why are all the alumni of my program going into fellowships and academia?

[thomasina]

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I was looking at the "where our alumni went" pages of various psychiatry residency programs (including my own program) in my region. It seems like many of the people who went to relatively fancy academic programs also end up doing fellowships (psychoanalysis, research, public health, child, geri, CL) or take on attending positions at academic institutions, and it seems less common for people in my program to take on community, VA, or state hospital jobs - for example, on my residency alumni page, it seems that only one person in over a 10-year period took a job at a state hospital right out of residency, and about one person every two to three years went into a community job. I don't think any of them went to work at a VA, and none of them went to smaller/?for profit community hospitals.

Why is this? I get that academia gives you exposure to cool cases, maybe there are different leadership opportunities, there is a ladder of prestige / credentialism to climb which might appeal to some, and sometimes people like teaching... but how are all these people - and these are people at fancy programs who I imagine could get most of the jobs they apply for - willing to take the salary cut and/or further delay making a normal attending salary? Do they experience a salary cut or are the people who choose this kind of path also able to carve out some other niche that offsets this cut that I am not seeing? (I'm sure if they really wanted the academic affiliation they could just supervise a few trainees to maintain the affiliation and call it a day.) Is it that academic jobs and fellowships allow greater flexibility? Is it that these jobs at VAs and smaller hospitals actually suck? Do these graduates just have really wealthy families/spouses or something that make academia possible? Is it just that the people that end up in fancy residency programs tend to be selected for neurotic overachievement and this continues on for them after residency, trumping financial comfort? Can somebody comment on what is happening here?

I almost feel like I'm doing something vaguely wrong in considering jobs beyond academic institutions, and I don't have many upperclassmen examples of people who just went out and got a job at a small hospital or group practice.

 

[brosa]

I will just make a guess here but "Is it just that the people that end up in fancy residency programs tend to be selected for neurotic overachievement and this continues on for them after residency, trumping financial comfort" sounds very probable.

 

[reca]

It does seem like more psych residents are doing fellowships. I don't know if you can attribute that to selecting for "neurotic overachievement." I think as psychiatry increases in competitiveness, so too does the number of psychiatry trainees interested in fellowship. The opportunity cost is considerably less than it would be for other specialties. I know two of our recent grads who went into fellowship actually outearned their peers who went straight into the "real world." One of them picked up a good amount of moonlighting and the other started a cash only private practice during fellowship that really took off a few months in.

 

[thomasina]

It does seem like more psych residents are doing fellowships. I don't know if you can attribute that to selecting for "neurotic overachievement." I think as psychiatry increases in competitiveness, so too does the number of psychiatry trainees interested in fellowship. The opportunity cost is considerably less than it would be for other specialties. I know two of our recent grads who went into fellowship actually outearned their peers who went straight into the "real world." One of them picked up a good amount of moonlighting and the other started a cash only private practice during fellowship that really took off a few months in.

What types of fellowships?

 

[reca]

What types of fellowships?

One was geri (the moonlighting one) and one was C/L (private practice one).

 

[wolfvgang22]

Why don't you ask them?

 

[NontradCA]

Probably because they want to be. Ive met a few psychiatrists with egos. I’ve never met one who was pursuing something that wasn’t self motivated and pressured by outside forces. I’m sure they’re out there, but I’d guess they’re the small minority. Its relatively easy to break into any subspecialty, practice setup or work environment you desire.

 

[hamstergang]

Do these graduates just have really wealthy families/spouses or something that make academia possible? Is it just that the people that end up in fancy residency programs tend to be selected for neurotic overachievement and this continues on for them after residency, trumping financial comfort?

You think that going into academia without a wealthy spouse leaves a psychiatrist in financial discomfort? Sure, it pays less than other options but it's hard to claim that such a salary, so far above the average household income, isn't comfortable.

 

[docksan]

Hear me out, but it could just be that they enjoy academia and don't care about money.

 

[splik]

There are couple of factors that play into this. One is that academic mentors often don't know anything else and tend to encourage their trainees to pursue the kind of career their biases say hold the most value. Some residents at certain programs may feel nudged in that particular direction. Residents at certain programs tie in some of their self-worth to that and in can be reinforcing. If everyone else is going a certain route there may be more pressure and less support for carving out a different path. There is also comfort and safety in academic environments if that is all you know. I talk to some residents and they are scared of practicing in other settings having heard hellish stories. This is why it is a good idea to do external moonlighting to get a flavor of what it is like in other settings. The financial issue is spurious, as you aren't noticing a pay cut if your pay is going up substantially from residency even if you could earn more elsewhere. Finally, if you have a really positive experience in training you are more likely to want to continue in training or working in an academic environment.

Also there is certainly a range even in academics. I make as much or more than many colleagues in non academic settings and see fewer patients and get to spend a lot of time with patients providing high quality care. The benefits aren't what they were, but they are still better than most other places. I do work longer hours and have more responsibilities but a lot of that is self-inflicted and related to professional advancement and career progression. I often think about going into private practice for example, but my subspecialty is so academic it would be hard (though not impossible) to do. Also for those who have a passion for medical education and training residents and students, it is hard to replicate that. sure you can get a volunteer appointment and do some teaching at most med schools, but that is very different from training students and residents on a daily basis

 

[PikminOC]

My friend works at henry ford. He makes enough. Has a good work life balance. Has residents for call. Isn't chasing rvu fairy.

 

[psychacad]

It's a very good question. I noticed this among my colleagues as well. I think part of it is general hesitance to step outside; the other part is external pressure. I do think the cost/benefit ratio for the majority of fellowships is pretty high and does not justify them. You can possibly make an exception for forensic/child if you're passionate about the field. It's a bit puzzling to me cause in psych, particularly at well known academic places, there is ample opportunity to pursue what you want in 4th year. The people who benefit the most from this are obviously employers/those same academic places as they are getting cheap labor.

 

[dl2dp2]

Do these graduates just have really wealthy families/spouses or something that make academia possible? Is it just that the people that end up in fancy residency programs tend to be selected for neurotic overachievement and this continues on for them after residency, trumping financial comfort? Can somebody comment on what is happening here?

Yes, especially people who go into a research dominant career, often have wealthy parents or spouse. There are several other factors at play. The high end cash psychiatrists, arguably the most lucrative subfield in our field, are typically fellowship trained and have some academic affiliation. So you might think of this as an investment rather than a sacrifice.

You think that going into academia without a wealthy spouse leaves a psychiatrist in financial discomfort? Sure, it pays less than other options but it's hard to claim that such a salary, so far above the average household income, isn't comfortable.

Sometimes yes, sometimes no. While perhaps the average academic job pays less than the average community job, IMO the variance is also higher especially if you include the subset of semi-academics who derive their income through running an outside business in some way and/or people in management at large institutions.


I think the impression that people from high end places are giving up on money is an illusion. In general people who make 1M+ in clinical psychiatry have a fancy pedigree. Some community psychiatrists end up making a lot of money, but often they do that through activities outside of clinical practice (i.e. real estate, etc)

 

[SourceOfDenial]

Yes, especially people who go into a research dominant career, often have wealthy parents or spouse. There are several other factors at play...

Uh, what? I feel like when psychiatrists write about psychiatrists who do mostly research(>50% FTE), they aren’t actually psychiatrists doing mostly research.

 

[Candidate2017]

I almost feel like I'm doing something vaguely wrong in considering jobs beyond academic institutions, and I don't have many upperclassmen examples of people who just went out and got a job at a small hospital or group practice.

Because The Man wants to keep you down. My program is openly disdainful of, and discourages, private practice, to the point where we feel they are trying to handicap us. There is also more than a hint of jealousy with respect to income.

 

[Celexa]

Because The Man wants to keep you down. My program is openly disdainful of, and discourages, private practice, to the point where we feel they are trying to handicap us. There is also more than a hint of jealousy with respect to income.

My (very academic) program is not nearly as hostile to private practice as what you describe, nonetheless the people considering it feel somewhat unconsciously shamed... which undoubtedly stems from the stronger encouragement to go into research/acaddmics/fellowship due to attendings needing to justify their own sacrifices to themselves.

As long as you are practicing good psychiatry no one should feel guilty about their practice setting.

 

[thomasina]

My (very academic) program is not nearly as hostile to private practice as what you describe

I don't think that my program is necessarily hostile to private practice. Actually, it seems like many psychiatrists in my hospital have a private practice on the side. It's more the small nonacademic/community hospitals that I never see anybody work at.