Child and adolescent psychiatry, a rewarding yet surprisingly underserved discipline, is one in which few medical students receive sufficient exposure. One out of five U.S. medical schools does not sponsor child and adolescent psychiatry residency programs. Furthermore, almost one-third of U.S. medical students have little to no clerkship experience in child and adolescent psychiatry (1). As a result, medical students often are puzzled by some of the most fundamental aspects of child and adolescent psychiatry training. Beyond the obvious questions about what constitutes the job of a child psychiatrist, many of the students at our institution have wondered about how one applies for such training, whether this training necessitates prior experience in other disciplines, and where residency opportunities exist. Given the lack of opportunity for experience during medical school, if you are considering training in this specialty, a mentor can help provide an introduction to this field, help you develop particular interests, and assist you in the important deliberations of whether this is the right specialty for you to pursue. In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) also has a mentoring program that can assist in connecting students with mentors. Finally, interested students should seize some time during their psychiatry clerkship to seek out clinical experiences in child and adolescent psychiatry. Other opportunities for exposure include possible electives during the fourth year of medical school. If your school is unable to arrange a rotation, consider a visiting clerkship at a program to which you consider applying.
Those who are attracted to child and adolescent psychiatry often are drawn to the opportunities that the field engenders. Residents work with children, adolescents, and their families. Trainees and attendings interface with both medical and nonmedical disciplines. It is not unusual to be part of a large team of professionals, all of whom care deeply about the well-being of children and adolescents. In fact, many who choose to train in child psychiatry begin general psychiatry training after initially having an interest in pediatrics. If pediatrics is a strong interest, some students may wish to look further at triple board programs. These 5-year programs provide training in pediatrics, general psychiatry, and child and adolescent psychiatry. After completion, residents will be board eligible for all three specialties. Alternatively, if you know at the time you apply for residency that you would like to train in child and adolescent psychiatry, some residencies offer 5-year programs with separate adult and child psychiatry components, while others offer integrated programs combining adult and child and adolescent psychiatry. The majority of residents will stay in the departments in which they do their general psychiatry residencies; it is important to consider this when looking at general psychiatry programs if you have an early interest in child and adolescent psychiatry training. For many students with such an early interest, it would be wise, when interviewing for general psychiatry, to meet some of the child and adolescent faculty in the local child program. Many general training directors who are eager to recruit interested students can make this opportunity available, even if they do not have a combined or integrated program. Most medical students do not realize how valuable they are and how much the general training directors need to recruit actively. Do not be afraid to ask for this on the interview circuit.
This article will review the basics of choosing to specialize in child and adolescent psychiatry. We will discuss the application process, the resulting interview trail, the nuances of the interview and the post-interview period, and the considerations as one negotiates the intricacies of the match itself. As the article demonstrates, becoming a child psychiatrist is no small task, but the rewards for this line of work are immense and deeply gratifying, and the experience begins with the decision itself.
Once you have decided to take the plunge and apply to child and adolescent psychiatry programs, you will need to formulate a career timeline. Unlike the other psychiatry fellowship programs, child and adolescent psychiatry training allows applicants to apply for entry after their third year of training, provided that all general psychiatry training requirements have been met. The most cited benefit of “fast tracking” into child psychiatry is that there is less total time in training, which facilitates earlier entry into the workforce. Some trainees feel that the burden of educational debt necessitates earning an attending level salary as soon as possible. Others want to devote time to childbearing and child-rearing. However, some trainees opt to complete 4 years of general psychiatry training prior to matriculating into a child psychiatry program. Many, especially those who completed full medical internships, feel that they could benefit from an additional year to consolidate their general psychiatry skills. In addition, many general training programs leave ample time in the fourth year for research, chief residency, and other electives. In general, fast tracking seems best for applicants who are certain that they want to be child psychiatrists. Those who are undecided or want additional experience in administrative and supervisory capacities may choose to complete a fourth year of general training.
Child and adolescent psychiatry has participated in the National Resident Matching Program (NRMP) since 1995. However, unlike general psychiatry, each program has its own application, rather than using a centralized application service such as the Electronic Residency Application Service (ERAS). Some programs also accept the universal application. In addition, the child and adolescent psychiatry match typically takes place in January rather than in March with the general psychiatry residency programs. Because the process begins earlier in the academic year, decision-making and paperwork need to be completed in a timely fashion. Applications are accepted in July for admission 1 year later, and most interviews are scheduled in the fall. Match lists are generally due by late December. Applicants will need to register with the NRMP, and will need to pay a registration fee, which will permit the applicant to generate a rank order list.
Most child psychiatry applications require a curriculum vitae (CV) and personal statement in addition to the demographic information, proof of training, proof of licensure, and United States Medical Licensing Examination (USMLE) scores requested in the application packet. Be sure to allow sufficient time to retrieve medical school transcripts, USMLE scores, and letters from internship and general psychiatry training directors. Your CV should contain information regarding education, work history, hospital appointments, and extracurricular activities. Some programs require that it be specially formatted; guidelines may be downloaded from most medical school websites. While many feel that personal statements in psychiatry can be longer than one page, it is more likely that an interviewer will take the time to read your statement if it is interesting and concise. If possible, keep it to one page, and do not regurgitate your CV. Try to give the reader a sense of your individuality, personality, and strengths. Many people decide to revise the personal statement used for the general psychiatry match, which can save time and energy.
Once your CV and personal statement are complete, you’ll need to decide where to apply. When applying to general psychiatry programs, applicants often have more flexibility in terms of mobility and familial obligations. However, those applying to fellowship programs often have already settled down, which may limit their search to a particular geographic area. Though many child psychiatry programs recruit heavily from their own general psychiatry programs, some also have heavy regional or national competition. A complete listing of accredited programs participating in the match can be found on the NRMP website (www.nrmp.org). Demographics and other statistics regarding each program can be found on the Fellowship and Residency Electronic Interactive Database Access System (FREIDA). Most residents apply to a good number of programs. Doing so will allow the applicant to explore different programs and will increase the likelihood of a successful match.
Once your application is complete and has been screened by the residency selection committee, you will be asked to schedule an interview visit. As the interview itself is your best opportunity to get a sense of different programs, it is an immensely important element of the process. Your experiences during the application will guide you through decisions that will affect the next 2 years of training, and possibly your career and academic trajectory. For these reasons, it is important that this article discuss the nuances of the interview in as much detail as possible.
The interview day will be among the most important experiences contributing to the choice of a particular residency. Naturally and understandably, the majority of energy will be devoted to one’s own performance; however, try to remember that you are interviewing as well as being interviewed. In other words, you need to scrutinize carefully the culture and the “feel” of the program as you make your way through the interview day. Any program that is making the effort to interview you has already decided that to some extent you are qualified for their program. The point now is to see if you and the program will be a good fit for each other, and this should be as much your objective as it is the program’s.
Prior to the interview, be sure to review the program’s website and any written materials provided. This will help you organize which aspects of the program to learn more about during your interview day. Programs will often publish faculty members’ names and interests, active research projects, specialty clinics and current residents’ names, and prior training programs. If there are particular faculty members that you would like to be able to work with closely during training, be sure to try to meet them during your interview day and inquire as to what extent such collaboration would be possible. Programs will vary in how accessible senior and prominent faculties are to the residents.
The residency training director, along with the other faculty, set the pace for your training experience. You will want to inquire as to what characteristics in residents have been seen as most compatible with their program. Faculty should offer continued availability to you following the interview and, to the extent possible, be willing to facilitate your meeting any particular staff even after the formal interview is over. Faculty can also give insight into the philosophy and possible theoretical bent of the program. At this stage of training, it is most important to have a didactically and philosophically balanced and diverse curriculum, and faculty will be able to discuss how this is achieved in their program. Faculty members are also in the best position to comment on any recent or anticipated changes in the program.
Make sure to meet with current residents during your interview day. If this is not possible, ask whether any residents would be willing to be contacted directly at another time. Residents can offer the best perspectives on how your daily life will be inside and outside of the program. Topics such as the call schedule, quality of call, coverage for vacations, moonlighting, cost of living, and peer competition are all best discussed with residents. The frequency of call, and whether it is primary or a back-up to other residents or staff, is often a prominent concern for any prospective resident. Beyond these considerations, it is important to get a sense of how rigid or flexible these systems are. Are call shifts easily traded between residents without administrative involvement? Do vacations have to be “locked in” prior to the year you begin, or is it left up to the residents to decide? These systems are ultimately reflective of a departmental culture, and you should seek a program whose culture best matches your ideal academic environment.
Another important topic to discuss with residents is their perception of the quality of supervision and didactics. Is supervision individual or in groups, weekly or in real-time? Are didactics protected time, free of immediate clinical obligations? Questions about issues such as the costs of real estate, day care, recreation, local schools, cultural activities and so on are also often best handled by residents, though faculty will have valuable input for these topics as well. Finally, do your best to get multiple perspectives on each of these topics. Individual impressions will vary among residents, and sometimes even with the same resident! Ideally, residents should offer you contact information for further questions following the interview day.
Other things to note during your interview day include the locations and conditions of the facilities, electronic versus paper records, availability of laboratory and imaging studies, relationships with other departments and access to libraries. Similarly, you should investigate the availability of any special accommodations that you might need in order to maximize your training experience.
At the end of the day, regardless of what has been said, whom you have met, and what you can remember, take some time to consider your intuitive sense of the program. Evaluate how the prospect of returning in a few months to start work there feels. Did you enjoy the interview day? Would you look forward to seeing any of those people again? Can you imagine yourself living in the area? Trust your gut, as your instincts provide invaluable guidance in this complicated process. Combining empirical observations with your own honed intuition is essential to creating your resulting match list.
The National Resident Matching Program (NRMP) was established in 1952. It remains the primary means of regulation and organization that helps tens of thousands of applicants into their respective postgraduate positions each year. The NRMP provides timelines, rules and contractual framework to facilitate this process. Child psychiatry utilizes the “Specialty Matching Services” which has managed the “match” for 34 subspecialties in 2006. The ultimate hope of the NRMP is to make the surprises on match day as pleasant as possible.
Do Not Ask and Do Not Tell
The cardinal rule of the NRMP is that neither program nor applicant may solicit a contingent commitment outside of the match. However, even the NRMP concedes that it is important for applicants and programs to have some sense of how highly they value one another. Communicating the level of interest to each other is often seen as something of a special art. In this light, phrases such as “You’d be a perfect fit for this program” or conversely, “I can see myself thriving in this program and I’d welcome the chance to be here” serve their purposes.
The interview season and the post-interview ranking period are a fine time for candid exchanges between applicants and program members. As long as these exchanges do not imply or a state a commitment, they are not in the realm of “match violations.” It is important to know who might be interested in you; it is of equal importance that you communicate that you find yourself especially drawn to those programs. To this end, e-mails, letters, phone calls, and revisits are commonly sufficient.
“We will rank you number one if you rank us number one,” is evocative of age-old and often frustrating playground arrangements. “I’ll be your best friend if you’ll be my best friend” did not work on the schoolyard and is equally problematic during the match. The fact that these deals are fraught with uncertainty and exclusivity is the basis for which the NRMP forbids such “outside” deals to be made between participants in the match. “Deal making” strips the applicant of the luxury of delineating his or her genuine preferences in private, with minimum outside distraction or pressure.
If You Do Not Want To Go There, Do Not Rank That Program
The actual rank order should be made with the care and knowledge that you are entering into a contractual agreement to go wherever you match. Though you do not have ultimate control of where on your list you will match, you do have the luxury of clearly stating where you do not want to go by not ranking a program. The ultimate rank order should be a reflection of both reality and your wishes. If the two seem far apart, the advice of confidants or mentors may be helpful in closing this gap.
If It Has To Be Sold, It Is Not Worth Buying
If you are being pressured by a particular program to commit to them, or if they have gone out of their way to convince you that you would best be served by their program without any encouragement on your part, proceed with caution. It is one thing to be told you are a great applicant, and it is quite another to be told that your greatness depends on your choosing a specific program. There is no road map to delineate the exact path to take in encouraging applicants to consider a certain program, but there are clear rules that prohibit applicants from being pressured to commit on paper or verbally to a program outside the match. It bears repeating: if it has to be sold, it is not worth buying.
As you would imagine, the goal of the NRMP, though simple, necessitates complex rules and algorithms. These features are described at length on their website: www.nrmp.org.
Choosing a child and adolescent psychiatry residency program is an exciting, but at times overwhelming process. You may be considering just a few programs in your local area or you may be applying to a broad range of programs across the country. Either way, you want to train at an excellent program and ensure that the final piece of your long journey of medical education is the best available.
Programs are required to teach a variety of therapeutic modalities—psychopharmacology, dynamic psychotherapy, family therapy, supportive psychotherapy, cognitive behavior psychotherapy, and group psychotherapy. Find out exactly how each is taught, and be wary of programs that stress any single modality.
As in general psychiatric training, supervision is the main method by which the art and science of child psychiatry is taught. Pay attention to the number of supervisory hours in both the inpatient and outpatient arenas. Ideally, a program will have supervisors with a range of therapeutic orientations, ages, and experience. Supervisors often serve as mentors as well as teachers, so a broad range of faculty will increase the chances that you will find someone with whom you truly connect. A combination of seasoned and wise supervisors with younger ones closer to training is ideal. Also, it is often extremely helpful to have supervisors who work in academic, community, and independent practice settings. Many programs have supervision on group, pair, and individual levels. Group supervisions can be a nice way to learn from your classmates’ cases and increase exposure to a broader number of patients. Ask about how supervisors are assigned— can you choose for your second year? Also find out about the availability of specialty supervision in a more focused area, especially for your second year.
Learning about psychopharmacology in children is obviously a key component of training. Some programs may have outpatient psychopharmacology clinics with an attending on site, while others may have a panel of psychopharmacology cases and review them weekly with a designated psychopharmacology supervisor. Be sure to inquire about the number of psychopharmacology cases a resident typically follows to ensure exposure to an adequate number of patients over time. Also, how available is your psychopharmacology supervisor for urgent questions or emergencies? Is your supervisor able to see a patient with you if you have a diagnostic question or sticky situation?
Formal didactics are another key aspect of a program. Seminars need to cover a range of topics in the biological and psychological realms. Areas specific to child psychiatry include developmental theory, child forensics, infant mental health, psychological testing, and family/systems theory. Some programs have didactics on one designated day, while others spread them across the week. Ask if didactics are protected time from consults, admissions, and other clinical responsibilities.
Child psychiatry involves consultation liaison work with pediatrics, as well as community organizations, courts, and schools. Thorough training is important since often a child psychiatrist is called upon to advocate for a child in a nonmedical or nonpsychiatric arena. Pay attention to exactly what each consult experience will involve because often consultation rotations are off-site from main teaching hospitals. Unfortunately this can lead to variability in quality of education. Consider speaking directly with faculty in these rotations, especially if you already know you are particularly interested in one of the areas.
A basic component of child and adolescent psychiatric training is the treatment of mentally ill children on inpatient and partial hospitalization programs. These rotations often are a core part of the first year, but sometimes occur during the second year. Direct detailed questions about the experiences to current residents and faculty. Are the child and adolescent units combined or split? How many patients will you carry? Will you do the case management and/or psychotherapy with your patients? Is there designated time for supervision? What is the nature of the relationship with the support staff? What are the demographics and backgrounds of the patients? Who covers the patients in the evenings and on weekends? Have the attendings been working as inpatient physicians for a long time, or is there high turnover? Will you rotate there full-time for several months or part-time for a longer period? What is the average length of stay for a patient?
Arguably, since the bulk of child psychiatry occurs in the outpatient setting, training in outpatient care is the most important factor differentiating the excellent programs from the adequate ones. In most programs you will start treating outpatients in the first year. Your caseload is key. You want to follow some patients for long-term treatment to watch disease processes unfold and change as patients age. Diversity of age, diagnosis, and background are important factors to consider. Learn how patients are assigned for each treatment modality. How many cases will you be expected to carry at a time? How many new patient evaluations will you do each year? Find out as much as possible about the clinic structure. Who is in charge? Are multiple insurances accepted? How much paperwork is involved? Will you have your own office? Are records computerized? Are there therapists or case managers available?
Additionally, many residencies have elective opportunities at some point during the 2 years. Electives can be meaningful chances to gain in-depth experience in areas of interest or to improve upon topics of relative weakness. Find out if electives are offered in specific blocks of time or on a longitudinal basis (e.g., a half-day per week for 1 year). Electives are usually clinically- or research-based, but can also be teaching or community experiences. Explore the range of possible electives—typically, larger hospitals have more opportunities. Often, programs have connections with outside organizations such as college mental health services, community mental health clinics, forensic court clinics, therapeutic schools, etc. Ask current residents if they actually can use the allotted time for electives, noting that sometimes particularly rigorous workloads can interfere with these other important experiences.
The culture of a program can be difficult to discern, but it is a crucial aspect to explore. Do your best to get a sense of how cohesive the residents are with each other and with faculty. Do they seem to like each other and support one another? If you get the feeling that this is a problem at a particular program, be very wary of ranking it. Some programs have difficult residents and groups that do not work quite well together. Explore whether this is a chemistry or personality problem in the group or a systemic problem in the program. Will you have time with your classmates or are you generally separated on different rotations? Do residents tend to spend time with one another outside of work? How available are faculty members, and how much do they seem to value teaching? Ask about how child psychiatry is related to the hospital’s general psychiatry department and pediatric department. A child psychiatry department that is well regarded by the hospital at large usually has financial stability and solid leadership.
Feedback from faculty and program directors is essential to assess your development as a child psychiatrist. The best programs offer ongoing mutual feedback between residents and faculty that is meaningful for training and clinical care. Are you observed and critically apprised of your clinical strengths and weaknesses? Do you get to observe your teachers interviewing and interacting with patients? Feedback and evaluation are crucial, both formative and summative.
At some point in your child and adolescent psychiatry training, you will begin to plan for the next step. You will want the flexibility in your training program to be able to identify areas of your own interest and flesh out that area during the residency. One way to do this is through an independent study or a research program. If you are strongly interested in an academic career path, or if you know that you plan to go into a particular area of study, make sure that the residency program has the ability to accommodate your special interests and will allow you to explore them through a research program or an elective of independent scholarly work. For example, would the program be flexible enough with scheduling if you want to begin analysis or advanced training in therapy? This ability, as well as the remainder of the training program, should have the support of the administration of the department. It is hoped that there will be support from the top down in the program that will allow you to develop into an independent child and adolescent psychiatrist. This should include support from the chief of the department, the training director, and other faculty members dedicated to making sure that your career develops. The emphasis should not be focused solely on getting the basic work done in the hospital or clinic. Ensure that there are adequate mentors in your area of special interest, if you have identified one. If there is a local faculty member with interests similar to your own, but who is not affiliated with the department, ask questions as to whether it is possible to go out of the department (or even the college) for independent work. Get a feel for whether or not this will be supported or discouraged. Openness to new ideas is difficult to assess, but these kinds of questions will let you know whether the administration is willing to think outside of the norm.
Once you have completed your residency, you will find that you are a desired member of the medical community with a very specialized talent—the ability to communicate with and about children. Ask questions about the opportunities for and support of teaching opportunities. You will want to begin to hone your skills as an educator, since you likely will be educating parents, children, schools, and colleagues when you are finished. Look for chances to engage in a variety of teaching styles—classroom, clinic, and wards. Is there instruction or support for learning how to teach? What form does that take? Some of the process of learning to teach is through watching mentors. Make sure that the system has the ability to accommodate your interests and has the depth in its faculty to have mentoring available. Mentoring takes many forms in psychiatry—individual supervision, research mentor, teacher, etc. Ensure that there is enough variety of interest among the faculty that you will be able to find someone to model multiple types of interactions with patients and colleagues. The identification of positive mentoring relationships can be one of the most important paths in your development. Do not take it lightly. If you see no one on the faculty roster sharing any interests with you, consider looking elsewhere.
Though work, money, call, and eventual career choices are important, it is also important to be able to live well while you are in training. This means taking care of yourself and your family. If you are considering starting a family during your training, be sure to inquire about parental leave. Ask about the policies for making up time lost if leave is extended. A question to pose to residents in the program is how they spend their spare time. Will your interests mesh with those of the people already in the program? Is there time for your family and other interests? Do other people in the program have outside interests, or are “off” nights spent recuperating from “on” nights? In addition to time for family, money to do things with the family can also be an important consideration. Talking about compensation or doing moonlighting outside of the residency can be difficult, but is necessary. Presumably, if you plan to moonlight or to open an independent practice, you will need to apply for and maintain a full license in the state where you will practice as well as a federal and sometimes state DEA number. Figure this into your cost of living. Ask about opportunities for moonlighting within and outside of the system. Examine the compensation from the residency and whether it will it cover expenses for the area in which the residency is located. Talk to the residents about these issues when you meet them. If there are moonlighting possibilities, how is malpractice covered? Are you able to extend the policy at your home institution, or do you need to purchase independent insurance? Is there support for opening an independent practice of adult outpatients? Is it encouraged or discouraged? Is there a mechanism to help you set this up and get office space? Is there a mechanism to generate patients for your independent practice?
If “location, location, location” is the mantra of real estate, “call, call, call” is often the mantra of choosing a residency. Your call schedule is an important part of choosing a residency and you should certainly ask about it during the interview process. Call is most significantly dependent on the number of residents in the pool. You want to consider who takes call—is it all covered by the first-year residents, or is it shared across the two classes? What is the frequency of call? What about weekends? What time are you off post-call? How frequently do you have call-free weekends? What are the responsibilities when on call? Will you be covering an emergency department, a hospital floor or both? Are you covering for all of the outpatients in the child clinic, or do residents cover their own outpatients even when not on call? If you are covering an emergency department, are there clinicians or general residents who see the cases and take care of disposition, or is that entirely your responsibility? Are there measures in place as stopgaps in case a particular call gets overwhelming? You’ll want to ask the residents in the program to describe their best and worst call night. If their best call night sounds like your worst nightmare, consider whether this program is right for you. On the flip side, if call is described as “a walk in the park” and there are rarely any children seen, consider whether this is helpful to your education. You want to look for a program that offers experience on call that is educational, but not overwhelming. When on call, you want to be supported. You should ask about back-up both on call and off hours. How easy is it to get in contact with a supervisor if you have questions about a phone call or a patient you have seen? Ideally, you will have frequent and educational contact with supervisors early in training that will allow for autonomy and development of your own style later in training. Is there always someone available to call? Ask the residents how often they actually call their back-up and what that experience is like.
While the “little things” may not seem important, they tend to be the things that are most annoying. You will be spending 2 years of your life with this institution, so you’d appreciate knowing that you’ll be comfortable there. Is the clinic comfortable? Is office space available? Will you have your own office scheduled at particular times, or will you be vying for offices at random? What type of support is there for scheduling, rescheduling, and insurance issues? Are there toys available for community use, or are you asked to purchase your own? Is there monetary support for purchasing toys and supplies? Is the medical notes system manageable? Is it computer-based or paper-based? What about lab and specialty services? Are they easily accessible, or do you have to give your left arm for a lithium level? How are the library services? Do you have access to the important online journals? Is there support to help you learn to search the medical literature? How easy is it to get a “hard to find” article?
You may find that you do not need to ask all of these questions for every program you consider. Find faculty and residents in your current program who have experience with programs you are considering. They may be able to answer many of these questions for you. You may also find on the interview path that residents and faculty at one institution may refer you to someone at a competing institution. Child and adolescent psychiatry tends to attract caring, friendly people. Comments directing you toward someone at a competing institution do not necessarily mean that the program does not like you or want you in their program, but more likely reflect the interviewer’s desire to help you make an informed decision about your career.
All of this leads to the post-interview period. Much happens after the interview itself, and a brief summary of these developments is helpful in delineating the flurry of events that leads up to match day itself.
On the day of your interview, most programs will provide you with a list of their current child residents, as well as contact information. If you are not given this information, be sure to ask for it; staying in touch with potential future colleagues is crucial in helping you make the best decision possible. Inevitably, after the interview day you will find that either you forgot to ask a question or you thought of additional information you need to know about the program. Generally, you can ask questions of the child fellows and receive the accurate information about the program you need to make your decision. Be cordial, friendly, concise, and well-directed with your inquiries. This the best way to obtain the information you need and to ensure that you make the best impression possible at each program.
In fact, every person you meet during the interview process is a future colleague. The world of child psychiatry is quite small. There are only approximately 6,000 child psychiatrists in the United States. Given such a small number, all interactions have far-reaching repercussions. It is particularly important to keep this in mind as you write your thank you notes and ultimately contact the program director to express your interest in your top choices.
Ideally, every person who interviewed you should receive a thank you note. This gesture demonstrates your thoughtfulness as you prepare to enter this close-knit community. Notes need not be elaborate. Make clear your appreciation for the time the interviewer took to meet individually with you and for the information received about the program. You might also mention your particular interest in the program itself.
All of these preparations lead to the generation of your rank list. It is entirely acceptable to approach your top-ranked programs, keeping in mind the balance between honesty and diplomacy. However, never mislead a program director. (Remember, every person you meet during the interview process is a future colleague.) If you tell a program director that you are going to rank their program first and they subsequently put you in their top three, but you do not match at their program, then they will know that you were possibly not altogether truthful. Program directors often speak with one another about applicants and share information. If you later apply for a faculty position, work on an AACAP committee, or refer a patient to that institution, you may encounter resistance. You do not have to risk your reputation or future working relationship in order to guarantee yourself a spot at one of your top programs.
In order to give yourself the best chance of obtaining a spot at your ideal program, personally call the program director and express your desire to be one of his or her child fellows. Be clear that you have decided to rank this program number one on your NRMP rank list, but do not worry if the program director does not immediately reveal where you stand on his or her list. Just as you are making your decisions, programs themselves are in the midst of intense discussions about how to rank their candidates for training. Directors will be delighted to hear of your interests, and each director has his or her own style for conveying this information.
Finally, multiple variables conspire to land you in a program. You might not end up in your first-ranked program, and it therefore makes sense to have in mind other residencies where you would feel at home. Contact those programs as well and express interest. As always, be sure to show enthusiasm and respect, but you need not let these programs know that they are not among your number one or two choices. What is most important is that you do all that you can to ensure ethically and respectfully that you match at a program that will meet your future needs.
All we have stressed, all of this careful planning, sets the stage for your eventual career path. Things happen quickly in a 2-year training program; it therefore makes sense to approach the various options for long-term professional development soon after you have begun your residency.
A helpful exercise is to project yourself into positive future life scenarios, and then to “think backward” to the experiences that will best allow you to achieve your goals. Next, identify the strengths and potential shortcomings of each residency program within the context of your specific professional and life goals. This process can be a useful filter for assessing which programs will best be able to meet your individual needs. It is also an important element in your early career planning.
Early career planning begins long before graduation from residency and will be a critical aspect of your child and adolescent psychiatry residency experience. Guidance in the preparation for post-residency practice is an important responsibility for all residency programs. Usually this is done through a combination of formal and informal means. Many programs have a practice seminar to give an overview of the central issues in transitioning to post-residency employment (2). As mentioned previously, individualized faculty mentoring is also very important. The mentoring process is complex, but one role of good mentors in a training program is to help facilitate decisions about career issues (2, 3).
The intersection between a residency program and your early career planning will affect you in three broad areas: professional development, personal priorities, and finances. Professional development has been broadly addressed throughout this article and includes progressive growth in your unique combination of specific clinical skills, capacity for teaching and supervision, research pursuits, independent practice interests, management and administrative abilities, and job negotiation skills. When evaluating residency programs, keep in mind whether the program will be able to train you and advocate for you in the career areas that you want to pursue. Are there faculty mentors who specialize in your area of interest, whether in clinical work, teaching, or research? What is the program’s track record of facilitating the career development of past residents with similar interests? It can be very helpful to speak with program graduates and ask them if they feel that they were appropriately prepared by their residency program to meet the challenges of their first few years out of training. Another important issue to consider is that one’s professional relationships take time to develop, and the period spent in child and adolescent psychiatry residency is an opportunity to network within the mental health resources of a community. With the relative shortage of child and adolescent psychiatrists, early career child psychiatrists have significant flexibility to relocate into new communities after training. However, those who settle close to where they completed residency often have an easier time integrating into the professional community in the initial period of professional practice.
Your personal life is also important to consider when choosing child and adolescent psychiatry residency training. This is true for the 2 years you are in training, and also because it is common for physicians to settle geographically close to where they completed training. In fact, geography can be as important an issue as the content and quality of a training program for some applicants, particularly for those with strong family and community ties. Ask yourself if the location of a given program meets your needs for developing personal relationships, raising a family, addressing the interests of a significant other, engaging in recreational activities, and facilitating your general well-being.
An area that is increasingly an issue for both psychiatry trainees and early career psychiatrists is finances. With many residents needing to manage debt in excess of $100,000 upon entering into child and adolescent psychiatry training, economic factors may be an important consideration for you in selecting a residency, balancing your time during residency, and structuring your career after residency. Again, speaking with recent graduates can give insight into the resources available during residency to help with both career development and management of personal finances, which may affect your early career trajectory. Faculty at both your home institution and the programs you are considering can be a valuable source of guidance. There are also several published resources that are helpful in preparing for one’s early career pathway, taking into consideration those factors important in choosing a residency and during residency training (4–8).
Choosing a child and adolescent psychiatry residency is the last step in shaping your formal medical training experience. It is necessary to be organized with respect to paperwork and applications, thoughtful about career planning, and alert to important mentoring opportunities. However, it is also essential to consider the quality of life outside of training. When considering various programs, be sure to talk to enough faculty members and trainees to get a “nuts and bolts” perspective and a true sense of a program’s culture. Be honest and respectful throughout the process. Most of all, do not underestimate the importance of your gut reaction when ranking programs. After all, as a psychiatrist, it is one of your most useful tools.