When choosing your residency, what would you have done differently?

[BigJaySon]

I've received A TON of help from this forum via threads and PMs.

I'm wondering if interns, residents, attendings, and other physicians could comment on what things go into deciding where to apply for residency, what specific criteria did you use when deciding, and what would you have done differently if you could go back?

Personally, I'm having a hard-time deciding on if location is more important than residency name; community vs academic; easier vs rigorous; and what would be ideal for a person who hopes to one day have a practice (I understand that a pp is down-the-line, but it is a goal I've had prior to medical school and I'm pretty goal-oriented in nature - let me dream plz).

Cheers,
Big J

---

Members don't see this ad.

 

[TexasPhysician]

I chose based on location and feel. I believe I made a good decision for me.

 

[Sushirolls]

Not allowed beliefs about prestige of a program influence rank list, and instead focused on the clinical training as priority to rank list. Does this program have clinical breadth of training to truly justify the 4 years of psych residency? Or is it nothing more than a means to an end program that is getting its pound of service flesh.

 

[Armadillos]

My number #1 and #2 were top 1-3 psych programs, instead I matched at a well regarded but less “prestigious” program near family that I ranked third.

I’m infinitely grateful as I had a great residency experience and honestly don’t feel like I missed out on any life stuff at all which prevented burnout and minimized any stress to my spouse. So my advice is to value location/family/friends highly and you will be a happy psychiatrist.

 

[Merely]

My number #1 and #2 were top 1-3 psych programs, instead I matched at a well regarded but less “prestigious” program near family that I ranked third.

I’m infinitely grateful as I had a great residency experience and honestly don’t feel like I missed out on any life stuff at all which prevented burnout and minimized any stress to my spouse. So my advice is to value location/family/friends highly and you will be a happy psychiatrist.

So Harvard and Yale?

 

[Armadillos]

So Harvard and Yale?

I interviewed at several Harvard programs, Yale and some big names on west coast. Exactly which of those are “top 3” isn’t really relevant to thread

 

[Monocles]

Make sure you go to a program that has a good fit in terms of patient population.

Ex: if you want to be cash only with high functioning patients in suburbia, don't go to a program that is heavily focused on inner city community work or vise versa. dont go to a VA heavy program and see geriatrics for 4 years if you want to do child, etc etc

It's good to be exposed to a bit of everything in training though, but you'll want to LIKE working with your residency's patient population because 4 (or 3) years is a long time.

 

[Marasmus1]

I think it depends on what your expectations are. I can not care less about the name of the institution and education I receive when it comes to my personal wellbeing. I had zero intention to be an exceptional psychiatrist. The most important reason why I chose psychiatry was lifestyle. So I made my choice according to my priorities. If you want to be a big gun in this field, make your choice accordingly.

 

[Merovinge]

Location is even more important than I had taken into account. Consider that many of your good friends, potentially a significant other, colleagues for life will come from where you train and you will have a big leg up if you choose to stay in that area post training. There is a reason even mediocre programs in Cali are so competitive. If you are single, I would strongly prefer a place that caters to the type of people you want to meet and if you are married/have a family there are definitely programs with a big focus on family friendly setups. If you go to almost any academic program you will generally get solid training so making sure you fit the personality of program and of the city will significantly change your experience over 4 years.

Please be true to yourself. If you are burnt out from med school and want a chill residency there's no overseer of medicine to judge you, but don't rank highly programs with large workloads and be miserable. If you secretly find people of low SES repulsive (hopefully you become enlightened during training) I would not rank highly a program with high public aid/inner city populations. You don't have to justify your choice to anyone so this is a perfect time to be true to yourself.

 

[When is graduation again?]

I agree with location being important.

Another thing to consider is the number of locations you rotate in. I've found that the more sites I rotate in, the less familiar with each site I become. It's tricky because you want a lot of exposure, but if you have too many sites, you're constantly looked at as a visitor or glorified medical student instead of an actual doctor. There's nothing worse than looking dumb because you don't know some minute policy specific to an individual place or how to place a specific order. You also never really master all the resources in the area available to each specific patient population.

 

[deleted736562]

I am lucky to have ended up where I am right now, because as an IMG it worked out nicely with visas and stuff. So I should have prioritized that when making the rank list.

 

[MacDonaldTriad]

I had zero intention to be an exceptional psychiatrist. The most important reason why I chose psychiatry was lifestyle.

Wow, I hope this wasn't in your personal statement. Very Millennial maybe, but not very comforting for those in your care.

 

[Merely]

I think it depends on what your expectations are. I can not care less about the name of the institution and education I receive when it comes to my personal wellbeing. I had zero intention to be an exceptional psychiatrist. The most important reason why I chose psychiatry was lifestyle. So I made my choice according to my priorities. If you want to be a big gun in this field, make your choice accordingly.

Bro wut

 

[pbdoctor1]

The fit with the program is most important, more than the location. Wellbeing is closely dependent on the physicians and directors above you. It sounds cheesy but if they are kind, decent, and intelligent it is more pleasant to work with for four years. Conversely if they are odd, rude, or deceitful they can destroy your career. Residency can be tough and will require support and help. The big wrinkle comes in when residency directors and attendings turn over frequently in programs. Competition has gone up in all residencies so the choices and locations are limited. It sounds strange but go with your gut with the people you surround yourself with. They will culiminate and imbibe their experience and history to your training as a psychiatrist. Good luck!

 

[Mass Effect]

Fit is important. Location is important (for many). But I hope you take the suggestions the way they're intended and that is based on everyone's personal experience which varies widely. I hope you don't walk away feeling scared about where you'll end up. The truth is there are way more malignant residents out there than there are malignant programs. Wherever you end up, just work hard, treat people nicely, and you'll do fine.

As for which type of program, only you can decide what you want out of your career, but I would vote large academic hospital every time. You'll see more, do more, and learn more.

 

[Orgone]

I chose on location and fit and remain happy that I did. I also still thank my past self for going with my intuition and ranking lower a program with more prestige, but where on interview day the PD gave out a very sheisty vibe. I think gut feeling is important with this decision.

 

[MacDonaldTriad]

The truth is there are way more malignant residents out there than there are malignant programs. Wherever you end up, just work hard, treat people nicely, and you'll do fine.

Amen

 

[Marasmus1]

Wow, I hope this wasn't in your personal statement. Very Millennial maybe, but not very comforting for those in your care.

it was not. But it was somehow brought up during my interview. I clearly stated that I do not have any desire to be a big gun in this field. I want to be a psychiatrist who helps people deal with their mental illness. Nothing more nothing less. I am doing it to the best of my abilities. The stronger desire will invite higher anxiety. I want a calm, peaceful life without extra struggle. I care neither money nor status. Psychiatry is the field that gives me the convenience and comfort I need. And yes If I was smart enough , I would definitely go for Derm.

 

[Merely]

it was not. But it was somehow brought up during my interview. I clearly stated that I do not have any desire to be a big gun in this field. I want to be a psychiatrist who helps people deal with their mental illness. Nothing more nothing less. I am doing it to the best of my abilities. The stronger desire will invite higher anxiety. I want a calm, peaceful life without extra struggle. I care neither money nor status. Psychiatry is the field that gives me the convenience and comfort I need. And yes If I was smart enough , I would definitely go for Derm.

Welp I don’t wanna be your pt lol

 

[Marasmus1]

Welp I don’t wanna be your pt lol

Thats fine. But dont we all prescribe lexapro for anxiety? The way we practice psychiatry right now, does it really matter where you go unless you have case report quality mental illness?

 

[Shufflin]

Thats fine. But dont we all prescribe lexapro for anxiety?

No

... The way we practice psychiatry right now, does it really matter where you go

Yes

Lots of small details you need to pick up come from learning on the wards, and that's heavily attending dependent.

 

[clausewitz2]

Thats fine. But dont we all prescribe lexapro for anxiety? The way we practice psychiatry right now, does it really matter where you go unless you have case report quality mental illness?

I think if your thinking is limited to "anxiety = throw an SSRI at it" then you shouldn't worry about your fears of becoming an exceptional psychiatrist being realized.

 

[erg923]

Thats fine. But dont we all prescribe lexapro for anxiety? The way we practice psychiatry right now, does it really matter where you go unless you have case report quality mental illness?

Attempting to chemically "treat" indicative anxiety is fruitless and harmful. Pathological anxiety states and disorders are best treated with a psychotherapy rather than medication of any kind. Is this not taught in psych residency, on like, day 1?

 

[Merely]

Attempting to chemically "treat" indicative anxiety is fruitless and harmful. Pathological anxiety states and disorders are best treated with a psychotherapy rather than medication of any kind. Is this not taught in psych residency, on like, day 1?

Are you suggesting medication is never indicated for anxiety..

 

[Mass Effect]

Attempting to chemically "treat" indicative anxiety is fruitless and harmful. Pathological anxiety states and disorders are best treated with a psychotherapy rather than medication of any kind. Is this not taught in psych residency, on like, day 1?

Medications being "fruitless" in treating mental illness is not taught on any day of residency because it simply is not true.

 

[erg923]

Medications being "fruitless" in treating mental illness is not taught on any day of residency because it simply is not true.

indicative anxiety is mental illness now?

 

[erg923]

Are you suggesting medication is never indicated for anxiety..

No

 

[clausewitz2]

While I think @erg923 significantly overstates the case, effective treatment of anxiety does involve not promoting an agenda of avoidance and emotional control and it is very easy to accidentally provide another safety behavior with medications.

 

[clausewitz2]

Whats going on here? Indicative anxiety vs pathological anxiety, folks. Its only been a few years since I haven't been in a med school environment but this is still taught, no?

"anxiety" shouldn't be treated with drugs. "Anxiety disorders".... sometimes.

The problem is this indicative v. pathological distinction is not often talked about in our field in those terms, which is perhaps part of the misunderstanding.

 

[erg923]

The problem is this indicative v. pathological distinction is not often talked about in our field in those terms, which is perhaps part of the misunderstanding.

what terms are used in your neck of the wood for this then?

 

[NickNaylor]

Getting back to the topic... I think the most useful thing you can do is to be candid about what you're hoping to do in your career (as much as you're able), clarify your interests as much as possible, and choose your program accordingly. With rare exceptions, a program is a program is a program. I'm not convinced that, in general, some programs are "simply better" than others. Certainly some programs will have specific strengths, but I'm not convinced that going to a "prestigious" or "highly ranked" program is going to make you a "better" psychiatrist. This is where having some sense of what you want to do and what your interests are can be helpful. If you know you want to have a career in academia, going to a big name academic program may be important. If you know or think you want to make psychotherapy a big aspect of your practice, then identify programs that have particularly strong psychotherapy training. Repeat ad infinitum. Taking things into account like location, presence of family, etc. may also be important to you, but I imagine this will vary from person to person.

 

[clausewitz2]

what terms are used in your neck of the wood for this then?

At least around here it is often something like disproportionate v. proportionate, although this obviously lacks specificity and is not communicating exactly the same concept. It does have the advantage of not committing you to a theory of precisely what is generating the anxiety, though, and keeps the focus on what is directly observable/reportable.

 

[Mass Effect]

indicative anxiety is mental illness now?

From your own post: "Pathological anxiety states and disorders are best treated with a psychotherapy rather than medication of any kind. Is this not taught in psych residency, on like, day 1?"

Using medications to treat pathological anxiety disorders is not "fruitless." And yes, pathological anxiety disorders do qualify as mental illness.

 

[Lexanoob]

I just wanted to provide a viewpoint that has not yet been expressed yet that may be helpful for OP. Based on my own experience and hearing from my peers who have also recently matched into psychiatry, it could be possible that the idea of being able to "choose" where you go seems to becoming more of a luxury, available to only most competitive applicants or applicants with the most realistic expectations (a.k.a. good, up to date advising). Half of the people from my school felt that, throughout the process of applying into psychiatry, they did not get the interviews that they had expected or end up matching where they wanted (some even "barely" matched).

Additionally, I (secretly) wasn't sure what I wanted out of a program regarding community vs. academic, easier vs. rigorous, etc., as these all sounded too abstract for me to realize how they would actually affect my training and career and, for some programs, there was poor inter-rater reliability -- I just loved psychiatry! I'd echo others above recommendations in, when choosing which programs to apply for, prioritizing geographic locations that you can actually imagine yourself living in (a.k.a. where is your network/ support? if that is important to you; what weather can you tolerate?; how would high/low CoL affect your life?), but otherwise start by catching your net wide. When interviews come in, stay open minded and "feel" it out. Perhaps this is a view that might drive some PDs/ ad coms crazy with increased applications but I think it's something that will be helpful to ensure that 1) you match and 2) you have considered all of the opportunities available for you, and have less regret about where you end up if you match lower than you wanted on your list.

Good luck!

 

[Marasmus1]

Attempting to chemically "treat" indicative anxiety is fruitless and harmful. Pathological anxiety states and disorders are best treated with a psychotherapy rather than medication of any kind. Is this not taught in psych residency, on like, day 1?

Wooow. Poor patients of yours

 

[Marasmus1]

I think if your thinking is limited to "anxiety = throw an SSRI at it" then you shouldn't worry about your fears of becoming an exceptional psychiatrist being realized.

I think if what you inferred after reading my post is ``anxiety=throw an SSRI`` then drop your desire to become an exceptional psychiatrist( if you have) before you feel devastated

My point was 99% of the psychiatrists throw SSRI at anxiety. There are many treatment modalities but psychiatry somehow evolved into 15 minutes med checks. Majority of the psychiatrists who try to do therapy fool themselves and their patients, while filling up their pockets. Majority of the residency programs do not prepare their residents for psychotherapy. I am not talking about a year long psychotherapy didactic`s during residency. Most of the psychiatrists who perform legit psychotherapy go above and beyond to learn it after residency.

I know my limitations. I am definitely not going above and beyond after my training is over. I will do what I was taught during residency.

 

[splik]

My point was 99% of the psychiatrists throw SSRI at anxiety. There are many treatment modalities but psychiatry somehow evolved into 15 minutes med checks. Majority of the psychiatrists who try to do therapy fool themselves and their patients, while filling up their pockets. Majority of the residency programs do not prepare their residents for psychotherapy. I am not talking about a year long psychotherapy didactic`s during residency. Most of the psychiatrists who perform legit psychotherapy go above and beyond to learn it after residency.

Given that the majority of psychiatrists are over the age of 60 and trained in the era when psychotherapy was more heavily emphasized, I don't see how the bold is possibly true. Also, there are a good number of programs that provide decent training in psychotherapy. I saw a good number of psychotherapy patients during residency including for twice weekly (and sometimes more frequently) therapy. My outpatient practice I only see patients for consultation or psychotherapy and do not prescribe meds at all. "The 15 minute med check" is so early 2000s, most systems have evolved to give 30 minutes for follow ups, and in major metropolitan areas (where most psychiatrists reside) there are a good number of psychiatrists who provide psychotherapy for patients.

Also the idea that your SSRI is as effective as my SSRI has been thoroughly debunked. RCTs show difference efficacy of drugs depending on the psychiatrist. The drug works better when the psychiatrist is more effective and has a stronger relationship with the patient. Conversely, a shîtty psychiatrist is going to get poor results prescribing the same meds as a highly effective one.

 

[Shufflin]

which is why I agree with Salvador Dali when he says "I am the drug."

we psychiatrists are the drug.

 

[SourceOfDenial]

which is why I agree with Salvador Dali when he says "I am the drug."

we psychiatrists are the drug.

Set and setting, therapeutic alliance— this is where the joy in this work comes from, at least for me.

What would I do differently? I guess based on my comment choose a program that told me to read more Carl Rogers?

For the most part it’s hard to know what you would do differently until after you’ve done it. You will make your own mistakes. Just pick somewhere and make the most of it.

 

[clozareal]

As someone extremely neurotic, I used an excel spreadsheet to score specific criteria for ranking residency programs:
Location (20%)
Reputation (10%) - rankings in Doximity and USN&WR
Research (8%) - in the specific areas I was interested in
Lifestyle (25%) - house staff morale, work/life balance
Teaching emphasis (7%) - mentorship, didactics, psychotherapy training by psychologists
Gut feel (20%)

I gave a ranked score to each of the above categories, came up with an overall rank score, and chose mainly based off of that.

Or so I thought. In the end, my gut feel was basically my confirmation bias and the programs I liked more were justified as having more pros than cons. I convinced myself of being objective when in fact, my subconscious was leading me all along.

If I could go back, the biggest factors for me would be:
1. Location: being close to family, being where I would want to practice afterwards because making friends and building a support network long-term is hard but extremely important and understated. Who your friends are during residency are going to be your friends after residency. I worry that it will only get harder the further I get along in my career and the closer I get to having a family.
2. Therapy training especially being closely associated with a psychoanalytic center. This is probably most of what I would want to be doing after training anyways. I'm finding med management dull and current DSM-5 diagnostic formulation to be extremely limited.

I could care less about research, didactics, reputation/prestige. Also, it's a huge crapshoot with the camaraderie of the residency program because you won't necessarily interact much with the classes above you, whom you interact with during the interview day. The class that you'll be spending most of your time with hasn't been chosen yet so picking based on how well the current residents get along doesn't necessarily translate to how well your class will get along.

 

[MacDonaldTriad]

Also, it's a huge crapshoot with the camaraderie of the residency program because you won't necessarily interact much with the classes above you, whom you interact with during the interview day. The class that you'll be spending most of your time with hasn't been chosen yet so picking based on how well the current residents get along doesn't necessarily translate to how well your class will get along.

Spot on. As an applicant on interview day, the odds of matching with the other interviewees is somewhere between one in ten or twenty. One year, the class can be thick as thieves, the next they barely socialize together. Sometimes they grow close later because interns are all over the place. It is like some reality TV show except it really is reality that you will be crammed together and endure long hours and experience the stress of learning a medical specialty together. This isn't easy so try to start out right and be good to each other next week.

 

[Merely]

As someone extremely neurotic, I used an excel spreadsheet to score specific criteria for ranking residency programs:
Location (20%)
Reputation (10%) - rankings in Doximity and USN&WR
Research (8%) - in the specific areas I was interested in
Lifestyle (25%) - house staff morale, work/life balance
Teaching emphasis (7%) - mentorship, didactics, psychotherapy training by psychologists
Gut feel (20%)

I gave a ranked score to each of the above categories, came up with an overall rank score, and chose mainly based off of that.

Or so I thought. In the end, my gut feel was basically my confirmation bias and the programs I liked more were justified as having more pros than cons. I convinced myself of being objective when in fact, my subconscious was leading me all along.

If I could go back, the biggest factors for me would be:
1. Location: being close to family, being where I would want to practice afterwards because making friends and building a support network long-term is hard but extremely important and understated. Who your friends are during residency are going to be your friends after residency. I worry that it will only get harder the further I get along in my career and the closer I get to having a family.
2. Therapy training especially being closely associated with a psychoanalytic center. This is probably most of what I would want to be doing after training anyways. I'm finding med management dull and current DSM-5 diagnostic formulation to be extremely limited.

I could care less about research, didactics, reputation/prestige. Also, it's a huge crapshoot with the camaraderie of the residency program because you won't necessarily interact much with the classes above you, whom you interact with during the interview day. The class that you'll be spending most of your time with hasn't been chosen yet so picking based on how well the current residents get along doesn't necessarily translate to how well your class will get along.

Wow lol

 

[Mass Effect]

Spot on. As an applicant on interview day, the odds of matching with the other interviewees is somewhere between one in ten or twenty. One year, the class can be thick as thieves, the next they barely socialize together. Sometimes they grow close later because interns are all over the place. It is like some reality TV show except it really is reality that you will be crammed together and endure long hours and experience the stress of learning a medical specialty together. This isn't easy so try to start out right and be good to each other next week.

This is perhaps the most important thing in this thread. If you want a happy residency, be good to your co-residents. Don't make life hell for everyone around you because you'll drag the entire program down.

 

[FlowRate]

I didn't really know, for sure, where I wanted to be geographically when I was choosing a residency program. The one place I most want to be did not interview me and, as far as I know, wasn't a particularly strong program--nothing wrong with it, but not listed as "this is good" when people talk about such things around here. So I chose the program where I thought I'd get the strongest overall training, with some emphasis on CL, which I later discovered I actually dislike. In retrospect, I don't think I would have done anything differently for my own situation, but like others ITT I would highlight the importance of location. I've known I wanted to leave this location since med school (ranked home program #1) and, now that I'm starting to think about job search and talk to attendings about their jobs, I wish I had more connections in places that I actually want to go.

Somewhat off topic, I'm in the northeast which I hear has a somewhat unique pattern of psychiatrist employment. The place I want to go has basically a ton of hospitals owned by giant corporations (some by HCA) and I wonder whether those sorts of jobs are at all open to something like 0.75 FTE so I can do PP on the side?

 

[Merely]

This is perhaps the most important thing in this thread. If you want a happy residency, be good to your co-residents. Don't make life hell for everyone around you because you'll drag the entire program down.

How do u do that do u have any tips

 

[Mass Effect]

How do u do that do u have any tips

How to do what? Be nice to people?

 

[Merely]

How to do what? Be nice to people?

Yeah

 

[Shufflin]

For children to learn and the few on SDN who need it:

From WikiHow: Being Nice in Everyday Ways

1. Acknowledge other people.
2. Be a good listener.
3. Be courteous, polite, and helpful.
4. Smile.
5. Practice empathy.
6. Never speak ill of others when they aren't around.
7. Look out for everyone, not just those closest to you.

 

[Marasmus1]

Given that the majority of psychiatrists are over the age of 60 and trained in the era when psychotherapy was more heavily emphasized, I don't see how the bold is possibly true. Also, there are a good number of programs that provide decent training in psychotherapy. I saw a good number of psychotherapy patients during residency including for twice weekly (and sometimes more frequently) therapy. My outpatient practice I only see patients for consultation or psychotherapy and do not prescribe meds at all. "The 15 minute med check" is so early 2000s, most systems have evolved to give 30 minutes for follow ups, and in major metropolitan areas (where most psychiatrists reside) there are a good number of psychiatrists who provide psychotherapy for patients.

Also the idea that your SSRI is as effective as my SSRI has been thoroughly debunked. RCTs show difference efficacy of drugs depending on the psychiatrist. The drug works better when the psychiatrist is more effective and has a stronger relationship with the patient. Conversely, a shîtty psychiatrist is going to get poor results prescribing the same meds as a highly effective one.

The drug does not work better when the psychiatrist is more effective and has strong relationship with the patient. It is the placebo effect and increased compliance with treatment that lead to better results.

Sorry my friend but there is no such a thing `` my escitalopram is better than your escitalopram`` in psychiatry.

 

[clausewitz2]

The drug does not work better when the psychiatrist is more effective and has strong relationship with the patient. It is the placebo effect and increased compliance with treatment that lead to better results.

Sorry my friend but there is no such a thing `` my escitalopram is better than your escitalopram`` in psychiatry.

No but there is a "I get better outcomes for my patients than you do." Just because an effect is not rooted in a biochemical difference does not make it a placebo, particularly if it is a result of training, skill, or deliberate choices.

I get not wanting to kill yourself through overwork and medicine still has really awful attitudes about this but if you aren't always trying to do better or improve your practice I think you are doing your patients a disservice and you certainly not practicing in a virtuous way.