Where have you interviewed? Med-Psych people, I know you're out there!

[Abram Hoffer]

If you've interviewed at any of the 13 or so Med-Psych programs, can you give us an idea of any of the differences you see among the programs?

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[atsai3]

If you've interviewed at any of the 13 or so Med-Psych programs, can you give us an idea of any of the differences you see among the programs?

FWIW, this is what I thought of Duke's med-psych program when I interviewed for the 2006 match: (note some of the information here may be outdated)

For the combined program, you interview with medicine and psychiatry on separate days. Both the medicine faculty and the psychiatry faculty make it very clear that they are interested in "quality, not quantity" and that if they don't identify any candidates they are truly interested in, then they don't rank the candidates, i.e., they would rather go with unfilled spots than accept subpar candidates. I suspect their experience in the past has been subpar psychiatry applicants trying to backdoor into the medicine program, but that is speculation on my part.

• In 2005-06 they made a substantial change in going to a one-year intern year (as opposed to the previous two-year intern "year"). In the past, you did 6 months of medicine and 6 months of psychiatry, and then another 6 and 6 -- but during the second year, you were still considered an "intern" (and hence still wearing the short white coat) while the other interns you entered with were doing JAR (Junior Assistant Resident) activities. It was kind of demoralizing to see your classmates advance to JAR status while you were kicking around as an intern for another year, so in 2005-06 they changed it to only one year of internship. The first year is pretty much a medicine internship (8 months medicine), and this was done for 2 primary reasons: (1) The medicine structure is more rigid than the psychiatry structure. On the medicine side of things, second year residents are JARs and have a different set of responsibilities, and it's only possible for the med/psych residents to do this during their 2nd year if they've done a medicine internship. (2) They've had some problems with attrition, with residents dropping out of med/psych to do just psychiatry. This creates administrative and scheduling problems for both programs. So front loading makes it a little easier in terms of being able to advance to JAR status with the rest of your intern class (and hence less demoralizing), but also in terms of having the 2nd and subsequent years being a little lighter. The later years of the program are more heavily weighted towards psychiatry.
  
• Some med/psych programs are dominated by what I would call the "hyper-competent hospitalist" type: docs who can handle pretty much any inpatient situation and hit doubles and triples every time they step up to bat no matter what kind of patient you throw at them. Other med/psych programs are dominated by what I would call the "I want to take care of the whole patient" type: docs who want to do primary care psychiatry. Because internal medicine is such a huge presence at Duke (40+ interns per class or something like that), the med/psych program is understandably dominated by more of the "hyper-competent hospitalist" type of faculty members. If this is any indication: When Dr. Gagliardi applied for residency programs as a 4th year medical student, she applied for medicine and med/psych programs. And Dr. Silvertooth started out in the medicine program and transferred to med/psych after her intern year. Of the residents, I would guess that only 2-3 of them are the primary care psychiatry type, with the rest being future hyper-competent hospitalists.
  
• The first two years are pretty tough. The PGY1 year of the medicine program kicks your ass. While the PGY1 year of the psychiatry program is relatively cush, the PGY2 year of the psychiatry program kicks your ass -- and you do the equivalent of the PGY2 year during Y2 of the combined program. So it's two tough years back to back. I'll bet that will make for some pretty dark days.
  
• The Associate Program Director for med-psych, Jane Gagliardi, is wonderful. She's a ball of energy and would rather walk up 8 flights of stairs than take the elevator. And I'd bet a quarter that her pulse is sitting at an even 50/min by the time you get to the top.
  
• The combined program has a long history at Duke, and it enjoys strong support from both programs. Dr. Ralph Corey, the former internal medicine program director, started the med/psych program, and he seems to be pretty much venerated at Duke by the medicine faculty and the psychiatry faculty alike. (He is no longer the medicine program director, but apparently he still commands an imposing presence at the institution. The chief resident refers to him as "the big man".)
  
• The Duke medicine residency has an international health program where you can opt to do a 3 month rotation abroad during your PGY3. If there is any scarcity, med/psych residents get dibs because Ralph Corey is such a strong supporter of the program.
  
• Unless your institution has a specialized med-psych service, your life as an attending can be difficult. If you are a medicine attending, your colleagues will try to give you all the borderlines. If you are a psychiatry attending, your colleagues will try to give you all the medically ill patients. This can make for a rich practice setting, but you don't get paid for the extra time you spend with the more complicated patients. So unless you are hypervigilant, your service will become a dumping ground. At Duke, the medicine services try to dump "awaiting dispo" patients on the med-psych service, but the med-psych service has complete control over who they do and do not accept. If they feel they're getting too busy, they can just say "we have too many patients" or "she's not appropriate for our service" and the matter is settled.
  

You have to be extremely circumspect when picking a med/psych program. In order for your training experience to be a good one and so that you don't just get lost in the cracks when you are 'off-service', you need the following: a strong medicine program director; a strong psychiatry program director; a strong medicine program director who supports the concept of med/psych training and who will advocate for your education; a strong psychiatry program director who supports the concept of med/psych and who will advocate for your education; and a strong med/psych program director who can manage the med PD and the psych PD. Same goes if you are interviewing for family med/psych. If your program doesn't have all of these elements, your training will suffer. (I interviewed for psych and med/psych -- and ultimately chose to go psych-only -- but for what it's worth, the only program that I felt met all of these criteria was Duke. Others on SDN may feel otherwise.)

-AT.