Special Report: Thriving in Residency Training: Establishing Identity, Finding a Mentor, and Growing as a Clinician

Back to table of contents Next article Clinical and (2) rushing to solidify a mentoring relationship after just a few meetings. The process of assessing the right fit for your career goals and personality requires time, patience, and diligence.Moving Toward Clinical MasteryEven with a great mentor, psychiatry training is difficult. Especially in the first year, you might sometimes feel as though you're experiencing whiplash as you transition between services on medicine, neurology, inpatient psychiatry, psychiatric emergency room, consult-liaison psychiatry, and outpatient work. Each rotation requires new skills, knowledge, and integration into a brand-new multidisciplinary team. Early in training and often while on call or night float, you may be asked to manage high-acuity and high-volume clinical situations with (ironically) the highest levels of independent practice. This can be understandably overwhelming! And you simply cannot know everything, nor are you expected to. Ultimately, however, there are some core skills in clinical care that are transferable across almost all psychiatric clinical work to ensure safety, build trust and rapport, establish boundaries, and develop a case formulation.Optimizing SafetyAwareness of your setting, which includes not only your surroundings but also your behavior and body language and those of your patients, is of key importance in maintaining safety. Creating an environment of safety to prevent injury and foster trust—the foundation of psychiatric clinical care—is especially relevant in acute care settings but also in outpatient and other settings. So how do you maintain safety?As Juan Lopez, M.D., and Clay Barnes, M.D., described in their Handbook chapter titled "The Psychiatric Emergency," the physical layout of your unit and your clinical care setting is important. Interacting with the patient in a layout that allows either of you to exit the conversation at will may decrease the patient's anxiety as well as any risk of injury. Particularly when interacting with seriously mentally ill patients, maintaining an appropriate distance with a neutral body stance with hands visible in a relaxed position and keeping eye contact intermittent and less intense can be helpful. It's important within the layout of your setting to know how to get assistance if your patient becomes agitated and aggressive. Where do other members of the clinical teamwork? Is security readily available from where you are seeing your patient? Even with more stable patients in clinic, positioning chairs so that you don't block the patient from an exit can be helpful. Is there a safety code to text or call to staff to alert them if you are feeling unsafe?Building Trust and RapportIn addition to paying attention to physical safety, it's important to develop your skills of self-observation and self-awareness in building trust with your patient. Have you had a difficult morning stuck in traffic and now feel agitated when you are meeting your patient? If you're not aware of your own emotional valence, you may behave in a way that agitates your patient as well (for instance, excessive tapping of your foot or shaking your leg). Seamus Bhatt-Mackin, M.D., and Aaron Feiger, M.D., in their Handbook chapter, "Blue Ink and Blind Spots: Working Toward Accurate Self-Knowledge Through Self-Awareness," suggest that practicing mindfulness techniques can help you observe your own emotional landscape and manage your stress so that it doesn't leak into your interactions with your patient.Taking a nonjudgmental stance toward your patient is another foundational aspect of building trust. Your patient is seeking care because of a mental health issue. Whether the patient's life experience has been similar to yours or not, it's important to remember that the patient needs your compassion and openness to share the personal information that will help both of you formulate an understanding of the patient's psychiatric issues and collaborate on a treatment plan.Approaching with curiosity and care and listening deeply with self-awareness will set you up well in building rapport with patients. Melanie Tervalon, M.D., in a seminal 1998 paper in the Journal of Healthcare for the Poor and Underserved titled "Cultural Humility Versus Cultural Competence," emphasized that practicing the three principles of cultural humility can guide trainees in mindfully working with patients from marginalized communities: critical self-reflection (for example, recognizing one's implicit bias); recognizing and changing power imbalances (for example, involving the patient in treatment planning), and advocating for institutional accountability.Establishing Boundaries and Clear CommunicationMaintaining clear and transparent boundaries is equally important in building trust with your patient. Clear communication about your role and the purpose of psychiatric treatment gives your patients an understanding of the work you are doing together. Your patients then have the opportunity to express their needs and thoughts within the known context of clinical care. For example, when patients are under an involuntary hold, communicating clearly what this means and when the hold expires gives them agency to manage their behaviors in their own best interest. In the outpatient setting, clear communication about a medication taper or side effects, for example, may allow patients to understand the benefits of following your recommendations.Developing a Case FormulationAs you and your patient get to know one another, developing a case formulation or narrative hypothesis of your patient's illness will inform your treatment approach. As the formulation evolves over time with integrating new patient information, it ensures you provide adequate care or choose effective approaches to address your patient's suffering. Although challenging at first, developing a case formulation is an essential clinical skill.A well-conceived biopsychosocial formulation of the patient provides scaffolding for your work together, but a comprehensive approach must also include an assessment of the cultural and structural factors that are part of your patient's experience. DSM-5-TR defines cultures as "open, dynamic systems that undergo continuous change over time; in the contemporary world, most individuals and groups are exposed to multiple cultures, which they use to fashion their own identities and make sense of experience." Integrating cultural formulation questions into a patient interview in a respectful, collaborative, and patient-oriented approach provides invaluable understanding as you develop your clinical hypotheses. You may have an opportunity to identify and address your own biases as well. However, a structural lens to case formulation is also essential and distinct from the cultural formulation. Structural formulations recognize the social policies, practices, and institutions that contribute to your patients' illness, often creating disproportionate burdens on marginalized communities and resulting in health inequities. Examples of structural factors may include discrimination (racism, sexism, etc.), poverty, geographical and environmental inequities, and disparities in health care access. Jonathan Metzl, M.D., Ph.D., and Helena Hansen, M.D., Ph.D., noted in a 2018 article in JAMA Psychiatry titled "Structural Competence and Psychiatry" that a comprehensive structural formulation accounts for these factors and promotes both patient- and systems-level treatment interventions. Table 3 outlines the fundamental aspects of the biopsychosocial and complementary structural and cultural formulations. As psychiatry residents often recommend or engage patients in psychotherapy, fundamental aspects of psychodynamic and cognitive-behavioral therapy formulations are also included.Making the Best Use of SupervisionAll clinical work within training should be supervised directly, indirectly, or through oversight. Knowing how to effectively use supervision will enhance the development of your clinical and nonclinical skills during residency.Supervision serves multiple clinical and training functions, ranging from promoting safe, effective patient care to providing essential skills for unsupervised practice and professional development. It is a relationship-based education and training that is work focused and manages, supports, develops, and evaluates the work of colleagues. Supervision in psychiatry residency is quite different from supervision in medical school or even in PGY-1 nonpsychiatry rotations. Depending on the venue and context, delays between making decisions and supervisory oversight may occur, increasing the need to prepare for and actively engage in supervision. Early on, you might feel dependent on supervisors for goal setting, overall guidance, and help with important clinical decisions. As you progress in training, you will become more able to identify supervision goals, including areas of knowledge or skill sets you want to refine before entering unsupervised clinical practice. A lot of what you learn in psychiatry occurs through supervision, so investing early in this relationship is pivotal!Regular supervision involves learning not only about clinical issues at hand, but also how to work effectively with each patient as well as deal with important system issues. Supervisors are there to help support and guide trainees through difficult patient care scenarios. A good rule of thumb is that if at any time you wonder whether to talk to the supervisor, just do it!To get the most out of your supervision, come prepared—bring clinical questions, questions from the literature or didactics, inquiries about navigating the medical/legal system, or, if related to psychotherapy, video excerpts. Strive to be receptive to feedback, process countertransference as it may inform the formulation and could unintentionally interfere in the treatment process, and be cognizant of the boundary between supervision and personal psychotherapy. If you are uncomfortable sharing feelings with a supervisor or the emotions triggered by a patient affect your ability to intervene appropriately, consider starting or continuing individual psychotherapy. Supervision is not psychotherapy. Supervisors have their preferred supervision techniques. Advocate for the ones that best meet your learning style and goals but be open to trying new approaches (see Table 4).ConclusionResidency training in psychiatry involves enormous growth. Opening yourself to deeply understand another human being to mitigate pain and suffering is a remarkable journey unto itself. The residency process will change you—how you understand yourself, others, and the systems in which you work. This experience may often seem daunting, but by anticipating your developmental milestones and challenges, finding community, and securing mentorship, you can do more than just survive your training—you can thrive along the way. ■Resources"Cultural Humility Versus Cultural Competence""Structural Competence and Psychiatry"ReferencesAmerican Psychiatric Association. (2022). Culture and Diagnosis. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). Accessed March 20, 2024.Barnes C, Lopez JD. The Psychiatric Emergency. In De Golia SG, Wang R (eds). A Psychiatry Resident Handbook: How to Thrive in Training, 1st Edition. American Psychiatric Association Publishing of Washington, D.C., April 2023Bhatt-Mackin S and Feiger A. Blue Ink and Blind Spots: Working Toward Accurate Self-Knowledge Through Self-Awareness. In De Golia SG, Wang R (eds). A Psychiatry Resident Handbook: How to Thrive in Training, 1st Edition. American Psychiatric Association Publishing of Washington, D.C., April 2023DeGolia SG, Wang R (eds). A Psychiatry Resident Handbook: How to Thrive in Training, 1st Edition. American Psychiatric Association Publishing of Washington, D.C., April 2023DeGolia SG, Wang R. Framing the Residency Experience. In De Golia SG, Wang R (eds). A Psychiatry Resident Handbook: How to Thrive in Training, 1st Edition. American Psychiatric Association Publishing of Washington, D.C., April 2023De Golia SG: Elements of Supervision, in Supervision in Psychiatric Practice: Practical Approaches Across Venues and Providers. Edited by De Golia SG, Corcoran KM. Washington, DC, American Psychiatric Association Publishing, 2019, p 3-24DeGolia SG, Corcoran KM (eds). Supervision in Psychiatric Practice: Practical Approaches Across Venues and Providers. American Psychiatric Association Publishing, WDC. April 2019.Edwards M, Polignano M. Centering Our Identities. In De Golia SG, Wang R (eds). A Psychiatry Resident Handbook: How to Thrive in Training, 1st Edition. American Psychiatric Association Publishing of Washington, D.C., April 2023Haghighat N, Vo P, Reddy H, Cooper T. Best Practices in Prescribing Medications. In De Golia SG, Wang R (eds). A Psychiatry Resident Handbook: How to Thrive in Training, 1st Edition. American Psychiatric Association Publishing of Washington, D.C., April 2023Khan MM, Goetz TG, Erickson-Schroth L. Gender and Sexual Identity. In De Golia SG, Wang R (eds). A Psychiatry Resident Handbook: How to Thrive in Training, 1st Edition. American Psychiatric Association Publishing of Washington, D.C., April 2023Maruca-Sullivan P, Tampi R, Wang R. Learning to Develop a Case Formulation. In De Golia SG, Wang R (eds). A Psychiatry Resident Handbook: How to Thrive in Training, 1st Edition. American Psychiatric Association Publishing of Washington, D.C., April 2023Metzl JM, Hansen H: Structural Competency and Psychiatry. JAMA Psychiatry 75(2):115–116, 2018Milne DL: Evidence-Based Clinical Supervision: Principles and Practice. Malden, MA, BPS/Blackwell, 2009Palermo D, Guthrie T. The Underrepresented in Medicine Experience. In De Golia SG, Wang R (eds). A Psychiatry Resident Handbook: How to Thrive in Training, 1st Edition. American Psychiatric Association Publishing of Washington, D.C., April 2023Thomas L and Sadhu M. Mentorship and Sponsorship. In De Golia SG, Wang R (eds). A Psychiatry Resident Handbook: How to Thrive in Training, 1st Edition. American Psychiatric Association Publishing of Washington, D.C., April 2023Watkins CE, Callahan JL. Psychotherapy Supervision Research: A Status Report and Proposed Model, in Supervision in Psychiatric Practice: Practical Approaches Across Venues and Providers. Edited by De Golia SG, Corcoran KM. Washington, DC, American Psychiatric Association Publishing, 2019, p 25-34M. Tervalon, J. Murray-Garcia (1998). Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education, Journal of Health Care for the Poor and Underserved, Vol. 9, No. 2. (May 1998), pp. 117-125Bourgois P, Holmes SM, Sue K, et al: Structural vulnerability: operationalizing the concept to address health disparities in clinical care. Acad Med 92(3):299–307, 2017 27415443Jacqueline BP, Lisa ST: Developing and using a case formulation to guide cognitive-behavior therapy. J Psychol Psychother 5(3):179, 2015McWilliams N: Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process. New York, Guilford, 2011Sallie G. DeGolia, M.D., M.P.H., is a clinical professor and co-residency director in Stanford University's Department of Psychiatry and Behavioral Sciences.Raziya S. Wang, M.D., is the former Designated Institutional Official and program director of the San Mateo County Psychiatry Residency Training Program and a former clinical assistant professor (affiliated) in Stanford University's Department of Psychiatry and Behavioral Sciences. They are the co-editors of The Psychiatry Resident Handbook: How to Thrive in Training from APA Publishing. APA members may purchase the book at a discount here. ISSUES NewArchived