A Look Into Psychiatry With A Program Director

Session 130

What makes a great psychiatrist? Dr. Jason Curry, a Psychiatry Residency Program Director at the University of Arizona Tucson, weighs in.

Last week, we had a great discussion with a psychiatrist. This week, we have a great discussion with a psychiatry residency program director. We dive in a lot more into the application process and what a program director may or may not be looking for.

Obviously, Jason is just one program director so take his information, his knowledge, and his wisdom with a grain of salt. Nevertheless, a lot of it will be applicable to other programs as well. For more amazing podcasts, check out Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:40] Interest in Psychiatry

Jason’s introduction into psychiatry really only happened late into medical school. He entered medical school thinking he would go into family practice.

His father is a family practitioner, a wholesome version of the quintessential country doctor where he would see patients in rural areas. He’d go drive out to see family members when they couldn’t make it to the clinic.

When they couldn’t pay, he’d accept small gifts of appreciation. And of course, he never asked for them, but they’d bring stuff they brought from their garden or crafts they made at home. His dad was a wonderful wholesome role model for him.

“It was a blessing to really see him involved in a community and also in patients' lives to see them develop through their lifetime.”Click To Tweet

Jason liked the idea of continuity of care in family medicine and really being there for a person throughout their lifetimes. He had seen the comprehensive care his father had given to patients, treating them from childhood to adolescence and adulthood.

Apparently, psychiatry was not on his radar. Into his third year rotation, he was on the psychiatry rotation. He made a series of mistakes on rotation that he had to learn from very quickly in order to deal with a different set of patient issues and understanding patients a bit more deeply than he had before.

It was dealing with those mistakes that really led him to a deeper appreciation for psychiatry and for people’s stories. So it was the medical school experience that has really set psychiatry apart for him.

What really drew Jason deeply towards psychiatry is that element of the adaptability and evolution of a story.

He realized that the beauty of a person’s story and their experience in their life can really be beneficially and drastically altered. All that without necessarily changing elements of that person’s life.

So they’re reworking the way a person intentionally and meaningfully conceptualizes their own life and their circumstances. This includes their connection to others and how healing is born out of that.

[Related episode: Psychiatry Was a No-Brainer for This Doctor]

[05:19] Types of Patients

Working within the residency, Jason is able to see the full gamut of mental health issues, be it anxiety, depression, bipolar disorders, psychosis, schizophrenia, cognitive disorders, ADHD, substance use disorders, other cognitive issues and dementia.

They see an expansive wealth of psychopathology.

And because they’re located here in Tucson, Arizona, and they’re a big catchment center for a mental health community, they get to see a very diverse set of patients. Not just in psychopathology, but also patients across a number of varying socioeconomic and cultural strata.

“There are two things they want to understand in medical school in this modern medical age – loneliness and trauma, which are both epidemiologic crises of our age.”Click To Tweet

All that being said, Jason sees two things in the modern age of medicine that students need to understand – loneliness and trauma. And if we could figure out ways to help patients navigate those, we would probably be in the best service to our patients.

[07:49] Traits that Make a Good Psychiatrist

As a program director at their school, Jason explains that the traits they’re looking for in residents are probably not too different from what program directors across most specialties would be looking for.

They want to see a proven demonstrated approach to academic excellence and rigor as a part of an applicant’s candidacy towards residency. That they are good listeners because it is vital to the practice of competent, effective medicine.

What might be a little different in terms of good listening with regard to psychiatry is that they are very interested in the content of what somebody is sharing. Because it’s important to have the appropriate data, the historical facts, the chronological development of issues and even on the person themselves.

What they also want to see for candidates is that they have a good year for context. They look at how they can align an understanding of not just the events but the context of a person’s social life, their cultural background there, financial health, or education.

“There are all these elements that we talk about when we talk about what's called the bio psycho social formulation of patient care.”Click To Tweet

Aside from context, another really important thing to look for especially when they’re sitting down with applicants is a growth mindset.

To understand what he means by this, he recommends reading the book called Mindset by Carol Dweck, a clinical psychologist. She differentiates the idea between growth mindset and fixed mindset.

Like much of medicine, psychiatry is one of those fields where we really would like to see somebody understand that their ability to function well comes from a belief. That they can develop skills over time and improve their ability to connect with others. And this is done through a growth mindset.

[10:50] Why They’re Looking for Academic Success Among Residents

Jason points out that program directors or graduate medical education offices would like to see a far more holistic and wholesome design for picking residents. So it is troubling that there is potentially this test.

That being said, what speaks to the value of the test is maybe one of their few ways to really standardize their understanding of how academically trained or trainable somebody may be.

This is the aspect where there’s not a lot of ways to compare candidates more equally because some schools are different,. Their focuses are different. Some schools are newer and some are older.

So it’s hard to know even, at times, compare the quality of a school compared with others.

“Not that the quality of the school necessarily dictates the quality of the candidate, but this is one of the ways that we just try and make sense of things.”Click To Tweet

[12:30] Reducing the Importance of Using Step 1 Scores

Jason explains that they’re certainly in a time where they’re trying to reduce the emphasis on their use of Step 1. He added that the GME at the University of Arizona is involved in what’s called the user study.

It’s a study they’ve developed for the past two years and their program is a part of it where they blind the program directors to the Step 1 score.

So all of their application review, invitations, and the selection of candidates are done without the program directors knowing the Step 1 scores. It’s not until after the rank list is set that the program directors have the ability to unblind themselves.

Moreover, there are some fields of medicine where there’s just a stronger correlation in terms of a Step 1 score to whether or not somebody’s going to pass the boards. Jason says that Psychiatry is not one of those fields however.

“There’s still going to be ongoing testing.”Click To Tweet

Ultimately, it’s important for them to know that somebody is equal to the challenge in terms of staying up to date with that basic fundamental information and with their test taking skills.

That way, they’re more likely to pass those necessary steps or tests all along the way. Whether that’s the inservice training exams or the boards or the recertification exams and any additional training that somebody might pursue.

[15:27] Addressing the Issue of Suicide Among Students and Residents

Jason says that the potential of their institution having to go pass/fail was not something the considered when they developed their user study.

Instead, what really motivated them was the rising suicide rates and depression for medical students.

Physicians have a higher suicide rate then the general public.There used to be this barrier or gap between the suicide rate for physicians and the suicide rate for residents and medical students.

So Jason understands that there’s part of training that maybe they’re not getting right, or at least there are certainly places for them to improve.

“Across the past ten years, five years especially, there is quickly closing this gap between the elevated suicide rate for physicians and the elevated suicide rate for medical students.”Click To Tweet

And perhaps this overemphasis on idealized versions of the candidate, including an idealized Step 1 score is one of those first places that they can really re-examine and evaluate whether it’s really necessary.

It was this concern for the wellbeing of medical students and the concern over increasing depression rate and increasing suicide rate that really led to the motivation behind the study.

[17:40] Debunking Some Myths Around Physicians Seeking Help for Depression

“There’s this perceived belief that it's a different type of fallibility in terms of having a mental health issue versus a physical medical issue.”Click To Tweet

There may not be the same level of concern for a physical medical diagnosis in terms of that impacting the ability of somebody to become a physician when compared to a medical psychiatric diagnosis.

Part of that is just cultural stigma that’s been embedded in our society for a very long time. And that stigma is often related to this idea that mental illness is some form of weakness. And that weakness is within that person and their mind. The more we understand mental illness, the more we understand that this is not true.

But there are certainly other ways that these illnesses have evolved and that can relate to genetic background. It can relate to the pressures around that person’s life, be them social, be spiritual, or existential and that they are normal for all of us.

“There are problems that are out there that we don't necessarily have to hide to feel like we're just as good as everybody else.”Click To Tweet

Jason says that we’re coming into an age where it’s understood that some of these problems are natural. They happen quite commonly and that shouldn’t be any reason that somebody should need to feel shame or feel less than others.

He adds that this is even maybe an additional benefit to their ability in some ways to understand how to help others in a more meaningful, holistic way.

[20:34] Common Application Red Flags

One common red flag is somebody who doesn’t have a clear understanding that there are skills that they can grow over time that would allow them to function better as a human being or as a psychiatrist.

So they may come with this idea that they’re a great doctor because they’re a natural talent. And it’s that natural talent that allows them to do this job better than anybody else.

And perhaps others aren’t able to do it in that same way because they don’t have this gift that they have. At times, this blocks somebody from learning how to grow or deal with problems.

“There's this natural assumption that if they can't muster it up through their natural talent that there's no way to overcome or navigate new or difficult situations.”Click To Tweet

Jason doesn’t think that failures of any kind academically is necessarily a red flag when it comes to at least her own programs review of an application.

But it’s another story when it’s consistent academic difficulty in different areas where there was maybe academic difficulty in the preclinical years in some courses. Then you see maybe a failure or suboptimal passes in the clinical years, or low scores or multiple failures in the Step 1 and Step 2.

Any one of these things wouldn’t necessarily be a red flag. But when there’s a combination of them, the program directors might be more concerned about the ability of somebody to make it through psychiatric training or a psychiatry residency in a successful way.

Going back to being smart enough as a natural talent, Jason thinks that’s the clear separation between results, orientation, and process orientation. Because there’s just so much in medicine to know, and psychiatry alone being so vast.

“You have the whole of medicine being so diverse and great that you can't possibly know everything.”Click To Tweet

It’s much more about being engaged within a process to help develop optimal answers over time. The value of process orientation over results orientation really serves not just the fundamentals of medicine well, but also a person’s approach to becoming more competent in any field of medicine.

[24:52] Success During Residency.

Jason’s personal take is to have this understanding that psychiatry is not the result that they’re looking for. It is in itself a process. People who graduate from their program are not psychiatrists first and human beings second.

“They are always primarily human beings and psychiatry ends up being an expression of humanity.”Click To Tweet

In order to be a really great psychiatrist and function well as a resident within psychiatry training, they are aware of this idea that they need to be healthy human beings first.

Connect with people in that idea that there’s not this vital hierarchy between who is the physician and who is the patient and who has this title or this name.

To be successful within residency, they really try and promote that idea to take care of one’s own self. This way, they’re ready to connect with other people on a team and assess their needs. They can help interact with them and provide excellent patient care. This happens through the health and wellbeing of the person taking care of themselves in order to serve others.

At their university, there are certainly tasks and standards that they employ in terms of residents performing really well in residency. One of those things is knowing that as a physician in many ways, whether you’re a junior resident, senior resident, CEO of a hospital organization at every level of physicianship, you are going to be viewed as a leader.

In this leadership role, you are able to work collaboratively with your teammates, be them your patients, other physicians, or other providers. Everybody can communicate through conflict and distress really well. “Psychiatrists are one of those fields that are really well suited to deal with conflict management.”

So their training and the competence of their physicians in psychiatry are built upon leadership through conflict management.

[28:30] What to Consider When Choosing a Residency Program

Jason describes psychiatry residencies being very diverse. All of them still have the requirements from the ACGME about what rotations need to take place at certain times. They are making sure that all of those are fulfilled in order to graduate somebody successfully.

“The way in which that path develops for residencies is very different.”Click To Tweet

Some residencies are more able to achieve those rotations and those experiences through a community based program. They’re seeing patients who are perhaps a bit more marginalized, have a lack of resources, and may not have the most resources available to them.

There are academic programs wherein the emphasis is not just on excellent patient care but also on research and performing or publishing in different academical domains. You have other programs that may be private programs or large medical system programs.

Their program at the University of Arizona is a mix of all of those things given the development that their program has had over the years.

All this being said, programs have different focuses. When choosing which residency program to go to, consider what program you’re interested in.

Pay more attention to whether there’s a desire to work with a specific patient population. Maybe you’re interested in a community-based setting or working within research or translational research. Or you might enjoy working in a private employment set up.

[30:36] Finding the “Warm Fuzzies” in a Program

“The main reason that medical students will match to a program is the exact same reason that that medical student may be with their significant other.”Click To Tweet

If you look at the NRMP survey data from medical students and the top reason they matched to a program by far and away the top reason is geography.

But imagine you go to your significant other and you say, the reason you’re together is because they live within 25 miles from you. If you were going to date someone, they definitely don’t want to know that you want to date them just because it’s convenient and they’re local to you. That can kill the romance very quickly.

So students need to understand that there are maybe other elements to that relationship that are vital and that give you those warm fuzzies.

Whether that’s the culture of the program that allows you to connect with people well. Or that you might be interested in a particular type of research and you want to train with that researcher in the program. Or it can be about the extracurriculars involved such as international rotations, volunteering, and advocacy.

So figure out what gives you those warm fuzzies and you can bring that out when you’re in an interview.

Program directors realize that location is a big reason why medical students will match to a certain residency. But if there isn’t that connection, whether you call it warm fuzzies or that purpose and meaning however you want to term it, it may not end up being the best fit.

[35:14] Some Resources You Can Look Into

The APA or the American Psychiatric Association, has a guide to applying for psychiatry residency called the A Roadmap to Psychiatric Residency. Learn about the ins and outs of when to apply, how to put a fourth year together, and how to select programs.

They have a great methodology to building a medical student career that aligns itself well with being a good candidate for a psychiatry residency.

Another is to check out the NRMP data. We have actually featured those on our previous episodes.

On top of that, there’s the NRMP Program Director Survey about what program directors are looking for, what they value when it comes to reviewing applications and candidacy. They have NRMP surveys from medical students in terms of what they were looking for and how they ended up matching to a program.

Those surveys have a wealth of information available in them and I’d recommend that people look into those.

[37:10] Prepping for the Grand Rounds

In Jason’s fourth year of residency, they were asked to give grand rounds. It’s a lecture given within a department that talks about an area of expertise or understanding in that particular field that somebody gets to share with others.

Four years into his program, he was still sorting out what his area of expertise was. He felt like after three full years of training that he wasn’t much of an expert in anything at that point.

So the anxiety of trying to put the grand rounds lecture together was building up with it all of the regular themes of impostor syndrome that most of us have to deal with.

So he asked himself a very fundamental question, which was – what is psychiatry?

And one of the scariest things happened at that point, which was no answer came to mind when he asked himself that after three full years of training.

But he was able to take a step back and just wait for something to bubble up, which it did. And the answer that came up once he put the anxiety aside and took a couple of deep breaths, was that psychiatry is the field of medicine best suited to celebrate the human experience. And this became his understanding of psychiatry.

So Jason wants to challenge others that as they’re looking at fields of medicine to not just describe it on that own field’s term, but develop a definition for yourself.

“Develop an understanding for yourself of what that medical field means to you because it will likely help to drive your purpose, understanding, and engagement within it.”Click To Tweet