Combined Residency Programs - Frequently Asked Questions

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Combined Residency Programs - Frequently Asked Questions

Postby DrDave » Sat Oct 03, 2009 5:28 pm

Here's some information I had put together many MANY years ago and just updated it a bit. I think it's still relevant.

1. What is a combined residency program?
2. In what fields can one do a combined residency?
3. What do people do with two specialties?
4. What are the pros and cons of doing a combined residency?
5. How long are the combined programs, and how much time is spent in each specialty?
6. Are combined residency programs competitive?
7. What is the best program for combined residency training?
8. What should I look for in a combined residency program?
9. Where can I get more information about combined residency programs?

What is a combined residency program?

A combined residency program refers to a special program where the resident completes training in two or more specialties simultaneously. For example, rather than doing an internal medicine residency and then doing a psychiatry residency, someone can do a combined program where they alternate fields throughout their training and complete both, usually in less time than if they were done sequentially.


In what fields can one do a combined residency?

The current combined residencies listed in the graduate medical handbook (so called "green book") in order of the number of open first year positions each year:
Internal Medicine and Pediatrics
Internal Medicine and Psychiatry
Family Practice and Pscyhiatry
Pediatrics, Psychiatry, and Child Psychiatry (Triple Board)
Internal Medicine and Neurology
Psychiatry and Neurology

Others could probably be done and customized, but the above programs are recognized by the respective boards.


What do people do with two specialties?

At this time, it is still relatively unclear what graduates of combined programs will be doing. Ideally, graduates would practice both areas of their specialty. One very early survey suggested that 95% of people who did both a medicine and a psychiatry residency were practicing psychiatry. More recent surveys suggest that most combined graudates practice primarily in one field, but some individuals do practice both fields. Some of the areas that have been well suited to dual training are: chronic pain management, substance abuse, geriatrics, consultation psychiatry, palliative care, and medical treatment of the chronically mentally ill. There are also several med-psych units throughout the country that are ideally staffed by a dual trained physician. These units are meant to be for patients who need to be in the hospital for both their medical and psychiatric problems, and thus are not well suited to either a general medicine or psychiatry unit.


What are the pros and cons of a combined residency?

The major advantage of doing a combined program is at least one year is usually cut off of training by combining residencies. Theoretically, you will obtain more "integrated" training because the program should have dedicated curriculum towards topics where the fields interface. Also, you are more likely to work with others who are in dual training or have completed dual training. These people with similar interests function as mentors and supports that otherwise are not likely to be present.

The major disadvantages are that most programs are not well balanced nor integrated between two departments. While many US graduates would be able to match at a top caliber psychiatry residency, they may have to compromise the quality of their psychiatry training some by going into a combined program. Additionally, if there is poor communication between the two departments, the residents may get stuck in between without any good advocates. In theory, a resident may get better quality training by selecting two different residencies and doing them sequentially.

Some of the other drawbacks of combined training are:
1. You proceed through residency at a different rate from the majority of your collegues. The initial interns you start with will move on while you will still have 1-2 years of residency remaining. Relationships with collegues becomes more difficult because of this.
2. Additionally, relationships with collegues may be more difficult to form, because you spend only part of your time in each department.
3. There may be some level of "jealousy" or other animosity towards combined residents because they are "different".
4. You lose out on some elective time.



Internal Medicine and Psychiatry -
5 Years
30 months medicine, 30 months psychiatry

Family Practice and Psychiatry -
5 years
30 months family practice, 30 months psychiatry

Peds, Psych, Child Psych -
24 months peds, 18 months adult psych, 18 months child psych

I'm not familiar with med/neuro or neuro/psych.


Are combined residency programs competitive?

Within every field, there is quite a bit of variability from specific program to specific program. Overall though, everything is relative.

Everything is competitive if you are a foreign medical graduate. As a US graduate, psychiatry is one of the least competitve fields. I base this statement on the fact that the match fill rate is fairly low. This means there are many open spots throughout the country. Of course, there are several competitive psychiatry residency programs throughout the country.

Internal medicine programs are moderately competitive. Decent programs can be difficult to match, and the top programs are very competitive. Internal medicine is not as competitive as surgery, however.

With the growth of managed care in the late 90's, there had been a trend towards more people going into primary care. This trend may be leveling off or even reversing. Time will tell. I do not know much about family practice residencies, but my impression is that in any given part of the country (except maybe California) family practice will be less competitive than internal medicine and more competitive than psychiatry.

Pediatrics programs in general are about as competitive as internal medicine programs.

I would say that the combined programs at any particular institution is going to be slightly more competitive than the more competitive of the departments. For example, at Program A, they have a great medicine program and an average psychiatry program. The combined med-psych program will probably be slightly more difficult to get into than the medicine program. I base this estimate on the fact that if you don't meet the requirements to get into either department, they won't bother ranking you, and there are less spots in the combined programs than there are in the categorical programs.

Also, I think there is some variability between the different types of combined programs. When I was looking at residency programs in 1996, all of the combined peds/psych/child psych programs filled every year. Usually, between half and 3/4 of the med-psych spots fill each year. I'm not sure off hand what the data has been on the combined FP-psych programs.


What is the best program for combined residency training?

Where ever you will be happiest.

I have my own opinions that I have based on meeting residents from various programs as well as reputations I know about the specific departments. Additionally, part of my bias probably relates to how long a program has been in existence and word of mouth reputation of various programs.

When I looked at programs, I looked at a few things to determine how strong I thought the program was. First, I looked at each department separately. I wanted to make sure I would get at least adequate training in each department. I would judge department strength on reputation, match fill rates, and number of foreign medical graduates. I don't by any means want to imply that foreign medical graduates are inferior residents, because if anything, I think the opposite is true. However, my experience has been that residency programs will choose a less excellent US graduate over a better qualified foreign medical graduate. I think a big part of this occurs because it is very difficult to assess the strength of foreign medical graduates because the medical education systems are so different throughout the world. Regardless of the reasons, programs that have higher numbers of foreign medical graduates are generally considered less desirable. Similarly, you can get a sense of the strength of a program based on which medical schools the residents came.

I think it is also important to look at the number of residents who have completed a program, as well as the current number and quality of those residents. Additionally, I look at how many dual trained faculty are present at a given program. The more, the merrier. I have learned, however, that you should not count on any one or even two staff members to guide you through training, because people do change where they work, and it may happen during your residency. Additionally perks at some programs are combined med-psych units and combined med-psych outpatient clinics. These facilities can be a huge advantage to learning how to integrate combined training in the real world.

To summarize, rather than name the names of programs here, I'll say that you can judge the programs yourselves looking at a few things, and in order, I would say they are:
1. Reputation of combined program and individual departments
2. Length of time the program has been around and had a good reputation
3. Number of residents who have graduated a program compared to the number whom have dropped out
4. Fill rates of combined program and individual departments, as well as quality of those residents who did match
5. Number and quality of dual trained staff
6. Presence of a combined unit and/or clinic


What should I look for in a combined residency program?

See above question.


Where can I get more information about combined residency programs?

I would definitely look at the FREIDA information on any program you are looking at. Of course, you should request the actual residency application materials from any program you are considering, as that information is likely to be the most current. If there are other questions, or resources that I have not mentioned here, please contact me directly and feel free to share your questions or additional information.
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Re: Combined Residency Programs - Frequently Asked Questions

Postby Guest » Thu Sep 02, 2010 2:46 pm

Dr. Dave:

I have been looking through the posts and have some questions re: med/psych units. In Idaho, we have a limited resource for acute care medical/psychiatric beds and treat most of these patients on the acute care floor. We are looking into the option of a stand-alone 6 bed unit to focus on these patients in a safer environment. We commonly see detox, agitated, aggressive and post surgical psychiatric patients. We also have suicidal patients but due to their level of medical need, requires inpatient care versus transfer to an inpatient psych facility.

Is there a list of Med/Psych Units I can find and/or contacts which I can contact that may help me in my search for overall operations of a unit like this???

Thank you for your assistance. Jeff Morrell, Program Director, St. Luke's Health System

Re: Combined Residency Programs - Frequently Asked Questions

Postby DrDave » Sat Sep 04, 2010 11:01 pm

I have been out of the loop for quite a while on combined med-psych units. One of the earliest people to set-up a combined unit, Roger Kathol, now is doing other types of work on integrated health care. He does have a website - Cartesian Solutions. I would suggest you try contacting him through his website and see if he has some current contacts.

Sorry I can't help you more.
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