Fellowship: A Road Too Seldom Taken Taken

Unlike our colleagues in internal medicine and general surgery, residents in psychiatry infrequently move on to fellowship.

This situation has had detrimental effects on the profession’s ability to provide needed psychiatric services in the four areas for which there exist both a public need and American Board of Psychiatry and Neurology (ABPN) board certification—child and adolescent, addiction, forensic, and geriatric psychiatry (we also can formally subspecialize in pain management).

The APA Board of Trustees’ recent vote to support the Academy of Psychosomatic Medicine’s wish to establish ABPN certification in consultation-liaison psychiatry suggests that there is general support for subspecialization. Also, good job opportunities await trainees who get added training.

If public health needs, job opportunities, and specialized knowledge are not inspiring residents to enter such fellowships, I would offer another reason to do a fellowship—to complement the training in general psychiatry that one receives in residency.

Readers may consider me a masochist for urging such a course. After all, as long as the future general psychiatrist passes the ABPN board-certification exam in general adult psychiatry, there should be no need to enhance his or her general psychiatric knowledge, right? My answer: Maybe.

The inevitable fact is that institutions of graduate medical education vary in their intellectual approaches to psychiatry. Thus, graduation from residency or passing the board exams might belie the fact that the residency graduate was schooled in an academic institution that had its own focus, interests, or purview of the body of knowledge of general psychiatry.

These variations likely result from fundamental differences in the institution’s philosophies of science or psychology. For example, in the institution in which I was a resident, we learned a great deal about dialectical behavioral therapy (DBT); it was an approach that was compatible with the institution’s intellectual foundation in Winnicotian object relations. But in three years of residency we had only one lecture on interpersonal therapy (IPT). In contrast, in the institution in which I am now a fellow, there is little emphasis on DBT, but tremendous interest in IPT, which is compatible with the department’s focus on evidence-based medicine.

Thus, variations do exist. The recently enacted Residency Review Committee’s (RRC) requirements for residency programs that require residents to demonstrate competency in five types of psychotherapy may ensure that all programs teach both IPT and DBT comprehensively. I think, however, that variations will persist in the future to the same extent that they do for internal medicine and general surgery programs.

These variations are not bad. As humans, we all need a model of the mind and brain to organize the facts of psychopathology and its treatment. But who today would claim to have all the answers about what mental illness is?

If variations will exist, then perhaps it is the responsibility of the trainee who wishes for a comprehensive general psychiatric education to seek it, and one can find it in fellowship.

Thus I encourage the open-minded psychiatry resident to consider fellowship not simply for the actual specialized knowledge base (methylphenidate versus extended-release methylphenidate versus dexedrine versus clonidine?) that he or she would gain, but for the experience in a different intellectual environment.

The field would gain, too, by having more physicians trained in more places, sharing information with each other more easily, fomenting a more general appreciation of the many interesting areas of psychiatry. I realize that debt burdens seriously diminish residents’ interest in fellowship. If the trainee is willing to moonlight or delay gratification just a little longer, however, there might be many rewards later.

This is not to say that residency programs should not be held to standards for providing a comprehensive general education in psychiatry. But even when meeting such standards—for instance, those of the ACGME, the RRC, or the ABPN—programs differ today in various ways, and these variations are sometimes positive and sometimes not. I think the psychiatrist-in-training may be all the better for having lived among many, rather than few, approaches to psychiatry, its scientific bases, and its methods of treatment. It will aid the individual physician, the public health, and the profession as well. ▪