Top Program Choices For Psychiatry Residency

[schwartz]

I'm applying for next year's match and with 15 days out to send out the applications, my research about the programs is almost complete. I'm a fairly strong applicant and I hope to get interviews from most everywhere. I still want to apply to 20+ places because 1) I'm inherently paranoid about these things, and 2) I have a ton of time in my hands, and want to use this opportunity to explore the different cities as well. I'm single, and I have NO geographical preferences (apart from preferring cold to very hot weather aka Arizona/Texas). These are what I have so far, not necessarily in order:

MGH/McLean
Longwood
Cambridge
Columbia
Cornell
NYU
MSSM
UCLA
UCSF
UCSD
UW-Seattle
MCW
Northwestern
UPenn
UPitt
UMich
MUSC
UNC
UTSW-Dallas
Brown
Yale

Please don't tell me that something on the list, like Yale, is not very competitive, and they are not traditionally considered as one of the top programs in the country. I've been speaking to many, many people since the start of my third year to come up with this list, and each program on it belongs there for one reason or the other. I've also left out some programs that seem good on paper but are notoriously workhorse-ish like Baylor or OHSU.

What are the other top programs in the country I have missed? Top either in overall training like MGH/McLean, or exceptional in a few particular aspects of psychiatry like Cambridge, Cornell and MCW in psychotherapy training.

TIA!

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[slappy]

You're probably not very interested in rural psychiatry, but if you are, Dartmouth has one of the top programs in the country. I've also heard good things about UNM in rural psychiatry.

 

[SmallBird]

Please don't tell me that something on the list, like Yale, is not very competitive, and they are not traditionally considered as one of the top programs in the country.

I don't think there is much risk of that - Yale is competitive, and 'traditionally one of the top programs in the country', and in particular has been very favorably reviewed on SDN

 

[Doctor Bagel]

I've also left out some programs that seem good on paper but are notoriously workhorse-ish like Baylor or OHSU.


TIA!

Not saying you should add OHSU because you've got a super long list with great programs as it is, but I wouldn't categorize OHSU as a workhorse and feel a little responsible for it having that reputation. OHSU is not one of those easy programs where people are hardly ever on call (until the later years) and where people work 30 hours a week while on inpatient psychiatry, but it's also not a program where people work more than 80 hours (or even up to 80 hours) or where you're routinely slammed in clinic or on call shifts. OHSU is likely in the top half of programs in terms of workload, but it's probably not even in the top quarter.

I've got no clue about Baylor.

 

[HarryMTieboutMD]

Other programs to consider that still provide high quality training and have renowned faculty, though they might not be as competitive (meaning, people want to live in NYC/Cali) as some of the others you mentioned:
South: Emory, Vanderbilt, Duke
Mid Atlantic: Hopkins
Midwest: Wash U, University of Chicago (despite what people on SDN say, this program is on the rise)

 

[FrasierMD]

I don't think there is much risk of that - Yale is competitive, and 'traditionally one of the top programs in the country', and in particular has been very favorably reviewed on SDN

Definitely can second that, SmallBird. If anyone has any questions about Yale, I am happy to share my experience (which has, in sum, been amazing).

 

[barzan]

Definitely can second that, SmallBird. If anyone has any questions about Yale, I am happy to share my experience (which has, in sum, been amazing).

Sure, I have one how friendly are they to IMG's?

 

[shan564]

Don't see why WashU isn't on the list, considering the overall feel that comes across from the OP.

 

[jakeislove]

Definitely can second that, SmallBird. If anyone has any questions about Yale, I am happy to share my experience (which has, in sum, been amazing).

How is quality of life in the area?

 

[SmallBird]

How is quality of life in the area?

Speaking for myself and my close friends, its pretty amazing, because:

- Our stipends are really good (PGY-1 start at > 64k with amazing benefits over and above this), and there are ample internal moonlighting opportunities from PGY-2 year that pay between $100 and $125 an hour
- New Haven has excellent restaurants that are cheaper than the bigger cities, and tons of cultural activities associated with Yale (plays, concerts, talks, etc.)
- Our weekend workload is minimal (I had 46 weekends off as a PGY-2 and will have a similar number this year)
- In terms of housing there are many options. I came to Connecticut with $0 and bought a house in a lovely area near New Haven at the start of my PGY-2 year. There is mortgage discount available for Yale affiliates which makes this easier. Some people choose to stay downtown and there are some really nice apartments.
- Very close to so many places. We go to New York and Boston on weekends, last month one of the attendings had us at his place in Martha's Vineyard, and there is a ton to see in New England.
- Perhaps most importantly, I really love going to work every day. I have had the opportunity to get involved with some amazing scholarly projects, and have had a lot of choice in terms of my clinical rotations. This year I am at the University Health plan for the entire year which is an entirely different experience, but an excellent learning opportunity.

Those are some of the advantages. I am obviously ridiculously happy, and biased, but hey, its three years in and I wouldn't still be saying this if I didn't believe it. And its true for a variety of my co-residents in various life positions (those with many kids, those who are single, recently married couples, etc.). Hope that answers your question!

 

[jakeislove]

Thanks, SmallBird!

 

[Nasrudin]

Wow. Yale is proper nice with the accoutrement. What's it like for fellows, smallbird? I'll have to apply there if I decide on fellowship.

I really think the ensemble of benefits, good hours, and means of moonlighting in house are underestimated factors. That and world class academics would make Yale a highly desirable residency.

I put a high premium on location in my applications and have since pondered the consequence of my decision. It'll take me a while to see if my roll of the dice for unpsych related factors will be worth it. But I can also now emphatically support applicants who choose to go to the best program for psych residents that they can place into regardless of location. Programs vary a lot on their ability to create a great professional/educational environment.

It takes a ridiculous amount of resources to make that happen. Yale obviously is not anemic in that department. And look at the smallbird. Happy as a mf'n clam.

 

[SmallBird]

Wow. Yale is proper nice with the accoutrement. What's it like for fellows, smallbird? I'll have to apply there if I decide on fellowship.

I really think the ensemble of benefits, good hours, and means of moonlighting in house are underestimated factors. That and world class academics would make Yale a highly desirable residency.

I put a high premium on location in my applications and have since pondered the consequence of my decision. It'll take me a while to see if my roll of the dice for unpsych related factors will be worth it. But I can also now emphatically support applicants who choose to go to the best program for psych residents that they can place into regardless of location. Programs vary a lot on their ability to create a great professional/educational environment.

It takes a ridiculous amount of resources to make that happen. Yale obviously is not anemic in that department. And look at the smallbird. Happy as a mf'n clam.

All of this applies for fellows except the hours and scholarly opportunities vary somewhat. The addiction fellowship appears to have an even better work/life balance and is very strong in terms of teaching and academic opportunity. The public psychiatry fellowship is another example of extensive resources as it is 50% clinical time and 50% funded scholarship (in a pretty broad sense). The child fellowship is quite intense I hear but the benefits are even better and I'm hoping to match into it. The CL fellowship is busy but less so than other programs at comparable academic centers in the area. Hope that helps - I'm not as informed about this, happy to answer other questions you might have if there is a specific fellowship that you become interested in.

 

[freemontie]

Not saying you should add OHSU because you've got a super long list with great programs as it is, but I wouldn't categorize OHSU as a workhorse and feel a little responsible for it having that reputation. OHSU is not one of those easy programs where people are hardly ever on call (until the later years) and where people work 30 hours a week while on inpatient psychiatry, but it's also not a program where people work more than 80 hours (or even up to 80 hours) or where you're routinely slammed in clinic or on call shifts. OHSU is likely in the top half of programs in terms of workload, but it's probably not even in the top quarter.

I've got no clue about Baylor.

Just out of curiosity- what do people think are the easy programs?

 

[notdeadyet]

You become a top program by producing top-quality clinicians.

You produce top-quality clinicians by lots of clinical experiences. You get that by working.

I can't think of any programs that most people would consider top programs in which its residents work less than what an average psych resident works.

But keep in mind that it's all relative. I am at a program that is known for working its residents hard, and I work way less than even the most Kush internal medicine resident. I also work way less than I ever did in prior careers in education and tech. Hard work in Psychiatry residency is still less hours than most professional careers I can think of.


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[MacDonaldTriad]

You become a top program by producing top-quality clinicians.

You produce top-quality clinicians by lots of clinical experiences. You get that by working.

I can't think of any programs that most people would consider top programs in which its residents work less than what an average psych resident works.

But keep in mind that it's all relative. I am at a program that is known for working its residents hard, and I work way less than even the most Kush internal medicine resident. I also work way less than I ever did in prior careers in education and tech. Hard work in Psychiatry residency is still less hours than most professional careers I can think of.


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Amen to this.

The ADS survey asks if clinical demands cut into the teaching mission, but I’m at a loss as to how to separate the two. You cannot teach psychiatry without seeing patients and seeing patients with guidance is the best way to learn psychiatry.

If you interview at a program that boasts about how little work they do, run. If you really are looking for a program with a light work load, just say so at interviews and the heavy work load programs will keep you off of their lists.

 

[st2205]

If you interview at a program that boasts about how little work they do, run. If you really are looking for a program with a light work load, just say so at interviews and the heavy work load programs will keep you off of their lists.

So will the easy programs.

 

[Nasrudin]

Well with good hours and moonlighting you can get plenty of clinical experience. You just get paid twice as much.

Hmmm. It's hard to pitch the hoo hah line to that guy. He's just smarter than you. And me. Cause I'm working stupid hard. Although not on psych. Truthfully I haven't heard of a murderous psych program.

 

[Armadillos]

Also something that isn't often mentioned in these conversations is its entirely possible that if a psych program attracts exceptional applicants they could still make significantly better than average psychiatrists with less hours because they are better at learning/generally more intelligent. Not to mention if the program had particularly gifted people in administration they might easily provide for better learning in a 40 hour week than another can in a 65 hour week.

For example, there is a phenomenal amount of potential "wasted" time that could happen in an sort of residency, whether its partially redundant lectures (or a lecturers periodically not showing up), having to do tons of secretarial type work because of poor support, having to do tons of social work because of poor support, navigating inefficient workflows, dealing with a bad EMR, commuting between distant clinical sites, having clinics with 50% no show rates, consult services that dont manage to deflect the BS consults,etc, etc. So its entirely possible a program could work less hours total, but have a higher total amount of meanigful hours per week.

 

[Nasrudin]

Also something that isn't often mentioned in these conversations is its entirely possible that if a psych program attracts exceptional applicants they could still make significantly better than average psychiatrists with less hours because they are better at learning/generally more intelligent. Not to mention if the program had particularly gifted people in administration they might easily provide for better learning in a 40 hour week than another can in a 65 hour week.

For example, there is a phenomenal amount of potential "wasted" time that could happen in an sort of residency, whether its partially redundant lectures (or a lecturers periodically not showing up), having to do tons of secretarial type work because of poor support, having to do tons of social work because of poor support, navigating inefficient workflows, dealing with a bad EMR, commuting between distant clinical sites, having clinics with 50% no show rates, consult services that dont manage to deflect the BS consults,etc, etc. So its entirely possible a program could work less hours total, but have a higher total amount of meanigful hours per week.

Exactly. Work is a more complex noun than is being portrayed here.

 

[notdeadyet]

Well with good hours and moonlighting you can get plenty of clinical experience. You just get paid twice as much.

Moonlighting is a great experience in and of itself, but it's not a replacement for training. You're just working. And you are working independently (or should be). It's not a training environment. Moonlighting is great for cementing in skills developed elsewhere, but if you haven't developed those skills fully, you're just cementing questionable habits. If this were not the case, folks who had terrible training would magically become great psychiatrists after their first year on the job, but this just doesn't happen. You don't know what you don't know.

Cause I'm working stupid hard. Although not on psych. Truthfully I haven't heard of a murderous psych program.

Amen to that. Even at a busy program, I've been able to moonlight a ton and have benefited from the experience greatly. Not just clinically but petting down my fear of growing debt.

 

[Nasrudin]

Ok. But even training is highly variable. And something that requires enormous resources to do effectively. Which is why I can appreciate the value of programs that are flush with the resources to do it at the top level. Part of that is lots of patients. But only to a certain point.

These aren't clean, simple, or exact measures.

But a program like the aforementioned Yale, seems to me like they would have the ability to maximize training by shielding dumb labor and providing great academics and supervision.

Not all systems can deliver this. The work could be equally voluminous in either scenario.

What I'm saying to applicants is to look for flush departments because I think it might be a good approximation of how strapped to the burdens of labor the whole outfit is. Including your teachers.

 

[notdeadyet]

Also something that isn't often mentioned in these conversations is its entirely possible that if a psych program attracts exceptional applicants they could still make significantly better than average psychiatrists with less hours because they are better at learning/generally more intelligent.

The great programs count on that. They recruit specifically for folks who've demonstrated an ability to master a great amount of knowledge and skill within the constraints of time.

The issue that I think is being missed is that the potential for learning in a residency is going to exceed the hours available, particularly in ambitious and talented applicants. You can cut the chaff as much as you want and there will still be lots to learn. Even in a well run program with great support, there is always something else that can be added.

It's a balancing act. You want a work-life balance. Very few people would want to go to even a fantastic psych program that averaged 65 hours a week (and none of the good ones I know of do). But the sort of folks that are attracted to the top programs are also the sort of folks that tend to be willing to work hard for the sake of becoming better psychiatrists. And the sacrifice of working less hard and expecting the knowledge to come through via osmosis is just not going to happen.

Even working relatively hard, there are entire modalities I'm not going to have time to learn and there is depth in some of them that I'm not going to get to fully develop. I'm cool with that, as I don't want to work like a maniac in residency. But I also wasn't willing to intentionally choose a residency that worked less but provided less quality training.

I think this is why you're not going to find top programs that don't ask their residents to work hard.

 

[notdeadyet]

Ok. But even training is highly variable. And something that requires enormous resources to do effectively. Which is why I can appreciate the value of programs that are flush with the resources to do it at the top level. Part of that is lots of patients. But only to a certain point.

Yep. But the great programs aren't busy just because you see a lot of patients. You also have a lot of diversity of training sites. And you have exposure to a lot of different modalities to try to gain structured experiences in within the time limitations of residency.

More work =/= better education. There are some programs out there that are exploitive in the hours that they work their residencies. But the great residencies tend to work more hours than other residencies because there's a lot of education to be had.

That's all. I'll sign off. My only $0.02 is that ambitious residents who are vested in getting the best education they can shouldn't rule out residencies that expect them to work hard and smart. You'd be ruling out many-to-most of the best of them.

 

[Dr.W]

Schwartz, first of all congratulations on reaching this point in your career. The world is your oyster! I'm currently a PGY4 resident at UT-Southwestern in Dallas. I also interviewed and applied nationwide due to the couples match. Honestly, I think that UT-Southwestern should be at the top of your list due to excellent overall training, breadth of experience, and genuine support by the administration. If you are interested in research, we have been a clinical site for some heavy hitting studies including STAR-D and are at the leading edge for current and future evidence based trials. Conversely, we also have great psychotherapy training as we work work alongside UT-Southwestern's clinical psychology department, as well as, have at least a years worth of training in psychodynamic supervision by a trained analyst. As far as living in Dallas goes, it's a great place to be single, there is a relatively large arts district, we have plenty of outdoorsy stuff to do (Paddle boarding, kayaking, cycling, running), and it has an excellent restaurant-bar scene. It gets pretty hot in the summer but we do get chilly enough to get snow in the winter. Finally, we are able to moonlight and make between $100-175 per hour, depending on the facility (outside of the program, of course).

Here's a recent list of some of our elective available. Also check out our tracks on the site!

http://www.utsouthwestern.edu/educa...aining/residency-program/electives/index.html

One of our two brand new hospitals:

http://www.buildingparkland.com

Best of luck and shoot me a message if you have any questions. When you get an interview here, let me know!
Dr.W

I'm applying for next year's match and with 15 days out to send out the applications, my research about the programs is almost complete. I'm a fairly strong applicant and I hope to get interviews from most everywhere. I still want to apply to 20+ places because 1) I'm inherently paranoid about these things, and 2) I have a ton of time in my hands, and want to use this opportunity to explore the different cities as well. I'm single, and I have NO geographical preferences (apart from preferring cold to very hot weather aka Arizona/Texas). These are what I have so far, not necessarily in order:

MGH/McLean
Longwood
Cambridge
Columbia
Cornell
NYU
MSSM
UCLA
UCSF
UCSD
UW-Seattle
MCW
Northwestern
UPenn
UPitt
UMich
MUSC
UNC
UTSW-Dallas
Brown
Yale

Please don't tell me that something on the list, like Yale, is not very competitive, and they are not traditionally considered as one of the top programs in the country. I've been speaking to many, many people since the start of my third year to come up with this list, and each program on it belongs there for one reason or the other. I've also left out some programs that seem good on paper but are notoriously workhorse-ish like Baylor or OHSU.

What are the other top programs in the country I have missed? Top either in overall training like MGH/McLean, or exceptional in a few particular aspects of psychiatry like Cambridge, Cornell and MCW in psychotherapy training.

TIA!

 

[MacDonaldTriad]

Yep. But the great programs aren't busy just because you see a lot of patients. You also have a lot of diversity of training sites. And you have exposure to a lot of different modalities to try to gain structured experiences in within the time limitations of residency.

More work =/= better education. There are some programs out there that are exploitive in the hours that they work their residencies. But the great residencies tend to work more hours than other residencies because there's a lot of education to be had.

That's all. I'll sign off. My only $0.02 is that ambitious residents who are vested in getting the best education they can shouldn't rule out residencies that expect them to work hard and smart. You'd be ruling out many-to-most of the best of them.

Notdeadyet’s advice is right on, at least at worth $0.04. Trying to keep hard work educational is a lot about mundane stuff like keeping computers working, making sure there are functional case workers to do placements, seeing to it that sheets are change in call rooms. At the end of the day, it is all about how many patients you see with supervision that is smart and well thought out and does a reasonable job of modeling the best practices. Inputs are volume and severity of pathology. Outputs are faculty with a tolerance of different learning curves and an ability to provide constructive feedback without making residents feel defensive or degraded. It really is a true learning contract, you provide the service to patients with guidance, and we will provide the spoon feeding learning that doesn’t come from books (assuming you do your share of reading). This really is medical school, but the students are adults and the work is more intense. Life just isn’t easy but you get by with a little help from your attendings who need to understand that you are what stands between them and being too busy to attend to their grants. It is stressful, but it is the best system anyone has come up with. When you think about what the system does, it works rather well despite the discomfort involved. Recent attempts to improve it have been met with questionable measurable improvements one could argue.

 

[Jester25]

Very solid list. Agree WashU should be on there. Not sure about UCSF.

I thought I was at a top tier program until I went to a fellowship at one of the programs on your list. Big difference.

Also, I've had a chance to interact with attendings from multiple programs. I would say without a doubt the most impressive attendings not from my home programs (either in residency or fellowship) were trained at UPitt.

 

[schwartz]

Thanks everyone for the suggestions, and also for the interesting discussion.

I definitely like the academic opportunities at Yale. The only reason it's so low on my pre-interview rank list is because of its location. I've been to New Haven before, and lets just say it's not my favorite place in the world. I'm the sort of person who'd like to go out for a drink at the drop of a hat, but after hearing all the "crime stories" from NH residents, I don't think I can do that there.

WashU was definitely on my list for their reputation in "biological psychiatry", but after speaking to my mentors, it seems like I can get very good at that just by reading on my own at any program, unlike I could for something like psychotherapy. Hence why it was dropped.

I will definitely check out Dartmouth and Vanderbilt though. I've heard mixed things about some of the other programs that were mentioned like Emory, Duke, and Hopkins, but I'll surely try to find more information about them before deciding. Thanks all!

 

[whopper]

I thought I was at a top tier program until I went to a fellowship at one of the programs on your list. Big difference.

Also, I've had a chance to interact with attendings from multiple programs. I would say without a doubt the most impressive attendings not from my home programs (either in residency or fellowship) were trained at UPitt.

Agree, also agree with the above statement that work is needed to make you learn. You don't want to avoid programs that make you work. You want to avoid scut-work and excessive/malignant work (e.g. over the maximum hours, not caring you didn't get enough sleep for your drive home). Residents should work hard but that work should be fair and with appropriate attending supervision.

 

[HarryMTieboutMD]

Thanks everyone for the suggestions, and also for the interesting discussion.

I definitely like the academic opportunities at Yale. The only reason it's so low on my pre-interview rank list is because of its location. I've been to New Haven before, and lets just say it's not my favorite place in the world. I'm the sort of person who'd like to go out for a drink at the drop of a hat, but after hearing all the "crime stories" from NH residents, I don't think I can do that there.

WashU was definitely on my list for their reputation in "biological psychiatry", but after speaking to my mentors, it seems like I can get very good at that just by reading on my own at any program, unlike I could for something like psychotherapy. Hence why it was dropped.

I will definitely check out Dartmouth and Vanderbilt though. I've heard mixed things about some of the other programs that were mentioned like Emory, Duke, and Hopkins, but I'll surely try to find more information about them before deciding. Thanks all!

1) If you are interested in getting an education in clinical neuroscience, Wash U should be on that list. If you are interested in becoming a therapist, you might want to look elsewhere. You should be reading no matter where you go, but your education will be greatly facilitated if the program's clinical teaching fits the type of psychiatrist you strive to be.
2) Emory and Duke are two of the biggest academic powerhouses in the South, with better reputations and more renowned faculty/NIH money than some of the places on that list. Emory offers analytic training if that's your thing.
3) Hopkins has some of the best, most intensive clinical training in the country. Perspectives is one of the great 20th century psychiatry texts, regardless of whether one agrees with its conclusions. The intern year is also medicine intensive, including significant ICU time, so the residents are able to handle medical issues on the psychiatry floors.

 

[Armadillos]

1) If you are interested in getting an education in clinical neuroscience, Wash U should be on that list. If you are interested in becoming a therapist, you might want to look elsewhere. You should be reading no matter where you go, but your education will be greatly facilitated if the program's clinical teaching fits the type of psychiatrist you strive to be.
2) Emory and Duke are two of the biggest academic powerhouses in the South, with better reputations and more renowned faculty/NIH money than some of the places on that list. Emory offers analytic training if that's your thing.
3) Hopkins has some of the best, most intensive clinical training in the country. Perspectives is one of the great 20th century psychiatry texts, regardless of whether one agrees with its conclusions. The intern year is also medicine intensive, including significant ICU time, so the residents are able to handle medical issues on the psychiatry floors.

Duke/Emory may be great places to be faculty. I've almost universally heard from psychiatrists both in real life and on this forum that MUSC and UNC are considered better places to be a resident than Emory/Duke due to various things ranging from shady supervision at grady to Duke's generally bad atmosphere to be a resident in. Basically everyone seems to give the same story that your life will be way crappier and you will at best be the same psychiatrist.

 

[HarryMTieboutMD]

Duke/Emory may be great places to be faculty. I've almost universally heard from psychiatrists both in real life and on this forum that MUSC and UNC are considered better places to be a resident than Emory/Duke due to various things ranging from shady supervision at grady to Duke's generally bad atmosphere to be a resident in. Basically everyone seems to give the same story that your life will be way crappier and you will at best be the same psychiatrist.

Emory is a GREAT place to be a resident. The level of pathology that presents at Grady is of epic proportions, and the medical director of psychiatry at Grady is also the Department's Vice Chairman of Education, so I am sure that supervision is adequate, without hand-holding. Additionally, Emory's program director is VERY invested in her job, ensuring that her residents receive exceptional training. Though Dr. Rappaport does not have Dr. Nemeroff's amazing mustache, he is sartorially immaculate and ever so charismatic.

 

[shan564]

WashU was definitely on my list for their reputation in "biological psychiatry", but after speaking to my mentors, it seems like I can get very good at that just by reading on my own at any program, unlike I could for something like psychotherapy. Hence why it was dropped.

I think that's a bit of an oversimplification. The idea that you could learn "biological psychiatry" from just reading is comparable to the idea that psychotherapy doesn't work... both ideas are perpetuated by the people in the opposite camp, but both are actually much more complicated than that. Also, the dichotomy is a bit overblown too.

 

[psychattending]

Thanks everyone for the suggestions, and also for the interesting discussion.

WashU was definitely on my list for their reputation in "biological psychiatry", but after speaking to my mentors, it seems like I can get very good at that just by reading on my own at any program, unlike I could for something like psychotherapy. Hence why it was dropped.

I am not sure that logic is sound. If this were true, then for a lot of fields all one has to do is read a book for residency training. Training, even is a "biological" program, is so much more than reading a book.

 

[whopper]

Agree. I've seen attendings tell their residents wrong information about the biological aspects, or simply not know something they should've known. I've seen attendings not have an algorithm on picking which antidepressant based on science, not know the biology of why benzo use can cause problems even several months after they've been stopped, or know why the dopamine theory of psychosis is considered outdated.

While a PGY-IV, I told all the residents to shoot for a $4 SSRI first, and one of the attendings asked if I had some type of inappropriate relationship with the citalopram drug rep.

(For those of you who can't tell why this shows he's clueless: 1) Citalopram is a generic, there was no drug reps 2) He didn't know it was a $4 med and didn't the prices of pretty much any of the psychotropics he prescribed )

 

[TexasPhysician]

Emory is a GREAT place to be a resident. The level of pathology that presents at Grady is of epic proportions, and the medical director of psychiatry at Grady is also the Department's Vice Chairman of Education, so I am sure that supervision is adequate, without hand-holding. Additionally, Emory's program director is VERY invested in her job, ensuring that her residents receive exceptional training. Though Dr. Rappaport does not have Dr. Nemeroff's amazing mustache, he is sartorially immaculate and ever so charismatic.

The level of pathology is certainly great due to the high volume. Much could have changed since I interviewed there, but on my interview, 90% of the residents I met were exhausted and over-worked. One resident told me there was no time to read. Another about fell asleep at the dinner.

 

[notdeadyet]

Agree. I've seen attendings tell their residents wrong information about the biological aspects, or simply not know something they should've known. I've seen attendings not have an algorithm on picking which antidepressant based on science, not know the biology of why benzo use can cause problems even several months after they've been stopped, or know why the dopamine theory of psychosis is considered outdated.

I agree with this, though I'm always a little slow to recommend algorithms for medication selection.

Algorithm's are a great place to start, but you will (or should) be abandoning that algorithm in a fair number of cases. Algorithms are typically based on very specific factors with very generic patients (who tend to be white, but that's another kettle of fish). Using SSRIs, as an example, there are compelling reasons to use many of the SSRI's as first choice, given the patient's other meds, weight, adherence, comorbidities, etc. Algorithm's don't capture all that.

Just tossing it out there. Med students are too easily swayed into the "pick anything you want, it doesn't matter" or they rx based on the Texas algorithm's and the like without letting actual evidence in front of them sway their judgment.

 

[whopper]

Agree. Picking/recommending meds in is very complicated and an algorithm could make things oversimplified. I'm in a new program. Worked with a resident for the second time so far in the program, and I was, ouch, I hate saying it, I really wanted to sit there and spend a heck of a lot more time with her about her choices.

Abilify 20 mg because the patient is depressed (with psychosis)--ouch.
Me: Why Abilify? Its' expensive, this patient is poor and without insurance. It's not an antidepressant. It's an augmentation for antidepressant treatment but not at 20 mg and all atypicals act as antidepressant augmentation agents at low-dosages. I've seen no data showing Abilify being superior to the other atypicals.

Patient is depressed and anxious: Sertraline, Buspirone, and Mirtazapine all started at the same time.
Me: Why? I don't get it. Start with one, add the others once one of them is at the max and showing some benefit but in need of more. Start with an SSRI. Why Sertraline? Why not Citalopram? This patient has no insurance and makes no money. That $16 difference is actually significant for the patient.
Resident: You can go up more with Sertraline.
Me: Go up more? It's not more efficacious. That 200 mg of Sertraline can't be considered more powerful than 40 mg of Citalopram because it's got more mgs.

GAD: Wellbutrin and Seroquel
me: why not an SSRI?
The patient was already started on Wellbutrin and Seroquel by the outpatient doctor.
Me: Why? Patient's psychiatrist told her that those meds work together well.
Me: I don't know anything showing Wellbutrin and Seroquel have some type of symbiotic relationship with anxiety disorders. Neither of them have an approval for an anxiety disorder. Seroquel could work but there's no reason to place it above an SSRI at this point, it's expensive, has more side effects, has less data showing it'd work for anxiety, has abuse potential for this already drug-addicted patient, and adding Wellbutrin won't change that. I'm thinking just another one of those attendings that don't know WTF they're prescribing and is making stuff up as they go along. Not the first, won't be the last, but I got to teach this to that resident.

 

[NickNaylor]

Agree. Picking/recommending meds in is very complicated and an algorithm could make things oversimplified. I'm in a new program. Worked with a resident for the second time so far in the program, and I was, ouch, I hate saying it, I really wanted to sit there and spend a heck of a lot more time with her about her choices.

Abilify 20 mg because the patient is depressed (with psychosis)--ouch.
Me: Why Abilify? Its' expensive, this patient is poor and without insurance. It's not an antidepressant. It's an augmentation for antidepressant treatment but not at 20 mg and all atypicals act as antidepressant augmentation agents at low-dosages. I've seen no data showing Abilify being superior to the other atypicals.

Patient is depressed and anxious: Sertraline, Buspirone, and Mirtazapine all started at the same time.
Me: Why? I don't get it. Start with one, add the others once one of them is at the max and showing some benefit but in need of more. Start with an SSRI. Why Sertraline? Why not Citalopram? This patient has no insurance and makes no money. That $16 difference is actually significant for the patient.
Resident: You can go up more with Sertraline.
Me: Go up more? It's not more efficacious. That 200 mg of Sertraline can't be considered more powerful than 40 mg of Citalopram because it's got more mgs.

GAD: Wellbutrin and Seroquel
me: why not an SSRI?
The patient was already started on Wellbutrin and Seroquel by the outpatient doctor.
Me: Why? Patient's psychiatrist told her that those meds work together well.
Me: I don't know anything showing Wellbutrin and Seroquel have some type of symbiotic relationship with anxiety disorders. Neither of them have an approval for an anxiety disorder. Seroquel could work but there's no reason to place it above an SSRI at this point, it's expensive, has more side effects, has less data showing it'd work for anxiety, has abuse potential for this already drug-addicted patient, and adding Wellbutrin won't change that. I'm thinking just another one of those attendings that don't know WTF they're prescribing and is making stuff up as they go along. Not the first, won't be the last, but I got to teach this to that resident.

Some of that is honestly frightening. Everything you mentioned is basic stuff we learned in our one month clerkship.

 

[slappy]

Some of that is honestly frightening. Everything you mentioned is basic stuff we learned in our one month clerkship.

That's quite impressive. Most medical students don't reach the level of proficiency at the basics in the 4 weeks of clerkship to start learning the costs of medications.

 

[schwartz]

Just tossing it out there. Med students are too easily swayed into the "pick anything you want, it doesn't matter" or they rx based on the Texas algorithm's and the like without letting actual evidence in front of them sway their judgment.

What is the Texas algorithm?

 

[Armadillos]

What is the Texas algorithm?

Shoot first, ask questions later

But more seriously
http://bit.ly/1AKdQpC

 

[TexasPhysician]

With a name like that, the Texas algorithm must be awesome!

 

[slappy]

What is the Texas algorithm?

http://www.cardinalinnovations.org/docs/TMAP Depression 2010.pdf

That's one of the three. http://www.bhrm.org/guidelines/tmap.pdf

 

[johnhoedack]

Emory is a GREAT place to be a resident. The level of pathology that presents at Grady is of epic proportions, and the medical director of psychiatry at Grady is also the Department's Vice Chairman of Education, so I am sure that supervision is adequate, without hand-holding. Additionally, Emory's program director is VERY invested in her job, ensuring that her residents receive exceptional training. Though Dr. Rappaport does not have Dr. Nemeroff's amazing mustache, he is sartorially immaculate and ever so charismatic.

Do you feel that Emory residents are overworked? I spoke with someone who did a SubI there last year who left with that general impression. This person seemed to feel that this work often came at the expense of education.

 

[HarryMTieboutMD]

Do you feel that Emory residents are overworked? I spoke with someone who did a SubI there last year who left with that general impression. This person seemed to feel that this work often came at the expense of education.

I am not an Emory resident (though I loved the program, it fell down on my rank list because I became (and still am) IN LOVE with my #1 program, at which I matched). However, I know some residents there, and they are not overworked. They work hard and are expected to function with some degree of independence, but they love their training and are happy to be at Emory.

 

[slappy]

While a PGY-IV, I told all the residents to shoot for a $4 SSRI first, and one of the attendings asked if I had some type of inappropriate relationship with the citalopram drug rep.

(For those of you who can't tell why this shows he's clueless: 1) Citalopram is a generic, there was no drug reps 2) He didn't know it was a $4 med and didn't the prices of pretty much any of the psychotropics he prescribed )

I missed this post before. While I agree with you on shooting for a $4 SSRI first, sometimes the generics have quite a different side-effect profile (thanks to FDA's way-too-lax definition of 'generics'), and one needs to be on guard for any and all adverse effects, including those not traditionally associated with the drug. How many times have you prescribed generic sertraline hoping it'll help the patient's anxiety like Zoloft would, only to find out it made it worse?

 

[Anduin]

Is it not pretty common to start an SSRI/SNRI + remeron at the same time? Works faster and greater remission rates.

 

[RedSox87]

There has been some chatter about Duke psychiatry residency on the discussion board. The unfortunate rumor is that Duke is a bad environment for residency in terms of work loading and other nonspecific social factors.

I am a second year Duke psychiatry resident and am happy to speak to this unfortunate misconception.

I have absolutely loved my training here. I have undoubtedly worked very hard as compared to other psychiatry programs. However, I feel rewarded in seeing a variety of patients, being entrusted with a great deal of responsibility and taking charge in the growth and care of my patients. I feel confident to tackle nearly any disease process I encounter (no, I'm not kidding).

I have encountered no malignant faculty in psychiatry or other specialties. We get psychotherapy training that I'd argue is among the strongest (and last of its kind) in the country. We have psychopharmacology lectures and an academic half day that is superb in preparing us, and we have some of the best benefits; financial, healthcare, training, and prestige; in the country.

PM if you want more information.

 

[RedSox87]

Please refer to the following videos that were recently posted to learn about Duke Psychiatry Residency. Interviews with our PD, chair, chief resident and vice chair.