What do you hate about it?

[notdeadyet]

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The problem with board scores is that while they are a poor indicator, they actually are the best indicator available. LORs actually have almost no reliability and validity in studies.

Oh, I'm with you that board scores are the best of a bad lot. At the end of the day, objective measurements tend to be proven out when compared to subjective measurements. (mind, the only studies I've seen have been on USMLE scores; I haven't seen anything indicating the high performance on a shelf correlates with success in that particular specialty).

It's interesting that LORs have little to no reliability. Are physicians bad at it? Do they throw out accolades to easily and non-critically to the point of making their word kind of meaningless? In private industry, you'd be hard pressed to find any manager that would take a GPA or degree above the recommendation of a trusted colleague. I've done several hires based on recommendations of folks I've trusted and have never been burned, whereas folks with great scores and degrees have proven dismal failures more than once.

 

[surftheiop]

Oh, I'm with you that board scores are the best of a bad lot. At the end of the day, objective measurements tend to be proven out when compared to subjective measurements. (mind, the only studies I've seen have been on USMLE scores; I haven't seen anything indicating the high performance on a shelf correlates with success in that particular specialty).

It's interesting that LORs have little to no reliability. Are physicians bad at it? Do they throw out accolades to easily and non-critically to the point of making their word kind of meaningless? In private industry, you'd be hard pressed to find any manager that would take a GPA or degree above the recommendation of a trusted colleague. I've done several hires based on recommendations of folks I've trusted and have never been burned, whereas folks with great scores and degrees have proven dismal failures more than once.

I've not started medical school yet, but it seems like in instances where there are application processes requiring letters of recommendation (med school / residency/etc.), there seems to be a "gentleman's agreement" to either decline to write a letter or to write very nice things because thats what is required for a successful application and few people want to really screw someone's career.

In the case of a colleague recommending someone, thats different because they went out of their way to give a good word, they weren't really socially forced into it.

 

[Ibid]

The thread has moved on but I will give my personal take on these points.

Bartleby

Honestly I agree with you that hospitals are potentially quite harmful, but I don't agree that there are no exclusive advantages to inpatient care. For instance:

*It's really hard to kill yourself as an inpatient.
*Someone can see if you are taking your meds, and can do so on a schedule.
*The patient cannot assault a stranger on the street, step into heavy traffic, or gamble his/her home away.

Those things are an advantage. My take on it is minimize hospitalizations whenever you can but don't take that to a 'there is no advantage to hospitalization whatsoever' extreme.

1. If someone is set on killing themselves then containment is the only solution so I have not been disputing that.

2. You can just as easily see someone take their medication when it is delivered to them at home. So I don’t see an advantage there.

3. The question of assault rather makes my point. A patient is at increased risk of being assaulted by other patients upon admission. The gambling and traffic are just the case for containment stated in a different way so I don't disagree as before.

I do take your points but I feel I am expressing a progressive point of view and not so much an extreme one. Evidence my point of view is not that far from yours or so I would not have thought.

Sloux

On the other hand, I agree with you that the amount of time that people spend in the hospital should be minimized. And it has been and it is getting shorter and shorter in the current insurance climate. in fact, in my experience the problem has now become the reverse: often patients don't get enough hospitalization days because insurance stops to pay for them and it has been observed in several studies that such circumstances result in adverse outcomes.

I don’t disagree with this and in fact I would take the logic one step further and say that when people do need containment it is seen as far too much of a disaster.

If psychosis was not so stigmatised then being in hospital would not be either. It is only that all my experience tells me hospitals are just nasty places. I also agree that attention to reducing length of stay while a good thing to concentrate on has been at the expense of the “correct” length of stay.

I will be arguing against myself now but for the example, far above, of young women with a personality disorder, planned admissions over a period of six to eighteen months may very well go some way to evening out a chaotic lifestyle. How that would be paid for in an insurance based system is another matter.

Majesty

1) The cost of having the inpatient to each person delivered to the house would be immense. I put this first not to be callous but because it is a reality.
2) You still could not account for safety because of adequate monitoring, physical plant etc (I am not talking about containment here).
3) The doctor and staff would not be working on their own turf and would be unfamiliar and therefore prone to more errors.
4) The patient could be HOMELESS!
5) There exist, I know its shocking, home environments that are detrimental to a patient's health. These can be minor annoyances or downright abuse.
6) Fast access to other staff when needed such as consults, labs, imaging etc.

1. This does not have to be true. In the UK whole wards have been shut, the staff retrained in a home treatment model and it is less expensive. Aus and NZ the same and some places in the US.
2. It has to be case by case but if want to eliminate all risk then you are just left with admitting everyone. Home treatment requires a more skilful team certainly.
3. Where home treatment teams operate there is no evidence of there being more errors. None I know of anyway. On the contrary all the evidence is that the quality of the interventions is better. Your point about turf is interesting because one of the advantages of home treatment is that the service user/patient feels more in control of the intervention. This brings huge benefits.
4. Without being funny saying a ward is better than the street is not saying much about the ward!
5. That I agree is an interesting point about the social context in which a person exists. The harsh truth about this is that when a person is discharged that is the environment they are going to go back to anyway. Once admitted its much harder to discharge someone back to their original situation and this leads to people living in hospitals for months and years on end.
6. I have never seen an example where this was a problem.

Overall my own feelings about this issue generally are two fold. Firstly in places the culture is far too risk adverse. Secondly and equally uncontroversial, I believe, is that once the culture is in place one needs resources to make choices possible.

My own solution is for an acute care service rather than a hospital. (I am not taking about brief community interventions which should continue as usual) An acute care service would comprise an inpatient unit and a home treatment team which share staff and resources. People would be admitted to the acute care service, not just an inpatient unit and they could move fluidly between the ward and home. Staff would rotate between both parts of the team. Understandably a logistical challenge but the skill of the team would increase exponentially and the quality of the interventions would be of a much higher quality. Say twenty people in each part instead of two wards of twenty.

In the end while psychiatrists have a duty to themselves, ultimately the risks belong to the patient as it is they who ultimately take them unless that choice is removed.

 

[whopper]

It's interesting that LORs have little to no reliability. Are physicians bad at it?

It's all statistics. Remember, case reports have no reliability or validity either. At most they should only be food for thought. I could, for example, give out a medication to 1,000, and if only 5 people get a benefit from it, and I only present those 5, you think that's reliable?

Add that LORs are a product of the applicant selectively choosing who'll likely provide the best letter. Some people are known to always give a good letter no matter how bad the person is, so some students lock onto a person like that.

I'd only give a LOR some credence if it was written by someone who I knew took the LOR seriously and would only write a good one for a good applicant.

 

[notdeadyet]

I could, for example, give out a medication to 1,000, and if only 5 people get a benefit from it, and I only present those 5, you think that's reliable?

Not at all. I had no idea that faculty were writing lots of LORs for so many med students that didn't deserve it. I would think that they would turn them down, or write an honest one that was damning with faint praise.

Some people are known to always give a good letter no matter how bad the person is, so some students lock onto a person like that.

That ain't just statistics. The above basically says that physicians are bad at it. And that's a pity for all involved.

If it's like you say, and physicians will write LORs for candidates undeserving, then physicians themselves are to blame. I wonder why this is such a thing in academia? Is it fear of confrontation? Or an ego thing that gets stroked by having students approach them? I'd be curious why physicians would be compelled to send out dishonest recommendations. Do they fall for the "every well-matched med student reflects well on the school?" Because that's poor logic, since long-term they're actually hurting their ability to match applicants well.

I've heard of this problem with reference deflation in academia, but not many other industries. In business, if an employee asks you to write a letter of recommendation, you tell them you can write them a strong one, or you tell them you don't feel comfortable writing them a strong one. If they press you on the latter, you write them one saying, "Tommy usually showed up on time and usually did established minimally accepted effort." You don't falsely bolster an applicant because, frankly, it reflects poorly on you.

It's odd that in academia, where people seem very conscious of the perception of their name, they'd be willing to weaken their reputation by writing these things willy nilly. Bummer.

 

[Ibid]

"Tommy usually showed up on time and usually did established minimally accepted effort." You don't falsely bolster an applicant because, frankly, it reflects poorly on you.

In industry I can tell you it is quite the reverse. The worse the employee the better the reference. Remember you want them to get the job!! By far the best way to get rid of someone.

I remember a friend making the mistake of giving his worst emplyee a poor reference. They didn't make that mistake again. Next time round they got a stunning reference and a lift to the interview.

 

[Manicsleep]

I think the point of trying to treat all psychiatrically ill in their homes other than for containment is just missing the boat. Home treatment models exist in the US as well. They serve a purpose, but they have limits.

I hope ibid is not referring to the severely mentally ill, the psychotic or the floridly manic. In those patients, containment is not the singular issue that makes them more appropriate for hospitalization. All those reasons given before are done better in a hospital setting than in the home. Ibid writes that he has never seen where faster access to staff, consults, imaging or labs be an issue in home care. I think the inpatients that he has seen must truly suck.

I agree PHP/IOP programs are very beneficial and work great, significantly reducing the days spent in the hospital and this may be where your ignorance of the US system comes into play. There is a place for outpatient care but to try and treat severely mentally ill in that setting with the use of case managers, ACT teams etc is successful only to a point. When a break happens, an inpatient hospitalization is needed and to say that the reason for this is only containment is just not the case.

 

[notdeadyet]

In industry I can tell you it is quite the reverse. The worse the employee the better the reference. Remember you want them to get the job!! By far the best way to get rid of someone.

I remember a friend making the mistake of giving his worst emplyee a poor reference. They didn't make that mistake again. Next time round they got a stunning reference and a lift to the interview.

Wow. What industry were you in, out of curiosity? It's shortsighted for someone to give their reputation a hit for the sake of saving HR the trouble of dumping a dead weight employee.

 

[whopper]

If it's like you say, and physicians will write LORs for candidates undeserving, then physicians themselves are to blame

True, but it's not just a physician thing. This happens in every field. If someone knows that a particular person will write them a good LOR, they'll lock onto that person. I think it's a human nature thing. Remember, the studies I looked at (from an industrial psychology class I took years ago) weren't for physicians but for people applying into college or for a job, but the same dynamics I've seen going on in those studies were going on the medical field.

 

[Ibid]

I think the point of trying to treat all psychiatrically ill in their homes other than for containment is just missing the boat. Home treatment models exist in the US as well. They serve a purpose, but they have limits.

Those limits keep moving. The rate limiting factor is risk adverse practitioners.

I hope ibid is not referring to the severely mentally ill, the psychotic or the floridly manic. In those patients, containment is not the singular issue that makes them more appropriate for hospitalization. All those reasons given before are done better in a hospital setting than in the home.

You have not given any examples and yes I do mean severely ill, psychotic although less so floridly manic.

I agree PHP/IOP programs are very beneficial and work great, significantly reducing the days spent in the hospital and this may be where your ignorance of the US system comes into play. There is a place for outpatient care but to try and treat severely mentally ill in that setting with the use of case managers, ACT teams etc is successful only to a point. When a break happens, an inpatient hospitalization is needed and to say that the reason for this is only containment is just not the case.

Mental health systems in the US are diverse so it is not possible to generalise about them.

I ask where are all these great examples? So far we have its better than being homeless and better than being in an abusive situation at home. That is not much of an advertisement for the inpatient setting itself.

For the record even hospitals that are considered world class imo are still toxic.

 

[Ibid]

Wow. What industry were you in, out of curiosity? It's shortsighted for someone to give their reputation a hit for the sake of saving HR the trouble of dumping a dead weight employee.

The public sector but generally the labour laws in the UK are so tough that good refs are standard practice for poor workers. That and the fear of being sued for slander.

Of course the reverse is true as well. If you are good some managers will sabotage your chances to keep you.

 

[notdeadyet]

True, but it's not just a physician thing. This happens in every field.

I believe you, and it sure sounds like you've done a lot more reading into this than I, but medicine is the first industry I've personally come across where people talk about discounting references entirely. This might be a reflection more of the industries I worked in in the past, which were fairly reputation-based and sending out false praise with your name on it is bad juju.

The public sector but generally the labour laws in the UK are so tough that good refs are standard practice for poor workers. That and the fear of being sued for slander.

I've heard this about EU in general but UK specifically. I think we have this to a lesser degree in the public sector as well. Dumping dead weight from one department to the next in government and sabotaging good employees prospects for the sake of your little fiefdom. Government work ethic is pretty ugly the world over.

 

[digitlnoize]

If LORs are so bad, then why do PD's rank them as so important (see NRMP stats I linked at the top of this page).

 

[Ibid]

I've heard this about EU in general but UK specifically. I think we have this to a lesser degree in the public sector as well. Dumping dead weight from one department to the next in government and sabotaging good employees prospects for the sake of your little fiefdom. Government work ethic is pretty ugly the world over.

Very true. The UK and Europe will never match the US for productivity for this very reason. The rest of the world is living off US productivity in very real way and it can't last. (Germany doing a bit of heavy lifting as well but thats about it)

If the dollar keeps sinking and I think it will things are just going to get nasty again.

Hows that for going off topic!

 

[Bartelby]

I believe you, and it sure sounds like you've done a lot more reading into this than I, but medicine is the first industry I've personally come across where people talk about discounting references entirely. This might be a reflection more of the industries I worked in in the past, which were fairly reputation-based and sending out false praise with your name on it is bad juju.

I expect in third year most of us work with at least two doctors who think we are amazing doctors to be, especially if we have a genuine interest in their field. Then I guess it just comes down to effusive those letter writers are, and differentiating between stuff like "functioned at the level of an intern" and "will make an excellent house officer" and "far exceeds his/her peers in the field of _____" is hard to do. So in the end maybe there is a ceiling effect? Also I agree that a letter from someone the interviewer knows personally will mean more, but with most of us applying so widely chances are low that our letter writers will be personal friends or colleagues of many of our interviewers.



But swinging this thread back to the original topic, what else do people dislike about psychiatry? Someone mentioned earlier about Psychiatry being on shakier scientific ground than other disciplines, I think that is one of my biggest dislikes. So much (everything really) comes down to clinical impression with no confirmatory objective tests and with no solid pathophysiological understanding of many diseases.

I also dislike how it usually seems that Psych consults in my hospital are not given the respect that others are-- we will hang on renal's every word, but Psych I think no one expects much of.

 

[Manicsleep]

Those limits keep moving. The rate limiting factor is risk adverse practitioners.

Whats your limit...what kind of practioner are you? Do tell.
What can be kept at home and how should they be treated. Please be detailed. You are often rather vague and it becomes a pointless exercise.

How many physicians, nurses, what kind of equipment, how severely ill can the patient be etc and who would be available for emergencies with what speed should something happen while changing meds/giving emergency meds etc.

 

[GoodmanBrown]

The two other things I dislike about psychiatry is first the science is on shaky ground, but that's in the process of being addressed. The second is the tediousness involved in dealing with non-medical/social work related issues that is universal in all of medicine, but is especially heavy in psych. This problem though can be leveraged in some ways, because in many cases the interdisciplinary nature of psychiatry also represents an opportunity to effect macroscopic changes on a social level that transcends the normal boundaries of medical practice. So if that kind of thing is your thing, then psychiatry is unique in its ability to give you these venues for exploration.

Can you (or anyone) expand on this a bit more? Do you mean you can work to change a patient's entire social situation? Or are talking about changing entire communities? If so, how?

 

[Ibid]

Whats your limit...what kind of practioner are you? Do tell.

I just gave an opinion on a issue. It’s not personal and I have no intention of making it so. I will just stick to the issue thanks.

What if I agree with you? As I expect on most things we would in anycase.

Ibid you insolent little turd. How dare you have the temerity to agree with me! You f’wit….on what do you base your concordance? I demand your curriculum vitae on my desk by first light countersigned by a public notary and don’t forget photographs. I want full frontal glamour shots!!!

(fake quotation for the casual readers info)

You see it's just silly making it personal.

How many physicians, nurses, what kind of equipment, how severely ill can the patient be etc and who would be available for emergencies with what speed should something happen while changing meds/giving emergency meds etc.

As far as an operational policy for a Crisis/Hometreatment team I want big bucks for that and I will be way over the odds as I don't need the work.

 

[whopper]

If LORs are so bad, then why do PD's rank them as so important (see NRMP stats I linked at the top of this page).

I'm the only medical doctor I know of that's actually looked at the science of the admission process.

The PD in my residency program, during my last year, for example, never touched anything from the field of industrial or consult liason psychology. The prior PD during my first 3 years did have a psychology degree and did incorporate what he learned from that field.

Most PDs are similar to the former, not the latter in their approach. They simply take in the data, not knowing how truly reliable and valid each method is. They believe that because they are psychiatrists, they already have a mastery of these types of things when in fact they do not. E.g. psychiatrists, unless specifically trained to do something, often are no better than a layman in many things such as detecting if someone is lying, marriage counseling, etc, because the overwhelming majority have no training specifically in that area. But since they are psychiatrists, many egocentrically and narcissistically start to think they are experts in those area.

This is an all too common phenomenon, e.g. psychiatrists rarely know how to do DBT, yet try to treat borderline PD patients with polypharmacy that usually does not work, and IMHO are really actually doing harm upon the patient that does not meet the standard of care, but I digress.

The science of the admission process has been well studied. Several corporations and universities have done several studies in this area because they want the best people. The overwhelming majority of psychiatrists do not study this in part of their curriculum.

I took an industrial psychology class in college, and during that time, was in an organization where I interviewed about 15 people a semester during an admission process. I actually started incorporating what I learned in that course into the admission process and found it very effective. I went through 6 semesters of this.

I then saw the PD during the MATCH process during my last year when I was actually a part of it because I was a chief resident, and I opined that her methods were far too personal and not evidenced-based. E.g. The PD during my last year put people at the top that she favored, on a friendship level, at the top of the MATCH lists, that IMHO was something of a boundary violation, not to mention some of them lied to her telling her they put our program at #1, yet they matched in other programs despite us giving them the top MATCH spots. (If you know the math of how the MATCH works, if they truly put us at #1, they would've matched at our program. It had to have happened that way by the algorithm). The PD even reacted in anger as if she was backstabbed after this occurred that only further reinforced my theory that some of the choices being put into the list were done for inappropriate reasons.

I do know for a fact that at Jefferson medical school, they employed an expert of sorts who actually studied the admission process. I've seen him give lectures on the science of the admission process and how best to incorporate psychology into making the educational curriculum better. So I wouldn't be surprised if Jefferson was actually using this data, but that's the only place I've seen that's done this as far as medical residencies go. Several corporations have people take psychological tests to try to put employees that match better together.

 

[sideways]

If I were a PD, I'd also rank the people I liked on a personal level highest on my list. Life isn't all about data.

 

[whopper]

But would you try to form a clique? Start putting in one person above another because they were going to hang out with you on weekends (yes with them being a resident and you being the PD)

If so, that's really crossing boundaries.

If two candidates were exactly the same other than that you had a notion that one might be one you'd get along with better, that's one thing.

To go on a temper tantrum because you became personal friends with an applicant, they told you they ranked the program as #1, and then didn't match--that's different IMHO.

 

[sideways]

But would you try to form a clique? Start putting in one person above another because they were going to hang out with you on weekends (yes with them being a resident and you being the PD)

If so, that's really crossing boundaries.

If two candidates were exactly the same other than that you had a notion that one might be one you'd get along with better, that's one thing.

To go on a temper tantrum because you became personal friends with an applicant, they told you they ranked the program as #1, and then didn't match--that's different IMHO.

Well no, I don't think residents and the PD should hang out. They are not peers. However, when sizing someone up, I have to trust my instincts. I mean, what's the alternative? Have a computer spit out its analysis on the world's best resident, then I meet the person and they make me ill?

One of the reason I think I'll enjoy psych is because of its relationship with instincts in evaluating others. Sure they can be wrong, but I happen to trust MINE.

 

[whopper]

I too would favor some candidates based on personal characteristics, though hopefully not crossing boundaries.

A guy coming into an interview, smelling bad and it's obvious it's because he hasn't bathed, is wearing hand me downs, now that's a type of thing that's going to make me think twice about letting the guy in.

The admission process as a whole is largely full of flaws, lack of valid and reliable information, and for residency, once you have the resident, you're often times stuck with them for years makes the process, IMHO, not a good one.

IMHO, programs should be more liquid in their ability to hire and fire residents. A resident being fired is to the degree where it's almost something of a blackmark because everything is so "you're either in for the entire duration or nothing" paradigm. I've seen several good residents being permanently blackmarked due to an overzealous PD, on the other hand bad residents not getting the boot they deserve because the program feared a lawsuit and all the commotion with firing a resident.

 

[sikegeek]

I hate that I joined the APA and now my mail box is stuffed with journals I don't have the energy to read and notices that my "subscription is about to expire" (which I wish it would.)

 

[digitlnoize]

I too would favor some candidates based on personal characteristics, though hopefully not crossing boundaries.

A guy coming into an interview, smelling bad and it's obvious it's because he hasn't bathed, is wearing hand me downs, now that's a type of thing that's going to make me think twice about letting the guy in.

The admission process as a whole is largely full of flaws, lack of valid and reliable information, and for residency, once you have the resident, you're often times stuck with them for years makes the process, IMHO, not a good one.

IMHO, programs should be more liquid in their ability to hire and fire residents. A resident being fired is to the degree where it's almost something of a blackmark because everything is so "you're either in for the entire duration or nothing" paradigm. I've seen several good residents being permanently blackmarked due to an overzealous PD, on the other hand bad residents not getting the boot they deserve because the program feared a lawsuit and all the commotion with firing a resident.

What's wrong with hand-me-downs? Not everyone can afford to run out and buy a fancy new suit...As long as it looked presentable, I think I'd be ok with it. A lot of docs I've worked with prefer to "dress down" (buisiness casual usually) when seeing patients...they feel it puts the patient more at ease than a stuff doc in a shirt, tie, and white coat.

Where are these overzealous PD's? I'd like to avoid them like the plague.

 

[whopper]

Where are these overzealous PD's? I'd like to avoid them like the plague.

You're only going to find these out by word-of-mouth or places like this forum. There's no guide to programs that'll point you out to the bad things about programs and during interviews, most programs will try to sell themselves to you, so don't expect it to be exactly blunt and honest.

As for the clothes, we'll have to agree to disagree. I will say that the post I gave was in specific reference to a memory I had where I was doing an interview, and the candidate sitting next to me was wearing sneakers, taped up glasses, hand me downs (I'm talking a jacket and pants that must've been from the 70s), and a terrible body odor. I was actually somewhat worried because I didn't know if his stink would've stuck to me.

 

[digitlnoize]

You're only going to find these out by word-of-mouth or places like this forum. There's no guide to programs that'll point you out to the bad things about programs and during interviews, most programs will try to sell themselves to you, so don't expect it to be exactly blunt and honest.

So, who wants to spill their guts about the bad programs? Don't make me come over there...

As for the clothes, we'll have to agree to disagree. I will say that the post I gave was in specific reference to a memory I had where I was doing an interview, and the candidate sitting next to me was wearing sneakers, taped up glasses, hand me downs (I'm talking a jacket and pants that must've been from the 70s), and a terrible body odor. I was actually somewhat worried because I didn't know if his stink would've stuck to me.

Ok, that's pretty bad. I will have to agree with you on that one...no getting around the BO factor. As someone who has had glasses break, I could overlook taped glasses, if they looked nice otherwise and had a good story (perhaps they broke the night before the interview). I could overlook a relatively stylish suit that is getting a little bit frayed. All those things combined...wow.

 

[notdeadyet]

I do know for a fact that at Jefferson medical school, they employed an expert of sorts who actually studied the admission process. I've seen him give lectures on the science of the admission process and how best to incorporate psychology into making the educational curriculum better. So I wouldn't be surprised if Jefferson was actually using this data, but that's the only place I've seen that's done this as far as medical residencies go. Several corporations have people take psychological tests to try to put employees that match better together.

Jefferson's far from alone in this. The U.C.'s (California flavor) have started using research and science to adjust their admissions process.

Unfortunately, the science is supporting what some are calling the "speed dating" approach. Rather than an applicant spend one hour interviewing with a faculty member, they spend 10 minutes with 6 faculty member, each of whom has a short set list of questions to drill down on a particular topic area (professionalism, humanism, intellectual curiosity, collaboration, etc.).

There's a lot of research on the effectiveness of this method and although it's in infancy stages, more med schools are moving this direction. There's a lot of data from business and industry supporting it (honest, sat through a mind-numbing presentation backing it).

My resistance to it was partly just gut (bad science, I know), and partly out of concern that the reason this method is effective is that physicians make particularly bad interviewers (anyone who interviewed widely can attest to this). It's a great workaround to poor interviewers, but it seems like throwing the baby out with the bathwater. I also worry that it leaves such a bad taste in interviewees mouths that they will be less likely to choose this particular program.

It'll be interesting to see. The problem I have with this approach is that the whole is usually much larger than the sum of parts.

 

[Famo]

I LIKE STUPID Crap meow meow meow meow Wait can u get banned in this game??

 

[Famo]

innapropriate picture madam

 

[notdeadyet]

You're only going to find these out by word-of-mouth or places like this forum.

Word-of-mouth >>> this forum. You always hear folks talk about how there are many malignant programs and when folks ask for names... tumbleweeds.

Very rarely does someone say anything remotely negative about a residency program, and when they do, it's almost always attacked by supporters. Even when two or three people chime in with negative impressions, its still met with what heavy resistance that usually resorts to name calling.

I'm not sure what it is, but folks are extremely sensitive about their residency programs to the point that any criticism of it seems to be taken very personally. I understand that you pay a lot of money to get into that residency and its reputation will follow you around the rest of your life, but I've heard a lot more honest criticism of programs in law and business than I've heard in medicine on SDN. I think it's the nature of the Conservative Profession ideal.

 

[digitlnoize]

Word-of-mouth >>> this forum. You always hear folks talk about how there are many malignant programs and when folks ask for names... tumbleweeds.

My problem is that I'm pretty poorly connected, so I don't have any great sources for this "word-of-mouth" you speak of. I go to DO school, so they're not much help there...no doctors in the family, I only know the couple of psychiatrists I've rotated with who are writing me letters...and you guys, of course. I've asked around with some upper classmates, but they tend to talk more about the programs they liked...

Any tips for finding these mouths?

 

[whopper]

Jefferson's far from alone in this. The U.C.'s (California flavor) have started using research and science to adjust their admissions process.

Glad to hear it. When you study the landmark cases in a forensic psychiatry curriculum, it's case after case after case of a doctor often screwing up to the degree where it went to Court, it was reviewed and the Court declared the practice could no longer be done.

It's not the same thing, but I think there's the same parallel...doctors doing something, thinking that simply because they are doctors, they are correct, even though they had no real expertise in the matter.

I figure, since there's so much data on the admissions process, why not actually use it? Why not hire an industrial psychologist as a consultant during at least one admissions process, learn from his/her advice, then start utilizing it in future MATCH processes?

You always hear folks talk about how there are many malignant programs and when folks ask for names... tumbleweeds.

Agree with everything you wrote. I know of a few programs I'd call malignant, but I don't write about them because it's all based on word-of-mouth. Now I trust those people because those are people I trust, but it could be considered libel, not to mention really blacklist some for being open and honest.

 

[Majesty]

Word-of-mouth >>> this forum. You always hear folks talk about how there are many malignant programs and when folks ask for names... tumbleweeds.

Very rarely does someone say anything remotely negative about a residency program, and when they do, it's almost always attacked by supporters. Even when two or three people chime in with negative impressions, its still met with what heavy resistance that usually resorts to name calling.

I'm not sure what it is, but folks are extremely sensitive about their residency programs to the point that any criticism of it seems to be taken very personally. I understand that you pay a lot of money to get into that residency and its reputation will follow you around the rest of your life, but I've heard a lot more honest criticism of programs in law and business than I've heard in medicine on SDN. I think it's the nature of the Conservative Profession ideal.

I also think that even in the most malignant programs, most turn out pretty good psychiatrists. Bottom tier malgnant programs aren't really discussed. So when people discuss these programs, alumni see it as an attack on themselves and their ability as opposed to an opportunity to advance the program. I know I did for a while.

 

[whopper]

Agree. I do think my own residency program was good, but I do think there were problems. Every program has problems. In hindsight I think I was a bit reluctant to mention some of the problems because my perspective is different now than it was then. As an attending, I feel less beholden to the program, and working with other residency programs, I got a better idea of how they handle some things vs the way my own program did.

 

[Manicsleep]

Your chance to say something is usually just after you leave. However, most residents are so happy to be done, they don't care. By the time they do care, things have changed, new administration, new rules etc etc so that your critical input may not have that much relevance. Kind of how it went with me. By the time I finshed fellowship, moved, got settled in, changed jobs and then got settled in again, the residency was a whole new world.

My program also doesn't do a lot to keep in touch such as asking for money and as I am not really nearby, it is a case of out of sight, out of mind.[FONT=OceanSansMM_512_800_][FONT=OceanSansMM_512_800_]
..

 

[Doctor Bagel]

Agree. I do think my own residency program was good, but I do think there were problems. Every program has problems. In hindsight I think I was a bit reluctant to mention some of the problems because my perspective is different now than it was then. As an attending, I feel less beholden to the program, and working with other residency programs, I got a better idea of how they handle some things vs the way my own program did.

The thing I've realized is that people honestly don't want to hear about what you perceive as problems in the program. And there really is no gain being a resident who notes problems. Instead, you should be one of those checked out people who assume that the things that suck in your program aren't going to be changed anyway. In my program, those guys appear to be the happiest (and of course most liked) by the admin types. This is my goal for next year. 🙂

I just got back from APA where I attended one emergency psych workshop (tried to avoid the topic due to my hatred of the area) and realized that maybe my perspective on it and how much it sucks is based on being a resident at a program with a dedicated emergency psych unit or attendings. Instead, we have the people with the least experience (interns + attendings (usually outpt) doing their 2 weeks of yearly call) making all the inpatient psychiatry decisions. So of course we're not skilled enough to not admit everyone who walks in the door. Maybe if we had actually emergency psych attendings to learn from, it'd be a better experience. Still not my career goal, so it likely wouldn't affect my career decision, but for people interested in it, it probably would be useful to actually go to a program with a psych ED.

 

[Doctor Bagel]

What's wrong with hand-me-downs? Not everyone can afford to run out and buy a fancy new suit...As long as it looked presentable, I think I'd be ok with it. A lot of docs I've worked with prefer to "dress down" (buisiness casual usually) when seeing patients...they feel it puts the patient more at ease than a stuff doc in a shirt, tie, and white coat.

Where are these overzealous PD's? I'd like to avoid them like the plague.

So theoretically you can ask questions like how many residents have you lost to get a feel for this type of stuff. If you ask enough people, you'll probably pick up on an honest answer. Now, how to interpret it is different. My program has lost 2 people in the last 3 or so years (one I think officially transferred but wasn't academically progressing and the other isn't having his contract renewed). People in my program honestly don't know what to think about this (I don't know what to think about this), and I'm still trying to process whether it actually says bad stuff about the program or mainly bad stuff about our selection process. And even there, though, the residents who haven't had these issues are all quite good and really neat people.

We're definitely a program that is more intense early on with less supervision and support. It's a very good training environment for some and not for others. We're not a place that really has the resources or time to handle struggling residents without really burdening everyone else. So maybe if residents are lost, it at least indicates that you're looking at that type of program.

Had I known about this losing residents stuff, I guess I might maybe have rethought my rank list. Maybe it's denial, though, but I don't feel like people are being unfairly targeted for being held back or for getting dismissed. But that whole process is a total black box, so we don't know, and we wind up in this weird rumors situation. I can say it's pretty psychologically distressing as a resident to see your colleagues not come back. But I still don't know how I would have interpreted this information if I were an applicant. Of course, if two programs were totally equal, the one that had lost people should be knocked down. And if I felt like I was a resident who was going to struggle, I probably would have been less likely to choose my current program.

As for feeling out malignancy in general, scutwork used to be good, but it's really not utilized. I can say the scathing reviews I've seen for programs I am familiar with (not psych) have been not entirely inaccurate. SDN's not so good for lots of reasons. And I don't know accurate these feelings were, but I think you can pick up on some stuff when you're interviewing if you pay attention. But then, I don't really think I adequately identified any of the flaws in my program while interviewing, so maybe my perceptions of other programs were way off too. Heck, I even missed the whole fact that we're a call heavy program, and that one's pretty obvious. BTW, not saying my program is malignant or a bad program, but like all programs, it has flaws, and I honestly didn't figure those out until I was here.

 

[OldPsychDoc]

The thing I've realized is that people honestly don't want to hear about what you perceive as problems in the program. And there really is no gain being a resident who notes problems. Instead, you should be one of those checked out people who assume that the things that suck in your program aren't going to be changed anyway. In my program, those guys appear to be the happiest (and of course most liked) by the admin types. This is my goal for next year. 🙂 .

Be the Yoked Monkey. 😉

 

[whopper]

I've noticed that several characteristics that made some people good interviewees made them worse residents. E.g. a person with histrionic traits, if not too extreme, and you only see the person for about 10-15 minutes often turns out to be a good interview, especially when the attending is an older male, and the applicant is a younger female. Think about it, and let's be honest. Older males are going to be more suspeptible to younger women, especially women that are a bit flirtatious.

Where I did residency, we've had a few histrionic residents, and I figured that's how they slipped in.

You only start noticing the histrionic person is possibly going to be a terrible resident as a result of the disorder after several hours, possibly weeks of seeing the person work.

I also noticed a particular resident that was a very good speaker, but the guy had paranoid personality disorder...not kidding. He actually drove 12 hours a week to drive to an address in a different state, even while doing the grueling schedule of a PGY-1, to pick up his mail because he didn't want the government to know where he was truly living. The guy's good speaking skills actually made him a big annoyance for me as a chief resident because he complained all the time about things that I could tell was a product of his paranoia, none of which was detectable during his interviews.

Unless you see something extreme, an interview, as far as I'm concerned, only tells me of the person's speaking skills, and I have noticed some psychiatrists that were excellent that weren't great at speaking but were excellent listeners..

 

[digitlnoize]

Older males are going to be more suspeptible to younger women, especially women that are a bit flirtatious.

So, you're saying I should do my interview in drag?

 

[toothless rufus]

So, you're saying I should do my interview in drag?

I don't recommend it. I think that's the mistake I made.

 

[peppy]

I just got back from APA where I attended one emergency psych workshop (tried to avoid the topic due to my hatred of the area) and realized that maybe my perspective on it and how much it sucks is based on being a resident at a program with a dedicated emergency psych unit or attendings. Instead, we have the people with the least experience (interns + attendings (usually outpt) doing their 2 weeks of yearly call) making all the inpatient psychiatry decisions. So of course we're not skilled enough to not admit everyone who walks in the door. Maybe if we had actually emergency psych attendings to learn from, it'd be a better experience. Still not my career goal, so it likely wouldn't affect my career decision, but for people interested in it, it probably would be useful to actually go to a program with a psych ED.

I think that's a good observation. An emergency psych assessment where you admit everyone who says they want to commit suicide is as sloppy as a general Emergency medicine doc who just blindly admits everyone who complains of chest pain. A decent psychiatrist ought to be able to stratify risk and have enough confidence in their assessment to call the bluff of a malingerer.

 

[Manicsleep]

I think that's a good observation. An emergency psych assessment where you admit everyone who says they want to commit suicide is as sloppy as a general Emergency medicine doc who just blindly admits everyone who complains of chest pain. A decent psychiatrist ought to be able to stratify risk and have enough confidence in their assessment to call the bluff of a malingerer.

Why interns should not work in the psych ER on their own. How have the new work hours impacted this?

 

[Doctor Bagel]

Why interns should not work in the psych ER on their own. How have the new work hours impacted this?

At my program, we'll still have interns on call alone (well, with an attending supervising by phone) for short calls and for weekend 12 hour shifts. For some reason, the RRC (I'm still not sure who these people are) have said it's OK for interns to have indirect supervision after being deemed sufficiently qualified. I've got to admit I'm glad they made this exception, because it's letting us have a workable call system next year.

 

[whopper]

I was not a fan of emergency psychiatry. You don't have enough time to really get to know a patient, unless you've worked in that setting for several months. Then you start seeing the repeat patients over and over again. Until then you're, IMHO, held hostage in the sense that you have to make decisions with too little time and information. Where I did residency we had plenty of malingerers go through the ER but most of the attendings didn't know how to deal with them. Many patients malingering suicide get into inpatient because the emergency psychiatrist does not have enough time or knowledge to kick someone out, the patient gets into a unit, then by the time the inpatient doctor figured out they're malingering, the institution wants the person to not be diagnosed with such because they then will have a problem billing for it. Then the patient gets some BS dx of depressive DO NOS, which in effect amounts to a free ticket to get in next time because now a doctor will be less likely to kick someone out with a prior history of a documented psychiatric disorder.

Or you get someone who, for whatever reason, is a behavioral problem but does not have a psychiatric disorder that warrants medication. E.g. a kid who bullies his classmates, an MR person who started to cry due to completely understandable reasons, etc, and someone in a position of responsibility over them has them sent to the hospital. Then the idiot ER doctor puts them on Zyprexa or something to that effect because they just want to process the patient and get them out of there.

I diagnosed a guy on my forensic unit starting last week with no Axis I dx whatsoever except for cannabis abuse and nicotine dependence. The guy went through over 12 doctors, each one diagnosing him with schizophrenia or schizoaffective disorder. I went through 7 of his hospital charts from previous hospitalizations, going through every single page, and none of them ever reported any signs or sx that met enough DSM criteria for either disorder. The guy has a history of bullying people. Every time he caused a problem, he was brought to the hospital, medicated, and discharged.

I took him off of meds after he went through 2 prior doctors during his current hospitalization, each one diagnosing him with schizoaffective disorder. He's been off of meds for 3 weeks and there are no signs or sx of psychosis or mania, but he's still bullying other patients for their food. The guy's on a one-to-one to prevent this. He does, however, meet every single criteria of antisocial PD.

The only possible mental illness he could possibly have that justifies his stay in a forensic unit is bipolar disorder and he's possibly in-between manic episodes. I highly doubt that.

I went through 7 charts, going through each one hoping to find anything---anything justifying that there was at least 1 doctor doing the right thing and not just diagnosing and treating in a seemingly perfunctory manner. Well there was 1 doctor that did write down that he did not see any signs or symptoms but only kept up with the diagnosis and treatment because several prior doctors diagnosed the guy with a mental illness. At least that I can understand and this guy demonstrated some intellectual honesty in his charting.

All the other doctors wrote notes to the effect of "patient is delusional, he bullies others for food," but there is no description of how he is delusional. E.g. when I write someone is delusional, I'll write "patient is delusional evidenced by his belief that aliens stole his ears and that he can get them back by eating cardboard."

The guy has a long history of committing crimes, then going to the hospital, then being discharged with the charges dropped because he's "mentally ill." Now my treatment team and I have to go through the tedious process of telling a judge that almost every single doctor botched their job and this guy really is a criminal.

A reason why I'm ranting here is because I don't want any of you medstudents or residents to be that type of psychiatrist that diagnoses and medicates just to get out of the door faster. This type of practice leads to serious problems. I realize that in an ER setting you often do not have enough time or data to make a very good medical decision and that such decisions are only the best you could do under those circumstances. In that case, document your limitations (E.g. "I did not witness the patient acting psychotic myself, but at the time I attempted to interview him, he was sedated due to emergency Haldol administration. I can only go on what the ER doctor reported to me and what is in his records to justify his diagnosis at this time.")

 

[MDchouette]

T

I just got back from APA where I attended one emergency psych workshop (tried to avoid the topic due to my hatred of the area) and realized that maybe my perspective on it and how much it sucks is based on being a resident at a program with a dedicated emergency psych unit or attendings. Instead, we have the people with the least experience (interns + attendings (usually outpt) doing their 2 weeks of yearly call) making all the inpatient psychiatry decisions. So of course we're not skilled enough to not admit everyone who walks in the door. Maybe if we had actually emergency psych attendings to learn from, it'd be a better experience. Still not my career goal, so it likely wouldn't affect my career decision, but for people interested in it, it probably would be useful to actually go to a program with a psych ED.

We have a dedicated psych ED staffed by attendings from the C-L service, who know the frequent fliers and aren't afraid to discharge them and to document when no psychiatric disorder is present. I'm not saying that there are no inappropriate admissions, but there is an active effort to minimize them. Our experience in the psych ED is grueling; PGY2 residents take night float there and rarely get much sleep. Although some residents hate the ED, I think few would disagree that it's an incredible learning opportunity, due to both the large volume of patients we see and to being supported by experienced attendings.

And, FWIW, the psych ED has been the source of my funniest patient quotes...

 

[Doctor Bagel]

Be the Yoked Monkey. 😉

That's the goal. 👍 I need to start embracing this now, which means I shouldn't care that we've heard absolutely nothing about who our program director is going to be starting in July!!. Seriously, people. Wait, yoked monkey doesn't care. 🙄

Now seriously again, has anybody ever heard of a program not having selected (or at least, you know, letting the residents know their selection) for PD when you're currently PD is leaving in less than 2 months. So other thing I hate, the whole we're psychiatrists and laid back, so we don't have to care about administrative details. Totally evident in my program and seems pretty evident when you talk to psych residents elsewhere. I didn't love internal medicine and am certainly glad I'm not an IM resident, but I loved the level of organization in the IM program here.

 

[skayr]

This slight was written a couple of days ago and the thread has obviously moved on from the topic of the potential harm of unnecessary psychiatric hospitalization, but this attitude is a pet peeve of mine and I can't let it go unchallenged.

Being pre-med does not preclude a person from having life experience relevant to a discussion of what constitutes appropriate mental health care. I was speaking as a daughter and sister of people suffering from severe mental illness, who has spent more time in inpatient and outpatient treatment environments than many resident psychiatrists and has seen the best and the worst of what involuntary hospitalization can do for (or to) a person. I speak also as a former case manager for adults with mental illness, and as someone who largely grew up in her parents' assisted living facility for adults with mental illness. But no, I'm not a doctor yet, so I guess I have zero credibility.

Bravo! well-said. I think the real life experiences that you describe will make you a better doctor - because you will have a deeper understanding of and more compassion for your patients.

 

[DOC PENGUIN]

3rd year medical school is actually shockingly "real world" in terms of how you get a good clinical grade. In order to be a successful doctor, the key ingredient is the ability and availability and the astuteness in carrying out certain repetitive tasks in a team context.

Everyone can deconstruct the system every which way, but there is actually no clear superior alternative.



Going back to the topic of involuntary admission -- you CAN be sued for incorrectly involuntarily admit someone for illegal imprisonment. This is very rare though. Also, while you can complain on and on about how emergency psychiatrists are covering their liability in terms of being conservative in admitting patients, it's VERY hard to predict who will attempt suicide in the immediate future. And while it's possible that iatrogenic damage can be done in a hospital, just like in any other specialty, there is a STANDARD of CARE for certain presentations (i.e. suicide attempt). Think of it this way, if you had a heart attack, generally you need to be hospitalized. On rare occasions you might get away with not having to hospitalize someone, and in some cases being in a hospital get you infected with a deadly bug -- one which might even kill you. However, this does NOT mean that in general someone who had a heart attack he should not be hospitalized. That is not logical and is poor practice.

On the other hand, I agree with you that the amount of time that people spend in the hospital should be minimized. And it has been and it is getting shorter and shorter in the current insurance climate. in fact, in my experience the problem has now become the reverse: often patients don't get enough hospitalization days because insurance stops to pay for them and it has been observed in several studies that such circumstances result in adverse outcomes.



Echoing some of Whooper's sentiments, I think anecdotally the variability of ability within psychiatry might be larger than, say, cardiology--though I can't back this up with data. This is related to the lack of competitiveness in terms of residency match.

The two other things I dislike about psychiatry is first the science is on shaky ground, but that's in the process of being addressed. The second is the tediousness involved in dealing with non-medical/social work related issues that is universal in all of medicine, but is especially heavy in psych. This problem though can be leveraged in some ways, because in many cases the interdisciplinary nature of psychiatry also represents an opportunity to effect macroscopic changes on a social level that transcends the normal boundaries of medical practice. So if that kind of thing is your thing, then psychiatry is unique in its ability to give you these venues for exploration.

I hate the attendings that give crap to consults, interns and residents just because of their specialty regardless of it. I hate that they discredit their medical knowledge and think they were the bottom rung of school. What i hate about psychiatry is the fight of the pharmacologists and the therapists. I also hate that most don't do a lot of psychotherapy, but there are always those who do. I do think the best way to be a psychiatrist is sign up for a dual psych/im program or do Neuro-psych. ya gotta keep up with those skills.
Psychiatry is usually hated by most because of the shaky science. A Psychiatrist is supposed to learn mental health on a medical and biological level. And i don't think DSM-5 is going to do that. I do think that we have to put more focus on biology and start researching ways to make more illness clean cut (psychosis and manic depression are examples of clean cut ton me, ADHD and Autism still need more research IMO.)
Perhaps i am just bitching as most of you probably think i am a troll or just hate me.