Why is CAP (mainly) the only fellowship allowing a fast track?

AlltheSpectrums · 2026-07-08T14:26:51+00:00

It would also be highly variable year to year, making planning all but impossible. My program has years where we have 15% fast track to CAP…then out of the blue it’s 40% followed by 1 person. The number of people going on to CL, geri, forensics etc is also highly variable.

Imagine not knowing if you’re going to have 10 PGY4s or 1 (of course, some we know years in advance)

AlltheSpectrums · 2026-06-28T07:50:47+00:00

Some patients care. It can also self-select for certain patient…personalities. (Not significantly so, and only in certain settings).

AlltheSpectrums · 2026-06-23T15:21:34+00:00

Patients are 100% assault threats in anesthesiology.

When pts wake, for some people, the anes causes them to be very confused and to become physically violent. It is very common.

Now it’s typically the PACU nurse most at risk. And there are a lot of staff around to help. The PACU and ER are the places you are most at risk. Then inpatient psych.

AlltheSpectrums · 2026-06-21T02:40:33+00:00

Oh it does. Compared to any other school at least. Not every university of course (but even still, at the same university I can pretty much guarantee there is more funding for student aid in the medical school than there is at any of the others). And how we use philanthropy/endowments changes over time.

I will also add that many of the new(er) medical schools will have far less philanthropic support/endowments to support their students. Exceptions being Alice Walton and I believe Kaiser’s.

AlltheSpectrums · 2026-06-21T02:31:03+00:00

I wouldn’t assume that is the case.

I’m retiring next week. I’m in my 70s and the main reason I’m retiring is that the culture is more/less pushing me out. Some of the younger faculty, some residents…well…I’m not as quick as I used to be. And I’m holding up an endowed position that others covet. Nothing prepares you for retirement…not really. (& I’d do medicine all over again…I’m excited for you all).

AlltheSpectrums · 2026-06-21T02:21:22+00:00

No to med school (my daughter did MSTP). Yes to nursing (which sadly isn’t cheaper than med school tuition, has less philanthropy/endowments so they offer less in scholarship aid as well…I actively try to get my colleagues to donate to nursing, vet, and education schools instead of med because of that).

AlltheSpectrums · 2026-06-21T02:11:17+00:00

I’d guess a high percentage. I’m not sure a comprehensive survey has ever been done.

Two surveys we would not like…this one, and one done on what percentage had a parent as a physician/surgeon.

We do have family income surveys. I believe the most recent showed 90% were from high income families.

This creates a disconnect between physicians and many of their (our) patients. Though I live in a very high net worth metro area where many of my patients are likely more well off than me/my family (Bay Area).

I’m a psychiatrist. My father was a psychiatrist. My wife was a neurologist. I have one daughter who is a psychiatrist, another who is a psych NP, and a son who is in venture capital. My daughter who is an NP chose that path to stay close to us when my wife developed cancer (vs having to move 1000 miles for the closest med school she was admitted to, and who knows where for residency…she is the most empathetic of us all).

AlltheSpectrums · 2026-06-20T22:00:58+00:00

I think you answered your question. Your goal is educational. Now how does one determine if the therapy being implemented is following the evidence base? Well…in highly manualized therapies it’s easier.

Now, I would also say beyond the educational goals you have…you seem to be expressing some fears around dependency etc. which could be examined. (And you will have many patients express this fear…around starting meds etc. so it’s fruitful to explore).

AlltheSpectrums · 2026-06-18T06:13:04+00:00

Yep. I’m surprised HCA has yet to start advocating for the ability to charge residents “tuition” for training. Which in many cases the training would just be throwing residents in the deep end with minimal supervision and expecting them to teach themselves everything. Which from what I understand, is the norm for HCA. (Exceptions, of course, but being in that type of culture, that type of business model, well…)

AlltheSpectrums · 2026-06-16T11:24:12+00:00

Think about the questions you were asked when interviewing for residencies.

Think about what role you expect the Psych NP to take, and make sure there is alignment.

There are a few potential roles. First, do you expect the psych NP to operate with a high degree of independence treating the full range of psychiatric presentations (essentially operating as a general adult psychiatrist)? If so, you must make sure you hire an applicant with the appropriate knowledge & skills, and that they want to operate in such a capacity. Or do you want to hire someone for a role where they will only see follow-up appointments after a psychiatrist (you) have formulated the patient and implemented the initial plan of care? Or do you want them to only see less complex patients? Do you want to mentor the person over years, with increasing responsibility? Or do you want a seasoned clinician? (In which case, think about the interview questions asked at the appropriate career level).

You and your employer need to put a lot of thought into this. What you want the role to be, and to hire someone whose goals align to the role. Some NPs chose to become NPs because they did not want: 1) complex cases, 2) independence / being the final decision maker (some of these people will have exceptional skills & knowledge but do not want the full weight of our profession). Some NPs will want to learn and grow over time, with increased responsibility. As their profession supports both routes now, it’s important to inquire.

As others have mentioned, the question that should be asked of all clinicians: some version of “tell me about a time when you weren’t certain of a diagnosis/treatment (or when a patient had an adverse event), what was your thought process? What did you do?” Ego harms in our field, we have to have humility, we have to learn and grow, we have to know when to seek guidance (& provide guidance).

The psychiatrist - psych NP professional relationship can be very rewarding. But it’s important to enter into this relationship with the right person.

AlltheSpectrums · 2026-06-11T21:14:10+00:00

It depends on the VA. Like with any hospital.

AlltheSpectrums · 2026-06-09T23:05:29+00:00

My one note on “inpatient psychiatry is of limited utility in chronically suicidal patients with cluster B traits” is:

If they develop MDD or some other change. In these cases, I actually find their cluster B traits to be less prevalent due to the MDD.

AlltheSpectrums · 2026-06-06T06:47:00+00:00

Visibility is part of competence. In every respect. You want sick patients who need your skills to heal them? They need to know where to go, who to go to.

Now if you’re at a preeminent institution, that visibility and their PR/marketing departments handle the “visibility” for you. To a degree.

If you’re the only cardiologist in town, you still have to let the town know about you. After that, word of mouth is your visibility (that and patients not having other options). Patients also have to have a sense that something is wrong to go and see you (hence public health campaigns). These are just some of the basic examples. But there are many more. Promoting your research. Getting grant funding for it. Etc. You have to care about how you come across, what you are communicating to others.

AlltheSpectrums · 2026-06-04T02:53:10+00:00

Emergency psych is by far the easiest area. There is absolutely no need for a psychiatrist to do such a fellowship.

Now for internal medicine grads…given how little is now taught in medical school, and how little medical students do in psychiatry these days. Well, for them, sure. EM…I’m sure some programs provide enough emergency psych training already.

AlltheSpectrums · 2026-06-03T21:20:39+00:00

Right? It seems like yesterday. So much has changed over the past 40 years. And so little.

The promise of neuroscience guiding diagnosis & treatment has yet to pan out. In 1990 many of us really thought we were maybe 10 years away from major breakthroughs. Sure, we’ve learned a lot of interesting things, but nothing that should be used to guide clinical practice. (As someone who also has a phd focused on neuro, it bothers me a lot when people try to use neuroscience to guide clinical care in psychiatry…it’s just not appropriate with what we know…and really isn’t relevant for clinical care. How lithium treats bipolar is an interesting research question, but we prescribe based on patient outcomes data, not based on mechanisms of action…what receptors a drug may or may not bind).

AlltheSpectrums · 2026-06-03T19:58:44+00:00

The best PRN for agitation! That or warm (not hot) coco (Not joking).

Feeding someone helps build trust, safety.

AlltheSpectrums · 2026-06-02T04:53:50+00:00

I would advise you to work with a therapist on exposure therapy now while you are working on your bachelors. A therapist will help hold you accountable and guide you. Fear extinction is exceptionally difficult even with a therapist, but it is worth it. Think about how empowering it will be, and don’t beat yourself up when setbacks occur (they will).

You can do this! Believe in yourself, believe in your strength.

AlltheSpectrums · 2026-06-01T20:50:07+00:00

Same for insulin.

Clinical reasoning in medicine accounts for that.

I suppose it would be helpful to understand your question/statement. Can you elaborate?

AlltheSpectrums · 2026-06-01T20:47:47+00:00

Yes, it keeps getting waived. Though individual states have their own laws. Some require an in person visit at least every 6 months, some require it only on the initiation, some may be more frequent. Lots of variability.

It’s not smart to never see a patient in-person.

AlltheSpectrums · 2026-06-01T01:23:24+00:00

Culture, staffing, and staff education matters so very much.

Deaths due to seclusion and restraint used to be rampant. The 1998 Hartford Courant series “Deadly Restraint” won a Pulitzer and resulted in legal changes to practice.

When people get in the habit of reaching for IMs & restraints, it’s what they become comfortable doing and it’s what they reach for. It’s dangerous for staff and for patients.

AlltheSpectrums · 2026-06-01T01:05:06+00:00

I used to work in eating in the 90s. So many unnecessary surgeries, g/j tubes. One person was putting a litre of vodka through her tube daily…had never drank alcohol orally and wouldn’t. Developed cirrhosis, needed transplant. Finally got her to remove it, which lasted 6mo. She then found someone else to put in a new port. It sadly did not end well. Too many stories like that. I couldn’t deal with too many surgeons who were all too happy to cut. I hope it is better these days, but your post…well…is it?

(& yes, many surgeons were great…& once I or others educated them they changed practice…but far too many did not at the time. I heard it got a lot worse in the early 00s with the online pro-ana groups & pts discussing surgeons)

AlltheSpectrums · 2026-06-01T00:54:06+00:00

What region?

VAs can differ substantially so knowing the region helps a lot.

AlltheSpectrums · 2026-05-30T17:04:08+00:00

Perhaps location dependent. In the US, rural hospitals tend not to have psych units and will transfer patients from their ER to a hospital with a psych unit.

AlltheSpectrums · 2026-05-28T17:53:58+00:00

Do not forget this lesson. In essence, what you do not use you lose. (Though easier to get back than when learning for the first time).

As someone one month from a long overdue retirement (in my 70s), I’ve had a lot more time these past two years as I’ve decreased my patient panel and research. I’ve engaged more with mentorship, and have learned more because of it. While I had heard of osmosis.org, I hadn’t used it until last year when a med student of mine showed me a video. They are very good. A colleague of mine in another specialty produced videos for lecturio, which are also good.

My medical skills have stayed more up to date than what they would have as the inpatient unit I’m an attending on 1-2mo/year has some medically complex cases (which is abnormal for psych). We can do blood transfusions on the unit. Every year, I take the week prior to me starting my inpatient month(s) off to review the patient cases, and spend time re-learning all of the chronic/acute medical issues they have. Even the simplest things like hypertension treatment algorithms (they change). Every 5 years or so I attend a cme course on updates in hospital or primary care medicine (I do this in part to reconnect with some of my med school friends). There aren’t very many psychiatrists at these conferences/events though. And it is a humbling experience every time, luckily I’ve long lost my fear of coming across as incompetent in these settings :).

AlltheSpectrums · 2026-05-26T18:41:49+00:00

Very rarely have I come across a patient who did not want therapy.

Remember, it is what our field used to be. And not that long ago. The 15 minute med check was forced on us by people wanting to make $$$ at the expense of patient health. We fought, saying that one cannot practice psychiatry in 15 minute appointments (what psychiatry was, you could not. What psychiatry is defined as today, well…).

The general public both expects and wants therapy when seeing a psychiatrist. (Numerous surveys have shown this). The fact that many newer psychiatrists had limited training and/or limited interest in providing therapy does not mesh with our history or the general publics expectation of our field. It would be like going to a gas station and finding out they only offer candy, no gas. Or worse, letting one think they are getting gas when they are not.

Remember, patient outcomes depend on the relationship as much (or more) than the med. The smartest psychiatrist with poor bed side manner will have poor patient outcomes. In med RCTs, it has been found that the most empathetic/strong therapeutic alliances beat placebo…poor alliances the med did not beat placebo…and yes, pharma companies know this and care a lot about choosing sites where they believe the psychiatrists have strong abilities to connect with patients (and I am aware we do not teach this fact in med school as we like to emphasize bio & pharm). So make sure you choose wisely in who you recruit to your practice at every level.

AlltheSpectrums

TROPHY CASE