Although the transition from residency training to independent practice is an exciting time in one's life, without preparation it can be unnecessarily stressful (1, 2). Many psychiatry residents feel that although their training programs prepare them well for the rigors of clinical work, the same cannot be said for the provision of information on career options and supporting decision-making around selecting a post-residency position and starting a practice (2).
Below, we provide a brief guide that outlines the career options available to new psychiatry graduates, factors relevant to selecting a position, steps that may be taken to qualify for independent practice, and how to start a thriving career. We describe these from the perspective of the transition to practice in the province of Ontario, Canada.
Making informed career decisions requires familiarity with the options available. In many contexts, numerous non-academic possibilities exist; these include private office practice, general inpatient or outpatient psychiatry in a hospital setting, providing care in shared-care models, working for the pharmaceutical or insurance industries, or a combination of these. Within the academic environment, one can take a position as a fellow, a clinician-educator, clinician-administrator, or clinician-researcher.
Each type of position provides the psychiatrist with a different mix of payment models and patient populations, each with specific advantages and disadvantages. Often, it is helpful to ask practicing psychiatrists why they chose their type of practice, what they consider important in selecting a position, and what they would have done differently were they in the resident's position at the present time.
Borus (3) has outlined the steps that residents commonly take in making a practice-choice decision (Table 1), and these will provide the framework for our discussion of the optimization of this process. It is of value to initiate this transition by the beginning of the last year of residency and to consult colleagues, mentors, and loved ones frequently.
TABLE 1.Steps for Practice-Choice Decision-Making
The first, and potentially most anxiety-inducing stage of making a practice-choice decision is undertaking the task itself. The second stage involves the definition of important professional and personal issues that will affect the practice choice. Important professional factors to consider include intellectual stimulation and preferred practice style. Remuneration, workload, and protected time for research, teaching, and administration are also important. In an academic department, clinician-researchers should have 50%–80% of their time allotted to research with salary support for the first few years. A clinician-educator should expect 10%–20% of his or her time to be protected for scholarship indefinitely (4). Important personal and family considerations should also be considered (Table 2).
TABLE 2.Factors to Consider in Selecting an Independent Practice Choice
Developing an “ideal job” profile can help to establish the qualities a desired position should possess. A helpful technique is visualizing the ideal career and personal life “5 years down the road.” Discussions with decision-facilitators, including family members and professional mentors, can aid in this process. It is at this stage, when important issues are prioritized, that feelings of depression often emerge (3). However, this is generally considered to be normative and is usually self-limited.
Next, the resident prepares a “professional presentation” by updating the curriculum vitae and creating a cover letter describing qualifications and special skills to potential employers. Having these reviewed by senior colleagues is a helpful exercise.
The resident then explores practice opportunities. This can involve perusing the classified sections of journals, web pages of hospitals and academic departments of psychiatry, contacting department chairs and chiefs of clinical service, and networking with colleagues and mentors. A number of websites list local, national, or international job opportunities. HealthForce Ontario (www.HFOjobs.ca), medicalemployers.com, mdsearch.com, mdjobsite.com, and mentalhealthjobs.co.uk are just a few of the online resources that can help connect residents to potential employers.
The resident then visits and/or interviews at potential work settings. Site visits allow for assessment of “goodness of fit.” Speaking with other residents, recent graduates, and senior faculty members can help the resident put his or her marketability into perspective. As relationships with colleagues are important determinants of professional satisfaction (5), it is important to meet potential future coworkers. Discussing these experiences with decision-facilitators can be useful.
Next, the process of contract-negotiation begins. Successful negotiation relies on preparation and bargaining. Developing clear professional goals that are congruent with those of the proposed employer and having the means to achieve these can be very persuasive. The resident needs to be aware that there is a power differential between him/her and departmental chairs. Taking a position of courteous assertiveness is generally the best approach to negotiation in this setting. By the end of the negotiation process, the resident should understand the balance between clinical and academic expectations relevant to a position. Because there is no such thing as a “standard contract,” a lawyer should review this document before signing (6). After selection and commitment to practice, a decrease in anxiety and depression is expected.
The last phase of practice-choice decision-making involves formally preparing for practice. In Canada, this begins with the completion of the Royal College of Physicians and Surgeons of Canada (FRCP(C)) fellowship examinations and is followed by the acquisition of an independent practice license from the College of Physicians and Surgeons of their province or territory. Since most psychiatric services rendered by psychiatrists in Canada are covered by government-paid health insurance plans, acquiring a billing number is vital. Other pragmatic professional issues that should be addressed before starting a new position are obtaining hospital privileges, completing facility orientations, and the acquisition of security passes and dictation numbers. For residents training in Canada, updating professional liability coverage requires a change of the Canadian Medical Protective Association code. Because these steps can take months to complete, the resident should initiate this process well in advance of graduation. At this stage, seeking guidance from recent graduates can be of value.
During residency, it is wise to become familiar with local billing codes. This can be facilitated via billing-tutorials provided by residency-training programs or by residents' completing “exercise” billings for patients and comparing these with their supervising faculty's billing submissions (i.e., “shadow billing”). Faculty members who have private practices can provide important information to residents on topics ranging from setting up a practice and office, to scheduling, medical-record management, and professional incorporation. The Canadian Medical Association (www.cma.ca) has produced a series of online documents that can aid trainees in navigating the complexities of setting up an office.
The end of residency is an exciting time that is marked by new challenges and losses. Leaving the resident peer-group and a familiar clinical system can be difficult. Understanding the emotions associated with these changes and utilizing supports can be helpful. Coping mechanisms listed by new psychiatrists as very helpful in adapting to early psychiatric practice include emotional support from spouse, play and recreation, ad-hoc consultations with colleagues, relationships with peers, vacation or time off, reading, creative activities, hobbies, and exercise (2).
Avoiding isolation is very important to one's success. Professional isolation is associated with increased levels of work-related stress and dissatisfaction with one's position (7). As a result, many new physicians in independent practice find it helpful to join a practice-group, where knowledge and experiences can be shared with other psychiatrists and the transition normalized. Unfortunately, physicians are often not very good at prioritizing and managing their personal health. In addition to attending to one's own psychological health, Puddester recommends that early-career physicians get their own primary-care physicians, participate in recreational activities, get adequate rest and proper nutrition, and nurture professional and personal relationships (8).
The early-career psychiatrist should consider retaining the services of an accountant, lawyer, and financial adviser as a means of easing the transition to practice. These professionals can help physicians optimize their earnings, review contracts, advise on legal issues relating to starting an office, and help construct a financial plan.
New psychiatrists will face myriad challenges in their first years of independent practice. Although by no means exhaustive, the following list is intended to help the trainee anticipate these issues and develop ways of managing them.
The stress of independent decision-making is a challenge faced by many new psychiatrists. However, adherence to the principles of diagnosis, treatment, risk-management, and documentation learned during training can mitigate these risks. The newly-graduated psychiatrist must realize that he or she is not alone and is encouraged to discuss cases with colleagues and/or ask for help.
Understanding one's limitations can also be helpful in easing the transition. New graduates often try to live up to the impossible standards set by the over-idealized “triple-threat” academic psychiatrists they encounter in training (9). Attempting to live up to these standards early on is unreasonable and can lead to feelings of inadequacy.
Setting limits can help to guard against one's tendency to work too much or too long. Educating patients and referral sources on the scope of available services can help promote an enjoyable workplace. Setting a reasonable number of work hours per week and guarding this closely may also help. Factoring extra time into one's day for administration and paperwork can save headaches and late home-arrivals, and maintain a healthy set of order and boundaries.
It is inevitable that psychiatrists will receive patient care-related complaints during their careers. These can feel hurtful, but it is important to remain calm and, if possible, take some time before responding to them. Documenting complaints and one's responses is sound, from a medico-legal perspective. If it is appropriate, one should not be afraid to apologize to the patient (and/or family member(s)). Under the Apology Act in Ontario, apologies cannot be used as evidence of liability against a physician (10), and disclosure may actually lessen the risk of being sued (11).
The transition to independent practice in psychiatry is an exciting time in a physician's life. Knowledge of the transition and its impact can be helpful, as can the nurturance of familial and collegial relationships. Consultation with decision-facilitators is vital throughout the transition process and beyond and can help ease the transition to independent professional life.
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