Medical Education US

Thanks. So you're saying that a residency program that focuses more on therapy will give you adaquate preperation for having a private practice in which you can also do a lot of thereapy in addition to meds. Is that correct? Are there a whole bunch of those residency programs around? For example, roughly how many good residency programs are there in CA that emphasize thereapy as well? Are we talking one or two or over a dozen? Are these school harder to get into than less therapy-oriented programs? Also, do a lot of psychiatrists get/want extra training in thereapy after residency bc they dont feel they have adaquate trainging, etc?

I wouldn't put it as strongly as "a residency program that focuses more on therapy will give you adaquate preperation for having a private practice in which you can also do a lot of therapy". I'd say it would help a great deal if such a practice is your goal. Let me be frank. There is less of a focus on psychotherapy training than there was 15 years ago. But picking a program that is strong in that area will put you way ahead if you want a private practice with a significant therapy component.

That is what I did, and it worked well. For me, the training I received in residency was adequate in itself for the intensive and demanding therapy practice I have now. I am not certain whether or not I would feel that way completing training now or not. Maybe not.

I trained in New York and can't speak to programs in CA; I only know of colleagues there who did not train with a strong therapy focus and one does exclusively managed care medication work, and is moderately happy with his work at best. The other aspires to a therapy component to her practice, but didn't get the background necessary during residency. Which leads me to my last point:

A common route taken by psychiatrists who wish to bolster their psychotherapy competence ( and the choice of my other colleague from CA) is to take additional training sometimes during but usually after residency. This can be done simultaneous with being in practice. Some choose a rigorous psychoanalytic training program, not because they expect to do primarily that kind of treatment (very hard to fill a practice that way), but for the intensity and quality of the learning experience. There are also psychotherapy training programs that require less of a commitment, are shorter and less ambitious.

I am also in NY Polymath. how competitive did you find it to be, to find a residency program?

Like anywhere, the programs with the greatest prestige are more competitive to get into. But there are alot of programs in NY, and psychiatry is not among the most sought after and highly competitive residencies in general. Most U.S. graduates interested in a psychiatry residency program in NY will find a spot.

is there any specific reaosn its not too competitive? Are there a lot of residencies available, or is that most med grads will go for other fields? Which fields do you find to be most competitive? thanks

So as not to get too far off topic, I've started a new thread:

Competitive Residency Programs and Psychiatry

That is a relief! I thought my dreams were going down the drain. I want to be a psychaitrist who does slightly more therapy than medicine prescribing. The whole reason I want to be a psychiatrist is because of therapy and it seems like it would fit my personality. Now what I want to know is, is your situation common, as you described it, because I think I'd like to do what youve done. Maybe after residency, start a private practice where I live in greenwich connecticut. Any help or direction would be greatly appreicated

Im wondering, what residency programs are strong in psychotherapy. Where did you go for yours which you said had a respectable degree of psychotherapy because I think I want to have the same kind of psychiatric lifesytle u do

I believe the question is not so much how common is a practice such as I've described, but rather whether it is a realistic prospect for someone who desires it. I can tell you that I know several psychiatrists in the Greenwich area who have practices resembling mine. My sense is that psychiatrists can make a go of it in private practice anywhere in the U.S., but to do a significant amount of therapy in private practice requires a good referral network and a community that values psychiatric treatment and is willing to pay for it. With perseverence, I believe it is doable, and Greenwich would be a good place for it. I can't speak to residency training programs strong in therapy teaching. I'm just not up to date on that. The program in which I received excellent psychotherapy training is no longer so constituted. Good luck!

I would be interested in learning the following:

1) What constitutes a "full" practice, and how long does it take to create one?

2) Whattaya do in the meantime? I mean, are you working the desk at 7-11 between patients, or how does that work out?

3) In a practice such as the one Dr. Polymath describes, from whence does the physician receive referrals?

4) Is it easy to keep overhead down when you have to run two offices?

Thanks, and Happy New Year!

Good questions! I'll do my best:

1. A full practice might mean you are busy enough that you are not accepting new referrals. However, I personally feel that the preferable degree of being full is that you are fairly busy, earning enough to meet your needs (including savings, maxing out Keough contributions, a modicum of luxury), so that you feel free to decline a referral that you feel would be especially burdensome or for whom another level or type of care would be desirable, and yet you do have room to accomodate the occasional referral that you are highly interested in treating.

2. If I understand you, you mean what do you do with the down time, especially before you have a full practice. Correct me if I misunderstand. My feeling has always been that I want to be as efficient as possible with my time in the office. This means I don't want a half hour between patients so that if I see 8 people for 45 minutes each, I'm in the office for 9 and a half hours instead of six. I like to schedule myself so I have the odd fifteen minutes or half an hour here and there for a bite to eat, returning phone calls, and the essential occasional trip to the bathroom. So if my practice is slow, I'm in the office less, i consolidate my hours for efficiency's sake. When I'm busier, the day is longer, more grueling, and I've got to be even more effective at making use of all the time to m anage the out-of-session duties (eg. return phone calls, call the pharmacy, call back therapists with whom I share patients I've just seen, etc.) Any extra gaps in the day, I read journals and keep up with the literature as best I can.

3. Referral sources are a very individual thing. While other (non-psychiatrist) physicians can be referral sources, I have found that they are often more comfortable referring to social workers or psychologists, I think because of a bias that the patient will think the MD is saying they are "sicker" if a referral is made to a psychiatrist. Of course this is not true of all non-psych MD's. Many participants in insurance plans get referrals directly from the plan. This works, but I don't do it because I don't want to be bound by the insurance rules, paperwork, bureaucracy and fee schedules. I get alot of referrals from non-psychiatrist mental health professionals, although these tend to be medication back-up patients. I think in the end it comes down to making personal connections over a period of time, so that people will think of you for a referral. Eventually, too, your own ex-patients will refer to you. (They generally tend not to do that while they are still in treatment with you as they have a kind of proprietary interest in you.) An old and wise teacher of mine once told me, "You will know your practice has reached its maturity when people call you and say, 'I was referred by your patient so-and-so'".

4. Over head is not a huge problem. When maintaining two offices as I do, you have a couple options: Lease two office suites with extra offices and rent out the ones you're not using; Lease offices and sublet space part-time for when you are in the other office; sublet small spaces for both offices for your personal use; or my method: marry another psychiatrist and share office space but be in one office on the day the other is not.

Good Luck!

[quote][/quote]The Question I have is why can't the system combine the field of psychiatry and psychology more efficiently? Why is it necessary for a psychiatrist to go through full blown medical school? It seems quite pointless to me. Rather a combination of courses from graduate and medical school would seem more beneficial to the goal of efficiently treating people. I would love to hear responses on this subject from people who have experienced it.

Juls7284,

In order to properly diagnose severe mental disorders and properly prescribe medications, you really should have a full understanding of what is learned in medical school and the four years of residency that follow. The adverse reactions that people encounter with medications can sometimes be confused with other psychological problems or may seem minor to a lesser trained professional. Also there are some medical disorders that can mimic psychiatric disorders, and a psychiatrist's training will significantly increase the chances of making the correct - and potentially life saving - diagnosis.

There are a few states that do allow psychologists to prescribe medications. I don't know how well that is working out.

Also, as many mental illnesses require controlled substances for proper treatment, I think it would be a huge risk for a state licensing board to suddenly increase the categories of professionals who can have access to controlled substances. That's probably not a main issue, but something I've thought about.

psychiatrist in private practice. Just to provide another perspective to that stated above, I see 70% of clients for therapy or therapy plus medication and 30% for medication only. i have no involvement in managed care, no direct dealings with insurance companies

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