What is your PGY3 like?

[letsdothis2020]

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Hello,

I'm curious to know what your PGY3 looks(ed) like? I'm trying to get a sense of how busy other third year adult residents are during residency. What is considered an average caseload? How many intakes per week is considered reasonable? Do you have adequate support from social workers/case managers? how many hours of supervision do you have per week?

 

[Evidence Based]

Our PGY-3 looks something like this:
Starting patient load
-30 pharm transfers from prior residents
-2-3 new combined pharm/therapy patients + 2-3 carryover therapy cases from PGY-2 year
-2 child therapy cases
1-2 intakes per week, done w/ attending faculty
Panel by the end of the year is probably in the neighborhood of 75-90
Tons of supervision: 3 hours general/pharm supervision, 1 hour adult psychodynamic supervision, 1 hour child supervision, 1 hour group CBT supervision, 1 hour group dynamic supervision. I'm doing a little extra CBT supervision as well
In theory many of our patients are held on teams with collaborating social workers or psychologists, and in addition to this we've hired several case workers for both our general and specialty (ex. first episode, chronic psychosis) teams
In addition to the above we have some half days of the week in integrated care, homeless health, bridge clinic, etc.

 

[Old&InTheWay]

Our PGY-3 looks something like this:
Starting patient load
-30 pharm transfers from prior residents
-2-3 new combined pharm/therapy patients + 2-3 carryover therapy cases from PGY-2 year
-2 child therapy cases
1-2 intakes per week, done w/ attending faculty
Panel by the end of the year is probably in the neighborhood of 75-90
Tons of supervision: 3 hours general/pharm supervision, 1 hour adult psychodynamic supervision, 1 hour child supervision, 1 hour group CBT supervision, 1 hour group dynamic supervision. I'm doing a little extra CBT supervision as well
In theory many of our patients are held on teams with collaborating social workers or psychologists, and in addition to this we've hired several case workers for both our general and specialty (ex. first episode, chronic psychosis) teams
In addition to the above we have some half days of the week in integrated care, homeless health, bridge clinic, etc.

If you are ending the year with 75-90 patients and PGY3's get handed down 30 what happens to the rest? I assume those who don't fast track into child keep them for 4th year, but then what?

 

[rjs2131]

My PGY-3 was a bit of a cluster to start but essentially boiled down to each clinic trying to transfer/fill our schedules within the first 1-2 months. I'd typically have 30 min - 1 hour of supervision for each half-day of clinic (so a typical clinic day would be patients from 8-11 and then supervision/admin from 11-12, lunch/lecture 12-1, patients from 1-4 with supervision/admin time from 4-5 PM). Not sure about specific #'s but by the end of the year I basically had 3.5-4 full days of clinic patients/week (the rest of the time was didactics).

As far as intakes...I think there was probably an average of 3-4/week? It'd be rare to not have a new patient/day at least.

 

[tellme_areyoufree]

Monday general mental health clinic, 4-10 patients seen; Tuesday AM GMH, ~4 pts seen; Tuesday PM clozapine clinic, 1-4 pts seen; Wednesday full day didactics; Thursday AM GMH clinic, ~4 pts seen; Thursday PM elective (for me this is something non clinical, others have research time or clinical time); Friday AM GMH, ~4 pts; Friday PM community SMI 1-4pts seen in state mental health clinic.

A mix of pharm and therapy but mostly pharm management.

Administrative time peppered in each day. Supervision a few hours each week split between various supervisors (cbt, psychodynamic, ptsd, clozapine, addictions, and weekly at least with GMH).

Total caseload around 100+ between the various clinics. 1hr intake, 30min follow-up. Day starts at 8 and ends at 4:30. 3 dedicated 1hr slots per week for new intakes.

 

[NickNaylor]

Our PGY-3/4 years are primarily outpatient with lots of psychotherapy and elective time. Most of the electives are outpatient-based though people will often do hospital-based electives as well (e.g., C/L, interventional psychiatry, junior attending on an inpatient service, etc.). Our program has essentially no call in PGY-3/4, so hours are typically normal office hours, M-F. Not sure what the typical caseload is in the outpatient clinic though I would guess that most residents probably have an average of 50-60 patients on their panel. Clinic is only 1 day/week though obviously responding to patient calls, dealing with refills, etc. is a full-time deal. Residents are expected to be doing 6 hours of individual psychotherapy with patients and 3 hours of psychotherapy supervision each week.

 

[Evidence Based]

If you are ending the year with 75-90 patients and PGY3's get handed down 30 what happens to the rest? I assume those who don't fast track into child keep them for 4th year, but then what?

We hold onto some for PGY-4, some get passed down, some back to PCP, and occasionally some go to attendings

 

[Bartelby]

It's been long enough that I don't remember all of my PGY3 case numbers anymore. In terms of handing down patients, a resident clinic should be focused on education. That means not all patients should be handed down to more junior residents. When a resident is graduating from the outpatient clinic patients can:

-go to a new PGY-3
-transfer to a rising PGY-4
-return to their PCP
-be referred to a psychiatrist in the community, or a community program
-go with the graduating resident to the resident's private practice
-transfer to a program attending

The new case load for a PGY-3 should be mainly determined by educational value rather than service needs. There are plenty of alternative dispo options for outpatients.

 

[splik]

It's been long enough that I don't remember all of my PGY3 case numbers anymore. In terms of handing down patients, a resident clinic should be focused on education. That means not all patients should be handed down to more junior residents. When a resident is graduating from the outpatient clinic patients can:

-go to a new PGY-3
-transfer to a rising PGY-4
-return to their PCP
-be referred to a psychiatrist in the community, or a community program
-go with the graduating resident to the resident's private practice
-transfer to a program attending

The new case load for a PGY-3 should be mainly determined by educational value rather than service needs. There are plenty of alternative dispo options for outpatients.

agree with the above. At my program the expectation was that patients would be discharged from resident clinic upon graduation of that resident. If you wanted to keep a patient in the clinic you had to find a PGY2 or PGY3 resident to accept the patient for the next year. Patients could also be referred back to the waitlist but the expectation was that patients should have educational value for residents and complement case mix (e.g. good cases for CBT, psychodynamic therapy, complex psychopharmacology etc). Resident clinic is a training clinic so patients should be selected with that in mind. It is tricky though, because the kind of patients who tend to end up in such clinics are often "red flag" patients which lead many residents to mistakenly believe that all psychiatric patients are refractory, help-rejecting psychosocial messes who are doomed to a lifetime of misery.

You are expected to have a minimum of one hour supervision per day (i.e. per 5 patient hours) but you should also have at least an hour of supervision per week for each modality of psychotherapy. I had 2 psychoanalyst supervisors, one CBT supervisor, one for group therapy, one for hypnosis in addition to additional individual and small group supervision. Residents were also expected to be in their own personal psychotherapy. If you have a particularly unusual case then you might solicit additional supervision (e.g. in psychopharmacology, or from a mood disorders or OCD or eating disorders expert etc).

Supervision is one of the key components of psychiatric training (particularly for psychotherapy but not just psychotherapy) and it makes all the difference. I had really wonderful individual supervisors that really made a big difference to my personal and professional growth. I still solicit some of them for advice today. It was not uncommon for residents to pay to continue with supervision after residency.

 

[robellis]

agree with the above. At my program the expectation was that patients would be discharged from resident clinic upon graduation of that resident. If you wanted to keep a patient in the clinic you had to find a PGY2 or PGY3 resident to accept the patient for the next year. Patients could also be referred back to the waitlist but the expectation was that patients should have educational value for residents and complement case mix (e.g. good cases for CBT, psychodynamic therapy, complex psychopharmacology etc). Resident clinic is a training clinic so patients should be selected with that in mind. It is tricky though, because the kind of patients who tend to end up in such clinics are often "red flag" patients which lead many residents to mistakenly believe that all psychiatric patients are refractory, help-rejecting psychosocial messes who are doomed to a lifetime of misery.

You are expected to have a minimum of one hour supervision per day (i.e. per 5 patient hours) but you should also have at least an hour of supervision per week for each modality of psychotherapy. I had 2 psychoanalyst supervisors, one CBT supervisor, one for group therapy, one for hypnosis in addition to additional individual and small group supervision. Residents were also expected to be in their own personal psychotherapy. If you have a particularly unusual case then you might solicit additional supervision (e.g. in psychopharmacology, or from a mood disorders or OCD or eating disorders expert etc).

Supervision is one of the key components of psychiatric training (particularly for psychotherapy but not just psychotherapy) and it makes all the difference. I had really wonderful individual supervisors that really made a big difference to my personal and professional growth. I still solicit some of them for advice today. It was not uncommon for residents to pay to continue with supervision after residency.

You were required to be in therapy as part of your residency? It’s so crazy how vastly different training is from program to program

 

[psych_0]

Our PGY-3 looks something like this:
Starting patient load
-30 pharm transfers from prior residents
-2-3 new combined pharm/therapy patients + 2-3 carryover therapy cases from PGY-2 year
-2 child therapy cases
1-2 intakes per week, done w/ attending faculty
Panel by the end of the year is probably in the neighborhood of 75-90
Tons of supervision: 3 hours general/pharm supervision, 1 hour adult psychodynamic supervision, 1 hour child supervision, 1 hour group CBT supervision, 1 hour group dynamic supervision. I'm doing a little extra CBT supervision as well
In theory many of our patients are held on teams with collaborating social workers or psychologists, and in addition to this we've hired several case workers for both our general and specialty (ex. first episode, chronic psychosis) teams
In addition to the above we have some half days of the week in integrated care, homeless health, bridge clinic, etc.

WOW! You're so lucky. My PGY-3 was:
- One day VA clinic where you inherit all the cases from the previous PGY-3 + any new one or f/u they could cram in your schedule from a recently retired attending (whose primary drug of choice was Xanax for PTSD). These patients were not checked out with an attending unless you specifically ask to have them checked out. Then 30 minutes of supervision at the end of the day, which was commonly useless b/c both you and the supervising attending just want to go home at the end of the day.
- Two days of clinic at the university hospital where you inherit all of the panel from a previous PGY-3 (minus the 30-40 easy ones they kept for themselves into 4th year) and do 1 new intake per clinic day. No separate supervision hours on these days, but you did have to check out every single patient and then briefly see them with your attending.
- One day of clinic at the local CMHC which was 2 new intakes per day + 11 follow-ups on the worst EHR you've ever used. No checkout on these days either, but the day ends with 30 minutes of supervision with a burnt out CMHC attending who commonly supervised via saying "Ok, any questions today? No? Ok, see you next week!"
- One day of didactics (4 hours) + supervision (3 hours in afternoon: 2 hours psychiatry supervision, 1 hour psychotherapy supervision)
- No therapy patients allowed at CMHC, no exceptions. No therapy patients allowed at the VA unless you really, really fought for it, then they would allow 1 per day.
- As many therapy patients as you wanted allowed at university clinic, but "supervision" was highly variable based on which psychologist you were paired with.

Our third year definitely sounds worse on paper than it was in real life, but the experience as a whole was less than favorable and all but one of my classmates took an inpatient job after graduating. Looking back, I don't know what I would change about it other than having better psychotherapy supervision.

 

[Celexa]

when you folks say you have 'supervision' for your med management patients, you mean you don't have to staff every one in real time? The attendings aren't actually seeing the patients?

 

[box8psych]

when you folks say you have 'supervision' for your med management patients, you mean you don't have to staff every one in real time? The attendings aren't actually seeing the patients?

My med management supervisor has not evaluated a single one of my patient's either in-person or virtually. I have been making all of the decisions on my own since I began PGY-3 year and only discussing specific patients/questions during our 1 hour of weekly supervision. This seems to be the norm at the community resident clinics around NYC. Do you staff each one in real time?!

 

[Celexa]

My med management supervisor has not evaluated a single one of my patient's either in-person or virtually. I have been making all of the decisions on my own since I began PGY-3 year and only discussing specific patients/questions during our 1 hour of weekly supervision. This seems to be the norm at the community resident clinics around NYC. Do you staff each one in real time?!

yes. every single patient except at the VA, where only intakes have to be staffed. but if I needed real time staffing it is available.

I had no idea it was so common in other places to not do that. I wish we didn't have to for every patient bc for the simple and stable ones it really can jam up clinic (each attending is seeing the patients of multiple residents--timing gets tight) but I'm glad to have the support for complex and difficult patients.

It really does boggle my mind how different places are.

My program gives us tremendous responsibility and independence on call so I don't in the least feel that we are being coddled or overly supervised in general...

 

[Evidence Based]

when you folks say you have 'supervision' for your med management patients, you mean you don't have to staff every one in real time? The attendings aren't actually seeing the patients?

Correct- all new intakes were seen in real time with an attending (who's there for the entire visit), but then after this the attending don't see patients. The way it works for us is that two residents share a weekly one hour intake slot, and we alternate weeks who takes the intake. Then we have an additional hour of supervision with the attending afterwards where both residents talk about cases with the attending. Repeat this twice per week with two different attendings.

 

[jbomba]

Really glad I dont have to sit there with an attending watching my every move for every intake.

 

[Celexa]

Really glad I dont have to sit there with an attending watching my every move for every intake.

Me too... although attendings staff every one of our patients they don't sit in on the majority of the interview. We do our thing and then go get them to briefly see the patient after we've seen the patient and formulated the plan. It gets really annoying when you want them and they're with another resident, though.

 

[Stagg737]

You were required to be in therapy as part of your residency? It’s so crazy how vastly different training is from program to program

We don’t have this, but one of our attendings did when she was in residency. I do one on one with myself as a patient once a month. I’m in the camp that thinks everyone should be on the patient side at some point. Both to gain the experience for your professional career and just to have an outlet after particularly draining experiences/ro

when you folks say you have 'supervision' for your med management patients, you mean you don't have to staff every one in real time? The attendings aren't actually seeing the patients?

In two of my clinics it’s just staffing once at the end of the day. At our academic center we staff every patient in real time and it sucks. It’s nice having the support, but if it’s a really busy day you’re sometimes waiting for an attending 5-10 minutes just to staff a patient. It’s easy to get behind for the whole half day and certainly limits the time which allows for learning there, which is unfortunate because some of our outpatient attendings are pretty outstanding, imo.

Correct- all new intakes were seen in real time with an attending (who's there for the entire visit), but then after this the attending don't see patients. The way it works for us is that two residents share a weekly one hour intake slot, and we alternate weeks who takes the intake. Then we have an additional hour of supervision with the attending afterwards where both residents talk about cases with the attending. Repeat this twice per week with two different attendings.

So how many intakes per week are you doing? Is that hour with the attending at the end of the day or after that intake?

 

[letsdothis2020]

Thanks for all of your responses. Helpful to know what it’s like at different programs around the country. For intakes, do they become part of your caseload if you’re the one doing the intake? We come into our third year with around 60 patients and have anywhere from 0-2 intakes per week. These patients, once admitted to the clinic become part of our caseload. We also have five child patients (one being a therapy case). I see that some of you have similar amount of intakes and some Have more (even everyday)? How have you been managing seeing all of these patients and your ever expanding caseload without compromising learning and patient care?

 

[jbomba]

What is your actual med supervision like? Ours is essentially an hour to ask questions, which I sometimes have a hard time filling up. Is this normal?

 

[Celexa]

Thanks for all of your responses. Helpful to know what it’s like at different programs around the country. For intakes, do they become part of your caseload if you’re the one doing the intake? We come into our third year with around 60 patients and have anywhere from 0-2 intakes per week. These patients, once admitted to the clinic become part of our caseload. We also have five child patients (one being a therapy case). I see that some of you have similar amount of intakes and some Have more (even everyday)? How have you been managing seeing all of these patients and your ever expanding caseload without compromising learning and patient care?

The default schedule has an intake but we can turn intakes into return patient visits if we don't have enough slots for our established patients

 

[Celexa]

What is your actual med supervision like? Ours is essentially an hour to ask questions, which I sometimes have a hard time filling up. Is this normal?

Since I'm staffing every patient it's hard to say what total amount of time that would be but it ranges from 'this is simple patient x, I am uptitrating their wellbutrin' to much longer and more complicated discussions. generally if I am unsure what I want to do I bring my attending 2 or 3 ideas and we decide together what is best.

 

[jbomba]

Since I'm staffing every patient it's hard to say what total amount of time that would be but it ranges from 'this is simple patient x, I am uptitrating their wellbutrin' to much longer and more complicated discussions. generally if I am unsure what I want to do I bring my attending 2 or 3 ideas and we decide together what is best.

we do that too, but we also have one hour a week to discuss whatever we want. It's during this one hour a week that Im often uncertain of what to discuss.

 

[Evidence Based]

So how many intakes per week are you doing? Is that hour with the attending at the end of the day or after that intake?

Supervision is directly after that intake. I probably average 1.5 intakes per week for my continuity clinic (there's one other "team" intake done per week that can be done by any LICSW, PhD, or MD that we may or may not follow going forward). There are other intakes during the week, ex. during primary care integration, but we don't follow those folks long term.

 

[reca]

agree with the above. At my program the expectation was that patients would be discharged from resident clinic upon graduation of that resident. If you wanted to keep a patient in the clinic you had to find a PGY2 or PGY3 resident to accept the patient for the next year. Patients could also be referred back to the waitlist but the expectation was that patients should have educational value for residents and complement case mix

This sounds amazing. At my program, resident clinic patients are definitely not chosen with educational value in mind and there's no expectation of being discharged from the clinic. I've had patients that my program director saw in residency 15 years ago. Especially at VA and community health clinic, most patients are just told that they can expect a new doctor every July.

 

[psych_0]

Most patients are just told that they can expect a new doctor every July.

I thought this was the standard. This was my exact experience with probably 75% of my panel during PGY-3