Why do some of the fanciest* of programs have such little contact with underserved populations?

[poiuytre]

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Some of the "top" programs like MGH, UCLA, Stanford have no access to a county hospital so the populations the majority of the residents there work with are not that diverse/sick. Yet these programs are very well regarded for their clinical as well as research opportunities. Why is that? Is it just research money that matters? Do people come out good clinicians even though they don't see as much as you'd see in county hospital? If you go to one of those programs could you still do public psychiatry or would you be at a disadvantage?

 

[wolfvgang22]

Some of the "top" programs like MGH, UCLA, Stanford have no access to a county hospital so the populations the majority of the residents there work with are not that diverse/sick. Yet these programs are very well regarded for their clinical as well as research opportunities. Why is that? Is it just research money that matters? Do people come out good clinicians even though they don't see as much as you'd see in county hospital? If you go to one of those programs could you still do public psychiatry or would you be at a disadvantage?

Answers in order:
Sometimes, yeah.
Sometimes.
It makes the learning curve steeper once you get out of residency if all you ever see is higher functioning patients and the "worried well" patient. How well one does depends on the work invested in the area of the field. So yeah, it may be a good idea to train in a place that sees serious mental illness if that is what you want to do. I found it easier to go from more challenging to less challenging patients as I level up as a psychiatrist, but there's more than one way to do it.
What big name programs give you is connections.

 

[nitemagi]

In some cases the issue comes down to funding. Underserved are also underfunded, and the funding that exists isn't going to a training program.

On the flipside there will always be gaps in training, no matter where you are. It will be up to you to advocate for you own education and pursue it (therapy training, moonlighting). During residency I moonlighted (moonlit?) in the jail, disability evals, county psych ER, and a private hospital (including detox units). Great experience.

 

[splik]

Some of the "top" programs like MGH, UCLA, Stanford have no access to a county hospital so the populations the majority of the residents there work with are not that diverse/sick. Yet these programs are very well regarded for their clinical as well as research opportunities. Why is that? Is it just research money that matters? Do people come out good clinicians even though they don't see as much as you'd see in county hospital? If you go to one of those programs could you still do public psychiatry or would you be at a disadvantage?

seeing as no one wants to do public psychiatry anywhere would be delighted to have you if you wanted to work in public/community psychiatry regardless of where you went. I do think it is better to go to a program that gives you a breadth of exposure including a county and veteran population, and ideally state hospital and correctional exposure as well as private practice etc. In my training I have rotations in county, state, VA, university, private practice, and community settings. The only main area I've missed out on is correctional and I'll be doing a forensic fellowship so will get jail and prison time next year anyway.

Although Partners would rather not treat any poor people, the reality is that Massachusetts has probably the largest insured population in the country and they do have some exposure, they do have some community clinics (the Lindemann, including freedom trail clinic), and MGH leads the Boston Healthcare for the Homeless program. also they do a psych ER (APS) which sees everyone though they might ship the poorer patients off elsewhere. Also they do have a public psychiatry fellowship and Derri shtasel has an endowed chair in public and community psychiatry). At least one of the residents is doing a jail rotation. So while I certainly wouldn't recommend people with a strong interest in community psychiatry go to MGH, there are certainly lots of opportunities to do stuff there. The situation is a bit more dire at places like Stanford (they shut out poor people from their psych clinics there) and UCLA (although at least they have a Harbor track where you can do your intern year at Harbor UCLA and Bob Liberman is still there and he had done a lot of important research in rehabilitation approaches in chronic mental illness like "schizophrenia")

But if you were interest in working with the underserved why would you want to go the fanciest program? You would be better of going to a community program since their focus is in community psychiatry. Sadly there is still a lot of tension in psychiatry and our grandees (often biologically oriented academic psychiatrists who are completely out of touch with real world practice) see public/community psychiatry as the ugly stepchild of psychiatry that is not in keeping of this image of a modern, scientific, technical, and specialist field they would like psychiatry to be. To the point where the APA had planned to get rid of their IPS meeting (their annual public/community psychiatry meeting) and pulled the funding for their public psychiatry fellowship program for a few years (funding was later reinitiated) and where there is little to no research into actual treatment programs in psychiatry done by the NIMH these days. TheRAISE study looking at first-episode psychosis wouldn't have happened but for an act of congress (as it was not in keeping with the kind of research that Tom Insel wanted to fund when he was director of the NIMH).

Edit: also columbia most people would consider a fancy program and they actually have an excellent community psychiatry curriculum led by stephanie le melle and they have the oldest public psychiatry fellowship in the country. so there are at least some programs that have decided this is an important area of psychiatry though the fancier programs often have a grandiose mission to train the leaders in the field, so they may not be looking to train community psychiatrists but people who will become state or county directors for mental health or lead larger public psychiatry programs or be involved in innovative service development programs etc.

 

[clausewitz2]

Not sure if it is fancy but UNC manages to be a serious research powerhouse (#9 psych department by NIH funding) and having very strong public/community psych exposure. They were a major site in RAISE and are gearing up to do proper comparative studies of different clinic models for integrated care. Having a super strong Family Medicine program next door probably helps keep them honest in this respect.

 

[FlowRate]

as I level up as a psychiatrist

What perks did you take?

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Harvard-Longwood may not be as fancy as MGH, but gets MMHC.

Seems like Emory could be considered fancy and I'd imagine also has good community training.

 

[shan564]

Not sure if it is fancy but UNC manages to be a serious research powerhouse (#9 psych department by NIH funding) and having very strong public/community psych exposure. They were a major site in RAISE and are gearing up to do proper comparative studies of different clinic models for integrated care. Having a super strong Family Medicine program next door probably helps keep them honest in this respect.

I would say the same thing about WashU also. Well-known as a research powerhouse, and I'd say that the majority of the patients we see are underserved.

 

[WingedOx]

I'd say that the majority of the patients we see are underserved.

This is psychiatry. With few exceptions anyone with severe enough mental illness is going to have issues with access to resources and care.

There really aren't many programs that don't have you doing inpatient treatment with the homeless that wander in off the streets. It's continued following of low SES/high poverty populations in the outpatient setting in medication and therapy clinics throughout the four years of training that separates programs.

 

[poiuytre]

Thank you all for your responses.
Even though I am interested in public psychiatry (or perhaps because of it) I would still like the opportunity to train at one of these institutions with connections and resources. I was just a little surprised to see that some of these places are far removed from the sickest in the population.
@Spilk thanks for sharing your knowledge of these three programs. Very useful!

 

[Trismegistus4]

Some of the "top" programs like MGH, UCLA, Stanford have no access to a county hospital so the populations the majority of the residents there work with are not that diverse/sick.

I've seen this idea on these boards before, and it's false. Tons of people with serious mental illness are on Medicaid, especially with the Medicaid expansion of the past few years. They are homeless, drug-addicted, streets-wandering psychotic... and they have insurance and get admitted to regular hospitals. You'll still get your poor, drug-addicted, homeless black person fix at any of these programs. Though I have to wonder why so many psych applicants have this obsession anyway. It's not like that population is any less boring and repetitive than the "worried well."

 

[Leo Aquarius]

Let's call a spade a spade. UCLA and Stanford have little exposure to the underserved poverty-stricken. The Harbor track is for only ONE resident at NPI, the rest of the residents spend 1 month in the Harbor Psych ER which they rave about. At Stanford you get an "underserved-ish" experience at their beautiful VA hospital, because they certainly do a lot of work there.

Listen, if you want an underserved experience then go to a program that has that focus.

I like the ideas posited by Trismegistus4. Make no mistake, psychiatric challenges abound at ALL levels of the economic spectrum.

Lastly, there's a camp who believes that if you can treat the sickest of the sick, then you can treat anyone, and would thusly say the county residents are best trained. This is a generalization at best.

 

[notdeadyet]

Keep in mind that many non-county places happily take Medicare, which many of the sickest of the sick are on due to disability.

That said, I would count not having a county program as a big part of your training to be a major drawback. I would also count not having a tertiary care center and good VA and good private experience to be drawbacks. You want diversity for good residency training.

 

[shan564]

This is psychiatry. With few exceptions anyone with severe enough mental illness is going to have issues with access to resources and care.

There really aren't many programs that don't have you doing inpatient treatment with the homeless that wander in off the streets. It's continued following of low SES/high poverty populations in the outpatient setting in medication and therapy clinics throughout the four years of training that separates programs.

Sure, on the inpatient unit. But that makes up a small minority of your overall training. Doing some quick math in my head, I'd say that about 90% of my clinical exposure is in in a setitng where the majority of patients are underserved. The inpatient unit (along with the ER, consult service, etc.) is in the inner city, and the majority of the patients are low SES. The outpatient clinic primarily serves a Medicaid/uninsured population - a minority of the patients in the clinic have regular insurance, but we no longer accept new patients who have insurance. The only time we primarily see insured patients is in the eating disorders rotation (1 month), geriatrics (1 month - many of those patients are also underserved, but they have Medicare), ECT (1 month - also many underserved patients who have Medicare), and child clinic (1 afternoon a week during 3rd year). There are also 10 months of electives, so you could see higher SES patients (for instance, there's an option to work at the WashU undergrad clinic) if you want to.

We don't actively emphasize the underserved bend to the program, probably because the program prefers to emphasize the academic strengths. But there's no question in my mind that you see a substantial amount of severe psychopathology from all perspectives.

 

[clausewitz2]

I've seen this idea on these boards before, and it's false. Tons of people with serious mental illness are on Medicaid, especially with the Medicaid expansion of the past few years. They are homeless, drug-addicted, streets-wandering psychotic... and they have insurance and get admitted to regular hospitals. You'll still get your poor, drug-addicted, homeless black person fix at any of these programs. Though I have to wonder why so many psych applicants have this obsession anyway. It's not like that population is any less boring and repetitive than the "worried well."

While a numerical minority, there remain many states that did not undergo a Medicaid expansion with ACA. Thus it matters whether the institution is committed to trying to address their needs even if they end up eating a fair amount of the cost or if they are bouncing people who can't pay.

 

[WingedOx]

Sure, on the inpatient unit. But that makes up a small minority of your overall training. Doing some quick math in my head, I'd say that about 90% of my clinical exposure is in in a setitng where the majority of patients are underserved. The inpatient unit (along with the ER, consult service, etc.) is in the inner city, and the majority of the patients are low SES. The outpatient clinic primarily serves a Medicaid/uninsured population - a minority of the patients in the clinic have regular insurance, but we no longer accept new patients who have insurance. The only time we primarily see insured patients is in the eating disorders rotation (1 month), geriatrics (1 month - many of those patients are also underserved, but they have Medicare), ECT (1 month - also many underserved patients who have Medicare), and child clinic (1 afternoon a week during 3rd year). There are also 10 months of electives, so you could see higher SES patients (for instance, there's an option to work at the WashU undergrad clinic) if you want to.

We don't actively emphasize the underserved bend to the program, probably because the program prefers to emphasize the academic strengths. But there's no question in my mind that you see a substantial amount of severe psychopathology from all perspectives.

btw, not belittling your specific program's exposure... just making an overall point.

 

[shan564]

btw, not belittling your specific program's exposure... just making an overall point.

Sure, I understand - I didn't mean to imply that you were trying to do that, just clarifying that I agree with your point and have a few further points to elaborate.