Program Red Flag?

[MiddleRoad]

I apologize for the lengthy post...

As an applicant looking into various programs around the country, I've used this forum to search for information both to prepare for questions I might want to ask when visiting and to see if a specific place seems like somewhere I want to be for the next four years. In general, it seems like there are many exceptional psychiatry residency programs in this country. By far, most of the information I've found in this forum has only increased my interest in the programs to which I've applied.

Nevertheless, I've noticed that the topic of interns and residents leaving certain programs has fostered a lot of discussion in this forum between trainees and attendings. My question is whether this problem is more a reflection of the individuals or the programs themselves. Certainly, every program likely loses a resident every so often, but when it becomes a pattern that is repeated two or more years in a row (as some residents have pointed out about their programs here), is it a reason for concern? Is it perhaps a reflection of the environment fostered by the program? Or maybe an indication of the selection committee not doing a good enough job of choosing their residents? Either of these two issues could be seen as strikes against a program.

Also, I figure that looking into how programs have adjusted to the new intern work hours is an important area to investigate. In addition to investigating intern schedule and the more typical metrics of comparison (number/type of hospitals, benefits, didactic time, etc) are there any other specific red flag areas that those of you who've already gone through this process can recommend for us applicants to look out for before our interviews?

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[nitemagi]

I apologize for the lengthy post...

As an applicant looking into various programs around the country, I've used this forum to search for information both to prepare for questions I might want to ask when visiting and to see if a specific place seems like somewhere I want to be for the next four years. In general, it seems like there are many exceptional psychiatry residency programs in this country. By far, most of the information I've found in this forum has only increased my interest in the programs to which I've applied.

Nevertheless, I've noticed that the topic of interns and residents leaving certain programs has fostered a lot of discussion in this forum between trainees and attendings. My question is whether this problem is more a reflection of the individuals or the programs themselves. Certainly, every program likely loses a resident every so often, but when it becomes a pattern that is repeated two or more years in a row (as some residents have pointed out about their programs here), is it a reason for concern? Is it perhaps a reflection of the environment fostered by the program? Or maybe an indication of the selection committee not doing a good enough job of choosing their residents? Either of these two issues could be seen as strikes against a program.

Also, I figure that looking into how programs have adjusted to the new intern work hours is an important area to investigate. In addition to investigating intern schedule and the more typical metrics of comparison (number/type of hospitals, benefits, didactic time, etc) are there any other specific red flag areas that those of you who've already gone through this process can recommend for us applicants to look out for before our interviews?

I'd say it's a yellow flag, not a red flag. Programs lose residents for all kinds of reasons. My old program consistently lost 1-2 residents a year, but was considered one of the top programs in the country. They worked residents hard, and that was a minor reason for attrition. A larger reason was the geography, and people wanting to be closer to family or a partner, who couldn't find work in that city. 75% of the time it was because of the geography. Now you could state that that itself is a problem with the selection process...

 

[psychphan]

I'd say it's a yellow flag, not a red flag. Programs lose residents for all kinds of reasons. My old program consistently lost 1-2 residents a year, but was considered one of the top programs in the country. They worked residents hard, and that was a minor reason for attrition. A larger reason was the geography, and people wanting to be closer to family or a partner, who couldn't find work in that city. 75% of the time it was because of the geography. Now you could state that that itself is a problem with the selection process...

That seems like more of a problem with the residents who choose to go there than a problem with the program itself. Presumably applicants were aware of the geography of the place they were going. Its not like once they got there the program was suddenly transferred from San Diego to Siberia.

 

[nitemagi]

That seems like more of a problem with the residents who choose to go there than a problem with the program itself. Presumably applicants were aware of the geography of the place they were going. Its not like once they got there the program was suddenly transferred from San Diego to Siberia.

True, but things come up that're unexpected -- a long distance relationship turns into an engagement, a wife loses her job and they need to be closer to family, things like that.

 

[peppy]

I definitely think it merits some skepticism and investigation. If you can confirm that it was because of some benign issue like people just wanting to move for family reasons, well, that's no big deal, but I wouldn't want to go to a residency that regularly fires residents.
That either implies the program director is difficult to please (my diplomatic way of phrasing that ) or that for some reason they have trouble attracting competent people. Trust me, you want your fellow residents to be competent. You don't want to end up having to clean up their messes.

 

[Doctor Bagel]

I'd say it's a yellow flag, not a red flag. Programs lose residents for all kinds of reasons. My old program consistently lost 1-2 residents a year, but was considered one of the top programs in the country. They worked residents hard, and that was a minor reason for attrition. A larger reason was the geography, and people wanting to be closer to family or a partner, who couldn't find work in that city. 75% of the time it was because of the geography. Now you could state that that itself is a problem with the selection process...

Jeez, so it happens at other programs, too. My program seems to lose a person pretty regularly, but I'm still not sure what that says. We had an intern last year who didn't have his contract renewed, and we had another intern who transferred to another specialty. The latter is something that just happens. The former is something that would have really scared me away from my program had I been an applicant. Apparently people remediating or not getting a contract renewed happens periodically here and honestly more than I'd like. However, it seems like the people who have issues have big issues. It's not like they were doing their job and falling a little behind -- they were falling a lot behind or not showing up or whatever. In that way, it's hard to fault for my program for having to do something about it.

Our tact now is to attempt to find a better way to screen out applicants who will have big struggles because with some of our past people, it's been foreseeable. We're a resident dependent program with a fairly intense first and second year, so we're not the best place for someone who needs a lot of extra help. In a way that's a shame, but I think it's nice that we're making an attempt to be honest with ourselves about our program and what type of residents we need. As an applicant, it's also a good idea to be honest with yourself. If you have issues that would make it hard to thrive in a more difficult program, consider that when making your rank list.

 

[Doctor Bagel]

That either implies the program director is difficult to please (my diplomatic way of phrasing that ) or that for some reason they have trouble attracting competent people. Trust me, you want your fellow residents to be competent. You don't want to end up having to clean up their messes.

Here's the weird thing with my program. In my class last year that lost 2 people, the remaining 6 or us are pretty awesome. We work well together, and I think we're all nice, smart, hard-working, easy to work with people. It's weird that we wound up with a class of 6 really good for the program people and 2 people with issues. That seems to be true in the past, too. And the people who've had issues seem like they're all people who had the capacity to be good psychiatrists. However, they had issues that would make them struggle in the early years of our program. That's where I think our current self honesty is a good thing.

 

[psychphan]

True, but things come up that're unexpected -- a long distance relationship turns into an engagement, a wife loses her job and they need to be closer to family, things like that.

Granted things happen, but 1-2 a year seems like a lot of "happenings". You said you were at one of the top programs in the country. Maybe those who left chose the program based on its reputation and not what was the best fit for them. Thus they weren't happy. Purely speculation, but seems logical to me since many ppl are so enthralled by prestigious names that they ignore other things that may actually be more important to them.

 

[MiddleRoad]

Thanks NM, for your post. I think your analogy of a yellow card is reassuring.

Our tact now is to attempt to find a better way to screen out applicants who will have big struggles because with some of our past people, it's been foreseeable. We're a resident dependent program with a fairly intense first and second year, so we're not the best place for someone who needs a lot of extra help.

DB, how has this new tact of screening applicants worked out? Did it improve things for this year's current intern class?

 

[Doctor Bagel]

DB, how has this new tact of screening applicants worked out? Did it improve things for this year's current intern class?

It's new for this year, so we'll see. Our intern class is also having an issue with this, which is I think driving some of our action on this issue. Like our class, our intern class = also largely awesome.

I agree that this is something to consider when picking a program. I'm still not sure entirely what it says about a program, though.

 

[nitemagi]

Granted things happen, but 1-2 a year seems like a lot of "happenings". You said you were at one of the top programs in the country. Maybe those who left chose the program based on its reputation and not what was the best fit for them. Thus they weren't happy. Purely speculation, but seems logical to me since many ppl are so enthralled by prestigious names that they ignore other things that may actually be more important to them.

Prestigious name is one thing, and people underestimate how rough intern call can be. It's not like these individuals were all incredibly happy anyway. I'd chalk it up to a "mis-match," and blame both sides equally, plus the x-factor of unknowns that happen in life. People have other things that emerge, and they may rationalize whatever to get into a program, but once there the grass is greener elsewhere.

 

[Wednesday]

I think that it's good if a program remediates (and sometimes eventually doesn't renew) residents once in a while. It shows that they are not just letting weak residents slide by. My program has an amazing program director and our program let a few people go throughout my years there (after extensive remediation attempts as far as I can tell). Trying to screen out all questionable applicants is a nice idea in theory, but nearly impossible to do. Oddly, I say this and yet I was scared away from NightMagi's program when I found out how many residents leave each year. Use your gut when meeting program directors (which I think have the most influence on the quality of life in residency) and pick a program because of the program and not (only) the location and reputation. I think being honest with yourself about how hard you think you can work is a good idea too. How independent will you be? How does this level of independence work for your personality?

 

[masterofmonkeys]

Given that I just withdrew from my program, maybe I should not be posting my opinion here but meh. People leave for all sorts of reasons, but when there's a consistent pattern of people leaving it needs to be investigated. The reasons might be benign, they might be because of something as simple as a mismatch, or it might be because programs don't deal well with residents when they do have a problem.

 

[Doctor Bagel]

Given that I just withdrew from my program, maybe I should not be posting my opinion here but meh. People leave for all sorts of reasons, but when there's a consistent pattern of people leaving it needs to be investigated. The reasons might be benign, they might be because of something as simple as a mismatch, or it might be because programs don't deal well with residents when they do have a problem.

So it sounds like you're saying your program had a role in your leaving. I know you've posted over the years about your struggles there. Do you mind if I ask what your plans are?

On the note of people leaving, we had a person a few years ago who transferred after struggling here. She's apparently now happy and doing really well at her current program. So there is a life after a poor fit program, which is good to know.

 

[digitlnoize]

I wish we could find out more about this phenomenon and why people leave.

It feels like it's discussed more here than on other SDN specialty forums, but that could just be me...

I could see a few reasons:

Bad Fit (location, program-resident issues, personality conflicts, etc)
Personal Reasons (spouse's job moving, family crisis, etc)
Resident not performing well (poor clinical performance, failed tests, etc)
People who didn't really want to do psych but wound up here due to the lower (current) competitiveness than most other fields (some FMGs, people with red flags, etc)

Any other suggestions?

To me, the question is which of these reasons are most common at which programs. If a program has a higher attrition rate due to "Poor Resident Performance" is that due to the quality of residents or poor training at the program?

There should be a survey...adding to my list of things I want to research at some point.

 

[nitemagi]

Depending on the specialty and the program, a malignant or unsupportive environment can also be a factor. Probably more common in surgical programs, but still.

 

[BobA]

Granted things happen, but 1-2 a year seems like a lot of "happenings". You said you were at one of the top programs in the country. Maybe those who left chose the program based on its reputation and not what was the best fit for them. Thus they weren't happy. Purely speculation, but seems logical to me since many ppl are so enthralled by prestigious names that they ignore other things that may actually be more important to them.

It's really not that unusual for programs to "lose" and "gain" 1-2 residents a year. It's a lot easier to change residencies than it is to change med schools - which might be your reference. Ask yourself how many of your classmates might prefer to be in a different location for med school and if they could switch would they?

Residency is in some respects a job. Moreover, there's some degree of quality control in that rarely programs may need to just let someone go for performance reasons.

You might find this interesting.

 

[masterofmonkeys]

Bob, residency is actually nothing like a job and it's actually not that easy to transfer. I know. Been there done that. Am there now. From the limited accountability of your seniors to the abuses of the guild system (fully licensed physician, 4 years of clinical experience including my 2 years of med school--how many jobs are there for me? lol) to the lack of legal protection to the regimented nature of residency training to the failure of valid grievance procedure, residency is NOTHING like a job.

I don't want to clutter this thread up so I'll be making my own thread after I'm done taking a breath.

 

[nitemagi]

Bob, residency is actually nothing like a job and it's actually not that easy to transfer. I know. Been there done that. Am there now. From the limited accountability of your seniors to the abuses of the guild system (fully licensed physician, 4 years of clinical experience including my 2 years of med school--how many jobs are there for me? lol) to the lack of legal protection to the regimented nature of residency training to the failure of valid grievance procedure, residency is NOTHING like a job.

I don't want to clutter this thread up so I'll be making my own thread after I'm done taking a breath.

MoM, I agree it differs from many jobs, as does the whole industry. But according to the supreme court residents are employees, not students. Really it's a bit of a hybrid role, lacking the full protections of either a student or an employee. On the flipside, my old hospital had a very well organized and powerful housestaff union, which can be one of the best protections and pathways for grievances.

 

[psychphan]

Bob, residency is actually nothing like a job and it's actually not that easy to transfer. I know. Been there done that. Am there now. From the limited accountability of your seniors to the abuses of the guild system (fully licensed physician, 4 years of clinical experience including my 2 years of med school--how many jobs are there for me? lol) to the lack of legal protection to the regimented nature of residency training to the failure of valid grievance procedure, residency is NOTHING like a job.

I don't want to clutter this thread up so I'll be making my own thread after I'm done taking a breath.

What program were you at, or do you not want to reveal that?

 

[notdeadyet]

I don't want to clutter this thread up so I'll be making my own thread after I'm done taking a breath.

Hope you've landed on your feet okay, MoM. Regardless of the circumstances, that couldn't have been an easy process...

 

[Scorcher31]

My program is a small program with only 6 residents per year, but I couldn't even tell you when the last time we lost a resident was for any reason. Maybe it's just luck, but I attribute it to aggresive inital screening by our program coordinator, a lightish call schedule, and a very supporitve program director. I'm sure larger programs are more likely to have occasional residents switch/leave but if some programs always keep their residents it would seem safer to me.

 

[Doctor Bagel]

Hope you've landed on your feet okay, MoM. Regardless of the circumstances, that couldn't have been an easy process...

Me, too. It's what we all don't want. And as you noted, there's a feeling that we have nothing if we haven't completed a residency in spite of all the learning, hard work, time and money we've put into this process. This is fairly unique in our field.

Share if you want but you don't have to.

 

[Doctor Bagel]

My program is a small program with only 6 residents per year, but I couldn't even tell you when the last time we lost a resident was for any reason. Maybe it's just luck, but I attribute it to aggresive inital screening by our program coordinator, a lightish call schedule, and a very supporitve program director. I'm sure larger programs are more likely to have occasional residents switch/leave but if some programs always keep their residents it would seem safer to me.

You're right -- all things being equal, I think we'd all want to be a programs that very rarely if ever lost people. One thing that I've mentioned before based on my experiences last year is that there's a pretty big emotional cost in losing a resident. We had a lot of issues last year that compounded this, but those issues aren't here now, and I think our interns are suffering through similar stuff.

As for screening, what does your program director look for? Are you guys also in the position to get the people you want? A lightish call schedule and a supportive program director are also huge. We have the latter but still don't have the former. Psych call is, I think, an unexpected surprise for lots of us because you don't get a good feel for what it's like in medical school.

 

[BobA]

Bob, residency is actually nothing like a job and it's actually not that easy to transfer. I know. Been there done that. Am there now. From the limited accountability of your seniors to the abuses of the guild system (fully licensed physician, 4 years of clinical experience including my 2 years of med school--how many jobs are there for me? lol) to the lack of legal protection to the regimented nature of residency training to the failure of valid grievance procedure, residency is NOTHING like a job.

I don't want to clutter this thread up so I'll be making my own thread after I'm done taking a breath.

Very sorry to hear about your situation. I tried to PM you but your mailbox was full. Feel free tom PM me if you want I have some info for you.

 

[Scorcher31]

Honestly, Dr. Bagel a huge chunk of it is probably luck.

It's actually the coordinator (secretary) that goes through all the inital applications 1 by 1. They basically look for any reason to not bring someone in for an interview due to the small size of the program. I wish i knew more specifics on the screening process but I just don't know. The coordinator also speaks with applicants during the interview process and does gets a feel for personality and plays a part in the acceptance process. You would be surprised at how many applicants sometimes just put on a show for the interviews, but don't know enough to be nice to the coordinators.

In general, all the applicants interview with both our assistant progam director and program director. They are probably the strength of the program and interestingly enough they are quite different from each other. The assistant director is heavy in psychopharm and teaching, and the director is heavy is psychotherapy. I think in general they look for people who the coordinator, assistant director and program director like.

Usually we get 1 or so of our top 6 choices and the rest are usually pretty high up there. The one thing I will say is it is a very DO friendly program, and I think it's a big mistake when programs don't draw from that pool as well.

 

[Sneezing]

Red flag = No moonlighting, no electives, no faculty who stayed on from that program, descriptions of department finance trouble beyond being tight. If a program sounds flat out broke and things are worsening real quick, I'd call that a red flag. Some financial struggles are expected. The program has no SW support. Why sign up for a job that is both resident and social worker?

Yellow flag = How receptive is the program to your possible unique career/academic goals? If you aren't feeling the love, stay away.

 

[MiddleRoad]

Red flag = No moonlighting, no electives, no faculty who stayed on from that program, descriptions of department finance trouble beyond being tight. If a program sounds flat out broke and things are worsening real quick, I'd call that a red flag. Some financial struggles are expected. The program has no SW support. Why sign up for a job that is both resident and social worker?

Yellow flag = How receptive is the program to your possible unique career/academic goals? If you aren't feeling the love, stay away.

The financial situation of a program is not something I considered. At my medical school research brings some money into the department and the home institution probably provides the rest of the support.

For those places where research isn't as strong, how do you assess the financial situation as an interviewee? Anyone out there at a place where they feel the lack of money has been detrimental to their training? I imagine having food, good speakers for grand rounds, stipends for research/learning, compensation for licensing/tests, parking, and good benefits are all nice perks, but it seems like some financially flush places don't provide all of the above.

 

[MiddleRoad]

Thank you everyone for all of your posts. Your honesty, experience and insight is helpful for all of us who are going through this process right now.

 

[Doctor Bagel]

The financial situation of a program is not something I considered. At my medical school research brings some money into the department and the home institution probably provides the rest of the support.

For those places where research isn't as strong, how do you assess the financial situation as an interviewee? Anyone out there at a place where they feel the lack of money has been detrimental to their training? I imagine having food, good speakers for grand rounds, stipends for research/learning, compensation for licensing/tests, parking, and good benefits are all nice perks, but it seems like some financially flush places don't provide all of the above.

It's hard to figure that out. If a program really cuts corners on dinners/lunches, maybe that's a sign they don't have a lot of money. Of it could just be poor planning on their part. It's hard to know.

My medical school's psychiatry department apparently either had or spent more money than my current department, but the negatives from that are more in line with minor inconveniences. We don't have a book/education fund, we never get catered lunches or even free coffee at lectures/conferences, and we've got to pay for Step III ourselves (a perk I didn't think about until I realized my medical school paid for it for their residents). We also have a crappy office situation where fifty million residents share one office in our outpatient clinic. However, we've got great social work (I'm not sure the department even pays for that) and other ancillary services. We also get almost all our meals free through VA meal tickets. Salary and benefits are average and dependent on the university, not the department.

The only significant educational downside that I've appreciated is when we were discussing how to deal with the new ACGME rules. There was some consideration of hiring a nurse practitioner to cover some of the services residents covered, and that was a total no-go I guess because of money. Fortunately the program was able to fix things so we weren't all loaded with more work even without hiring extra help.

 

[Sneezing]

The little things you mention are fairly irrelevent. Ask the residents overall about the financial health of the program. Even some of the interviewers. I can't recall what some of them were when I was on the interview circuit. Perhaps firing office staff? Or letting go SW? Or closing whole inpatient units down? Or faculty who left but no real active attempts to replace them. Its a very subjective thing but imagine yourself as the chair faced with running the whole department what things would you cut? Ask about those.

One inverse way without needing to ask directly is to ask about things they are doing to think of expansion.

 

[MonkeyNuts!]

Where does one look for data on how many residents a program has lost or gained?

 

[Scorcher31]

Where does one look for data on how many residents a program has lost or gained?

Unfortunately, I think you have to rely on Student doctor network, residents during interviews, other residents a year ahead of you that are at the program, or the program director while interviewing. I'm not sure if there are any better ways.

 

[digitlnoize]

Unfortunately, I think you have to rely on Student doctor network, residents during interviews, other residents a year ahead of you that are at the program, or the program director while interviewing. I'm not sure if there are any better ways.

Yet. Give me a few years. Knowing the attrition rate of medical residents would be some important data to have, especially in "shortage fields" like ours.

Even if we don't know the exact programs, I don't even think there's anywhere to look up the number we lose each year total. The US might think it's producing 1,000 FP docs each year, but 300 might drop out for all we know...Can we afford a 30% drop in primary care numbers?

Or, if each 8 person psych program loses 1 resident per year, that's 12.5% drop over the expected number of psychiatrists produced. That's HUGE and would be nice to know. We are one of the oldest (>55% are >55yo), slowest growing, and least popular specialties out there. Adding another 10% loss would cripple the mental health system...

 

[Doctor Bagel]

Yet. Give me a few years. Knowing the attrition rate of medical residents would be some important data to have, especially in "shortage fields" like ours.

Even if we don't know the exact programs, I don't even think there's anywhere to look up the number we lose each year total. The US might think it's producing 1,000 FP docs each year, but 300 might drop out for all we know...Can we afford a 30% drop in primary care numbers?

Or, if each 8 person psych program loses 1 resident per year, that's 12.5% drop over the expected number of psychiatrists produced. That's HUGE and would be nice to know. We are one of the oldest (>55% are >55yo), slowest growing, and least popular specialties out there. Adding another 10% loss would cripple the mental health system...

The thing is that lots of people transfer into psychiatry from other fields, so I'm not sure we're losing people. My program had zero problems replacing the people we lost. If you've done a general medicine or FP intern year, you can transfer into psych as a PGY2.

As for how to find this stuff out, ask when you interview. It's not listed anywhere. And I'm still not entirely sure how to interpret it, so there you go.

 

[digitlnoize]

The thing is that lots of people transfer into psychiatry from other fields, so I'm not sure we're losing people. My program had zero problems replacing the people we lost. If you've done a general medicine or FP intern year, you can transfer into psych as a PGY2.

As for how to find this stuff out, ask when you interview. It's not listed anywhere. And I'm still not entirely sure how to interpret it, so there you go.

That's a very good point. On my list of concerns, this is pretty far down the list. I think most people make it through most programs in one piece. Still, it's a project I might undertake at some point...