Why are top psych programs and most all programs in a crappy city?

[drmistga]

---

Members don't see this ad.

Now before anyone starts throwing the flame thrower about how certain programs are amazing in good cities, this is a generalization. But take psych-I know offhand for example take Upenn, hopkins, OHSU(debatable location) and then within the cities they are often in the worst areas. I mean does serving an underserved population have something to do with it-like hopkins still blows my mind as to how that became such an elite place or why they never made the move somewhere else-I dont know I guess there are lots of programs in great cities-probably more now that I think of it-but in general the top programs are not in cities I would want to live really.

 

[tr]

1) You need a lot of land to build a hospital, and land is cheaper and more readily available in slummy neighborhoods

2) Nobody wants to live near the hospital if they can help it (loud ambulances at all hours of the night, various ill undesirables hanging about), so the fact of the hospital's being there sends the property values down

3) Actually, despite these factors there are some very nice programs in very nice cities (Columbia/Cornell/NYU in NYC, UCSF in SF, McGill in Montreal, MGH in Boston)

4) What's your definition of a "nice city" anyway? Frankly there are lots of places I wouldn't want to live that probably qualify as "nice cities" for people who have different desires than I (Atlanta and Raleigh-Durham come to mind)

 

[PsychMD2100]

Your question speaks to a broader question of urban decay since the post-War era of the 1950s. As interstate highways were built and cars became more available to everyday Americans thanks to an end of war rationing, the suburbs took on a life of their own. Many people with the economic means left the inner cities for the 'burbs. Thankfully, this is beginning to reverse as sprawl has reared its ugly head.

To speculate on why the top notch places are often in terrible locations, these prestigious academic centers started in their respective city centers. With time, the center of gravity shifted to the 'burbs but these centers of excellence couldn't simply pick up and move because they had already put down roots. Thus, they've been left to care for the populations that remained behind.

As mentioned, though, things are beginning to change even around places like Penn, Hopkins, etc. People are fed up with trying to commute an hour one way. They're starting to move back into the city and this is helping to change these inner city areas for the better.

 

[whopper]

then within the cities they are often in the worst areas. I mean does serving an underserved population have something to do with it

There are several answers which are psychiatric fact and not just my mere opinion.

1) Psychiatric disorders though not extremely rare are not commonplace. Therefore you would expect to see them in higher concentrations in areas with dense populations. "Crappy cities" tend to have this.

2) Most people with a psychiatric do slide down the socioeconomic scale because their mental illness makes them unable to take care of themselves socially & economically.

3) "crappy cities" as you put it tend to be areas where people are not happy--therefore increased incidence of depression. Such areas have depressed economic outlooks, higher crime & drug abuse, higher rates of murder etc. Further, most "crappy" areas are laden with drug abuse with increases the incidence of dual diagnosis patients.

4) Areas where there is little oppurtunity have more people wanting to use the hospital system for gain. Urban centers are often areas where homeless accumulate, and hospitals in this vicinity often get homeless malingering for "3 hots & a cot". While many of these patients really do not need psychiatric services, if they show up to a hospital faking a psychiatric illness, you need a psychiatric dept to deal with it.

The following I don't know is fact but I believe might be...

Another factor, and this is an area which I'm not well studied on is that from what I understand, the more densely packed a population is, per capita, you're going to see more mental illness. Now I could be wrong on this so if I am, someone correct me. I did do a google search to see if some sources back this and I did find some sources, but this is not to say its been verified enough to back it up as an accepted fact.

 

[drmistga]

I guess I was thinking more along the lines of what keeps a great program great-its docs that are with the program and to me it seems a bit strange that top docs in their field would want to live in less desirable cities-I understand training in a city that is inner city or not as desirable but I am thinking down the line as a doc when I am 40 or something I may be sick of the grind-just a thought.

 

[whopper]

What makes a residency program great IMHO.

You got docs with good knowledge & experience that teach well. The hours won't kill you. You'll get a good overall diversified education, you'll be able to get into a fellowship should you choose.

Hate to say this, but there is no book that'll tell you which programs are good and which aren't. Most guides that try to rate programs do so by factors that hardly anyone cares about, e.g. programs ranked by how much money they get for research.

The above was an actual method I saw that some source tried to use to rate programs as "prestigious" and therefore more desirable for a resident. I say it was bogus. That type of methodology only tells you 1 thing--how much money that program will get for research.

Research though nice is one of the lower priority reasons to pick a program.

Another I hate to tell you is the most important thing I've found in picking a program is to just find out from reliable sources "under the table" in a program. Every program you'll interview at will tell you that their program is phenomenal. I was a medstudent doing IM rotation and everyone at that IM program hated it but told the candidates their program was great.

According to the program director at LIJMC, the #1 reason why medstudents pick a program is simply the location.

As for "crappy cities", some have good programs. In general, I've noticed that urban programs in "crappy" areas tend to kill residents with work hours, and programs in nicer areas tend to be easier. However, this is only a generality, and further, seeing the "crappy" areas sometimes trains you better. You'll get better traning being in warzone than a marble temple. My advice is try to get a program that offers a little of everything.

 

[Anasazi23]

I was just talking about this with someone who's looking for a cardio fellowship out of medicine. It seems that many good hospitals in general, not just psychiatry residencies, are located in "crappy" areas. Hopkins, Yale, MGH, etc. (I can't agree with Columbia being in a nice area. The immediate surrounding area's a dump. The men's shelter is located directly across the street).

 

[sga430]

most of the well off dudes dont want to be poked around by residents. this is probably especially true in psych.

 

[Chewbacca Jung]

I think that historical reasons explain both why the programs are where they are (educated people lived in the cities 100-200 years ago) and why those old major urban areas are dumps (free ways, white flight, and suburban explantion, sprawn and rot...). Functional and logistical reasons explain why those hospitals are still there (that's where the patients are that will pay for you to experiement on them, and it costs way to much to move).

Colorado is a good example of this. The psych program has been living out of a 100 year-old assylum for the past... 100 years. They are now in the process of moving to a place way out on the plains-- towards the outer rim of the Denver greater sprawl. Even though the land is cheap, the cost of opperating two hospitals is prohibitive, as they make the shift. So now they have a bright shiney new building on the plains.

The fun part, of course, happens in 50 years, when reurbanification has reached its nader, and everyone will be wondering why all these great programs are way out in the boon docks. Then in 100 years, they'll be buying back their old land.

So I think some of these programs are hedging on reurbanification, others are too steeped into tradition to consider such a radical change in identity. Some are just slow. Others realize that urban/suburban trends aren't really all that stable, and it may be best to sit tight and loose a few applicants here and there to San Diego.

 

[lloyd braun]

When I interviewed at Hopkins, I was actually excited about the prospect of working with the Baltimore population. I asked the PD about involvement with the community, and he said that JHH had the option to move elsewhere several years ago, but decided to stay in their current location to reflect their long-time commitment to serving the inner city Baltimore population. That's pretty dope, I thought.

 

[Chewbacca Jung]

I asked the PD about involvement with the community, and he said that JHH had the option to move elsewhere several years ago, but decided to stay in their current location to reflect their long-time commitment to serving the inner city Baltimore population


I agree with you, that if that is the genuine sentiment of the PD, that is pretty encouraging, with respect to the PD and the program. But those whose best interests lie with the community, tend not to be the ones holding the pocket book-- nor fiscal responsibility to the shareholder. So, I'm sorry to be a little cynical, but at a major university hospital like Hopkin's, loyalty always lies with Hopkin's first. Then the community. I imagine there were other reasons, more economical in origin, that influenced the board members to vote to stay. But hey, what ever helps with PR.

 

[whopper]

"crappy" areas also are areas where several other nonpsychiatric problems occur..

E.g. diabetic who doesn't ever take their meds, now walks into the ER with a hole in the toe so big the bone is exposed. They've been soaking that hole in salt water everyday for a month thinking it'd actually work.

Crack addict having her 5th baby while simultaneously high on crack & heroine, brought in by her pimp who was having her do her profession even while pregnant

41 y/o guy has stroke after taking in crack cocaine. He can't move half his body and he's in the ICU, yet manages to walk down 4 floors so he can obtain another hit of crack, smoke it and walk back into the ICU.

Seen all the above in Newark NJ.

People in crappy areas don't have money, often don't take care of themselves and their medical problems which could've been stopped in early stages eventually end up ballooning into something big & bad.

 

[PsychMD2100]

It's hard for me to agree with the claim that applicants choose based on location as their #1 criteria.

Selection criteria are as varied as the applicants themselves. To say that location is the #1 factor is a broad generalization.

Looking back into my college and med school experiences, I would hardly say that people chose based on location. If anything, there were people who hated where we were but wouldn't trade the education we received for anything.

Likewise, it's an individual process for picking residencies. When you look at the list of resident bios at these programs in "crappy" places, there's an impressive distribution of people from all over the country. Sometimes, the locals are a minority. Many times, people will turn down a great location in favor of the stronger educational experience.

 

[RustNeverSleeps]

It's hard for me to agree with the claim that applicants choose based on location as their #1 criteria.

Selection criteria are as varied as the applicants themselves. To say that location is the #1 factor is a broad generalization.

Looking back into my college and med school experiences, I would hardly say that people chose based on location. If anything, there were people who hated where we were but wouldn't trade the education we received for anything.

Likewise, it's an individual process for picking residencies. When you look at the list of resident bios at these programs in "crappy" places, there's an impressive distribution of people from all over the country. Sometimes, the locals are a minority. Many times, people will turn down a great location in favor of the stronger educational experience.

It seems that, relative to college and med school, people seem to pick residencies more on the basis of location, with the exception of people in really competitive fields who sometimes cannot afford to be as choosy.

Another point that others have mentioned is that location is in the eye of the beholder and what determines a good location (i.e. proximity to family and friends, climate, cost of living, urban v. suburban, etc.) varies from person to person. For instance, UPenn may be in the bad part of Philadelphia, but a lot of people want to live in Philadelphia (not necessarily right by the hospital, though). Many people think Boston and NY are nice cities, but I would never want to live there because it is too cold and too expensive.

 

[maranatha]

It's hard for me to agree with the claim that applicants choose based on location as their #1 criteria.

Likewise, it's an individual process for picking residencies. When you look at the list of resident bios at these programs in "crappy" places, there's an impressive distribution of people from all over the country. Sometimes, the locals are a minority. Many times, people will turn down a great location in favor of the stronger educational experience.

It seems that, relative to college and med school, people seem to pick residencies more on the basis of location, with the exception of people in really competitive fields who sometimes cannot afford to be as choosy.

I've noticed that the more competitive the program, the more diverse the locations of the residents. OTOH, the less competitive the program, the more local the residents tend to be. Only exception would be Utah...But being 20 to 30 minutes away from some of the best sking in the country probably makes this an exception. 😀

 

[whopper]

"It's hard for me to agree with the claim that applicants choose based on location as their #1 criteria."

The info I got was from the program director from LIJMC, and said he conducted a study on it. He brought that up because he told me during the interview, he really wanted candidates to see that his program had a lot to offer and not miss candidates that would choose another place just because of the location.

He said according to his study, this was the case because most candidates wanted to settle down in the area where they chose residency and chose the program based on location because the candidate wanted to live in that area.

 

[PsychMD2100]

With all due respect, assuming a perfect scientific method, what was the power of that study? N = 25? N = 50? Remember, there's about 17,000 residency positions each year in the US. You've also got to remember that the people that attend LIJMC may be a self-selecting group that will skew the outcome of the study.

If you've got a link to the study, I'd be happy to take a look.

Otherwise, I've got to wonder about this study performed by a single individual in a single location in Long Island. Have the results been duplicated elsewhere?

After looking at the origins of the residents at these programs in "crappy" places, one gets the distinct impression that location was not a factor in their decision. Inner-city Philadelphia, Baltimore, New Haven, way-North Manhattan would hardly be described as places that most residents would want to settle and practice.

It underscores that education is #1 for many people and location is secondary. While I wouldn't go so far as to say that education is #1 for all, I don't think location readily surpasses education, as that study would suggest.

 

[RustNeverSleeps]

With all due respect, assuming a perfect scientific method, what was the power of that study? N = 25? N = 50? Remember, there's about 17,000 residency positions each year in the US. You've also got to remember that the people that attend LIJMC may be a self-selecting group that will skew the outcome of the study.

If you've got a link to the study, I'd be happy to take a look.

Otherwise, I've got to wonder about this study performed by a single individual in a single location in Long Island. Have the results been duplicated elsewhere?

After looking at the origins of the residents at these programs in "crappy" places, one gets the distinct impression that location was not a factor in their decision. Inner-city Philadelphia, Baltimore, New Haven, way-North Manhattan would hardly be described as places that most residents would want to settle and practice.

It underscores that education is #1 for many people and location is secondary. While I wouldn't go so far as to say that education is #1 for all, I don't think location readily surpasses education, as that study would suggest.

I think you are sort of mis-stating the location factor for purposes of argument. Attending UPenn does not mean that you are limited to practicing in inner-city Philadelphia, obviously. A lot of people like Philadelphia and to them, one of the advantages of Penn is living in Philadelphia (but not necessarily living in inner-city Philadelphia) and the ease of transitioning to a professional career there or in the surrounding areas. I just don't get the leap from people matching in high quality programs in bad parts of less-than-excellent cities to assuming that "one gets the distinct impression that location was not a factor in their decision." Also, the relatively weaker of match lists -- strictly in terms of med schools -- of educationally strong programs like Pitt (which had to scramble last year, I believe) and JHU argues for the importance of location.

In addition, there obviously many studies published with N's of 25-50. That can be plenty of people if the effect size is reasonable. Also, depending on the methodology, the study could have easily included more people. I agree that it is good to scrutinize data, but there is a certain "truthiness" aspect to rejecting a study sight unseen and going with your gut feeling. (But as you can see from my avatar, I really like Stephen Colbert, so that is not necessarily a bad thing.) 🙂

 

[lloyd braun]

"Also, the relatively weaker of match lists -- strictly in terms of med schools --of educationally strong programs like Pitt (which had to scramble last year, I believe) and JHU argues for the importance of location."

Western Psych had to scramble last year??? Are you sure??? This program impressed me the most, and I think Pittsburgh is a beautiful city.

 

[whopper]

"With all due respect, assuming a perfect scientific method, what was the power of that study? N = 25? N = 50? Remember, there's about 17,000 residency positions each year in the US. You've also got to remember that the people that attend LIJMC may be a self-selecting group that will skew the outcome of the study."

Good question, however I did not get into that level of detail. He did though say that his work was conducted not only with his own program but with others. Hate to say this but you might want to give LIJMC a call (Long Island Jewish Medical Center).

I can also say from personal experience that several residents I knew did choose programs by location. What happened with them was that except for "name brand" programs, they didn't see one program as much better than another, so just based it on living location. That made sense to me because most people I know don't know if a program is good or not and don't have any guides that'll allow them to discriminate the program in terms of better & worse other than the more famous ones--e.g. Ivy League programs--which sometimes are better only because the name inspires more applicants---> better applicants --> better residents --> better program.

 

[PsychMD2100]

Thanks RustNeverSleeps,

I think I've met you on the interview trail. Without giving specifics, I think we've talked before.

In any case, points well taken. I've wrestled with the location/lifestyle vs. prestige/education bit for a while. I can't say that I've found a solid answer--but I guess that's my point: it's an individual process.

 

[maranatha]

I've wrestled with the location/lifestyle vs. prestige/education bit for a while. I can't say that I've found a solid answer--but I guess that's my point: it's an individual process.

I'm ranking my top 1 and 2 in places that I do not plan on staying--not based on location. My main criteria are that I think the programs are strong educationally and that I "fit" in with the residents. (Both programs are, however, in cities I'd be happy to live in 4 to 5 years, even though I will not stay.) I'd also consider them to be middle of the road as far as work hours are concerned. N=1.

Any one else?

 

[Chewbacca Jung]

I did not apply to any programs that were in cities where I did not want to live-- particularly Boston, New York, D.C, Philly,...-- too big, too expensive. And I don't think I sacrificed my education in anyway, as I found some great programs in some great areas (great by my criterea, any way). So, I don't think you have to go to these monstopolises to get the education you want, unless you must have that big-shot-program name emblazened on your reseme. There are plenty of options in psych which don't compromise your future.

 

[worriedwell]

Also, the relatively weaker of match lists -- strictly in terms of med schools -- of educationally strong programs like Pitt (which had to scramble last year, I believe) and JHU argues for the importance of location.

Two things, one is that yes Pitt had to scramble to fill two years ago (not sure about last year). I don't really know what that says about the program but it is truth, others can speculate on what that means.

Second, be very careful about looking at match lists and judging the quality of residents based on the name of the institution where they went to med school. Having been around the block a bit in and around some "reputable" psych residency programs and seen away rotating med students from different name and non name institutions as well as interacting with and hosting numerous applicants, this way of judging people is a major pitfall. In fact, sometimes I feel like that great applicant from a lesser known school who is bright, hard working and personable gets less benefit of the doubt when the committees meet for these things. The irony is that they know people look at their paper match list and judge them by names and therefore they love having that hopkins name on their list. but when its somebody from a lesser known school who matches at a program that clearly has strong academic resources, you can be sure that individual can handle their business and are extremely competent and usually win you over with their personality as well. In fact, the unfortunate reality is that some "lesser" residents in the big name programs were ones who got the benefit of the doubt because they went to hopkins or penn or harvard.

The best psychiatry applicant in a given year from a place like Albert Einstein or Thomas Jefferson are without question "better" residents than a middle of the pack applicant from Columbia. I promise this to you because I have seen it. But if you saw a match list filled with Columbia and Stanford and UCSF you'd think this program is loaded with brilliant residents. I'm not saying they aren't brilliant (they probably test well and did something right to get into those med schools), I'm just saying that this probably means the program is more interested in pedigree than well roundedness and competence save for maybe a very select few (i'm talking no more than 5) residency programs who can pluck the cream of the crop from the best name med schools.

best,
worriedwell

 

[PsychMD2100]

Nicely said, worriedwell.

Along similar lines, I found it interesting that some top programs take PGY-2s every year--not just when someone drops out after internship. Rather than being a detriment, I think it adds several layers of enrichment to a given program.

I'll cite University of Washington as an example. When I was there, I heard that they have a fully-trained OB/Gyn and a fully-trained ophthalmologist there as residents who came in as PGY-2s. Many of you know that psychiatry is a common second career within the profession of medicine. As I recall, they didn't have the name-brand schools behind their name but they had a ton of life experience and clinical expertise.

I agree that it comes down to individual motivation on the part of each resident. In the aforementioned examples of Pitt and Hopkins, I think both institutions select for "hungry" applicants as much "hungry" applicants look for programs like them. While they may not have the elite diplomas, there's a shared sense of purpose at both places.

 

[makushin]

Now before anyone starts throwing the flame thrower about how certain programs are amazing in good cities, this is a generalization. But take psych-I know offhand for example take Upenn, hopkins, OHSU(debatable location) and then within the cities they are often in the worst areas. I mean does serving an underserved population have something to do with it-like hopkins still blows my mind as to how that became such an elite place or why they never made the move somewhere else-I dont know I guess there are lots of programs in great cities-probably more now that I think of it-but in general the top programs are not in cities I would want to live really.

If the OHSU program is at OHSU on "pill hill" I have to disagree. My aunt lives in that neighborhood, I've always really liked that area, and I've lived all over. Inexpensive too. Not sure what you're after though.

 

[JMD]

If the OHSU program is at OHSU on "pill hill" I have to disagree. My aunt lives in that neighborhood, I've always really liked that area, and I've lived all over. Inexpensive too. Not sure what you're after though.

Yeah, other than the rain, this is the first time I have heard anyone talk about Portland in a negative light. People in Portland really seem to be there because they love the place. And the area the hospital in is really nice, with beautiful views, homes, etc.

Again, I guess it comes down to what your criteria for "crappy" is.

 

[RustNeverSleeps]

I agree that it comes down to individual motivation on the part of each resident. In the aforementioned examples of Pitt and Hopkins, I think both institutions select for "hungry" applicants as much "hungry" applicants look for programs like them. While they may not have the elite diplomas, there's a shared sense of purpose at both places.

But you are assuming that the people Hopkins and Pitt get are there first choices -- that they didn't rank some people from elite schools (or other strong applicants from non-elite schools higher) and just not get them.

 

[PsychMD2100]

RustNeverSleeps,

I'm not assuming anything. Different strokes for different folks. Chill, dude.

 

[Doctor Bagel]

Yeah, other than the rain, this is the first time I have heard anyone talk about Portland in a negative light. People in Portland really seem to be there because they love the place. And the area the hospital in is really nice, with beautiful views, homes, etc.

Again, I guess it comes down to what your criteria for "crappy" is.

Yeah, I was surprised, too. IMO, Portland's a nearly perfect city -- well, aside from poor educational opportunities, the perpetually bad economy and high real estate costs. 🙂 OHSU's not exactly in the ghetto, either, even though I suspect it's a bit boring to live right by the school because there's nothing there but the school. Eh, anyway, I miss PDX! 🙁

 

[Chewbacca Jung]

Portland's a nearly perfect city -- well, aside from poor educational opportunities...

Sorry to put you on the spot, but Please define "poor educational opportunities". thank's 🙂

 

[Doctor Bagel]

Portland's a nearly perfect city -- well, aside from poor educational opportunities...

Sorry to put you on the spot, but Please define "poor educational opportunities". thank's 🙂

Well, Oregon in general has an underfunded higher education system, so going into various professional programs in Oregon and Portland can be hard. For example, there's no MLS program in Oregon. If you want to go law school in Oregon, you have to move to Eugene or pay at fortune to attend Lewis & Clark. Nursing school is impossible to get into in Portland because there are so few programs for the number of interested applicants. The main PA program is at a private school, which again is expensive. All the ancillary health programs at OHSU are hard to get into, etc. Medical school is hard to get into in Oregon -- my story. 🙂

It really depends on what you want to do. Portland State is an okay school -- I did my postbacc work there. It's not exactly a great university, though. The town just doesn't have the same educational resources as say Seattle or even Oklahoma City.

As for public schools, that really depends on where you live. My niece and nephew go to pretty good schools in Portland, but some schools are horrible. If you want to live in a good school district, it will cost you a lot of money if you buy. You can easily rent in a good school district, though.

 

[Chewbacca Jung]

gracias