is just the beginning.

I emphasize this not to scare you with the thoughts of "but I've already been in school forever, you mean I STILL have to do more." Instead think of it as reassurance that you CANNOT make a wrong choice as to where you end up. It's the start of the picture. You will need to continue to read textbooks and journals and study in a variety of different ways after residency. I'll get to some of the ways of how.

3. You are becoming a psychiatrist. And something I've learned is a key factor in that is understanding multiple perspectives. The patient's self-report is one perspective on a situation. You can bet good money their partner or their mother has another. As does their last doctor.

Now extrapolate that to your training experience. You will get only a certain range of training experiences in residency. Recognize there will always be limitations. You are trained to be well exposed only to the range of patients you are exposed to. So figure out where the limitations are, Then figure out what you'd like to know Also, and figure out how to learn that as well. Do not expect a curriculum as well planned out as medical school (if your medical school curriculum was even that well planned out). Because Psychiatry is a blend of many perspectives including but not limited to the biologist, the psychopharmacologist, the researcher, therapist (and the many forms of them), the educator, the social worker, there are many competing entities vying for your time, there is not a "complete" or "perfect" curriculum.

Some of the best learning experiences I had were during my moonlighting during residency. I went to the county jails, private hospitals, county emergency psych unit, and did disability evaluations. Learning to think and assess in different ways is a continual process and will help you to grow as a clinician.

4. You must advocate for yourself. You must be a self-directed learner. That means you can't only rely on others to tell you what to do or what to study. Find a mentor, but a single mentor may not be enough. Find ones that stretch you, that can give you information but also that can change your perspective. And be ready to move to a new mentor in the future.

5. Do not expect to master every therapy in residency. A lot of people come in wanting a program that's "good in psychotherapy" frankly before you really know what psychotherapy really is. And that's fine. That's where you are. There are many many psychotherapies. Look around. Expect to maybe get good at 2 during residency. I learned some CBT and DBT. I went to extra workshop trainings outside of residency that I paid for out of my pocket. And I decided to continue trainings AFTER residency. Now here's the difference -- you can do a little extra training in therapies AFTER, while having a full-time dayjob. In fact they're all arranged that way. Weekend workshops, online/skype supervision, etc. They are designed for the working professional. But it's up to YOU to seek them out. There are professional organizations that have conferences and workshops on any number of therapies. And don't be spooked by the evidence based therapy boogeyman (as Yalom calls it). Recognize many psychotherapies aren't well researched but aren't disproven either. I'm a big fan of various hypnotherapies, psychodrama, gestalt therapy, all of which have been around for decades.

6. Get into your own therapy. I can't really emphasize this enough, even if you're the most high functioning person there is. Again there is an inherent benefit to being a therapist by understanding what it feels like to be in therapy. You can empathize differently, but also understand the process itself from many perspectives. Plus, it's another way to de-stress from your working life.

So breathe, relax. You can and will be able to become what kind of psychiatrist you want to be. But it will take a bit of vision and effort.

Those are my thoughts of reassurance and perspective. I KNOW others have their own after going through the process of matching and/or residency.

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[spinnerette]

You made an interesting point about psychotherapy.
How much training would a med student have on psychotherapy in general?
For me, I did an away rotation at this place. I was able to learn a few modalities and did them on real patients (with attendings of course) for several hours a day for a couple weeks. It was fun. So I knew what I wanted from a residency program.
Over the interview trail, I met quite a few med students who knew what they were talking about in terms of psychotherapy training but do you think that's not the majority?

So as usual around this time of year I notice the threads deconstructing every aspect of training and choices, from the free food to whether the PD is fuzzy enough for you.

So I thought I'd share some brief thoughts I have about the whole process and a bigger picture aspect to keep in mind. These are in no particular order, and they all overlap, but hell I'll number them anyway

1. Your program is not YOU. As much as we would like to imagine that everyone that comes out of X medical school or X medical school and Y residency must be a good doctor or a good psychiatrist, there is more to what you get out of it than what the environment is. An outstanding environment is a great pre-condition to coming out to be a good clinician, but I wouldn't say it's sufficient. There is the element of YOU, namely the many factors of your aptitude, language ability, openness to new experiences, ability to discern science from propaganda and that no single perspective is an actual Truth. Even in the best residency (which there isn't) no one will force you to learn information. You may be forced to learn enough to be sufficient or adequate. Getting beyond that is a different matter. So be content with whatever program you get, because that is just the backdrop upon which you develop who you are as a clinician.

2. We are meant, especially in the modern era of ever-increasing information and new data, to be lifelong learners. This means what you learn in residency is just the beginning.

I emphasize this not to scare you with the thoughts of "but I've already been in school forever, you mean I STILL have to do more." Instead think of it as reassurance that you CANNOT make a wrong choice as to where you end up. It's the start of the picture. You will need to continue to read textbooks and journals and study in a variety of different ways after residency. I'll get to some of the ways of how.

3. You are becoming a psychiatrist. And something I've learned is a key factor in that is understanding multiple perspectives. The patient's self-report is one perspective on a situation. You can bet good money their partner or their mother has another. As does their last doctor.

Now extrapolate that to your training experience. You will get only a certain range of training experiences in residency. Recognize there will always be limitations. You are trained to be well exposed only to the range of patients you are exposed to. So figure out where the limitations are, Then figure out what you'd like to know Also, and figure out how to learn that as well. Do not expect a curriculum as well planned out as medical school (if your medical school curriculum was even that well planned out). Because Psychiatry is a blend of many perspectives including but not limited to the biologist, the psychopharmacologist, the researcher, therapist (and the many forms of them), the educator, the social worker, there are many competing entities vying for your time, there is not a "complete" or "perfect" curriculum.

Some of the best learning experiences I had were during my moonlighting during residency. I went to the county jails, private hospitals, county emergency psych unit, and did disability evaluations. Learning to think and assess in different ways is a continual process and will help you to grow as a clinician.

4. You must advocate for yourself. You must be a self-directed learner. That means you can't only rely on others to tell you what to do or what to study. Find a mentor, but a single mentor may not be enough. Find ones that stretch you, that can give you information but also that can change your perspective. And be ready to move to a new mentor in the future.

5. Do not expect to master every therapy in residency. A lot of people come in wanting a program that's "good in psychotherapy" frankly before you really know what psychotherapy really is. And that's fine. That's where you are. There are many many psychotherapies. Look around. Expect to maybe get good at 2 during residency. I learned some CBT and DBT. I went to extra workshop trainings outside of residency that I paid for out of my pocket. And I decided to continue trainings AFTER residency. Now here's the difference -- you can do a little extra training in therapies AFTER, while having a full-time dayjob. In fact they're all arranged that way. Weekend workshops, online/skype supervision, etc. They are designed for the working professional. But it's up to YOU to seek them out. There are professional organizations that have conferences and workshops on any number of therapies. And don't be spooked by the evidence based therapy boogeyman (as Yalom calls it). Recognize many psychotherapies aren't well researched but aren't disproven either. I'm a big fan of various hypnotherapies, psychodrama, gestalt therapy, all of which have been around for decades.

6. Get into your own therapy. I can't really emphasize this enough, even if you're the most high functioning person there is. Again there is an inherent benefit to being a therapist by understanding what it feels like to be in therapy. You can empathize differently, but also understand the process itself from many perspectives. Plus, it's another way to de-stress from your working life.

So breathe, relax. You can and will be able to become what kind of psychiatrist you want to be. But it will take a bit of vision and effort.

Those are my thoughts of reassurance and perspective. I KNOW others have their own after going through the process of matching and/or residency.

 

[JabsterL]

You made an interesting point about psychotherapy.
How much training would a med student have on psychotherapy in general?
For me, I did an away rotation at this place. I was able to learn a few modalities and did them on real patients (with attendings of course) for several hours a day for a couple weeks. It was fun. So I knew what I wanted from a residency program.
Over the interview trail, I met quite a few med students who knew what they were talking about in terms of psychotherapy training but do you think that's not the majority?

Nope for me, i only learned therapy for about 45 minutes in med school durin a residency interview/therapy didactic with a psychotherapist a month ago..
Thanks very much Nitemagi for your words of wisdom -- No doubt, psych and residency and psych residency are just like everythin else - u get out of it what u put in, regardless of where, with whom, etc. - it comes down to U and what u make of it. That don't mean I'm not still very anxiously awaiting where i end up 3 weeks from today however...

 

[nitemagi]

You made an interesting point about psychotherapy.
How much training would a med student have on psychotherapy in general?
For me, I did an away rotation at this place. I was able to learn a few modalities and did them on real patients (with attendings of course) for several hours a day for a couple weeks. It was fun. So I knew what I wanted from a residency program.
Over the interview trail, I met quite a few med students who knew what they were talking about in terms of psychotherapy training but do you think that's not the majority?

I would say it depends. At most they have what you had, which is an experience for a few weeks. But they don't understand say the difference between all the different modes of therapy, and have yet to experience working with a patient longitudinally to really turn their life around, and so don't know whether they like it or not, nor which modalities resonate with them. Most medical students don't know much more than that they want to learn "CBT and psychodynamic psychotherapy," as if these are the only 2 modalities in existence, or the only 2 with any evidence base or clout. They aren't. They're still good to know, of course

 

[whopper]

I've often advocated that medstudents and residents need to be able to rant. What they go through is a heck of a lot tougher than what attendings go through but attendings make a lot of money doing it.

That said, residents do need to accept that their training should be tough. I certainly don't advocate that they should accept being in unfair conditions such as stuck with an attending that doesn't teach, tries to blame a resident for a mistake the attending made, etc.

I'm fine with residents ranting about their 80 hour week schedules, lack of sleep, etc, but that is certainly part of the training. Rant all you want, I think we should be supportive but don't freak out and think it's unfair just because it's hard.

 

[JabsterL]

I've often advocated that medstudents and residents need to be able to rant. What they go through is a heck of a lot tougher than what attendings go through but attendings make a lot of money doing it.

That said, residents do need to accept that their training should be tough. I certainly don't advocate that they should accept being in unfair conditions such as stuck with an attending that doesn't teach, tries to blame a resident for a mistake the attending made, etc.

I'm fine with residents ranting about their 80 hour week schedules, lack of sleep, etc, but that is certainly part of the training. Rant all you want, I think we should be supportive but don't freak out and think it's unfair just because it's hard.

Ya I always feel that for most med students and residents, as long as you truly love the field and its subject matter and you're being taught well and treated with some semblance of human decency and respect by your bosses (attendings) and co-workers, most of us have a work ethic and willingness to "sacrifice" when we gotta such that we won't mind workin' even 100 hours a week -- well, as long as you also have a decent, understanding support system n hopefully some other protective factors like faith, positive ways to relieve stress (like exercise n good food!), n so on...

 

[MDchouette]

Ya I always feel that for most med students and residents, as long as you truly love the field and its subject matter and you're being taught well and treated with some semblance of human decency and respect by your bosses (attendings) and co-workers, most of us have a work ethic and willingness to "sacrifice" when we gotta such that we won't mind workin' even 100 hours a week -- well, as long as you also have a decent, understanding support system n hopefully some other protective factors like faith, positive ways to relieve stress (like exercise n good food!), n so on...

I see your point, and I really love my program... But under no circumstances would I not mind or be happy working 100 hours a week. I like my husband and my free time too much.

Feeling supported by those above me (program directors), liking my co-residents, and having a place to vent (for my program, it's a weekly process group) have been key program elements that have kept me generally happy during residency. #2 might be the most important.

 

[flash]

Nite magi - well said and your thoughts could not be more accurate and on the money, imho. I encourage all graduating students bound for psychiatry and residents to re-read, reflect and act on your post. I know I will. Thanks!

PGY1

 

[dl2dp2]

6. Get into your own therapy. I can't really emphasize this enough, even if you're the most high functioning person there is. Again there is an inherent benefit to being a therapist by understanding what it feels like to be in therapy. You can empathize differently, but also understand the process itself from many perspectives. Plus, it's another way to de-stress from your working life.

While I agree with almost everything you say, being at a psychodynamically heavy program, we are often pressured by senior people in the department to go into psychodynamically oriented long term intensive therapy, which I have strong doubts about either in terms of efficacy in even stress relief or maktherapist more effective therapist. My therapist cautioned me about entering into psychodynamic treatment without a cause and just because of pressure as a huge time and money sink. However I do agree having some experience of your own therapy in some time limited way is often helpful.

 

[nitemagi]

While I agree with almost everything you say, being at a psychodynamically heavily program, we are often pressured by senior people in the department to go into psychodynamically oriented long term intensive therapy, which I have strong doubts about either in terms of efficacy in even stress relief or in helping you to become a good therapist. My therapist cautioned me about entering into psychodynamic treatment without a cause and just because of pressure as a huge time and money sink. However I do agree having some experience of your own therapy in some time limited way is often helpful.

Getting into your own intensive psychodynamic therapy is only really useful, IMHO if you're planning to practice that form of therapy.