Residency prepares new psychiatrists to practice medicine, but leaders say the first years after training bring a different kind of learning curve: owning a full episode of care, leading across a complex system of treatment levels and getting comfortable acknowledging what they don’t yet know.
The stakes of that transition are rising. The U.S. could face a steep decline in its adult psychiatry workforce over the next decade, with workforce adequacy projected to fall to 42.8% by 2037 as psychiatrist supply shrinks and demand rises, according to a study published May 5 in Psychiatry Online. The supply of psychiatrists serving adults is projected to decrease 12.3%, from 37,260 full-time equivalent physicians in 2024 to 32,660 in 2037.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: what skills are new psychiatrists missing on day one?
Eduardo Trinidad, MD. Chief Medical Officer of Capitol Park Mental Health Hospital (St. Paul, Minn.): The biggest gap I see in new psychiatrists is not medical knowledge. It is learning to own the whole episode of care.
I experienced that transition firsthand. More than 20 years ago, I went directly from residency into private practice while also providing inpatient psychiatric and eventually electroconvulsive therapy care. Residency gave me a strong clinical foundation, but independent practice quickly taught me that being a psychiatrist requires more than making the right diagnosis or choosing the right medication. You have to make decisions with incomplete information, communicate with them clearly, coordinate the people around the patient, and remain accountable for what happens next.
That is the transition I see new psychiatrists navigating today.
They are generally well trained clinically. Where they often need development is in the operational side of medicine: prioritizing competing demands, leading an interdisciplinary team, documenting the clinical reasoning behind decisions, managing transitions of care, and understanding how their decisions affect nursing, pharmacy, social work, families and the broader health system.
Documentation is a good example. A note is not simply a record of what happened. Good documentation communicates your formulation, risk assessment, rationale and plan so that the next clinician can safely continue the patient’s care.
Perhaps the most important is developing judgment. Independent practice requires knowing when to act, when to gather more information, when to ask for help, and when uncertainty itself creates risk.
Residency teaches psychiatrists how to practice psychiatry. The first years after residency taught them how to lead care. As physician leaders, our responsibility is to create environments where that transition is supported through mentorship, feedback and progressively greater autonomy.
Matthew White, MD. Chair of the Behavioral Health Service Line for Sutter Health (Sacramento, Calif.): One of the biggest opportunities for those new to the field is learning to think beyond the individual patient encounter and relationship, and rather thinking about their role as a resource within a larger system with an array of available treatments and levels of care. Training is still heavily oriented around the traditional model of psychiatrist-led outpatient practice, where impact is measured one patient at a time. But today’s behavioral health landscape is very different. Patients now move through multiple levels of care, including Collaborative Care Models, bifurcated therapy and medication management, interventional psychiatry, partial hospitalization programs and inpatient care.
Effective psychiatrists need to understand how patients step up and step down across that continuum and how to provide the most efficient and effective treatment, even if it is outside their own office. Sutter Health is addressing this as we train the next generation of psychiatrists to meet the modern needs of patients with our new physician residency program where future psychiatrists will gain exposure to all levels of care and treatment modalities as well as population health principles.
The question is no longer, “How do I care for this patient?” It’s also, “How do I help support patients receiving the right level of care at the right time?” Spending months seeing stable patients in extended clinic visits may provide excellent care for those individuals, but it may miss opportunities for more effective care and may not align with broader population health needs when access challenges leave patients waiting for treatment.
Tobias Wasser, MD. Chair of Psychiatry and Behavioral Health, Fairfield Region, for Hartford HealthCare (Conn.): The most important thing that new psychiatrists are missing on day 1 is the comfort to acknowledge that they don’t always have the answers. Psychiatry isn’t (yet) as objective as many other fields of medicine. The decisions we make impact human lives in complex ways, we don’t fully understand the ways our medicines work and each day the field is evolving with a growing and greater number of treatment options. The pressure early attending psychiatrists feel to “know” the answers can be enormous and overwhelming.
What typically comes with time and experience is a growing comfort with acknowledging all that we still have to learn about our specialty and our patients. Often the fantasy is that when one transitions from residency to being an attending, you have to portray confidence and omniscience to show others that you are prepared. In fact, it’s often the willingness to admit what we don’t know and when to seek help or consultation that we demonstrate our best professional leadership.
An important way that new attending psychiatrists can develop this skillset is through mentorship. Whether through peers or a trusted advisor, having someone to bounce questions off of and learning from others that it’s OK to acknowledge our shortcomings and opportunities, is an important part of any psychiatrist’s growth trajectory. It’s that maturity of recognizing our own limitations that helps develop the best physicians, psychiatrists and leaders!
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