What is a skill residency didn't prepare you well on for your career and one that did?

[Beedoc]

When trying to rank my programs, I realized each program was unique, either with more psychotherapy or neuro based, different variety of populations, different experts, ect.

So what skillset from residency did you wish you learned from residency, and what skillset did the residency program teach you that was valuable to your practice/job/outside of work?

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[psych_0]

You will have a tough time gathering this from your interview day, but the most valuable thing I learned from various attendings was how to say no:

- No to the homeless malingerers who are "suicidal" or "don't know what I'll do to myself if I don't get admitted"
- No to the borderlines who feel "only Xanax works for me!"
- No to the antisocials who want to come to the hospital because "I woke up wanting to hurt someone"

List goes on and on, but having to say no is one of the hardest parts of psychiatry that textbooks won't teach you. It comes from experience and watching skillful attendings do it well was priceless for my current day-to-day life.

 

[J ROD]

Yeah, I have no problem saying no.....on the other hand, where I went to med school and residency, did not prepare well to work with dementia. We did not admit it and did limited geriatric training. Basically, now I see a majority of geriatric consults and help run a geriatric unit. Had to learn how to manage them over last year and half with on the job training geriatric fellowship basically with another MD that has done geriatrics. My residency best trained me to be efficient, yet fast, and able to handle most anything as we had a large breath of experiences and tons of hands on management alone with no in house attending. We saw plenty of child, ID, addiction. Just not geri.

 

[Celexa]

You will have a tough time gathering this from your interview day, but the most valuable thing I learned from various attendings was how to say no:

- No to the homeless malingerers who are "suicidal" or "don't know what I'll do to myself if I don't get admitted"
- No to the borderlines who feel "only Xanax works for me!"
- No to the antisocials who want to come to the hospital because "I woke up wanting to hurt someone"

List goes on and on, but having to say no is one of the hardest parts of psychiatry that textbooks won't teach you. It comes from experience and watching skillful attendings do it well was priceless for my current day-to-day life.

I came into the thread about to say boundaries, but this sums most of it up well.

I would add in addition to saying no to people who are difficult/rude/demanding, you also need to learn how to say no to the patients you like who will pull you towards bad treatment plans through various types of psychological distress. For example, the patient who always wants a med change, idealizes you as a psychiatrist, but won't go to therapy. You will need to learn how to stop making med changes and insist on the treatment that will actually help the patients long term. It's much harder than it sounds. I learned through observing many attendings and psychologist therapy supervisors (some for what to do, and some for what not to do) and synthesizing a style that works for me.

Setting boundaries might be the most important skill in all of psychiatry.

 

[Celexa]

Forgot to include what residency didn't teach me. In direct contrast to the poster above, I got plenty of geri experience but bare minimum of child. It's mostly OK given my interests but sometimes I feel the lack.

 

[clausewitz2]

I would add in addition to saying no to people who are difficult/rude/demanding, you also need to learn how to say no to the patients you like who will pull you towards bad treatment plans through various types of psychological distress. For example, the patient who always wants a med change, idealizes you as a psychiatrist, but won't go to therapy. You will need to learn how to stop making med changes and insist on the treatment that will actually help the patients long term. It's much harder than it sounds. I learned through observing many attendings and psychologist therapy supervisors (some for what to do, and some for what not to do) and synthesizing a style that works for me.

Setting boundaries might be the most important skill in all of psychiatry.

Very much this. It is the patient you identify with, have a good rapport with, find it easy to interact with, and in other circumstances might be friends with who are the real challenge. If you're not equally suspicious of positive counter-transference you wake up one day and wonder how the hell you ever got to the point of having them on some ridiculous melange of various drugs that only ever seems to work for a month or two at a time.

 

[MacDonaldTriad]

This is probably the best question I ask in my annual graduate survey. "What didn't you learn that you should have". The most frequent answers are hard to address. Billing, negotiating office land lords, office parking, negotiating job offers, admittedly, stuff we are not good at. When you think about the prime goal of creating talented psychiatric clinicians, I don't apologize for missing a few of these. Of all the stuff we need to cram into your heads to make you effectual at your job, we do OK. Once you fly the nest, the demands become much more varied and less generalizable to any given individual's training needs. Adult problems suck and will always exist. Things do get better, but that doesn't mean easy.

 

[troutscout]

I was really grateful my residency program granted us the flexibility to use our entire fourth year as elective time - I was able to do an away rotation in integrative psychiatry and also complete additional certifications in sports psychiatry and integrative psychiatry. I wish I would have had some glimpse into what private practice psychiatry could look like - residency prepared me well for employed positions but there were no examples of outside-of-the-box practices. I also wish I had more perspectives specifically on negotiating, what locums is really like, and working efficiently in the real world.

 

[FlowRate]

Great thread topic!

how to say no

Probably the biggest downside to one of the hospitals in which we did a bunch of CL and ED work. That department only said "no" to the most egregious cases. They basically required 5 years of documented extreme malingering with provable aggressive/manipulative behavior in order to DC an instrumental homeless SI. They also pretty much never said "no" to any primary team ask. Thankfully the other hospital CL team was more reasonable on those topics.

geriatric training

Huge one for me. We were very well resourced between geri and neuropsych fellowship programs and specialists such that we did very little outpatient geri treatment. My new setting is the opposite and general outpatient psych is the first stop (aside from primary care) for dementia. The geri training I did get was primarily inpatient management of behavioral/psychiatric sx and in systems with much more SW support for some of the most important geri work (family/home assessment, preparing for nursing home / behavioral unit placement.)

stuff we are not good at

Our residency program addressed this by having resident alumni who stayed in the area in private practice (and also insurance company employed) roles come in to talk to us about these things during 4th year didactics. I think it was helpful. Even though the majority of residents do fellowship and/or stay academic, the majority of residents also really wanted that education, recognizing that it's good to be prepared to navigate other career options.

 

[jbomba]

I was really grateful my residency program granted us the flexibility to use our entire fourth year as elective time - I was able to do an away rotation in integrative psychiatry and also complete additional certifications in sports psychiatry and integrative psychiatry. I wish I would have had some glimpse into what private practice psychiatry could look like - residency prepared me well for employed positions but there were no examples of outside-of-the-box practices. I also wish I had more perspectives specifically on negotiating, what locums is really like, and working efficiently in the real world.

Where did you do the integrative psychiatry month?

 

[hebel]

I wish I had more training related to ADHD and Autism presentations in "undiagnosed" adults. I had plenty of experience with these disorders in CAP settings, but rarely went over these in the context of evaluating for a potential new diagnosis in adults.

 

[Ludwig2000]

I was really grateful my residency program granted us the flexibility to use our entire fourth year as elective time - I was able to do an away rotation in integrative psychiatry and also complete additional certifications in sports psychiatry and integrative psychiatry. I wish I would have had some glimpse into what private practice psychiatry could look like - residency prepared me well for employed positions but there were no examples of outside-of-the-box practices. I also wish I had more perspectives specifically on negotiating, what locums is really like, and working efficiently in the real world.

What is locums really like?

 

[MacDonaldTriad]

New onset adult ADHD strikes me as a rationalization for our field to make money as the pusher man (look up Blood Sweat and Tears if you are under 55, and here is a shoutout for Meat Loaf who passed away today, he would do anything for love).

I have little confidence that any well designed curriculum in managing this will allow us to not feel like we shouldn't get into the shower when we get home. I guess it is clear that my curriculum will continue to lack this subject. I have no guilt about this and think it is a virtue. I defy any peer reviewed academic to try and make this subject an RRC training requirement.

We need to distance ourselves from this. Of course the operative words are "new onset adult". If someone has ADHD as a child doesn't mean that it evaporates at age 18 but give me a break with the number of college students who never realized they had a stimulant deficiency.

 

[Candidate2017]

I wish I had more training related to ADHD and Autism presentations in "undiagnosed" adults. I had plenty of experience with these disorders in CAP settings, but rarely went over these in the context of evaluating for a potential new diagnosis in adults.

Your local NPs are likely experts on undiagnosed adult ADHD.

 

[FlowRate]

New onset adult ADHD strikes me as a rationalization for our field to make money as the pusher man (look up Blood Sweat and Tears if you are under 55, and here is a shoutout for Meat Loaf who passed away today, he would do anything for love).

I have little confidence that any well designed curriculum in managing this will allow us to not feel like we shouldn't get into the shower when we get home. I guess it is clear that my curriculum will continue to lack this subject. I have no guilt about this and think it is a virtue. I defy any peer reviewed academic to try and make this subject an RRC training requirement.

We need to distance ourselves from this. Of course the operative words are "new onset adult". If someone has ADHD as a child doesn't mean that it evaporates at age 18 but give me a break with the number of college students who never realized they had a stimulant deficiency.

I think most of us see "new onset" as one of the data points we look for so that we can rule out ADHD. "Yeah I was totally normal for 30 years and I just now started having problems." Has me thinking "Great, let's talk about all of the things this could be except for ADHD."

The difficulty of "adult ADHD" is that retrospective recall is extremely inaccurate, availability of records/collateral is poor, and social media algorithms are convincing everyone that everything is ADHD. It's a rare patient who's thinks that they have ADHD and who doesn't report that it's always been a problem.

Also, the "I was just so smart that I was able to compensate for my inattention and earned a 4.0 through HS, college, law/med school, and only as I entered residency/practice was it a problem" conundrum. Or the "I was doing fine until everyone had to WFH and now I can't get anything done" issue.

I think those are the situations that give any honest doc a lot of pause and aren't so clear cut in one way or the other as "adult onset" or "records and collateral from childhood" or "obviously extremely hyperactive and inattentive during interview and about to get fired from their job for repeatedly filling orders incorrectly." That's where residents (and, frankly, lots of practicing docs) are hoping for guidance and a more compelling mix of conceptualization and evidence base.

(not to beat a dead horse...)

 

[Stagg737]

Still a PGY-4, so still in the grind, but I will say that attending a few webinars about contract negotiation for physicians and how to evaluate a job offer is something that wasn't really covered in my program. I've gotten a lot of that info from here, those webinars (Merritt Hawkins, HCA, etc), and one or two attendings that have worked in PP previously. If I hadn't actively sought this info out though I would probably be pretty clueless about what to look for in contracts.

Also, I think the skillset of setting boundaries and saying no can help with contract negotiation as well. So a pretty essential skill for our field and life in general.

 

[alina_s]

I wish we’d been given some pointers on how to learn about the legal aspects of psychiatry in a new state. We learned all about age of consent, privacy rules for teenagers, commitment laws, CPS regulations, parental rights when a kid is taken into foster care where I trained. When I went to a FQHC in a new state, I was completely in the dark and management was clueless.

 

[calvnandhobbs68]

I wish we’d been given some pointers on how to learn about the legal aspects of psychiatry in a new state. We learned all about age of consent, privacy rules for teenagers, commitment laws, CPS regulations, parental rights when a kid is taken into foster care where I trained. When I went to a FQHC in a new state, I was completely in the dark and management was clueless.

This is 100% true. Esp around hospitalization criteria which can vary wildly state to state. Also the teenager consent thing which is hugely different state to state (ex the state I’m in now 14yo+ can technically broadly give consent for any mental health treatment including meds, state I was in before could only be treated for 30 days and couldn’t consent to meds without parental consent).

 

[Merovinge]

I wish we’d been given some pointers on how to learn about the legal aspects of psychiatry in a new state. We learned all about age of consent, privacy rules for teenagers, commitment laws, CPS regulations, parental rights when a kid is taken into foster care where I trained. When I went to a FQHC in a new state, I was completely in the dark and management was clueless.

Did you learn anything about this process? Not sure I will ever practice in a different state, but if I did, it would be awfully anxiety provoking, particularly in CAP.

 

[FlowRate]

I wish we’d been given some pointers on how to learn about the legal aspects of psychiatry in a new state. We learned all about age of consent, privacy rules for teenagers, commitment laws, CPS regulations, parental rights when a kid is taken into foster care where I trained. When I went to a FQHC in a new state, I was completely in the dark and management was clueless.

In our "psychiatry and the law" 3rd or 4th year didactic, knowing that I almost definitely wasn't going to stay in state to practice, I asked "will we be going over a range of state laws for these issues or how to figure out local state laws more easily?" The faculty leading it responded "no, but you'll figure it out." Pretty big disappointment.

 

[Dr. ADT]

Still a PGY-4, so still in the grind, but I will say that attending a few webinars about contract negotiation for physicians and how to evaluate a job offer is something that wasn't really covered in my program. I've gotten a lot of that info from here, those webinars (Merritt Hawkins, HCA, etc), and one or two attendings that have worked in PP previously. If I hadn't actively sought this info out though I would probably be pretty clueless about what to look for in contracts.

Also, I think the skillset of setting boundaries and saying no can help with contract negotiation as well. So a pretty essential skill for our field and life in general.

I think contract negotiations should be discussed in PGY4 didactics. I did a lot of moonlighting in PGY4 and therefore was somehow prepared.

 

[alina_s]

Did you learn anything about this process? Not sure I will ever practice in a different state, but if I did, it would be awfully anxiety provoking, particularly in CAP.

In retrospect, I wish I’d known to ask the leadership in a job interview about age of consent, involuntary detention…and if they didn’t know or couldn’t tell me how to find out, politely decline. It’s my responsibility to learn all of this, but administrators should be able to provide some guidelines for the organization and I was completely on my own in that first job. Moving to a 3rd state, I was in a larger organization and had other psychiatrists and administrators I could ask. Some of it can make a big difference in how you practice- WA has unique laws around involuntary treatment- and could impact whether you want to work there.
I don’t even remember getting psychiatry and the law lectures in didactics, but a list of areas where state laws vary would’ve been helpful.

 

[elbandito1]

Testifying in court. Due to variations in state rules, sometimes residents are allowed to testify / not. Reflecting back, I think “mock court hearings” during residency could have assisted somewhat. Others have made good points above

 

[Merovinge]

Testifying in court. Due to variations in state rules, sometimes residents are allowed to testify / not. Reflecting back, I think “mock court hearings” during residency could have assisted somewhat. Others have made good points above

We didn't need mock court hearing since we all went to real court hearings held for our inpatient unit and watched our attendings. Residency programs that take involuntary patients should be required as part of training (if it was up to me). It actually boggles my mind people could be a board certified psychiatrist and work at places that have only taken voluntary patients.

 

[Desired Member]

Great thread topic!

Probably the biggest downside to one of the hospitals in which we did a bunch of CL and ED work. That department only said "no" to the most egregious cases. They basically required 5 years of documented extreme malingering with provable aggressive/manipulative behavior in order to DC an instrumental homeless SI. They also pretty much never said "no" to any primary team ask. Thankfully the other hospital CL team was more reasonable on those topics.

Huge one for me. We were very well resourced between geri and neuropsych fellowship programs and specialists such that we did very little outpatient geri treatment. My new setting is the opposite and general outpatient psych is the first stop (aside from primary care) for dementia. The geri training I did get was primarily inpatient management of behavioral/psychiatric sx and in systems with much more SW support for some of the most important geri work (family/home assessment, preparing for nursing home / behavioral unit placement.)

Our residency program addressed this by having resident alumni who stayed in the area in private practice (and also insurance company employed) roles come in to talk to us about these things during 4th year didactics. I think it was helpful. Even though the majority of residents do fellowship and/or stay academic, the majority of residents also really wanted that education, recognizing that it's good to be prepared to navigate other career options.

General outpatient psych is a first stop for dementia? Yikes. I would send them to neurology. I haven't ever prescribed donepezil, memantine, etc. I really don't have more than cursory knowledge of dementia. Maybe I'll learn more studying for boards...

 

[Desired Member]

We didn't need mock court hearing since we all went to real court hearings held for our inpatient unit and watched our attendings. Residency programs that take involuntary patients should be required as part of training (if it was up to me). It actually boggles my mind people could be a board certified psychiatrist and work at places that have only taken voluntary patients.

Not sure if I'm bragging or venting here, but in my first month of residency I had to go to court on a patient. I had never gone to court. I had never seen anyone go to court. My attending that had seen the patient was out of town and the covering attending refused to testify as he knew the patient.

 

[Merovinge]

Not sure if I'm bragging or venting here, but in my first month of residency I had to go to court on a patient. I had never gone to court. I had never seen anyone go to court. My attending that had seen the patient was out of town and the covering attending refused to testify as he knew the patient.

Definitely venting, that's a program fail, but at least you got to see it. Court is somehow always scary but hopefully you saw that it doesn't have to be. It's one of the few times we get to let someone else be responsible, it can be a bit much to always have the buck stop with you.

 

[raeka]

You will have a tough time gathering this from your interview day, but the most valuable thing I learned from various attendings was how to say no:

- No to the homeless malingerers who are "suicidal" or "don't know what I'll do to myself if I don't get admitted"
- No to the borderlines who feel "only Xanax works for me!"
- No to the antisocials who want to come to the hospital because "I woke up wanting to hurt someone"

List goes on and on, but having to say no is one of the hardest parts of psychiatry that textbooks won't teach you. It comes from experience and watching skillful attendings do it well was priceless for my current day-to-day life.

As a resident, points 1 and 3 are definitely huge deficits of mine, as I did the majority of my ED training at a VA where discharging patients from ED who wanted admission was not part of the culture, and I did most of my call solo so pretty much had to teach myself how to handle these situations. What advice would you give on the best approach to take with these patients?

 

[psych_0]

As a resident, points 1 and 3 are definitely huge deficits of mine, as I did the majority of my ED training at a VA where discharging patients from ED who wanted admission was not part of the culture, and I did most of my call solo so pretty much had to teach myself how to handle these situations. What advice would you give on the best approach to take with these patients?

1) Documentation is key. Document as much information as you can to support your opinion. Collateral is obviously important if they're not frequent flyers. As far as actually saying 'no,' that will just come with experience. I try and be direct with them instead of beating around the bush. "Hey Raeka, I know you're in a tough spot, so we'll get you some food and make sure you get into the shelter. I am not going to be admitting you to the inpatient unit because there is no reason at this time." If they start to get pissed off and threaten suicide, I usually encourage them to seek a second opinion at a different hospital then calmly walk away.

2) I ask them about why they want to hurt people (most common response is "I don't know"), who they want to hurt (common response "anyone who ****s with me"), and what would happen if they were to hurt someone (common response "Go to jail or some ****, I don't know man!"). Then I document that they can clearly tell the difference between right and wrong + that there is no treatable psychiatric condition that would prevent them from understanding the consequences of any potential actions. Also comment that they do not appear to be manic, psychotic or paranoid on exam. If they have a specific target, you do your duty to warn. We have local PD in our ER so they usually handle that for us. Usually they're purposefully vague:

- "I'm going to kill Jimmy!"
- Do you have any guns? "No."
- Do you know where Jimmy lives? "No, but if I see him imma kill him!"

"Ok, bye." Calmly walk away.