Wash U in St. Louis

[TheMan21]

How competitive is the program? Heard anything good or bad about it? Thanks!

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[shan564]

How competitive is the program?

By national standards, moderately competitive. By Midwestern standards, more competitive than most. By "top program" standards, not competitive at all. Probably near the top in terms of quality-to-competitiveness ratio, especially if you're interested in academia.

Heard anything good or bad about it? Thanks!

Yeah, but I'm a bit biased...

 

[SmallBird]

How competitive is the program? Heard anything good or bad about it? Thanks!

I know one psychiatrist who trained there and she is pretty awesome!

 

[Smallville86]

How do you feel WashU, as a program, compares to other strong programs in the Midwest/MidAtlantic/MidSouth- Northwestern, UChicago, Michigan, Pitt/UPMC, Vanderbilt? If anything, I have a bit of a leaning TOWARDS the Interior, growing up and going to undergrad + med school in what others would call "fly over" country

Also, when people say that WashU is a more "biologic" program, what does that even mean?

 

[splik]

Also, when people say that WashU is a more "biologic" program, what does that even mean?

WashU has an interesting history which they take seriously. They see themselves as having pioneered the "medical model" of psychiatry during a time when most of American psychiatry was psychodynamically oriented. Essentially people like Samuel Guze, George Winokur (who later went to Iowa which is very similar) and Eli Robins were responsible for the development of diagnostic psychiatry which is something I believe is very much emphasized there today. Diagnostic psychiatry is what led to the development of DSM-III and the current versions of the DSM - the search for refining and developing more reliable criteria for mental disorders on the belief that mental disorders were like other medical illnesses that existed as valid entities in external nature - they were 'things' or 'natural kinds' - and that with precise diagnostic criteria could be diagnosed reliably like other types of illness.

They believed that mental illnesses could be clearly distinguished from normal mental life, and that different mental disorders could be delimited as separate from one another, like they were distinct 'natural kinds' and that by looking at family histories, symptom clusters, clinical course of illness, response to treatment, and biomarkers one would be able to more accurately map out the diseases of pathology that underlie mental illness.

They further believed that there was a strong biological basis for mental illness, that mental illnesses should be treated by medically trained individuals (i.e. psychiatrists), with biologically targeted treatments.

There was (and probably still is) a very strong emphasis on rigorous diagnosis using the DSM at WashU more so than many other places, for better of for worse.

Psychodynamics was seen as an aberration for the most part and nothing to do with the legitimate practice of psychiatry. I have some sympathy to this, although the WashU approach seems reductio ad absurdum to me.

 

[DJspreadsheet]

How do you feel WashU, as a program, compares to other strong programs in the Midwest/MidAtlantic/MidSouth- Northwestern, UChicago, Michigan, Pitt/UPMC, Vanderbilt? If anything, I have a bit of a leaning TOWARDS the Interior, growing up and going to undergrad + med school in what others would call "fly over" country

Also, when people say that WashU is a more "biologic" program, what does that even mean?

UChicago a strong program? Sounds like you have some research to do.

 

[Leo Aquarius]

How do you feel WashU, as a program, compares to other strong programs in the Midwest/MidAtlantic/MidSouth- Northwestern, UChicago, Michigan, Pitt/UPMC, Vanderbilt? If anything, I have a bit of a leaning TOWARDS the Interior, growing up and going to undergrad + med school in what others would call "fly over" country

Also, when people say that WashU is a more "biologic" program, what does that even mean?

You're caught in medical student mindset. Name brand doesn't mean great psychiatry program. Take Sheppard Pratt. You've probably never heard of it. Turns out to be one of the best psych residencies in the country. Take it's neighbor, Johns Hopkins. Turns out to be one of the most demanding work-horse programs in the country. Name brand is only meaningful if you want to be a professor somewhere someday.

UChicago was one of the Chicago programs applicants tended to avoid when I was on the interview trail. Never would have guessed if you're thinking "Ooh, that was such a prestigious medical school and it's ranked soooo high. Must be a great residency for [fill in the blank]." Nope.

 

[shan564]

WashU has an interesting history which they take seriously. They see themselves as having pioneered the "medical model" of psychiatry during a time when most of American psychiatry was psychodynamically oriented. Essentially people like Samuel Guze, George Winokur (who later went to Iowa which is very similar) and Eli Robins were responsible for the development of diagnostic psychiatry which is something I believe is very much emphasized there today. Diagnostic psychiatry is what led to the development of DSM-III and the current versions of the DSM - the search for refining and developing more reliable criteria for mental disorders on the belief that mental disorders were like other medical illnesses that existed as valid entities in external nature - they were 'things' or 'natural kinds' - and that with precise diagnostic criteria could be diagnosed reliably like other types of illness.

They believed that mental illnesses could be clearly distinguished from normal mental life, and that different mental disorders could be delimited as separate from one another, like they were distinct 'natural kinds' and that by looking at family histories, symptom clusters, clinical course of illness, response to treatment, and biomarkers one would be able to more accurately map out the diseases of pathology that underlie mental illness.

They further believed that there was a strong biological basis for mental illness, that mental illnesses should be treated by medically trained individuals (i.e. psychiatrists), with biologically targeted treatments.

There was (and probably still is) a very strong emphasis on rigorous diagnosis using the DSM at WashU more so than many other places, for better of for worse.

Psychodynamics was seen as an aberration for the most part and nothing to do with the legitimate practice of psychiatry. I have some sympathy to this, although the WashU approach seems reductio ad absurdum to me.

I agree with pretty much all of the above in terms of the "philosophy" of the program. As usual, splik has a way of succinctly describing what I was already thinking, but would have taken me twice as many words to describe.

As a WashU resident, I'd just add/clarify a few things:
Yes, the program emphasizes the "medical" or "biological" approach to psychiatry. But that doesn't mean that they expect you to become a purely medical psychiatrist and ignore psychotherapy altogether. There are lots of faculty members with varying areas of expertise in both psychological and biological areas. The previous department chair was actually an expert on temperament and personality disorders, and is a major critic of unnecessary pharmacological treatment (he even tries to treat real bipolar I without pharmacotherapy sometimes) - he even has an extensive Wiki page here http://en.wikipedia.org/wiki/C._Robert_Cloninger ... if the program were so anti-psychotherapy, then he wouldn't have been our chair for a while.

So the reputation that we're "anti-psychotherapy" is a bit of a self-fulfilling prophecy, since it only happens because we attract residents who are more interested in biological psychiatry. In reality, if you want to learn psychotherapy, you can take on as many therapy patients as you want, and you can choose from several different super-expert psychotherapy supervisors. So in effect, you have the opportunity to learn psychotherapy here just as well as at any other place.

Part of the emphasis of the "biological" model is that we probably value research more than the average department, both from the perspectives of the investigator and the clinician. If you're interested in research/academia, the benefits of that are obvious - strong funding, strong support for research careers, practically guaranteed academic job when you graduate, etc. For a resident who isn't interested in doing research, that means that the faculty will always be up for utilizing the latest data and implementing ideas with which they might not have direct experience... they're always up for using the latest "evidence-based psychiatry." There are also critics of that approach in the department, so you get to learn from both. Also, because of the extensive academic feel of the department, pretty much every faculty member is a specialized super-expert in something, so you can learn a lot of different approaches to psychiatry.

Another aspect of the "medical" model is that they really emphasize that we should also remember how to be regular doctors. Unlike many other departments, we often get patients with active medical problems or drug-related problems that need to be managed (and the consult teams are happy to help us when we're outside of our comfort zones, of course). And so you get exposure to people with a wider variety of problems. In the last couple of weeks, I've diagnosed a guy with a subdural hematoma, managed opioid withdrawal, managed CHF and titrated phenytoin in the same patient, diagnosed TMJ syndrome in a patient who had been unnecessarily taking amoxicillin (provided to him by a friend) for an "ear infection," and cross-covered on two different patients with Huntington's. And I could make the same sort of list for any 2-week period.

I also have to clarify the emphasis on "rigorous diagnosis using DSM" - yes, we do expect every patient to have a firm DSM diagnosis, but to a large extent, the "rigor" of that refers to separating genuine pathology from "other." Nobody will yell at you if you diagnose somebody with MDD+psychosis instead of schizoaffective disorder, but they'll expect you to be able to defend that diagnosis and understand the basic differences between those two diagnoses in terms of prognosis, treatment choices, follow-up, genetic influences (i.e. what we've learned from family studies about schizoaffective manic vs. schizoaffective depressed vs. schizophrenia vs. mood disorders, and how that influences our management), etc.

 

[TheMan21]

helpful info

thanks for this- very informative. thanks to splik as well.

 

[shan564]

After this thread, somebody sent me a private message to ask me more about the WashU program. I ended up typing a pretty extensive response. I figured that I might as well post it here so that others can potentially benefit from it too.

Here are the questions I was asked:

I've heard it's a strong biological program with great training in pretty much everything, great research if you're into that, and decent to solid training in therapy if you're into that. Any more specifics on the training? How did you find your intern year to be with medicine and neuro? What is the call schedule like for the first few years? How does outpatient work and do residents feel like it's well-run? What's St. Louis like as a resident? Feel safe going home after dark?

If you're more biologically/research-oriented, I think that this is probably one of the best programs around. As you probably know, the program is less competitive than many other similar-caliber programs, since the competitiveness of a program tends to be inversely proportional to its distance from the nearest large body of water. What many people don't realize is that this comes with a nice side benefit... if you're interested in research/academia/teaching, the program also heavily recruits faculty from within. The department chair has clearly told us that if we want to stay when we graduate, they'll give us financial support for our research, help us find mentorship/grant money, provide a salary without requiring you to pay them back by having a lower research:clinical ratio, etc. So it's a great way to become a faculty member at a top medical school... at most other "top 5" type med schools, I'd expect that you'd have to fight for a faculty spot when you graduate.

Also, I think that the environment here is very friendly. Everybody respects everybody else. I've never heard of any academic politics.

As far as the actual clinical training, I think the biggest thing that sets us apart is the diversity of experience that you can get. Every place will give you an opportunity to see plenty of general inpatients and outpatients, but in order to be a good well-rounded psychiatrist, you have to do a rotation in eating disorders, chemical dependency, VA, consults, ECT/TMS/VNS, emergency, geriatrics, day hospital work/recovery programs, etc. And you should be at a tertiary referral center for your neuro rotation. And you should have plenty of elective time to hone your own personal interests. And you should see plenty of patients from different socioeconomic and cultural backgrounds. And you should be at a place that's popular for patients with no insurance. And a city with enough poverty so that you can see what schizophrenia looks like if it's untreated until age 50. And a place that's a tertiary referral center for all of the local hospitals. And a place with leading experts in all sorts of different mental illnesses. I don't think there's any other training program that gives you all of those things - the only places that come close are Cleveland Clinic (which is not a major center in psychiatry) and Baylor (which is much more psychodynamic rather than biological). If a program makes you rotate through inpatient psych or schizophrenia service or something like that in 2nd year, that just means that they're trying to squeeze more work out of you. There's no educational value to seeing more general inpatients in PGY2... you should learn everything you need to manage those patients effectively in your PGY1 inpatient rotations. PGY1 should be for learning how to deal with acute general inpatients, PGY2 should be for learning all of the specialized psychiatric areas, PGY3 should be for learning to work independently, and PGY4 should be for pursuing your own interests with electives.

I haven't done medicine yet, so I can't answer that question. Neuro has been pretty good so far. Not good enough to convince me to change specialties, but they do a great job of exposing us to a good combination of rare/unusual cases and common bread-and-butter stuff. And they actually appreciate our input into the psychiatric side of things.

PGY1 is the worst for call - it's q5. Personally, I look forward to call days because it gives me a chance to practice independently and teach my students how to do a full psych assessment. By the way, another great thing about WashU is how smart the students are. They're really easy to teach.
In PGY2, the call days are longer (since you don't have the 16-hr work limit anymore), but they're also much less frequent. You just share the overnight call schedule in the ED with all of the other residents. So you have to take an overnight call about once every 8-9 days on average (since 1 of the 11 residents is taking the day shift in the ED, and the other two are taking the weekend day shift). But then you get your post-call day off, which is nice. So in PGY2, you're essentially working normal business hours except for 3-4 days a month, unless you're on the ED rotation (which is 5 days/wk of 12-hr shifts, but you get a lot of downtime when there are no psych consults in the ED).
After that, there's no call. PGY3/4's are welcome to moonlight in the ER, and you get paid pretty well for that if you want to do it. If you don't want to do it, you can work normal business hours. PGY3 is pretty chill because 1/3 of your patients won't show up for their appointments, and if you think that's compromising your experience, you can just moonlight and make extra money. PGY4 is even better because it's all electives or supervision. Some people will take 8 months of research time in 4th year - last year's chief was working on an epidemiological project (mostly from home) and just coming in to the hospital to see a few outpatients. For your electives, you can do pretty much anything, as long as you can convince the PD that it's educational.

All of 3rd yr is outpatient, plus as much of 4th year as you'd like it to be (since it's mostly electives). I've never heard anybody complain about how well it's run. You can choose your supervisor, and they're not allowed to say "no" (although you probably wouldn't choose somebody who would want to say "no"). And you can rotate through different supervisors, or keep the same one. The PGY3 outpatient coordinator is one of the friendliest and most accessible people I've ever met... when she's covering an inpatient team, she doesn't even expect her residents/students to pre-round on the patients... she just sees everybody together. I think the outpatient residents have just the right balance of autonomy and supervision. They also spend some time at a few of the community clinics... I think it's a couple of half-days every week.

The didactics are one of the best things IMO. We get a LOT of didactics, and they're all VERY useful. I come out of every didactic feeling like I will be a better psychiatrist because of it. I actually look forward to didactics every day. We don't have "protected" didactic time like some programs do, but that's because we have at least 7-8 hrs of didactic time every week, and it'd be silly to block off that much time - it'd comapromise both the learning/yield of the lecture, and the ability for you to provide continuity of care to your patients, which is very important for your learning.

St. Louis is great. It gets a bad rep because of the crime statistics, but that's unfair because crime here is measured differently due to the zoning of the city. As it happens, the city is 90% ghetto (the other 10% is the neighborhood at the edge of the city that contains our hospital, med school, and Forest Park, which is a spectacular park) and the suburbs are much nicer - so if you look at the crime stats for the whole metro area, St. Louis is right around average. But because we are in a nice neighborhood that is not too far from a not-so-nice neighborhood, we get a very diverse range of patients, ranging from the richest people in town (since we're a "high ranked" hospital) to the poorest people in town (since we're often the closest hospital) to the sickest people in town (since we're usually the referral center).

Since we're in the nice part of town (google "Central West End St. Louis"), I don't have any issues with walking home at night. But for the people who are a bit insecure, the hospital provides a free shuttle service for residents who want a ride home at night. In my year, around half of the residents walk to work every day. The director of the inpatient service, a full professor who makes a ridiculous amount of money doing forensic work, takes the public train to work every day.

Another great thing about St. Louis is that it's cheap - I was able to buy a 3-bedroom townhouse with a garage and a basement in the Central West End (which is my favorite part of town - full of young professionals like us, and happens to be walking distance to the hospital) on a resident's salary. If you look at the Wiki article on this neighborhood, the first adjective they use to describe it (not including "central" and "west") is "affluent." And I actually do feel affluent on a resident's salary here. I drive a BMW (insurance and gas is cheaper here too), I can go out to the restaurants/bars in the Central West End without ever having to worry about spending too much, and I still feel like I'm living in a nice area, since that salary allows you to live in the best part of town. There are plenty of million-dollar condos in this neighborhood, but you can get a pretty nice place in the $130-150k range. I paid $200k for my 3-bedroom because I plan to have roommates, which will offset the higher mortgage. Thanks to the magic of physician mortgage programs, I was able to get that $200k mortgage despite having over $300k in student loans (but they wouldn't approve me for any more than that $200k, so I wouldn't have been able to buy a house in Chicago). My mortgage is actually lower than what the previous owner charged to rent out the same house.

Well, I probably spent more time on that response than I should have. I guess I was feeling very loquacious today.

 

[TheMan21]

After this thread, somebody sent me a private message to ask me more about the WashU program. I ended up typing a pretty extensive response. I figured that I might as well post it here so that others can potentially benefit from it too.

Here are the questions I was asked:



If you're more biologically/research-oriented, I think that this is probably one of the best programs around. As you probably know, the program is less competitive than many other similar-caliber programs, since the competitiveness of a program tends to be inversely proportional to its distance from the nearest large body of water. What many people don't realize is that this comes with a nice side benefit... if you're interested in research/academia/teaching, the program also heavily recruits faculty from within. The department chair has clearly told us that if we want to stay when we graduate, they'll give us financial support for our research, help us find mentorship/grant money, provide a salary without requiring you to pay them back by having a lower research:clinical ratio, etc. So it's a great way to become a faculty member at a top medical school... at most other "top 5" type med schools, I'd expect that you'd have to fight for a faculty spot when you graduate.

Also, I think that the environment here is very friendly. Everybody respects everybody else. I've never heard of any academic politics.

As far as the actual clinical training, I think the biggest thing that sets us apart is the diversity of experience that you can get. Every place will give you an opportunity to see plenty of general inpatients and outpatients, but in order to be a good well-rounded psychiatrist, you have to do a rotation in eating disorders, chemical dependency, VA, consults, ECT/TMS/VNS, emergency, geriatrics, day hospital work/recovery programs, etc. And you should be at a tertiary referral center for your neuro rotation. And you should have plenty of elective time to hone your own personal interests. And you should see plenty of patients from different socioeconomic and cultural backgrounds. And you should be at a place that's popular for patients with no insurance. And a city with enough poverty so that you can see what schizophrenia looks like if it's untreated until age 50. And a place that's a tertiary referral center for all of the local hospitals. And a place with leading experts in all sorts of different mental illnesses. I don't think there's any other training program that gives you all of those things - the only places that come close are Cleveland Clinic (which is not a major center in psychiatry) and Baylor (which is much more psychodynamic rather than biological). If a program makes you rotate through inpatient psych or schizophrenia service or something like that in 2nd year, that just means that they're trying to squeeze more work out of you. There's no educational value to seeing more general inpatients in PGY2... you should learn everything you need to manage those patients effectively in your PGY1 inpatient rotations. PGY1 should be for learning how to deal with acute general inpatients, PGY2 should be for learning all of the specialized psychiatric areas, PGY3 should be for learning to work independently, and PGY4 should be for pursuing your own interests with electives.

I haven't done medicine yet, so I can't answer that question. Neuro has been pretty good so far. Not good enough to convince me to change specialties, but they do a great job of exposing us to a good combination of rare/unusual cases and common bread-and-butter stuff. And they actually appreciate our input into the psychiatric side of things.

PGY1 is the worst for call - it's q5. Personally, I look forward to call days because it gives me a chance to practice independently and teach my students how to do a full psych assessment. By the way, another great thing about WashU is how smart the students are. They're really easy to teach.
In PGY2, the call days are longer (since you don't have the 16-hr work limit anymore), but they're also much less frequent. You just share the overnight call schedule in the ED with all of the other residents. So you have to take an overnight call about once every 8-9 days on average (since 1 of the 11 residents is taking the day shift in the ED, and the other two are taking the weekend day shift). But then you get your post-call day off, which is nice. So in PGY2, you're essentially working normal business hours except for 3-4 days a month, unless you're on the ED rotation (which is 5 days/wk of 12-hr shifts, but you get a lot of downtime when there are no psych consults in the ED).
After that, there's no call. PGY3/4's are welcome to moonlight in the ER, and you get paid pretty well for that if you want to do it. If you don't want to do it, you can work normal business hours. PGY3 is pretty chill because 1/3 of your patients won't show up for their appointments, and if you think that's compromising your experience, you can just moonlight and make extra money. PGY4 is even better because it's all electives or supervision. Some people will take 8 months of research time in 4th year - last year's chief was working on an epidemiological project (mostly from home) and just coming in to the hospital to see a few outpatients. For your electives, you can do pretty much anything, as long as you can convince the PD that it's educational.

All of 3rd yr is outpatient, plus as much of 4th year as you'd like it to be (since it's mostly electives). I've never heard anybody complain about how well it's run. You can choose your supervisor, and they're not allowed to say "no" (although you probably wouldn't choose somebody who would want to say "no"). And you can rotate through different supervisors, or keep the same one. The PGY3 outpatient coordinator is one of the friendliest and most accessible people I've ever met... when she's covering an inpatient team, she doesn't even expect her residents/students to pre-round on the patients... she just sees everybody together. I think the outpatient residents have just the right balance of autonomy and supervision. They also spend some time at a few of the community clinics... I think it's a couple of half-days every week.

The didactics are one of the best things IMO. We get a LOT of didactics, and they're all VERY useful. I come out of every didactic feeling like I will be a better psychiatrist because of it. I actually look forward to didactics every day. We don't have "protected" didactic time like some programs do, but that's because we have at least 7-8 hrs of didactic time every week, and it'd be silly to block off that much time - it'd comapromise both the learning/yield of the lecture, and the ability for you to provide continuity of care to your patients, which is very important for your learning.

St. Louis is great. It gets a bad rep because of the crime statistics, but that's unfair because crime here is measured differently due to the zoning of the city. As it happens, the city is 90% ghetto (the other 10% is the neighborhood at the edge of the city that contains our hospital, med school, and Forest Park, which is a spectacular park) and the suburbs are much nicer - so if you look at the crime stats for the whole metro area, St. Louis is right around average. But because we are in a nice neighborhood that is not too far from a not-so-nice neighborhood, we get a very diverse range of patients, ranging from the richest people in town (since we're a "high ranked" hospital) to the poorest people in town (since we're often the closest hospital) to the sickest people in town (since we're usually the referral center).

Since we're in the nice part of town (google "Central West End St. Louis"), I don't have any issues with walking home at night. But for the people who are a bit insecure, the hospital provides a free shuttle service for residents who want a ride home at night. In my year, around half of the residents walk to work every day. The director of the inpatient service, a full professor who makes a ridiculous amount of money doing forensic work, takes the public train to work every day.

Another great thing about St. Louis is that it's cheap - I was able to buy a 3-bedroom townhouse with a garage and a basement in the Central West End (which is my favorite part of town - full of young professionals like us, and happens to be walking distance to the hospital) on a resident's salary. If you look at the Wiki article on this neighborhood, the first adjective they use to describe it (not including "central" and "west") is "affluent." And I actually do feel affluent on a resident's salary here. I drive a BMW (insurance and gas is cheaper here too), I can go out to the restaurants/bars in the Central West End without ever having to worry about spending too much, and I still feel like I'm living in a nice area, since that salary allows you to live in the best part of town. There are plenty of million-dollar condos in this neighborhood, but you can get a pretty nice place in the $130-150k range. I paid $200k for my 3-bedroom because I plan to have roommates, which will offset the higher mortgage. Thanks to the magic of physician mortgage programs, I was able to get that $200k mortgage despite having over $300k in student loans (but they wouldn't approve me for any more than that $200k, so I wouldn't have been able to buy a house in Chicago). My mortgage is actually lower than what the previous owner charged to rent out the same house.

Well, I probably spent more time on that response than I should have. I guess I was feeling very loquacious today.

This sounds great! I did end up getting an interview invite to WashU, and I am very excited to see it first-hand.

 

[whopper]

I know one psychiatrist who trained there and she is pretty awesome!

You might want to ask her about her specific experiences.

A program can be bad but produce a good psychiatrist because that individual, on their own, due to their desire to be a good doctor went beyond what the program offered for them. Other programs are good, but then kink out later.

My own general residency program, while I was there had an attending as the PD that was considered one of the best teaching doctors in the state, IMHO one of the best I've ever seen despite working with some of the top doctors in the field now. I still think the program, despite it being small and not recognized much, was a great program because of him while he was there. He left my fourth year and, ahem, I think most of the positives the program had to offer left with him. I had hopes, but I talked to a few residents after I left and my hopes weren't realized.