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

[Marasmus1]

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.

I agree. I will stay in private practice in a major urban area. So if my patients think they are not receiving the service they want, they can see a different psychiatrist. I can not care less about that. As I said I have no desire for money beyond paying my bills, feeding my family etc. I also do not have a desire to be exceptional but I will try to improve my knowledge base as much as I can to help my patients better. I would not like to be misunderstood on that one

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[StilgarMD]

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.

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.

I agree. I will stay in private practice in a major urban area. So if my patients think they are not receiving the service they want, they can see a different psychiatrist. I can not care less about that. As I said I have no desire for money beyond paying my bills, feeding my family etc. I also do not have a desire to be exceptional but I will try to improve my knowledge base as much as I can to help my patients better. I would not like to be misunderstood on that one

I think what makes a lot of what you're saying so unpalatable is experience concerning how people say they'll act and how they actually end up acting, as well as a knowledge that people slide overtime.

To touch on your escitalopram point - it is ridiculous to believe we know enough about how these drugs work to make claims like this. First off, there are environmental influences in mental illness - in subtle circumstances, long term psychological stressors or in more acute settings, triggers, which have obvious influence on the course of someone's disease. If you're so content as to go by the book and provide minimum pharmacological interventions, you're doing your patients a profound disservice. Second, compliance with drugs is a big problem, especially in psych, and if the patient notes the apathy in your care, they're less likely to take it then if (on the other extreme) someone who clearly cares deeply about helping them provides the same prescription. And we're wired to pick up on these things (theory of mind), and unless you're some stellar actor (which, given the derm comment, you'd probably be doing that were it the case), people will see through it very quickly.

A broader comment on your attitude is that you might say "I'll be perfectly proficient", but we're all human. we slide overtime. Youth and enthusiasm wane and hopefully additional expertise and experience buffer the decline in quality of care or keep it going up. Even the most exceptional folks will have rough days, and maybe not communicate and listen as they might on their better days. When it comes to any long term behavioral pattern, you're far more likely to overshoot or undershoot than hit the mark, and everything you've said is evidence you'll consistently undershoot your goal of "proficient". 'I will try to improve my knowledge base', in the context of your other comments, are clearly empty words. We should be trying to bring the field up, not preserve a flawed status quo. Practitioners with attitudes like yours are obstacles to the field improving.

 

[Merely]

It’s funny because probably a majority of psychiatrists have the same or even worse attitudes than marasmus yet by the responses on this board you’d think everyone was an Ivy League trained academic, dedicated psychiatrist

 

[Mass Effect]

It’s funny because probably a majority of psychiatrists have the same or even worse attitudes than marasmus yet by the responses on this board you’d think everyone was an Ivy League trained academic, dedicated psychiatrist

Didn't you just ask how to be nice to people?

 

[FlowRate]

It’s funny because probably a majority of psychiatrists have the same or even worse attitudes than marasmus yet by the responses on this board you’d think everyone was an Ivy League trained academic, dedicated psychiatrist

Also, being frank about a self-expectation below "excellence" may lead others to consider whether they truly act in line with the ideals they promote. Is this person just more honest about their goals? Is the danger of such an attitude that "all fall short" or that one sees their own shortcomings projected?

We have, let's say, at most 98 hours a week to divvy up while still being reasonably rested/healthy. Do you spend all of that time reading psychiatry books? Seeing patients? What makes one a better psychiatrist? How much time should you spend enjoying other activities vs honing your skills as a psychiatrist? Where is the point of marginal returns?

(I am not trying to say that any of this is why I think any specific persons in this thread reacted one way or another but that these are reasons physicians more generally might react negatively to said poster, including myself.)

 

[ridethecliche]

I matched at a program that wasn't even in my top 10... I haven't started yet, but I remember thinking that I'd be happy matching at any of my top 5-6 spots (of which my home program was one). Didn't end up working out.

The only thing I would have done differently is mentally prepare myself for ending up anywhere on my list. I wasn't ready to match so far down. I had liked the program during my interview day, but didn't want to be in said location.

All said and done I think I'll be fine and content etc, but just know that if it's on your list... you may end up there. And if you liked the place, it's a helluva lot better than not matching.

 

[ridethecliche]

Re: aspirations etc.

I don't think there's anything wrong with striving to be competent and good. Chasing 10/10ths is what defines excellence and people have other priorities. I don't think merely worded it the way most people would have liked, but there's no doctrine that says that you can't do well at a job if you don't want to be the best at it. Like flowrate, it's not how I would have expressed the sentiment, but the reaction was certainly interesting.

 

[MacDonaldTriad]

just know that if it's on your list... you may end up there.

This for sure.
Fortunately, an applicant's ability to effectively appraise a program during an interview day is suspect and matching high or low on a list may have less to do with the quality of training than you think.

Every early fall, I start to get e-mails from interns I interviewed asking if I have openings because they are doing family medicine somewhere and want out. When I ask why they had family medicine on their rank list they say "I didn't think I would reach down that far". So the other absolute rule is if you are unwilling to do it, don't have it on your rank list.

 

[Marasmus1]

I think what makes a lot of what you're saying so unpalatable is experience concerning how people say they'll act and how they actually end up acting, as well as a knowledge that people slide overtime.

To touch on your escitalopram point - it is ridiculous to believe we know enough about how these drugs work to make claims like this. First off, there are environmental influences in mental illness - in subtle circumstances, long term psychological stressors or in more acute settings, triggers, which have obvious influence on the course of someone's disease. If you're so content as to go by the book and provide minimum pharmacological interventions, you're doing your patients a profound disservice. Second, compliance with drugs is a big problem, especially in psych, and if the patient notes the apathy in your care, they're less likely to take it then if (on the other extreme) someone who clearly cares deeply about helping them provides the same prescription. And we're wired to pick up on these things (theory of mind), and unless you're some stellar actor (which, given the derm comment, you'd probably be doing that were it the case), people will see through it very quickly.

A broader comment on your attitude is that you might say "I'll be perfectly proficient", but we're all human. we slide overtime. Youth and enthusiasm wane and hopefully additional expertise and experience buffer the decline in quality of care or keep it going up. Even the most exceptional folks will have rough days, and maybe not communicate and listen as they might on their better days. When it comes to any long term behavioral pattern, you're far more likely to overshoot or undershoot than hit the mark, and everything you've said is evidence you'll consistently undershoot your goal of "proficient". 'I will try to improve my knowledge base', in the context of your other comments, are clearly empty words. We should be trying to bring the field up, not preserve a flawed status quo. Practitioners with attitudes like yours are obstacles to the field improving.

Well nobody is holding you back. Go bring the field up. But Im not being part of it.

My point is misunderstood as evidenced by 3 paragraphs of tangential and circumstantial response to my statements. I said I do not have desire to be exceptional psychiatrist. I did not say I wont care about my patients well-being. On the other hand, my well-being is the most important subject for me. My life experience is that the more you try to be proficient and great, the more anxiety and feelings of emptiness follow. This is a lifelong struggle. Once you were given a degree of proficiency or great, you will desire to be greater. Once you become greater, you will desire to be greatest. And greatest can only exist in comparison, because being great is an endless journey. Once you start comparing, you will bring anxiety and insecurities to your life because while you struggle to be more than you are, you will also struggle to protect what you accumulate such as power, money, recognition, sense of being important etc.

Why can not some become a regular urban area psychiatrist without any of these desires? Do we all have to strive for something more, something greater, awards, papers in best journals? And please ask yourself and answer honestly, the ones who strive to be proficient or great are doing it for themselves or their patients? I have a very strong opinion on that one which I am reluctant to share because i do not want to launch a different argument.

 

[clausewitz2]

Well nobody is holding you back. Go bring the field up. But Im not being part of it.

My point is misunderstood as evidenced by 3 paragraphs of tangential and circumstantial response to my statements. I said I do not have desire to be exceptional psychiatrist. I did not say I wont care about my patients well-being. On the other hand, my well-being is the most important subject for me. My life experience is that the more you try to be proficient and great, the more anxiety and feelings of emptiness follow. This is a lifelong struggle. Once you were given a degree of proficiency or great, you will desire to be greater. Once you become greater, you will desire to be greatest. And greatest can only exist in comparison, because being great is an endless journey. Once you start comparing, you will bring anxiety and insecurities to your life because while you struggle to be more than you are, you will also struggle to protect what you accumulate such as power, money, recognition, sense of being important etc.

Why can not some become a regular urban area psychiatrist without any of these desires? Do we all have to strive for something more, something greater, awards, papers in best journals? And please ask yourself and answer honestly, the ones who strive to be proficient or great are doing it for themselves or their patients? I have a very strong opinion on that one which I am reluctant to share because i do not want to launch a different argument.

If by "exceptional" you mean something statistical, being an outlier of prestige or status or academic accomplishment, then sure, I am totally in agreement with you. It is perfectly respectable not to aspire to any of that.

What I understand by "exceptional" is something more like striving always to cultivate the dispositions and habits of whatever you take the embodiment of the ideal psychiatrist to be. My point is teleological, not statistical. The only comparison I am suggesting is you to your own self from, say, last year.

Are you better at your craft now than you were a year ago?

If not, why not? What are you going to do to keep from stagnating and sliding slowly into incompetence.

For Aristotelian types like me excellence is more about pursuing an ideal rather than winning or beating others. More about being exceptional and outstanding than "the best". Otherwise it's like asking "who is the best painter?" - not a very well formed question and not one you can really answer without a hell of a lot of caveats.

Aspiring to be "good enough" really is a recipe for losing your edge but also making it more likely that you will actually fail to be good enough. It's like saying you only want to be "honest enough" or "generous enough"; if you are in the position where you are saying "I could do better but I choose not to" it is tremendously unlikely that you are doing very well at all.

Again, I am not talking about working yourself to death when I say doing better. At some point too many hours almost certainly means you are doing less well for this field. I am talking about always having an eye to "what can I learn here? What do I not understand yet? What is it I could be doing differently that might make this go better?" and then taking steps to make use of the answers to those questions.

 

[Armadillos]

If by "exceptional" you mean something statistical, being an outlier of prestige or status or academic accomplishment, then sure, I am totally in agreement with you. It is perfectly respectable not to aspire to any of that.

This is how I interpreted the post that careened this thread off the rails and was surprised to see it cause such a response from everyone. I do think the original topic of thread was useful for applicants so maybe we should try to refocus back to that theme?

 

[deleted736562]

You can live with not being "exceptional" and practice psychiatry better than the hordes of psychiatrists who sell themselves as Jesus II. I mean really, who are we to judge? At the end of the day your work speaks the loudest, not what you think your intentions or motives are or whatever PR crap people write in their PS. I have no clue how marasmus practices.

 

[pbdoctor1]

Given the shortage of psychiatrists to treat patients and expansion of mid level encrouchment, this perspective by a few individuals for mandating exceptionalism is irrelevant in relation to absolute need for more graduates. This idea of pushing for "exceptionalism" persists to enable individuals with unfulfilled egos to self elevate and comparatively judge colleagues. The added harmful effect is that this dishonest holier than thou status signaling is commonly doublespeak used to enable or excuse toxic and abusive behaviors. Similarly this agenda of suggesting residents be "nicer" as the greater solution has the unintended consequence of naive residents who take this advice becoming manipulated and abused by malignant seniors or abusive attendings and eventually burning out. It only serves one discretionary purpose which is to encourage paternalistic obedience by those who wish all residents behaved accordingly. It does absolutely nothing to discourage residents who simply don't care. Most residents in a normal positive environment will want to learn and model behaviors of those above them. Conversely negative environments impede learning with punishment and model bad behaviors by giving toxic attendings and PDs a free pass to stagnant and slide into incompetence while simultaneously calling for exceptionalism to those below them. What should be most important is a program provides an environment that helps residents foster enough knowledge/experience, not burn out, and successfully graduate. The field needs as many as it can get!

Going back to the original question, the best answer is first to prioritize excluding programs that pose a risk of being fired or toxicity. As advised by members earlier in this thread, do not rank a program you don't want to go to, especially malignant residencies (no matter how few of them exist). Aside from that, go on to rank based on location, gut feelings, positive fit or whatever will make you happy in the four long years.

It is up to the training environment to drive the behaviors of the resident to learn, be nice, and also not burn out. Some residencies simply don't have this as a foundation because of poor leadership and teachers who instead focus on behaving like self rightous authoritative figureheads. Applicants have almost no control over most criterias given the randomness and competitiveness of the match and they definitely don't have any control once they become a resident. The only thing an applicant has control over is if they rank a program or not, however that in itself is a very important decision.

 

[MacDonaldTriad]

You must have some really deep scars to feel the need to call us out for suggesting people be nice to each other. I still think the majority of people following this discussion would think this wasn't nearly so "malignant", "manipulative", or "abusive" as you suggest. I hope you have some vacation time planned soon because you really sound like you need it.

 

[Mass Effect]

You must have some really deep scars to feel the need to call us out for suggesting people be nice to each other. I still think the majority of people following this discussion would think this wasn't nearly so "malignant", "manipulative", or "abusive" as you suggest

So much yes to this! Sometimes, people need to lash out and rightly so, but the myopic viewpoint is tiresome. Sometimes, even attempting to see the other side of issues can lead to a world of less stress.

Hard to believe the simple advice of being nice to your colleagues could cause controversy.

When I was a resident, the vast majority of the problems that erupted could have been avoided if people had been nicer to one another. That isn't malignant, manipulative, or abusive advice. That's real advice for the real world. People -- especially residents -- won't get very far with mean, bullying behavior.

Also, there are some seriously skewed perspectives on this thread. No one mandated exceptionalism nor do I think it's a bad thing that some want to be exceptional. I certainly don't have the energy and time to devote to such an endeavor, but the post that stirred all these replies gave a different vibe and that was one of simply cashing a paycheck. I am glad the OP came back to explain because the original post was not very clear. To those who aspire to be exceptional - thank you! We need you out there doing the research, writing the textbooks, teaching the courses so the rest of us can learn and do right by our patients. Some of us praise your efforts and recognize that you're not just a bunch of unfulfilled egos self-evaluating and judging colleagues. We also recognize that you're not toxic and abusive just because you have goals that others don't.

The bottom line is this: whether you're at the pinnacle of success or an intern barely skating by: be nice to others.

 

[pbdoctor1]

You must have some really deep scars to feel the need to call us out for suggesting people be nice to each other. I still think the majority of people following this discussion would think this wasn't nearly so "malignant", "manipulative", or "abusive" as you suggest. I hope you have some vacation time planned soon because you really sound like you need it.

DIdn't you just ask for others to be nice?

First of all ouch. What an unnecessarily cruel personal attack to try to falsely place stigma and discredit the discussion.

Look it's easy to advise residents to be nice to one another but it's more important that everyone be nice, universally. If one reads carefully however the discussion focused on the importance to balance out the unilateral call for residents to be nice while not addressing the reality of power dynamics from toxic superiors who could care less. Pointing out the unintended consequences shouldn't spark phoney outrage or give credence to feelings of hostility when presented with an alternative perspective to the echo chamber of individuals trying hard to signal "nice" but selective moral authority. It appears disingenuous or worse agenda driven.

Its equivalent to individuals preaching for everyone else to be nice so they can get a free pass to simultaneously act like a jerk. It's much worse when it's a crazy boss.

Placing reaction formation aside, there's one good advice you suggested that everyone can agree on relating to the original discussion, which is for applicants to not rank malignant residency programs precisely because of this.

 

[Mass Effect]

Look it's easy to advise residents to be nice to one another but it's more important that everyone be nice, universally. If one reads carefully however the discussion focused on the importance to balance out the unilateral call for residents to be nice while not addressing the reality of power dynamics from toxic superiors who could care less

Sometimes, even junior residents can take control and wield the power over their peers. I've seen it happen. It's not always toxic superiors.

Pointing out the unintended consequences shouldn't spark phoney outrage or give credence to feelings of hostility when presented with an alternative perspective to the echo chamber of individuals trying hard to signal "nice" but selective moral authority. It appears disingenuous or worse may be agenda driven

I don't know that any of the outrage was phoney. I remain surprised that a post about new interns being nice to one another could spark controversy. In all my years on SDN, this is perhaps the most absurd controversy I've witnessed.

Its equivalent to peers preaching for everyone else to be nice so they can get a free pass to simultaneously act like a jerk (hint). It's much worse when it's a crazy boss

!!!

Let's not stigmatize the word "nice" in order to continue a discussion that's about anything but. We all have our stories. We all have our battle scars. We all cope in different ways. Residency is tough. Sometimes tougher than it needs to be. I really hope that whatever it is that happened to you (and I have no doubt that you were wronged in some ways), that you can heal and persevere. Hopefully someday, you can have the same wish for those jerks and crazy superiors you referenced because they could likely use it too.

/endthread (hopefully)

 

[pbdoctor1]

I'm fine but would prefer the discussion refrain from personal attacks.

I'm more concerned with the prevailing widespread burnout and suicide in our field. What's troubling is this culture of silence between doctors. There are diverse perspectives out there and applicants benefit if we encourage open and honest dialogue instead of attributing stigma, shame, and suppression.

I'm sad to hear your frustration being affected by so many of these toxic residents or coresidents you referenced, but the majority of residents I've seen have peers who got along great together or easily ignore those peers who were not so nice. They could never do that with a program director or attending who was not supportive or nice themselves. You're right to suggest that environment almost always shapes the situation and reflects the ability and concerns of those in charge of the program. It's a fair point that the consequences of toxic leaders have as much or greater effect on a residents experience often without any accountability to repeat itself over and over. This is why burnout and suicide is persistent in certain residencies.

Many of us agree with you that there are people in our field have who aren't so nice and we wished everyone be nicer but many of us want to encourage real solutions.

Some of this is out of a applicants control and the best advice suggested earlier may be to avoid and not rank some programs and then proceed to other criterias

 

[deleted736562]

So much yes to this! Sometimes, people need to lash out and rightly so, but the myopic viewpoint is tiresome. Sometimes, even attempting to see the other side of issues can lead to a world of less stress.

Hard to believe the simple advice of being nice to your colleagues could cause controversy.

When I was a resident, the vast majority of the problems that erupted could have been avoided if people had been nicer to one another. That isn't malignant, manipulative, or abusive advice. That's real advice for the real world. People -- especially residents -- won't get very far with mean, bullying behavior.

Also, there are some seriously skewed perspectives on this thread. No one mandated exceptionalism nor do I think it's a bad thing that some want to be exceptional. I certainly don't have the energy and time to devote to such an endeavor, but the post that stirred all these replies gave a different vibe and that was one of simply cashing a paycheck. I am glad the OP came back to explain because the original post was not very clear. To those who aspire to be exceptional - thank you! We need you out there doing the research, writing the textbooks, teaching the courses so the rest of us can learn and do right by our patients. Some of us praise your efforts and recognize that you're not just a bunch of unfulfilled egos self-evaluating and judging colleagues. We also recognize that you're not toxic and abusive just because you have goals that others don't.

The bottom line is this: whether you're at the pinnacle of success or an intern barely skating by: be nice to others.

Really now?

I think it's actually very interesting that a very simple statement like "I don't want to be exceptional" generated such oohs and a response, "oh you're not gonna be good enough for your patients". It speaks loads about the culture of medicine and how superficially judgemental we all are. Exceptional here was read as competent. And then we wonder why people burnout? Sorry but ... Definitely a moment worth stopping on. There was really nothing unclear at all about the original statement.

The reality is that physicians are asked to treat their job as something unlike a job, which is quite hypocritical as it flies right in the face of reality and the way medicine is practiced nowadays. While a lot profess to follow the mantra, probably only a very small and truly exceptional bunch can transcend this reality, the rest is all talk.

Frankly can easily argue that marasmus showed a good level of self-awareness and reality-based judgement that is likely to BENEFIT his patients. We shouldn't discourage his honesty.

I will also echo dismay at personal attacks and assumptions thrown at pbdoctors' way by the same folk asking people to be nice. Ouch.

 

[TexasPhysician]

Keep in mind that 95%+ of all psych residents will have only trained in 1 general psych residency. This makes the discussion more suggestive. Had I been able to train in 2-3 gen psych programs, I could probably be more objective.

It boils down to checking in with peers to get a sense for how much they were enjoying residency.

I have business interests, so choosing a program that allowed ample moonlighting was great for me. I was able to try multiple different jobs and look for inefficiencies to determine where/how to start a practice.

With my primary practice going well, I’m able to look into adding different pieces to expand and opening semi-related businesses.

 

[Sushirolls]

Really now?

I think it's actually very interesting that a very simple statement like "I don't want to be exceptional" generated such oohs and a response, "oh you're not gonna be good enough for your patients". It speaks loads about the culture of medicine and how superficially judgemental we all are. Exceptional here was read as competent. And then we wonder why people burnout? Sorry but ... Definitely a moment worth stopping on. There was really nothing unclear at all about the original statement.

The reality is that physicians are asked to treat their job as something unlike a job, which is quite hypocritical as it flies right in the face of reality and the way medicine is practiced nowadays. While a lot profess to follow the mantra, probably only a very small and truly exceptional bunch can transcend this reality, the rest is all talk.

Frankly can easily argue that marasmus showed a good level of self-awareness and reality-based judgement that is likely to BENEFIT his patients. We shouldn't discourage his honesty.

I will also echo dismay at personal attacks and assumptions thrown at pbdoctors' way by the same folk asking people to be nice. Ouch.

Good summary.
Exceptional does not equate to competence.
A good psychiatrist should be able to self reflect and know strengths/weaknesses.

I suspect some psychiatrists who may judgmentally criticize some one for not throwing themselves on the sacrificial alter of physician temples (of the bygone era), also strangely support the clearly unexceptional training that exemplifies ARNPs as permissible.

 

[MacDonaldTriad]

Self reflection is essential for balance. I will point out that when your flashlight illuminates the false gods of sacrificial alters and temples, someone else looking at a different angle might wonder if some of the flashlight holders don't have some authority issues contributing to the prisms they look through. Like always, both points of view have validity.
Training is hard. It is unacceptable when it is unnecessarily hard, but it will remain hard. The trick is to not let the bumps in the road scar you too deeply. There are malicious faculty in some programs; when this happens, it is very destructive and serious, but it isn't as common as some suggest. The vast majority of academic psychiatrists are well meaning and want to make the transition to specialist as painless as possible.

 

[Mass Effect]

It’s funny because probably a majority of psychiatrists have the same or even worse attitudes than marasmus yet by the responses on this board you’d think everyone was an Ivy League trained academic, dedicated psychiatrist

Upon review of the thread, it seems you're the one who said on page 1 that you wouldn't want to be Marasmus's patient. So then you get to page 2 and you criticize those who said less insulting things?

Really now?

Yup, really.

I think it's actually very interesting that a very simple statement like "I don't want to be exceptional" generated such oohs and a response, "oh you're not gonna be good enough for your patients"

More hyperbole only lessens your point. No one said what you put in quotes. The person who came closest is the very person who then criticized everyone else for saying pretty darn close to the same thing he/she said on page one (@Merely).

It speaks loads about the culture of medicine and how superficially judgemental we all are. Exceptional here was read as competent. And then we wonder why people burnout? Sorry but ... Definitely a moment worth stopping on. There was really nothing unclear at all about the original statement

Saying there was "nothing unclear at all about the original statement" when you have multiple people objecting to it is pretty tone deaf and shows an unwillingness to accept differing opinions.

The reality is that physicians are asked to treat their job as something unlike a job, which is quite hypocritical as it flies right in the face of reality and the way medicine is practiced nowadays. While a lot profess to follow the mantra, probably only a very small and truly exceptional bunch can transcend this reality, the rest is all talk.

Hey, people are free to treat the job however they wish in my book. If you notice, I didn't reply to Marasmus's post.

I will also echo dismay at personal attacks and assumptions thrown at pbdoctors' way by the same folk asking people to be nice. Ouch.

And something else I didn't do is attack pbdoctor. I actually don't think there have been any attacks thrown PBD's way, but as a general rule of thumb, I think it's understood by most that when you post bold or potentially controversial things, people are going to reply with their thoughts. I think bold and controversial posts are fine and they spark great discussion most of the time, frankly.

Good summary.
Exceptional does not equate to competence.
A good psychiatrist should be able to self reflect and know strengths/weaknesses.

I suspect some psychiatrists who may judgmentally criticize some one for not throwing themselves on the sacrificial alter of physician temples (of the bygone era), also strangely support the clearly unexceptional training that exemplifies ARNPs as permissible.

Seems like the holier-than-thou tide has shifted.

Self reflection is essential for balance. I will point out that when your flashlight illuminates the false gods of sacrificial alters and temples, someone else looking at a different angle might wonder if some of the flashlight holders don't have some authority issues contributing to the prisms they look through. Like always, both points of view have validity.
Training is hard. It is unacceptable when it is unnecessarily hard, but it will remain hard. The trick is to not let the bumps in the road scar you too deeply. There are malicious faculty in some programs; when this happens, it is very destructive and serious, but it isn't as common as some suggest. The vast majority of academic psychiatrists are well meaning and want to make the transition to specialist as painless as possible.

Thank you for saying what I was thinking. Self-reflection is important. I also think it's important not to throw around words like "abusive" or "toxic" lightly. Those words are radioactive in medicine and unfairly categorizing people as these things is often recognized as a disservice to whatever cause is trying to be achieved. Do abusive and toxic people exist in medicine? Sure, but they're rare (at least when we stick to the actual meaning of the terms). Just because someone is criticized doesn't mean the critical person is abusive. Just because someone had a hard time at a residency, it doesn't mean the residency is abusive. If we want to combat burnout and suicide in medicine, then we need to have HONEST conversations. Judging by the general residency forum, many are gunshy when a resident complains about getting in trouble with his/her program and claims innocence in whatever the charge is. Time and time again, the truth is eventually revealed and it turns out the root of the conflict was not one sided. I think we all need to take our own inventory when we discuss things like malignant, toxic, or abusive people/programs. Usually, there's a lot more to the story and it isn't as black and white as we think. Usually, there's layers upon layers of gray.

 

[deleted736562]

More hyperbole only lessens your point. No one said what you put in quotes. The person who came closest is the very person who then criticized everyone else for saying pretty darn close to the same thing he/she said on page one (@Merely).

This is not true. That point is not an exaggeration and was implied by almost every single poster who objected to the initial statement of marasmus. The whole idea is that settling with "not exceptional" and prioritizing lifestyle is unacceptable for a physician and will be detrimental to patient care. In fact the very first reaction was your prototypical moral indignation, and mentioned patients in his care. Merely "merely" echoed that sentiment. If anything that was an understatement.

Saying there was "nothing unclear at all about the original statement" when you have multiple people objecting to it is pretty tone deaf and shows an unwillingness to accept differing opinions.

Circular logic at its best. I'm saying it's interesting PRECISELY because many people objected and interpreted the statement I a certain way and your counter argument is that I'm tone deaf because a lot of people read it in a different way? I guess groupthink doesn't exist in your terminology. I actually understand why so many reacted the way they did and explained in a post afterwards.

And something else I didn't do is attack pbdoctor. I actually don't think there have been any attacks thrown PBD's way, but as a general rule of thumb, I think it's understood by most that when you post bold or potentially controversial things, people are going to reply with their thoughts. I think bold and controversial posts are fine and they spark great discussion most of the time, frankly.

Talking about tone deaf.. Pbdoctor read a certain post as a personal attack. I read it as a harsh personal attack as well even before seeing pbd's reaction and im not concerned. I guess bringing out scars you assumed occurred in an impersonal discussion as a clear attempt to invalidate their opinions (do you even know that person?) and then topping that off by telling them they need a vacation is not personal and not an attack. We must be hypersensitive. All that matters is if one thinks they are nice; good to know.

 

[Mass Effect]

The whole idea is that settling with "not exceptional" and prioritizing lifestyle is unacceptable for a physician and will be detrimental to patient care. In fact the very first reaction was your prototypical moral indignation, and mentioned patients in his care.

Please pause your outrage long enough to go back through the thread and show me this post because that did not come from me.

Talking about tone deaf.. Pbdoctor read a certain post as a personal attack. I read it as a harsh personal attack as well even before seeing pbd's reaction and im not concerned. I guess bringing out scars you assumed occurred in an impersonal discussion as a clear attempt to invalidate their opinions (do you even know that person?) and then topping that off by telling them they need a vacation is not personal and not an attack. We must be hypersensitive. All that matters is if one thinks they are nice; good to know.

Again, this did not come from me. But I was as perplexed as the person who made the post that suggesting new interns be nice to their classmates could somehow be turned into a bad thing.

I have not attacked PBD. Quite the opposite as I meant what I said in that I have no doubt PBD has been wronged in some ways and my wish for him/her is healing and perseverance. It's clear he/she is a strong, intelligent, articulate fighter who will hopefully turn whatever has happened into a positive for others. I just tend to pause when I hear a resident write such strong words like abusive and toxic repeatedly used to describe senior residents, attendings, AND training directors all at the same program. Those are very strong words and I hope that whoever uses them has reflected on the appropriateness of them. Venting is one thing, but identifying and labeling someone as abusive because of personal conflict is unfair and does more harm than good for all parties involved.

 

[deleted736562]

To clear something, "you" was not meant as you personally in that post, but in the same meaning as "one". I'm not referring to you when I mentioned moral indignation or even personal insult. The posts are on page 1 frankly and can be easily accessed by anyone well intentioned who wants to review the thread.

I also think we owe it to be careful and prudent about personal assumptions we make about other posters instead of running away with facts we create about others. It certainly has "not so benign" and patronizing aspect to it, as a way to discount their views. Maybe pbd did have a difficult experience or maybe he knew someone who did or maybe something entirely different. I don't know. It wouldn't be unusual given the burnout epidemic among doctors and some of the highest rates of suicide among professionals.

 

[Shufflin]

I forgot what this thread was originally about...

 

[Mass Effect]

To clear something, "you" was not meant as you personally in that post, but in the same meaning as "one". I'm not referring to you when I mentioned moral indignation or even personal insult. The posts are on page 1 frankly and can be easily accessed by anyone well intentioned who wants to review the thread.

I also think we owe it to be careful and prudent about personal assumptions we make about other posters instead of running away with facts we create about others. It certainly has "not so benign" and patronizing aspect to it, as a way to discount their views. Maybe pbd did have a difficult experience or maybe he knew someone who did or maybe something entirely different. I don't know. It wouldn't be unusual given the burnout epidemic among doctors and some of the highest rates of suicide among professionals.

We all bring our own experiences to the table and to our posts. I would argue that several here made assumptions, including you, PBD, and me. And while you call out the post in particular that bothered you, there are other posts that bothered me just as much. So the assumption train goes both ways.

With that said, I agree with @Shufflin that the point of this thread has been lost in all this crap so let's just agree to disagree on this subject.

 

[Marasmus1]

Guys that statement is coming from a person ( me) who did research at IVY league institutions, well published and scored very high on standardized tests. I tried to be exceptional but as you grow older, you see certain things more clearly . Aiming to improve patient care is one thing trying to be great is another. Greatness may come or not and I am not interested in it. I am not aiming for it. We have to separate certain terminology. I will try to do my best for my patients to the best of my abilities but I have dropped the desires. Desires helped me come where I am now, but it also left many scars behind. So no more desires for me except that I will make sure to minimize uncomfort and inconvinience in my life by any means. For me the discussion is over. I will not say any more words.

 

[Duloxetini]

The definition of greatness is relative to those asked the question.

Ask a patient that's had many doctors what makes one (or more) of them stand out as great and you'll get a very different answer relative to asking a psychiatrist what it means to be great in the field.

I hope we can start this thread anew. Theres a lot to be fleshed out here that doesn't require the level of malarkey* and mud slinging that this thread devolved into. Folks are interested in this field. Let's guide them to what they should know about themselves and programs to know what to look for. As someone that recently went through the process, it's quite daunting. Add to that what happened at a program like Drexel and it's even more so.

*I just really wanted to use that word

 

[kopftonmd]

I hope we can start this thread anew. Theres a lot to be fleshed out here that doesn't require the level of malarkey* and mud slinging that this thread devolved into. Folks are interested in this field. Let's guide them to what they should know about themselves and programs to know what to look for. As someone that recently went through the process, it's quite daunting. Add to that what happened at a program like Drexel and it's even more so.

Should applicants be concerned about hospitals closing, à la Drexel/Hahnemann? Or should that not be a concern since it's hard to know if/when/how stuff like that happens?

 

[Laradd]

Should applicants be concerned about hospitals closing, à la Drexel/Hahnemann? Or should that not be a concern since it's hard to know if/when/how stuff like that happens?

You should ask that in your interview. "Do you plan on closing your hospital soon?" I would love to hear the answer to that question

 

[NickNaylor]

Should applicants be concerned about hospitals closing, à la Drexel/Hahnemann? Or should that not be a concern since it's hard to know if/when/how stuff like that happens?

I highly doubt that this is something a program director would be aware of. In general, I think most large academic hospitals are a relatively safe bet. Where you might start to get in trouble is smaller programs based out of smaller community hospitals that may not be as "stable," for lack of a better word.

 

[hallowmann]

Its important to recognize that things change. 4 years is a long time. I would encourage myself to focus on identifying the culture of programs and making sure that matches an environment I would like to work and train in. People come and go, policies change, work honestly increases and decreases, but the culture takes a lot longer to change than 4 years.

Guys that statement is coming from a person ( me) who did research at IVY league institutions, well published and scored very high on standardized tests. I tried to be exceptional but as you grow older, you see certain things more clearly . Aiming to improve patient care is one thing trying to be great is another. Greatness may come or not and I am not interested in it. I am not aiming for it. We have to separate certain terminology. I will try to do my best for my patients to the best of my abilities but I have dropped the desires. Desires helped me come where I am now, but it also left many scars behind. So no more desires for me except that I will make sure to minimize uncomfort and inconvinience in my life by any means. For me the discussion is over. I will not say any more words.

I believe this has already been said, but if not, I'll say it. The issue people seemed to have with your statement is their definition of exceptionalism being inconsistent with your definition of exceptionalism. Greatness to you is very different than greatness to me. To me, an exceptional doctor is one that strives day in and day out to improve and do right by their patients, even at the expense of their ego. Sometimes they become famous, which I believe most closely approximates your definition of greatness, but most of the time they don't.

I feel most do appreciate your clarification, as it is more consistent with how most doctors are (only a small fraction practice in Ivory towers after all).

Should applicants be concerned about hospitals closing, à la Drexel/Hahnemann? Or should that not be a concern since it's hard to know if/when/how stuff like that happens?

I mean, I think you should be aware of the economical climate of the hospital system you're about to join. That said, it may have nothing to do with the quality of the training or your fit into it, both of which are very important.

 

[pbdoctor1]

Its important to recognize that things change. 4 years is a long time. I would encourage myself to focus on identifying the culture of programs and making sure that matches an environment I would like to work and train in. People come and go, policies change, work honestly increases and decreases, but the culture takes a lot longer to change than 4 years.

This is a very important point. It is 4 long years. The chances of leaving a residency are slim to none.

Cultures don't change and it can be a serious problem for a few toxic residencies as SDN members have described. There is reason why burnout and suicides exists in residency.

 

[hallowmann]

This is a very important point. It is 4 long years. The chances of leaving a residency are slim to none.

Cultures don't change and it can be a serious problem for a few toxic residencies as SDN members have described. There is reason why burnout and suicides exists in residency.

To be clear, I don't just mean malignant vs. not. The cultures of some programs may simply not match your personality, and that can make a difference with regards to your success during residency.

 

[pbdoctor1]

To be clear, I don't just mean malignant vs. not. The cultures of some programs may simply not match your personality, and that can make a difference with regards to your success during residency.

There is a level of group think in residency cultures which includes residents, attendings, and PDs. It may not even be malignant but it is a one set mind. If a resident doesn't mesh well it can be either annoying at best or career ending at worst.

A poor fit is challenging for both applicants and programs. The irony however is that the serious consequences always fall hard one way and it's upon residents. Then again as pointed out by others most psychiatry residencies are generally reasonable and supportive. The malignant programs that still exist are just terrible and unethical, as discussed quite extensively by SDN members. A culture of burnout and retaliation is prolific there for a reason and a risky proposition for any resident.

Either way I'm afraid applicants may not have a choice in the matter nor do residency programs. The only control they have is not ranking a program.

 

[sloop]

I really like my program. My co-residents are some of the smartest, most dedicated people I’ve met. I have a lot of pride in this place and I think it provides clinical training that is arguably the best that can be had. I ranked this place number 1 and, knowing what I know now, I wouldn’t change that decision.

Having said that, I did not prioritize lifestyle very highly and I would probably pay more attention to lifestyle if I was doing it again. I was even quite skeptical of programs that would advertise work-life balance or similar. I chose my program in part because I wanted to work hard and be the best psychiatrist I could be. I’m not sure that I was prepared for how grueling a rigorous psych program can be.

Many of the things that were attractions for me as an applicant (ICU, highly medically capable psych units, highly resident-dependent services, extremely complicated referral cases) have been sources of a lot of stress. In retrospect, having already paid the price of such experiences, I’m very grateful to have had them. They have all made me a better psychiatrist but some of them carry a price of stress and time that may not be justified depending on what you want to do. I paid no attention at all to this point as an applicant but it deserves at least some attention.

 

[Merely]

I really like my program. My co-residents are some of the smartest, most dedicated people I’ve met. I have a lot of pride in this place and I think it provides clinical training that is arguably the best that can be had. I ranked this place number 1 and, knowing what I know now, I wouldn’t change that decision.

Having said that, I did not prioritize lifestyle very highly and I would probably pay more attention to lifestyle if I was doing it again. I was even quite skeptical of programs that would advertise work-life balance or similar. I chose my program in part because I wanted to work hard and be the best psychiatrist I could be. I’m not sure that I was prepared for how grueling a rigorous psych program can be.

Many of the things that were attractions for me as an applicant (ICU, highly medically capable psych units, highly resident-dependent services, extremely complicated referral cases) have been sources of a lot of stress. In retrospect, having already paid the price of such experiences, I’m very grateful to have had them. They have all made me a better psychiatrist but some of them carry a price of stress and time that may not be justified depending on what you want to do. I paid no attention at all to this point as an applicant but it deserves at least some attention.

Yeah I mean if you want to be a run of the mill community inpatient or outpatient doc your program is not really gonna offer many advantages, I feel your program is for someone wanting to be an academic psychiatrist/leader