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The Unexposed Communities

David Fipps, DO
David Fipps, DO

Ideas to increase recruitment from David Fipps, DO, psychiatry resident physician, Greenville Health System, University of South Carolina—a PGY4 general adult psychiatry resident who has Matched into a C-L Psychiatry Fellowship at the Mayo Clinic, Rochester. He is a 2019 recipient of the ACLP Webb Fellowship Award.

Throughout the past few years, the percent fill rate of C-L Psychiatry Fellowship has remained steady, within the 60 to 70% range.

Considering the great need for subspecialty-trained C-L psychiatrists, as well as a general desire to enhance the field as a whole, there has been much focus on resident recruitment initiatives.

As an applicant who just completed the interview and Match process, I can attest to the fact that the decision of whether to pursue a Fellowship in C-L Psychiatry is multifactorial and highly specific to one’s individual circumstances and experiences.

Successful recruitment initiatives will likely need to have a multifactorial approach. However, there is one avenue of focus for recruitment initiatives that may unveil an untapped resource that holds a strong personal connection for me.

There are close to 200 adult psychiatry residency programs without affiliated C-L Psychiatry Fellowships, and 25 US states that do not have a C-L Psychiatry Fellowship within the entire state! These 25 states hold 56 psychiatry residency programs and hundreds of psychiatry residents.

This does not mean that these programs do not have exposure to C-L Psychiatry services, nor does it imply that the education received at these programs is inferior. However, simple exposure and appropriate education are not the only facets that motivate one to pursue further training.

My state (South Carolina) does not have a C-L Psychiatry Fellowship and, at the time of my Fellowship application, my residency program had no-one boarded in C-L Psychiatry. My interest in C-L Psychiatry prompted me to start a C-L Psychiatry interest group for my residency and its affiliated medical school. From my experiences in these groups, many medical students and early residents have a very prominent interest in C-L Psychiatry, considering the proximity to medical school, non-Psychiatry rotations, and step 3 studying. However, without mentorship to provide guidance, answer questions, and lead residents through the process, this interest may fall to the wayside and remain a conceptual interest, rather than one that prompts action.

Intrastate collaboration

It is not uncommon for intrastate collaborations to occur, therefore allowing some intermingling of mentorship and exposure for programs within a state that has a C-L Psychiatry Fellowship. For example, the Society for Liaison Psychiatry in New York City holds educational and social events for area residents with an interest in learning more about the specialty. However, 56 programs in the US do not have that capability.

C-L Psychiatry Fellowship exposure for the hundreds of residents in this catchment area would require crossing state lines and applying for limited state licensure outside of the state in which they train. Many of these programs may also be located in areas with significant psychiatry shortages (such as my own program), thus the focus may not be on training subspecialists, but rather increasing the local psychiatry workforce.

Many of the residents in my groups who initially voiced an interest in C-L Psychiatry would become discouraged without access to mentors who can demonstrate the value of a C-L Psychiatry Fellowship and who have successfully navigated the waters of the application process, Fellowship, and job prospects.

In these unexposed programs, one of the largest deterrents to action may be a lack of emphasis about the value of C-L Psychiatry training. As a C-L Psychiatry rotation is an ACGME requirement for adult Psychiatry residency training, all residents experience C-L Psychiatry; however, the value of Fellowship training may not be evident considering the attending may not be Fellowship trained, or even boarded in C-L Psychiatry. Despite my strong interest in C-L Psychiatry, I did not meet a C-L Psychiatry boarded psychiatrist, who also did a C-L Psychiatry Fellowship, until my first Fellowship interview in my PGY4 year.

Information about opportunities

For those residents who are interested in C-L Psychiatry and see the value of the training (most of those in my interest groups), the next largest deterrent appears to be lack of available information about the opportunities for residents to excel in C-L Psychiatry, the application process, and Fellowship training in itself.

ACLP offers amazing educational resources, mentorship programs, trainee travel awards, prestigious Webb Fellowships, and much more for trainees; however, without knowledge of these opportunities they will not be pursued. I know of many trainees who would jump at all these opportunities; however, their insecurities of the process act as a deterrent.

For example, without faculty knowledgeable about ACLP, residents may not know to even apply for travel stipends or mentorship programs. Without a C-L Psychiatry Fellowship at one’s institution, it is difficult to perform C-L Psychiatry-specific research to be competitive for awards. Without faculty who have experience with the Fellowship Match, residents are often ignorant on their competitiveness (creating a “why even try,” mentality or an overcompensated time/financially consuming interview season)—particularly when there is a pervasive fear among these residents about being up against seemingly more competitive internal applicants to a Fellowship program.

Potential recruitment focus

Thus, we have the potential recruitment focus: outreach to these programs that lack exposure, particularly those in states with no C-L Psychiatry Fellowships at all. A collaboration between Fellowship programs and unexposed residencies could play a valuable role in breaking down some of the barriers to proceeding from an interest in C-L Psychiatry to applying to a Fellowship. Offerings could include collegial conversations about navigating the application process to the more complex mentorship and/or co-authoring of C-L Psychiatry papers. Sending thought leaders in C-L Psychiatry to give lectures or grand rounds to these unexposed communities would also go a long way to fostering interest in the field.

This collaboration could have an individual, regional, and/or national scope. Efforts could be as small as individual Fellowship programs providing outreach to individual residencies. On a regional level, states could develop regional C-L Psychiatry branches which would hold events for nearby residents with C-L Psychiatry interest but little exposure. On a national level, one could see a collaboration between ACLP and the American Association of Directors of Psychiatric Residency Training (AADPRT), intertwining C-L Fellowship directors with psychiatry residency directors.

ACLP has already made notable efforts that could be built upon for this concept, such as by: advertising the C-L Psychiatry mentorship program to AADPRT; expanding the accessibility of ACLP website educational materials to non-members; partnering with AADPRT to create a C-L Psychiatry Fellowship application resource guide, etc. Whatever the scope may be, this collaborative focus would provide more opportunities to those who are craving such mentorship and guidance for future C-L Psychiatry aspirations.

It appears that once an interest in C-L Psychiatry has been established, the catch is being able to find mentors to foster that interest all the way to Fellowship training and beyond. These simple steps to increase exposure and access to educational resources could go a long way towards beginning this process.

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