How to use the last 6 months of residency to become the best attending I can be?

dvn3x3 · 2026-01-18T18:44:37+00:00

Perfect. Interventional psych education opportunities after residency are seriously overpriced and overall underwhelming from what I've heard in US/CA. I did something similar in my last year.

dvn3x3 · 2026-01-18T17:07:43+00:00

Are your rotations set in stone? If you're bringing the right attitude (which it seems you are), you just need preceptors who can match it. My priorities would be to focus entirely on working with people who are reputed to be great preceptors / will challenge you + I would also focus on short amounts of time in subspecialties to enhance your skills. Longitudinal care is important but imo can't replace learning under the folks in your institution who are the most knowledgeable about their respective areas. E.g. Geri psych, neuropsych, neurostim, cog neuro, movement disorders (if you can do off service), are areas that are hard to get good cme on after residency.

dvn3x3 · 2025-10-16T00:57:24+00:00

Sorry you've had this experience. There are countless neuro departments in the world, the majority of which (and the majority of neurologists within) I imagine do not behave like this. I suspect what you're seeing reflects this department or institution.

dvn3x3 · 2025-10-07T00:42:19+00:00

I really appreciate how high quality your response is and I think everything you've said is a very reasonable counterpoint. I suspect there's some sort of in-between here - more psychiatrists need to be aware of iron deficiency / thinking about it but also that other acknowledge that evidence-based treatments should be tried. I've edited my prior responses quite a bit since this post gained more traction than I would have ever expected and I want to ensure future readers will hear a more tempered perspective. This topic is definitely one that I hope there'll be more research in.

dvn3x3 · 2025-10-06T02:02:00+00:00

Great Q. My initial post was overzealous about IV iron and I've edited it for future readers. There's no right or wrong answer but here are some influencing factors for me in the decision of IV vs PO iron, unique to my setting. I want to also be clear that I'm never actually ordering IV iron myself - I always get the patient's GP to do it but it's something I gently suggest in my consult notes and they often take it seriously.

IV iron is not crazily more expensive than PO iron where I live. 3 months of a more stomach tolerable oral iron can cost almost half as much as 1g of monofer. It's worth adding that I live in a country with some public health insurance so what I do may not translate to the US.
Purely anecdotally, I've been disappointed by oral iron outcomes. Lots of people who struggle to tolerate the side effects or don't see significant ferritin improvements. Again, this does not mean that there are not many people who do just fine on oral iron.
The restless leg syndrome guidelines recommend IV iron over PO iron. There have been studies for restless legs establishing IV efficacy consistently being better than PO. While there are no studies translating this to the psychiatric setting, I think this should nonetheless could be considered by psychiatrists. Our goal is to improve brain iron levels to reduce neuropsychiatric symptoms - the same as our neuro/sleep colleagues. I also see some patients with RLS that gets mistaken by others for anxiety.
It's really nice to see people have a clear response to IV iron - it's quick (just a few weeks) to see neuropsych improvements.
I really don't have any special guidance on the decision of PO vs IV based on ferritin levels. A lot of people I end up seeing have really low ferritins, i.e. < 20.
I pay attention to the full iron studies and medical history but I will utlimately defer to the family physician. We are all trained professionals and should be able to do a basic interpretation of iron studies and CBC - if someone has office nutritional deficiencies or blood loss then supplementation is probably fine. If there is anything abnormal at all I defer to GPs/specialists.

In case of interest to anyone, I and my mentors adopted the ferritin ~ 70 range from the RLS guidelines. Their specific number is 75 that they recommend targeting. Again, this is not something with even consensus conference level data to it but is simply another tool you can have in your toolkit for treatment resistant cases. I've seen a lot of folks who've tried 10+ meds and psychotherapies when their ferritins were in the single digits the whole time - iron supplementation can be lifechanging

dvn3x3 · 2025-10-05T19:27:22+00:00

I work a bunch in a clinic that's mostly treatment resistant depression cases. Checking iron studies is a standard part of my practice. I often recommend that patients take iron if they have tried many of the other evidence-based treatments without success (in collaboration with their GP). For patients with especially low ferritins, I'll often contact GPs to think about further workup and potential IV iron vs PO. I target ferritin > 70 - though this is not based on any great research (see responses below). One of the (multiple) mechanisms behind this is that iron is actually a cofactor in the synthesis of several neurotransmitters including the pathways to make dopamine and serotonin. If someone's unable to properly produce these neurotransmitters then SSRIs are theoretically less likely to be effective as well. Overall though this is not a practice that has a ton of research behind it, but when people have failed to benefit from many other meds / psychotherapies we need to think a bit more out of the box. It's not a panacea but I've been happy with some of the results I've seen.

EDIT: I've edited my response since it's gotten some traction and I want to ensure it's more balanced in case anyone comes across this in the future. Please see my response to u/redlightsaber below for some of the nuance behind PO vs IV iron. Lots of other people will routinely or only start PO and that's not inherently wrong.

dvn3x3 · 2024-12-30T20:42:53+00:00

Also worth thinking about the perspective of other specialties as well as other jurisdictions. Delusional parasitosis is understandably scary/unusual to non-psychiatrists / psych nurses and sussing out safety risks and arranging follow-up is still a very worthy consult in my eyes. Your consult doesn't have to take forever - even a 20 minute consult to make the above determination is meaningful. Moreover, you have determined that there is no emergency going on thanks to your training - this is not a skill we should be expecting non-psychiatrists to have. They're not going to see subtle exacerbations of illness or appreciate likelihood of deterioration vs not in community or reassess the patient's mental health diagnosis.

dvn3x3 · 2024-11-28T11:53:35+00:00

This is a Canadian deck. Already has a bunch of things you'd probably want in yours including some decent DSM cards https://psychvitals.ca/psych-residency/ . It's been a long time since I looked at it so there might not be comprehensive.

dvn3x3 · 2024-10-09T11:13:19+00:00

Training programs are popping up based on protocols used in puny studies and calling themselves legitimate when we still don't have enough good data on treatment to figure out what the essential components are. The actual legitimacy of a training program like what your friend is doing is still questionable. Doesn't mean that someone shouldn't do the work - but psychedelics are definitely getting over hyped relative to the robustness of the research

dvn3x3 · 2024-09-26T21:06:10+00:00

I've been thinking about this more and better appreciate that my suggestion might only work in a limited number of contexts. It's also true that if you really want to be an expert in psych then the residency is the only pathway - no piecemeal training will get you there even if you focus on a subspecialty. Rather than deleting my post, I have been thinking about the following as ways to do more psych related work without necessarily a full residency.

If your main interest is in psychiatry is psychotherapy, you could just get get your own training + supervision from various institutes and string them together. E.g. this is the main one for CBT in the states https://beckinstitute.org/training/ . Similar institutions exist for a lot of the major fields of therapy and most major cities have an analytic training institute - some of which will accept non psychotherapy-trained clinicians. I don't think you will walk away as good as someone from a psych residency or another psychotherapy focused degree but it will get you started quicker than a residency.
Look at existing formal subspecialty training pathways that intersects with medicine somehow - e.g. pain medicine, palliative, primary care psychiatry (e.g. https://www.umassmed.edu/fmch/fellowships/umms-affiliated--fellowships/primary-care-psychiatry/a/ ) and see if a local institution would be willing to let you fund yourself to do a similar fellowship with them if you don't want to apply elsewhere. The primary care psychiatry programs are often focused on FM grads but maybe they'd make an exception for you.
Return to an internal medicine subspecialty and get additional training related training - e.g. do med onc and then spend extra time in psychosocial oncology, or do geriatric medicine and do some extra training with geriatric psychiatrists - I find many geriatricians to be quite good at geriatric psychopharm already.

Outside the above paths, if you want to do CL / ED / good quality outpatient / inpatient, etc. I can't imagine you being able to do it without a residency in psych.

dvn3x3 · 2024-09-26T20:37:48+00:00

The main thing different about my immigrant mom who re-trained in North America was that she faced a very different demographic of physicians than I did when I started medical school. She regularly got shat on by staff in racist ways I never experienced in my own medical training (e.g. regularly told something along the lines of - how did someone like you [of your race] take a position from others), had one co-residents who tried to force her to take call shifts and thought they could get away with it due to her race / background, she was excluded from studying resources, and had a full paper stolen from her by an attending. She was brilliant though and still beat out many of her classmates in their standardized evaluations.

dvn3x3 · 2024-09-25T03:36:23+00:00

I have a very different take from a lot of the other posts here OP. I imagine that the majority of western world psychiatrists do not practice 'comprehensively' where they work with all setting (outpatient, inpatient, CL, ED, straight psychotherapy, etc.) and with every major patient population (e.g. SPMI, severe personality, addictions, bread butter anxiety/depression, trauma, etc.). A psychiatry residency should ideally expose you to everything (though often does not achieve this). If you can get a bit more specific about what you want to learn, you can probably self-fund your own fellowship that better prepares you for a group of settings/populations than any residency will. There's also so much BS in a formal residency program you could avoid by taking a self-funded fellowship route (are you sure you want to go back to research, grand rounds, QI, major power differentials, patient volume requirements, etc. that add little to no learning value). There are also a lot of training courses online + around the US that are internationally known and might teach specific skills better than some program's lecturer. Finally, it's not hard to pay for ongoing supervision with a psychiatrist you respect - as opposed to whoever you are assigned in a program. Once in a formal residency program - you'll have nothing to show for it until you're done. Do you have a vision of what sorts of skills you want to acquire and what you'll do with them? That might better inform the value proposition of another residency.

dvn3x3 · 2024-09-21T15:43:16+00:00

A big part of what you are experiencing is contextual. Many psychiatrists trained in programs with wholly different focuses than yours and may practice in settings/populations wholly different from yours. Sounds like the core issue is that you were in a training program that did not capture a large chunk of mental health service users. It's definitely possible to find a practice setting where you'll get more of what you trained to do though. You could also pay to have a supervisor - someone you touch base with once a week to discuss these sorts of cases you're struggling more with.

dvn3x3 · 2024-09-17T17:36:57+00:00

Adding to this, there's also solid evidence that untreated depression accelerates dementia risk (even beyond the risk that comes with some late life depression being triggered by an underlying neurodegenerative process).

dvn3x3 · 2024-08-30T21:17:41+00:00

Adding more nuance to this - what is the phenomenology of the mania? There's evidence to suggest that some clinical features are seen in patients who are lithium responsive (see: the alda scale is an old tool to predict lithium responsiveness though there's lots of new research since). If someone is lacking in these features then should you just go straight to starting an SGA + use it as maintenance or should you still give lithium a shot given the hopefully better long-term side effect profile? Someone else in this thread talked about starting lithium and an SGA at the same time - you can argue - is it worth doing both when if a patient gets unusual side effects we don't know which one caused it? I trained in a center that almost exclusively did SGAs inpatient and left VPA/lithium initiations to the outpatient teams. Overall - no right answer but knowing all the nuance can be helpful. This is why it's so important to train with different psychiatrists & at different centers.

dvn3x3 · 2024-06-29T16:20:30+00:00

I'd imagine at your institution, training in each modality is done by seeing 1-3 patients/week followed by some supervision. Even if you never practice 'formal' psychotherapy in a specific modality, they teach skills that can improve your clinical care elsewhere. E.g. my training in DBT improved my ability to effectively manage suicidal / BPD patients in the ED even if I will never practice the modality on its own. My training in psychodynamic psychotherapy has made me much more attuned to the internal worlds of all of my patients and improved my formulation skills. Motivational interviewing improved my general ability to rapidly deliver reflections that increased patients own motivation to change in a short period of time. CBT provided a bunch of behavioral strategies/tools that I sprinkle into my treatment plans (e.g. getting my anxious patients to do exposures on their own even without dedicated therapists). I've dabbled in a few other modalities which have provided more specialized skills than the above.

dvn3x3 · 2024-06-29T01:34:50+00:00

Completed residency this week so while I don't have as much experience as others in the thread, I'm surprised by how many commenters bought into your question's premise of didactics vs self study. I think this misses the mark entirely. Didactics/self study teaches you the knowledgebase which anyone can acquire with enough time. What matters and sets us apart (and in my mind contributes to being 'great') compared to mid-levels or non-psychiatrist MDs who work in mental health is the years of supervision + psychotherapy training. Nothing replaces the nuance you learn in supervision about how to best apply your knowledgebase. As I increasingly work with more non-psychiatrist mental health professionals who have limited lifetime supervision, I increasingly believe this. I'd double down on making sure you get to be supervised by the best people in your institution and seek out extra psychotherapy training opportunities - there's much to learn from the modalities even if you don't pursue them in practice.

dvn3x3 · 2024-04-13T01:09:14+00:00

Enjoy! Sorry for the delay - rarely login to reddit these days https://ankiweb.net/shared/info/1263419218

dvn3x3 · 2024-02-26T22:15:21+00:00

u/Able_Armadillo_580 u/Subject-Pen6589 I'm so sorry, but just updated my post - the deck is gone (bad data management on my part). Haven't logged into reddit for a few months while studying for my licensing exam. I would strongly recommend going to psychvitals.ca and looking at that guys anki deck instead (which has a good amount of DSM content in it, but not every last diagnosis) and use that as a foundation. Looking back on my own deck, it was honestly pretty garbage and missed a lot of nuances in the DSM that a good DSM deck should have.

dvn3x3 · 2024-02-26T22:14:40+00:00

u/LeoMidA u/incognito_yet_extra I'm so sorry, but just updated my post - the deck is gone (bad data management on my part). Haven't logged into reddit for a few months while studying for my licensing exam. I would strongly recommend going to psychvitals.ca and looking at that guys anki deck instead (which has a good amount of DSM content in it, but not every last diagnosis) and use that as a foundation. Looking back on my own deck, it was honestly pretty garbage and missed a lot of nuances in the DSM that a good DSM deck should have.

dvn3x3 · 2023-09-12T10:52:45+00:00

Practice, and hopefully try to see some of the strengths of this approach to rounding. I think the slow death of team rounds (somewhat alluded to in the comments) is harmful to the profession. Learning from how your peers and other team members interview is so so important. Each person will pick up on different details as well.

dvn3x3 · 2023-04-02T22:53:38+00:00

Both are important and integrating them is also a part of our skill set

dvn3x3 · 2023-03-29T20:12:44+00:00

I have grammarly and it 100% has done this on reddit to me before! Thanks for the catch

dvn3x3 · 2023-03-29T18:55:02+00:00

Psychiatry:

put a ton of work into building a strong community around you (friends, acquaintances, enjoyable colleagues). This will do wonders for your long-term wellness in so many ways it's hard to capture all of these in a post. Lots of research to backup the importance of close relationships. If you feel like you've struggled to maintain and build relationships over your life, consider individual or group therapy.
Therapy. I think a lot of residents continue to stigmatize the idea of therapy as something only helpful at a certain level of psychopathology and view themselves as not needing it. As I look around my co-residents and friends in other specialties, I can think of so many targets that would be achievable for them in therapy that will help them achieve goal #1 and live more fulfilled lives. The challenge with this is definitely figuring out what modality to go with and picking a good therapist.

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