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Psychiatry residency – Curriculum differences between universities


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I was wondering if there was a big difference between how psychiatry was taught across the country.

When visiting SDN I found that in the US some schools seem to have a more ‘’biological’’ approach while others are strong on psychotherapy. Is it similar here in Canada?

I have a degree in neuroscience/neurobiology (+ multiple psychology courses) so I feel psychiatry is a logical choice for me, however I’ve started to doubt this during my psych rotation.

I have always been very interested in the neurobiology of psychiatric disorders this doesn’t mean that I don’t see a value in psychotherapy but that for me a psychological model needs a solid neurobiological plausibility.

During my psychiatry rotation we had a presentation on personality disorders. When explaining how a patient with BPD interiorizes trauma the psychiatrist used a psychodynamic model that to me was pure speculation. When I contested this ‘’model’’ he told me that there is some knowledge that can’t be obtained empirically/scientifically and that we have to take his word for it…. Seriously?

Is this a constant around the country? Is contemporary Canadian psychiatry really this disconnected from modern research?

A US psychiatrist suggested me to look into the NNCI (https://www.nncionline.org/). Is there something similar here in Canada?

Thank you for your help

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Different schools definitely have differing levels of exposure to psychotherapy. For example I am told it is a very limited component of the psychaitry program at Western. But all programs have some level of psychotherapy teaching whether you like it or not. Unfortunately, we know very little of the brain  and psychotherapy may be a byproduct of that gap in knowledge. Though, take what I say with a grain of salt, other than 6 weeks of psyche in clerkship, I haven't received much more exposure to the field other than from what some of my classmates have told me.

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We just don't know enough to have a strong neurobiological plausibility. Lots of theories, not much certainty and clarity....yet. The final frontier of medical research, in my opinion, is the understanding of the brain.

Psychotherapy skills in multiple modalities are required competencies in psychiatry residency, per the RC. You also get tested on it in the exams. Some of us pursue additional advanced training in it and some of us do not. How the curriculum is delivered varies depending on the clinical and research interests of the program you train at, but they all cover the same basics.

I would not judge all of psychiatry being disconnected from research by speaking with one person whose understanding and teaching of personality disorders derives from a psychodynamic perspective.

My advice would be that if you are bent on the biological side of psychiatry, make sure you ask about it when touring during carms to see if the program has strengths or not in that area. It will be variable; likely the bigger schools will have something for "everyone" to meet your learning interests.

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  • 2 weeks later...
On 8/20/2019 at 6:20 PM, LostLamb said:

We just don't know enough to have a strong neurobiological plausibility. Lots of theories, not much certainty and clarity....yet. The final frontier of medical research, in my opinion, is the understanding of the brain.

Psychotherapy skills in multiple modalities are required competencies in psychiatry residency, per the RC. You also get tested on it in the exams. Some of us pursue additional advanced training in it and some of us do not. How the curriculum is delivered varies depending on the clinical and research interests of the program you train at, but they all cover the same basics.

I would not judge all of psychiatry being disconnected from research by speaking with one person whose understanding and teaching of personality disorders derives from a psychodynamic perspective.

My advice would be that if you are bent on the biological side of psychiatry, make sure you ask about it when touring during carms to see if the program has strengths or not in that area. It will be variable; likely the bigger schools will have something for "everyone" to meet your learning interests.

A lot of psychotherapy is speculation, but that doesn't mean that it doesn't work.  Medicine is about pattern recognition.  When you work with a lot of patients with personality disorder you pick up on patterns that seem to occur over and over in patients with that diagnosis.  With more time, you recognize similarity in early life patterns of patients who go on to develop a particular personality disorder.  Formulations are ways to understand these patterns.  At the end of the day its just a best guess of linking cause and effect, but that's really no different compared to when we are try to determine the cause of other medical illnesses.

There is a lot of bizarre things that have been brought forward in psychological theories that have no real basis.  Like many other fields, sometimes people just come up with a theory and are bounce-determined that their understanding of things is right.  Sometimes people just want to put things out there to get their name out there. 

Overall psychotherapy is becoming less and less of a focus of psychiatry.  This will continue to be the case as we get a better understanding of the biology of mental illness and more effective treatments to address this.  However, psychotherapy is a treatment that by and large patients want, many patients improve with it and access to psychotherapy elsewhere is pretty poor. 50 years ago psychodynamic psychotherapy was really the main treatment that was available for patients, even for inpatients.  These days inpatient psychiatry is about assess, stabilize with medications and discharge. This is only becoming more the case as the clinical volumes are increasing rapidly and new psychiatrists are being trained around this model of care.  10 years from now psychotherapy will be even less of a focus of psychiatry residency than it is now. Bigger training programs are in general going to offer better access to psychotherapy training just based on the fact that they have more services available and more expertise.

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I want to thank the three of you for replying.

I decided that it would be better to get some more exposure before coming back and now that I have spoken with different attendings and residents I think I have something new to add.

In few words, I'm still quite disappointed by the approach taken by most psychiatrists in this institution.

I have seen doctors using Freudian terminology to describe patients (super-ego, references to the sexual phases of development: anal, oral, etc...). Doctors explaining hallucinations as projections of the patient's desires. There are even doctors using hypnosis in the institution. Really disappointing. 

Most of them agree that psychotherapy is something most psychiatrists don't practice anyway which makes me wonder why residents waste so much time on it. On top of that, most psychotherapy models have basically no neurobiological plausibility which explains why most of their efficacy relies on the doctor-patient relationship... when a treatment's efficacy relies mostly on this concept you're not better than a shaman or a religious leader giving advice. Many researchers agree that psychotherapy relies heavily on the placebo effect so it's hard for me to justify so much training to become a faith healer.

On the other hand, one of my attendings suggested me to avoid psychiatry as it is becoming more and more biological (clearly not the impression I have). He claimed that we are turning acute diseases into chronic disorders that benefit only pharma companies and psychiatrists. He also added that psychiatric medication only made things worse and patients were better back in the day when psychoanalysis was the dominant force.... what?? Is like if I had been reading the wrong history books. This is a relatively young doctor that is very passionate about psychoanalysis, however works as an inpatient doctor, not doing therapy and working primarily with psychosis.

I'm heavily considering neurology and maybe a Behavioral Neurology/Neuropsych fellowship as a way to address my brain/mind interest while staying scientific about it.

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You can help patients with psychotherapy without getting all Freudian.  CBT is a well established modality with a solid research base for many disorders and it makes sense.  DBT is a very practical skill set that works and has a growing evidence base for borderline personality disorder as well as other conditions.  If you want an opportunity to save lives within psychiatry, learn to become good with trauma therapy for patients with addictions, young people are dying in large numbers from addictions. I suspect I know what institution you are at just based on the description you provided. 

Also, I would argue against your statement that psychotherapy is all placebo.  What can reasonably be said is that many different psychotherapies work about the same and work better than waitlist control. What has been established over and over again is that the therapeutic rapport is a very important common denominator in all therapies.  As a patient you are coming in, talking about some things that you normally probably wouldn't discuss to someone who generally cares about you and wants to see you get better.  The fact that you are discussing it with a highly educated professional is going to create some placebo effect, but processing difficult emotional content and putting effort into thinking about and working around these problems is a big aspect of it.  The reality is that discussing this with a psychiatrist or psychologist wouldn't be entirely different from discussing it with a spiritual leader in that regard. 

Also keep in mind that what we say isn't always what we actually believe.  We all have days where we are frustrated by what we are doing and may say things based on that.  I would hope that a psychosis psychiatrist wouldn't truly believe that  psychosis was best treated by psychoanalysis.  There was a time when that was the case, and that time was also closer to the time that being institutionalized meant there was about a 50% chance that you weren't leaving, ever.

SPMI is largely biological and requires biological treatments, everything else is adjunct.  Lesser severity illnesses are generally a combination of crappy life circumstances, and to a lesser degree, genetics.  In reality there is a very limited amount that we can do to target crappy life circumstances, but society is having higher and higher expectations for us that we can.  Unfortunately this is probably a contributing factor (one of many) to why we are trying to use medications to fix problems that are rooted elsewhere.

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You can pursue whatever research interests you want as an attending if you can find funding for it.

Psychiatry is making a relatively rapid move towards more neurobiologic models, but by rapid, we're still talking in terms of decades before we have more neurobiologic models we'll be acting on and teaching residents (10-20 years).

During your residency training if you want more exposure to the basic and clinical sciences, you are better off pursuing neuropsychiatry through neurology.

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