VA vs university hospital

[Alemo]

Hi guys,

I’m wondering about the relative pros and cons between VA inpatient sites and university inpatient sites, specifically at places like U Michigan or Duke. I know the VA involves CPRS and a predominantly older male population that I would think shows less first break psychosis, mania, etc. Inpatient at university hospitals I assume would run the gamut in ages, pathology, SES. Can any residents speak to these differences? Also, I’d love to hear any current residents thoughts on Duke or Michigan.

Thanks!

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[wolfvgang22]

You are correct, but there are a lot more female veterans these days and a lot of veterans aged 20 to 50 now due to the recent wars, so it isn't just all Vietnam veterans anymore. 1/2 of my patients at my particular VA caseload are under 50 or female.

 

[Mass Effect]

If you're talking about for residency, go with inpatient university hospital. The VA is great for a rotation, but I wouldn't have wanted it to be the bulk of my training.

 

[WingedOx]

The Ann Arbor VA has a good reputation, from what I know, but I had a royal pain in the ass of a time trying to get one of my patients an intake MH appointment there when he moved to Livonia.

/random tangent rant.

 

[Stagg737]

Saw way more patients with substance abuse issues (especially alcohol) at the VA than any other rotation I did and was told by attendings and PDs on rotations and at residency interviews that it's to be expected.

 

[WingedOx]

I'm not exactly sure what you're asking though. Is this for a rotation or residency selection?

 

[Mass Effect]

Saw way more patients with substance abuse issues (especially alcohol) at the VA than any other rotation I did and was told by attendings and PDs on rotations and at residency interviews that it's to be expected.

Right, the VA does have a lot of substance abuse issues (and PTSD). But these days, you'll see substance abuse issues in whatever residency program you end up in and in psychiatry, you have to do addiction as well. I maintain, though, that the VA is an excellent rotation site, but I don't think it's beneficial to do your residency at a VA.

 

[Alemo]

Thanks for all the responses. I’m asking about residency training. I know training at U Michigan is pretty heavily made up of the VA (maybe 8 months or so of inpatient psychiatry out of the 4 years). I’d like to know what the pros and cons of this are. Duke also has heavy VA exposure.

 

[Mass Effect]

Would that be your only inpatient experience? I'm not familiar with their curriculum. Where would your outpatient exposure be?

 

[BillyWalksOnMars]

I would go with University community based care over the VA any day of the week. The VA comes with a lot of systemic BS that really skews the treatment. Lots of substance, personality, but more important is the huge component of secondary gain you see in the patients. They literally have incentive to lie to you to try to increase their service connection.

 

[WingedOx]

I don't know much about Duke, but Michigan is still Michigan and is a fantastic program. It's not THAT VA-heavy, and the Ann Arbor VA (despite my frustrations with them) is one of the best in the Midwest. The amount of VA experience they have absolutely shouldn't prevent you from ranking them highly. Plus, despite some of the headaches, you can learn a lot in VA rotations.

 

[notdeadyet]

There are residencies that have a lot of VA rotations and there are residencies that are primarily VA-based, with a handful of electives at other sites. I would avoid the latter. It's not a good model.

People can talk about how there are more women veterans each year as much as they want, but since women make up only about 16% of the military, they will always be a minority population at the VA. VA patients are currently about 90% male. This is problematic, since women make up half the population (and more than half in mental health care).

Veterans you will care for at the VA are still predominantly white, and will continue to be before you end residency training. The U.S. military is currently about 40% racial/ethnic minorities, but that is a VERY recent trend (the number was 25% in 1990). The VA is roughly 80% white. It will be decades before the VA population resembles current America. Military veterans also overwhelmingly tend to speak English conversationally fluently. This is also not representative of the U.S. at large.

I'm in academics and work primarily at the VA; I'm at the VA because I believe in the mission. But even I would not recommend a primarily VA training program. I'm passionate about caring for veterans but I am able to do a better job of it BECAUSE I trained at a program that is not primarily VA-based. As the demographics of veterans change, I'll be able to provide better care for veterans and can use non-VA modalities as they are adopted. Even if your goal is to work at the VA, there is no real upside to training exclusively at one.

The VA is a great training site and I would not have trained at a program that didn't have a healthy amount of VA exposure as part of the four environments you should ideally train in during residency: VA, county hospital, tertiary care center, and private practice.

 

[WingedOx]

Veterans you will care for at the VA are still predominantly white,

This has some notable exceptions. The VA used by Northwestern and UIC is a big one. I'm sure there are others in urban centers.

 

[WisNeuro]

People can talk about how there are more women veterans each year as much as they want, but since women make up only about 16% of the military, they will always be a minority population at the VA. VA patients are currently about 90% male. This is problematic, since women make up half the population (and more than half in mental health care).

Veterans you will care for at the VA are still predominantly white, and will continue to be before you end residency training. The U.S. military is currently about 40% racial/ethnic minorities, but that is a VERY recent trend (the number was 25% in 1990). The VA is roughly 80% white. It will be decades before the VA population resembles current America. Military veterans also overwhelmingly tend to speak English conversationally fluently. This is also not representative of the U.S. at large.

These all depend on the VA. As for the gender issue. Many of the larger VAs have women's clinics now, with dedicated mental health professionals in those clinics. So, there are places where you could get a rotation only seeing female Vets. As for the ethnicity issue, that also varies quite a bit. When I was in the PNW, definitely mostly white. I did some training in the south where my patient population was about 50% AA/Latino. So, the VA in general, the mean is a white dude, but if you really want certain patient population exposure, you can choose some locations and definitely get it within the VA system. I do generally agree though, it's good to get exposure from non-VA institutions during training. My patient population and day to day work is vastly different than when I was in the VA doing the same job.

 

[Monocles]

DO NOT. I repeat. DO NOT go to a training program that is VA based.

At any sort of VA based program, your salary is mostly or majority paid by the VA so unfortunately there will be clauses that say that you must do 5/6th (83%) of your rotations in the VA. No matter how good the rotations may be, this means that the bulk of your years will be treating primarily PTSD and substance cases. I have colleagues who train in a VA based program and one of their biggest complains is that their outpatient pgy-3 year feels like they are treating the exact same patient ad infinitum.

 

[thoffen]

There is the difference in patient population, but there is a lot of variability between sites of either class, so you have to judge that individually. The largest difference, IMO, is going to be institutional. On the one hand, the VA is likely to have a copious amount of institutional support for your sick patients that you won't find elsewhere, and on the other hand the VA will require you to jump through a variety of hoops which do not add value to the patients, and in particular there is a large degree of enabling people to utilize the system for gain instead of treatment. None of these things are absent from academic sites, of course, but you are likely to encounter at the least greater autonomy in choosing who gets what services based on actual clinical assessment. The downside of the academic setting for me is seeing a number of people in need of additional outpatient services who are unlikely to be able to receive them. It's better than working for a private hospital; at least I have time to engage in identifying these needs and am not impeded by financial pressures to the same degree.

 

[Armadillos]

I like the VA and may work there, but you would get a pretty diminished experience if thats where you did the majority of your rotations. One of the biggest drawbacks to me is there are a substantial number of patients who are solely coming to apts in order to beef up or maintain their resume for service connected disability.

 

[J ROD]

Personally, I think having a mix of the two is excellent training. Personally, I prefer the blend of psychosis and substance abuse at the VA. But, if I did not work at my University I would not know how to treat Borderlines well, women, etc. I also see more complex cases at University and more diverse experiences. But, I wish I had the services available for regular folks I have for veterans. I really like the structure of the VA treatment team. Where medical providers handle the medical, SW handles SW, and I can do Psychiatry. Because at the University I am doing all 3. I often times feel overwhelmed and having to compromise.

Clinic would be more diverse at University but at the same time the pure amount of borderlines in my clinic is equivalent to PTSD and substance at VA. I prefer to do substance and PTSD. Have always wanted to work with vets. So, pending on your career choices, some things may or may not make more sense.

 

[UTsksk]

I've been having this concern between two programs. One has a VA hospital and university hospital while the other program has a state hospital for inpatient psych. Is state hospital enough exposure to feel comfortable?

 

[leapfr0g]

Hi guys,

I’m wondering about the relative pros and cons between VA inpatient sites and university inpatient sites, specifically at places like U Michigan or Duke. I know the VA involves CPRS and a predominantly older male population that I would think shows less first break psychosis, mania, etc. Inpatient at university hospitals I assume would run the gamut in ages, pathology, SES. Can any residents speak to these differences? Also, I’d love to hear any current residents thoughts on Duke or Michigan.

Thanks!

Hi, at Duke:
1st year: 2 months inpt at VA (with ECT available in hospital, amazing attendings (one of which is trained med-psych) with a flair for teaching psychotherapy if interested), 1 month VA neuro consults, and about 1 month VA ED psych consult (PEC), 1 month VA ED (on medicine side, can have option to swap for Peds outpt if interested in child)
2nd year: about 4 weeks of a blend of PEC, VA inpt psych consult depending on your schedule.
3rd yr: about 1/2 to 1 day of VA outpatient psych clinic (option to do women's mental health) with options to do more elective time
4th yr: electives, so its up to you

Population of Durham VA is at least 1/2 AA. One side of the inpt is "younger" with exposure to first break, PTSD, substance, depression, etc, and the other side is older and more "geri psych".

VA is a good way to see psychiatry practice with resources, stronger psychology and social work support, MHICH (ACT outpt) teams for SPMI. Overall a great experience, don't think this program is "VA" heavy, but def a part of our training which, IMO, is a strength.

 

[splik]

I've been having this concern between two programs. One has a VA hospital and university hospital while the other program has a state hospital for inpatient psych. Is state hospital enough exposure to feel comfortable?

in the old days, junior psychiatry residents used to cut their teeth on state hospital patients and many people lament the fact that so few residents get exposure to such a setting. state hospitals are great places to see extreme psychopathology, severe psychotic illnesses, there is a lot of neuropsych, and get comfortable with clozaril and various 2nd, 3rd, 4th, 5th, and 6th line treatments for major mental disorders. The long length of stay also makes things a bit more chill and means you actually get to know and work with the patients and see them improve (or not as the case may be). Obviously different states have different kinds of hospitals. In california, most state hospital patients are forensic patients. I think if that were your only exposure to inpatient that would be severely limiting. In most other states, there is a larger proportion of civil commitment patients in state hospitals and ideally you will get exposure to both. you also want to make sure that the hospital is not too dangerous. residents were pulled from our state hospital for a while when i was a resident because it was too dangerous to work in with patients routinely being killed by other patients and staff being attacked leading to a vicious cycle of staffing shortages and more dangerous conditions.

The ideal is to train wherever you can have exposure to as many different kinds of settings as possible. My own training including working in academic, county, VA, state hospital, private practice, correctional settings, and community mental health which made for a very broad experience.

 

[MedMan80]

in the old days, junior psychiatry residents used to cut their teeth on state hospital patients and many people lament the fact that so few residents get exposure to such a setting. state hospitals are great places to see extreme psychopathology, severe psychotic illnesses, there is a lot of neuropsych, and get comfortable with clozaril and various 2nd, 3rd, 4th, 5th, and 6th line treatments for major mental disorders. The long length of stay also makes things a bit more chill and means you actually get to know and work with the patients and see them improve (or not as the case may be). Obviously different states have different kinds of hospitals. In california, most state hospital patients are forensic patients. I think if that were your only exposure to inpatient that would be severely limiting. In most other states, there is a larger proportion of civil commitment patients in state hospitals and ideally you will get exposure to both. you also want to make sure that the hospital is not too dangerous. residents were pulled from our state hospital for a while when i was a resident because it was too dangerous to work in with patients routinely being killed by other patients and staff being attacked leading to a vicious cycle of staffing shortages and more dangerous conditions.

The ideal is to train wherever you can have exposure to as many different kinds of settings as possible. My own training including working in academic, county, VA, state hospital, private practice, correctional settings, and community mental health which made for a very broad experience.

An attending at my old program recently was knocked out and had his nose broken at the state hospital :S

 

[WingedOx]

I've been having this concern between two programs. One has a VA hospital and university hospital while the other program has a state hospital for inpatient psych. Is state hospital enough exposure to feel comfortable?

lol no.

 

[UTsksk]

Ap

in the old days, junior psychiatry residents used to cut their teeth on state hospital patients and many people lament the fact that so few residents get exposure to such a setting. state hospitals are great places to see extreme psychopathology, severe psychotic illnesses, there is a lot of neuropsych, and get comfortable with clozaril and various 2nd, 3rd, 4th, 5th, and 6th line treatments for major mental disorders. The long length of stay also makes things a bit more chill and means you actually get to know and work with the patients and see them improve (or not as the case may be). Obviously different states have different kinds of hospitals. In california, most state hospital patients are forensic patients. I think if that were your only exposure to inpatient that would be severely limiting. In most other states, there is a larger proportion of civil commitment patients in state hospitals and ideally you will get exposure to both. you also want to make sure that the hospital is not too dangerous. residents were pulled from our state hospital for a while when i was a resident because it was too dangerous to work in with patients routinely being killed by other patients and staff being attacked leading to a vicious cycle of staffing shortages and more dangerous conditions.

The ideal is to train wherever you can have exposure to as many different kinds of settings as possible. My own training including working in academic, county, VA, state hospital, private practice, correctional settings, and community mental health which made for a very broad experience.

Appreciate the advice. I'll stick with the programs that offer multiple psych experiences.