Daniel Knoepflmacher, MD (Host): Hello, and welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, neuroscientific research and other important topics on the mind.

In this special edition of On the Mind, which is our first foray into video podcasting, we'll be providing an insider's look at Psychiatry residency training, which is a topic near and dear to my heart as the Training Director of the General Psychiatry Program here at Weill Cornell. I'm thrilled to be joined by two talented residents from the residency program here, Dr. Maya Graves and Dr. Nathan Spitz. Welcome to the podcast, guys.

Maya Graves, MD: Thanks, Dr. K. It's so nice to be here. I'm really excited for the next hour ahead.

Nathen Spitz, MD: That was really generous for you to call us experts, but it's our pleasure to be here as well.

Daniel Knoepflmacher, MD: Well, I'm thrilled to have you guys here. And we're going to be having a discussion today where we'll be keeping in mind a specific audience, and that audience is medical students who may be considering a career in Psychiatry. Over the past decade, interest in our field has continued to grow. There were over 1,700 US medical students applying to psychiatry residency programs last year and many hundreds more from around the world. These numbers have grown over the past several years, and that's been making Psychiatry an increasingly competitive specialty.

Applying can be a daunting experience for medical students, so the three of us are going to try to help alleviate some of that anxiety by sharing tips on how to navigate the application and interview process, and also provide some perspective on what life is like as a resident in Psychiatry.

So, let's jump right in. Maya, Nathan, I want to begin by asking the two of you to share a little bit about your personal stories. This is something I do on every episode of the podcast, so this is no different. And I want to know and have our audience be able to hear how each of you ended up choosing a career in Psychiatry, and maybe you were considering some other things along the way, but saw the light. So, I just wanted to hear your stories. Maya, if you could start.

Maya Graves, MD: Sure. My name is Maya as Dr. K said. I'm from Indianapolis, Indiana. So coming to New York City was an absolute no brainer for me. I was dying to get out of the Midwest and I was looking for a new environment with an area where I can be challenged by experiences, where diversity is a little more celebrated. And of course, I just wanted to live and work in the best city in the world.

So, I actually came here in 2018. I did medical school here as well, so staying in the city was another no-brainer. Now, choosing Psychiatry is a completely different story. I came into medical school not super differentiated, but Psychiatry had never crossed my mind. Not something that I'm familiar with in my personal life, in a professional way. Not something I experienced or saw much through other people with my family. But nevertheless, I chose Surgery. I was going to be a surgeon. I'd identified as a surgeon as I came closer to the boards. In the medical school, I was confident I was going to be a transplant surgeon.

And it was not until my clinical year, which I have to give a disclosure, I was in my own therapy throughout the course of my clinical year. And surgery had come, I absolutely loved it, I thought I was thriving. And Psychiatry just happened to be the next rotation I went through. And as I'm going to therapy weekly, my therapist is like, "You're a new person. You are brighter and more excited to tell me about things and actually willing to talk about work. Like, what's going on here?" And you know, I was just like, "Yeah, Psychiatry has been great." Nothing too special, like not changing my mind whatsoever, but I do give kudos to my therapist because she kept pushing me and asking, "So, why were you so different when you were on Psychiatry? There was like a light in you. You were invigorated for the first time." And I really sat back and thought about it and started thinking about, "So, why did I go to medical school? What do I want to do with my life? How do I see my life over the next five to 10 years?" And the life of a surgeon was just not really what aligned with my values. Additionally, I walked away from Psychiatry clerkship really feeling like I had done something that mattered. I didn't give someone's physical function back, I gave someone's life back.

It wasn't until June. June was when I finally did my Psychiatry sub-I, I had to get out there and actually do some more work to feel confident in my decision. But by the end of June, coming July, I made the last minute decision to pivot to Psychiatry, and I couldn't be more thankful that I did.

Daniel Knoepflmacher, MD: Never looked back since.

Maya Graves, MD: Absolutely not.

Daniel Knoepflmacher, MD: Well, I love that story because it shows like what a personal decision was. And that kind of introspection and thinking about your values, I think is the important thing for whatever specialty people decided medical school that they should take into account on. So, Nathan, tell us about your story.

Nathen Spitz, MD: Howdy, y'all. My name's Nathan. So, I grew up in a three-stoplight town in a rural-- I know people are probably tired of me saying that. I feel like that's how I introduce myself throughout my residency interviews, but it's true. So, that is where I grew up. In the very long life story short, my mom ended up being diagnosed with stage III thymic carcinoma my first day of middle school. Middle school is tough for everybody, but that definitely compounded the toughness. And while starting to navigate all the chaos and uncertainty of having a parent with cancer like that, I was starting to question my sexuality in this white, rural, Christian, very homogenous place where it was not tolerated to be anything but that.

So, I navigated middle school. My mom ended up passing away when I was 13, also in middle school. And back then, I mean, it feels weird to say back then while I'm in my 20s, but nobody talked about mental health. I didn't know a single person who had depression or anxiety or who took medications, and I took all of that angst and uncertainty and just kind of shoved it down. It reared its ugly head as I navigated high school, whether it was depression, panic disorder, anxiety, things that I didn't have a vocabulary for. I didn't know really what I was experiencing. And I had to go to my primary care doctor, I think, three different times before I was even referred to a psychologist who was more than an hour away with months-long waiting lists while I'm really, really struggling here in Iowa.

I was fortunate to be able to start therapy, to get connected or to start an antidepressant and that together they really did save my life. I really then personally became aware of the impact that mental health can have on a person, the importance of sharing and talking about what we're experiencing, how we're feeling. And that really lit a fire within me to try and hopefully improve the field and improve the path for people after me to hopefully not feel so alone or so isolated or to have to fight so hard to get access to potentially life-saving care.

So, I entered college and medical school pretty certain on being a psychiatrist. Lo and behold, here we are. I mean, I was a little swayed at different points, but ultimately ended up sticking with Psychiatry. And we can talk more about why it's so awesome later. But in terms of New York city, while Maya was doing her sub-I for the first time in Psychiatry in New York. Growing up in Iowa, I had friends and I'd lived in DC for a year and always loved coming to New York city and got the opportunity to do a month-long internship in our Psychiatric Emergency Room or CPEP at Weill Cornell and had such a great time here. I was fortunate to be invited back for the residency.

Daniel Knoepflmacher, MD: I'm struck by listening both of you about your ability to be open and kind of tell your stories. And I don't want to go out too far on a limb, but I sense that there is a generational shift where there's less stigma when it comes to talking about mental health or mental illness for that matter. And along with that, I had mentioned earlier that there's been an increasing interest in Psychiatry among medical students. I'm curious, have you guys sensed that? When you were in medical school, was there a general increase in interest that you could sense among people? Do you have any ideas why you think this might be the case?

Nathen Spitz, MD: Definitely. And even for being in rural Iowa, the amount of people applying to Psychiatry has increased each year. You can see on the NMRP or residency ranking program, the amount of applications that are growing. And I think a lot stemming, or at least from my perspective, from the COVID-19 pandemic. We saw a really strong emphasis on concept of work-life balance or having the understanding or discussions about how we stay well, both in and outside of work. And I think Psychiatry or as people, one, saw a rise in whether it's a youth mental health crisis, whether it's the isolation or anxiety that people experienced, I think it really opened a lot of doors for people to start to have conversations about how mental health or their own mental health or others were impacting them.

And with that work-life balance and an importance of mental health, I think psychiatry as a field has a lot of flexibility that people came to appreciate as they were working remotely or having kind of hybrid work experiences to start to realize that psychiatry is not only practiced in a hospital, that you can work from home, that you can work in schools or in carceral systems or in organizations. And I think that like flexibility piece, or at least amongst my classmates,

was something that maybe people who weren't as exposed to psychiatry has started to come to appreciate throughout medical school.

Maya Graves, MD: Yeah, I don't want to repeat everything Nathan has said, but I 100% agree with his perspective on the shifting change in clinical interests among medical students. I also think that our generation has come to kind of look at work a little bit differently than perhaps past generations. I think medicine in the past was very hierarchical and patriarchal. And if someone before you suffered, you have to suffer as well. And I feel like Psychiatry was one of the few specialties that I didn't get a sense of that. There actually was an emphasis on who you are outside of Medicine, even from my first experiences as a clerkship student. And I've only seen the opportunities for personal growth in addition to professional growth widen as I've moved into Psychiatry.

There are so many places you can work as a psychiatrist. And if never stepping foot into a hospital is a something that one person wants, like you can do that as a psychiatrist and still be a doctor. I don't think there are many other specialties that you can say that. So, there are just a lot of flexibility, a lot of choice-making, decision-making that's much more flexible in Psychiatry than other specialties.

Daniel Knoepflmacher, MD: Well, you don't have to get me to jump on and say that it's the right field, obviously. And I agree with everything you guys both said. And there's also all these new developments in Neuroscience and new treatments that are emerging, which make it exciting as well. With that, we have medical students who are applying to this specialty, and I want to hear from you guys what advice you have for them, maybe even at the early phase, thinking about what could they do to strengthen their applications.

Maya Graves, MD: So in terms of application strengthening while still in medical school or even before medical school, I would say show what you're doing rather than talking about it. Get involved, explore, figure out things that you like. But also, as importantly, figure out things that you don't like, because I think as you build a future and as you build a career, it's important to understand your own boundaries in order to create something that feels worthwhile getting up and going to do every single day.

I know for myself, specifically with Psychiatry, just kind of having an interest in others and the world. Take time to go see different forms of the theatrical arts, read books, you know, go outside in nature. I think one thing that you can do for Psychiatry that's very different than preparing for other specialties is figuring out who you are because the program is going to be interested in you and what you bring as a person in addition to you becoming a psychiatrist. They're going to teach you how to be a psychiatrist no matter what. They want to know why you.

Nathen Spitz, MD: And something that I think may be undervalued or something that I didn't hear a lot of that I found a lot of benefit in terms of strengthening my application for Psychiatry residency is find mentors or people in your corner, whether it's mentors in or outside of Psychiatry. I think early in medical school, if you even have an interest connecting with your attendings, talking to the residents, I think that they can help guide you or help to show you different possibilities of things that are available to you while you're in medical school. Whether it's opportunities for research exposures, whether it's ways to get involved in volunteering with different organizations, or NGOs or things like that in the community, whether it's getting connected to national organizations, for example, like the American Psychiatric Association or the APA, I think mentorship and connecting with other people, starting these conversations early can really help, like Maya said, open a lot of doors for you to explore and to find whether it's psychiatry, whether it's something else, or whether it's specific areas within psychiatry, that, at least for me, I think was really impactful in helping me strengthen my application, is connecting early.

And, Dr. K, I'm wondering I feel like on all these threads on Student doctor network or Reddit people are always wondering what the magic recipe is for the application. I'm wondering if you have any tips or tricks.

Daniel Knoepflmacher, MD: I mean, you guys said it all, yeah, I should turn over the whole process to you guys this year. I mean, I think the applications, both of what you guys said, first of all, thinking about genuineness of experience and showing passion through what you do, that it's not kind of done to check boxes, but that you're searching, trying to find the experiences, so you figure out what you want to do. And then also, what you said, Nathan, about mentors is really important.

Trying to think if I have anything else to add. Maybe to help alleviate some anxiety, this isn't neurosurgery, right? And in terms of competitiveness, and if you can do well as a medical student and you do things that show that you really genuinely want to become a psychiatrist, that's good enough. You don't have to be the like most unique exceptional at this, that, or the other thing. I mean, that's great. And I know you guys have your exceptional pieces, but that will just come out of who you are and what you do and don't try to reverse engineer, that's what I would say.

There's another important piece that I want to turn to though in the application, which is a personal statement, which I think people get anxious about. So, what advice would you guys have? I remember both of your personal statements and really enjoyed both of them and they made an impact. So, I think you guys are good people to talk about this.

Maya Graves, MD: Yeah. I love talking about my personal statement because in crafting it, I received a lot of negative feedback. I remember I wrote from my heart. I had to, in what, a thousand words explain how I came from being dead set on being a surgeon to now, two months before applying, I swear I want to be a psychiatrist. This is not a backup plan. This is number one. I'm not double applying. And I think my advisor at medical school was really cautionary with me. She wanted me to have the most convincing application possible, and our opinions and how to craft that were quite different. So, I'd written a beautiful personal statement, very vulnerable, talked about myself, my family, interpersonal relationships. Basically, I wanted to create a story that made sense as to why I wanted to be a psychiatrist two months before applying. And I sent it off, I was so proud. And my advisor did not email me back, she called me, and said, "This is a beautiful story, but you cannot submit these to residencies. "And I was like, "What? Why? What's the problem?" She's like, "You disclose way too much. They're going to have red flags about mental health in your family, what if you become mentally ill. You've talked about addiction, you've talked about just a lot. And you frankly said you were scared of an inpatient psychiatric unit. And she was like, "This is a great story, but this is not a personal statement." And we got off that telephone call and, you know, I was a bit jarred. I was really proud of this. And instead of, you know, just throwing it away, my gut feeling was like, "I need to talk to a psychiatrist about this." And I went to a mentor of mine. I had her read the personal statement and her response is, "This is perfect. This makes sense. You need to move forward with this, and I will speak to your advisor on your behalf if she's not comfortable signing off on this when creating your application." And ultimately, once my mentor, who was a psychiatrist, spoke to my advisor, who was not in the field of Psychiatry, we all agreed that this was the right thing for me in my application, given that my path was not direct whatsoever.

So, I guess, all in all, I'm saying seek diverse opinions. Do what you think is right. And if your gut says yes, talk about these things, then talk about it, because I was able to talk about my personal statement, very passionately throughout my interviews. And I know that it was a big talking point for a lot of program directors.

Nathen Spitz, MD: And earlier you'd mentioned how to strengthen your application. I did not realize how long residency applications were. I don't remember the final, I think like in the printed format, mine was like 18 pages or something heinous like that, which I imagine is very difficult for people to read through in the residency, kind of reviewing process of who to extend an interview to, et cetera. And with that in mind, I think the personal statement is a great opportunity for people to string-- you know, I'm going to use this analogy of string or thread-- to kind of thread all of these different aspects of your application together and to give some context as to how or why you arrived at this point in your life, whether it's talking about how or why you were interested in research or the impact that this community service had on you or a particular patient interaction. I think that the personal statement's a great place for you, like Maya said, to show and not just tell all of these experiences, motivating factors, et cetera, and to create this narrative. I feel like the personal statement's a great place for you to create a cohesive narrative and story. So that way, when people are done reading it, they have a better sense of not just who you are, but how you are or why you are, and to see if and how you could be a part of their respective residency program.

And, Dr. K, you can chime in as well. I think the final paragraph of the personal statement is a great opportunity for you to also showcase yourself, or to sell yourself, or to talk about what's coming next, or if and how you would be a great member of the specific residency community. This may be controversial advice or opinions, but I tried to personalize the end of my personal statement as well. I think that it can go a really long way, especially for programs that you're interested to show that extra effort, to show that you are intentional and that you have done your research. And that, with all of these amazing life experiences and things that you did in medical school, that you could continue that and contribute and continue to grow and build a residency program. But I don't know if you have any other advice or opinions on personal statements.

Daniel Knoepflmacher, MD: We could do a whole episode just on this for medical students in general. You know, I think everything you guys said is right on. Definitely get a lot of people to read it. Remember that there may be people reading this who aren't from your generation. I like to think I'm in sync with your generation, but you know, you never know that maybe there's things I won't get.

And then, thinking about what you said about kind of tailoring that last paragraph. That's something that people can do in the application because it's electronic, that they can send a specific paragraph to each program, or at least the programs that they're most interested in. One thing that you guys didn't have that started last year that is part of this year is there's 10 signals. When you apply, you can signal 10 programs that you have some extra special interest in them.

The other thing I would add is, I think, it's less interesting reading an essay where you're just kind of rehashing what's in the rest of your application about all the things you've done. Use the essay to identify who you are, maybe go deep in a personal way that gives you a sense of the passion or why you're choosing this field based on some of those individual experiences, but you don't have to highlight every award you've won, every, you know, amazing experience you've had. That's another thing that I think this is your chance to kind of speak to the people reading your application. And then, following up on that, was this something that alluding to what Maya mentioned that then be prepared to talk about it? Because whatever you say, you want to get questions on it because that shows they really read your application closely, and be ready to speak about that.

More questions for you guys though. This is the first part, the application, but then you get your interview. I'm wondering what you guys remember about interviews if you had some amazingly bad or good questions from people and really what tips would you give to prepare and to do well with the actual interviews?

Nathen Spitz, MD: To speak to being prepared to talk about your personal statement. This was a one-time thing. This does not happen often, but I think there's a myth or rumor that in Psychiatry interviews you will be therapized or analyzed. I do have one memorable experience with the program not to be named, where I did, I offered vulnerable information about my experiences growing up and how it led me to be a psychiatrist. And for 45 minutes, I talked about my life prior to the age of 18 and its impact on myself for development. I remember that as a bad or maybe a missed opportunity in that I wasn't able to really talk about myself as a medical student, to talk about why I would be a great fit for that program, to have questions or answers or discussions about kind of the mutual benefit or alignment of us as a program, and an applicant. So, that is not common of my colleagues. I did not hear very many other people receiving that type of question. But I think some of the best or most memorable, maybe to contrast that, good questions I thought were when programs asked why I would be a good fit for that residency. I think it's I think it's broad enough for us as applicants to get to share information that we want to talk about, or maybe to follow up on things or to share new pieces of information to our interviewers. And I think it also creates, you know, for us to talk about why specifically that program to show whether there are specific rotations or programs or mentors that we want to work with, and to also highlight our life outside of the program to talk about our supports, to talk about things that we like to do to create maybe a comprehensive picture for us as applicants. So, maybe a tip in the interview is something that I did that I found was helpful as there's tons of documents online with some of the most commonly asked questions and to just not that you have to rehearse line by line what you're going to say, but maybe have a few bullet points or different scenarios or different talking points so that if you do talk about something earlier in an interview, if you get asked, you're not regurgitating or saying the same response for each question. So, do a little homework ahead of time and I think it will pay dividends in the end.

Maya Graves, MD: Yeah, I totally agree with Nathan on having talking points. I would say keep them extremely broad too, so that they're applicable to multiple different ways a question might be posed to you by or during an interview. I also think one of my favorite questions that gave me a little bit of insight into the program was when program directors or any other interviewer asked, "So, how do you take care of you?" And I think, one, it's a question that the first time I was asked, it caught me off guard. I'm like, "Wait, how do I take care of me? I've been in medical school. I don't take care of me. But it shows that I think the program does care about your genuine well-being. And they want to know that you come in with some tools and knowing, when you're having a bad day, how to move forward. Because in Psychiatry, there are bad days. We're dealing with really hard situations and hard life scenarios that can be quite heavy sometimes. And I think when a program recognizes that, speaks about that, and also wants you to play an active role in your own sort of healing or wellness in addition to what they can provide you, it really does show that they care and this is something they deeply think about, recognize, and understand.

Nathen Spitz, MD: I think it's a great way, that question specifically too, to build some rapport with your interviewers as well, whether you're, like Maya said, a live, a theater, person, or you're interviewing in New York to maybe build some spontaneous riffs about things that your interviewers like to do, or whether you're interested in food, or cuisine, or exercise, or nature. I found that some of the most organic conversations or talking points came from that style of question too.

Maya Graves, MD: Dr. K, what's your favorite question to ask applicants?

Daniel Knoepflmacher, MD: This is like mirror experience, because you guys are kind of hitting on all the things that you want to know when you're interviewing. You want to know what is it about this person and this program that will be a good match? I'd say when I'm looking at programs, I want all different kinds of people with all different kinds of interests. We're striving for diversity in the community. But you know, we have what we have in our program. We're in New York. There's specific things about it. I want to make sure that this person is interested in that, and that's going to be happy here with what we have to offer. I think that question about wellness is really important because, as you said, residency can be challenging, Psychiatry can be challenging, and you want to understand someone's resilience and ability to kind of thrive in spite of those challenges. And then lastly, just that certain quality of who are you, you know, does that come through and is there a genuineness and what are your interests? And it could be, "Wow, I love that same reality show," and we spent a few minutes talking about that, or it could be that you're into something that I have known nothing about, but you're so clearly passionate about it. And it's amazing to listen to your thoughts about that.

So, all of that, I think coming through in interviews are pluses. Great advice. So, you've done the interviews. You're at that last part of the process. And you want to think about how to assess and compare different programs. because you have to submit a rank list, which then is what results in your match. So, what did you guys do? How did you come up with criteria? How did you go through that process?

Maya Graves, MD: I, after every single interview, just jotted down exactly how I was feeling, what I liked, what I didn't like, because you do the rank list so far after the point when you interview. And while I may not remember the way I felt, I trust my own notes. I trust that what I told myself at that point in time is the way I'm feeling now and will be reflective of where I think I might best fit.

So, I would say that is first and foremost. Just, you know, keep active logs and active notes of your thinking and your thought process of why this program over that program, why this geographic region over that geographic region, why this patient population-- you know, there are a lot of different things.

Additionally, I think being honest with yourself about where you want to live is huge. You're giving up your 20s, 30s, to spend more time in a hospital than you do outside the hospital. So, you better choose somewhere where, when you're outside, you're happy living there. You know, that's very different for everybody. Some people need like an urban jungle to explore. Others just want to be close to family and friends. So, make sure you know what you need because, as we've all said, residency is very time consuming and it can be hard. So when you're not actively working, you want to make sure that you've made a decision where you're comfortable outside the hospital and you're ultimately happy.

Nathen Spitz, MD: And Maya had kind of brought up this piece of advice, and I think it holds true in creating your rank list as well. Seek input and advice or thoughts or opinions from a bunch of different people, whether it's from the programs that you're interested in. Some of the most important or impactful conversations I had were with residents after the interviews. I think during the interview day, at no fault of the residents, I think there may be some censoring or some kind of generalities in which people talk to try and put the best foot forward from the program. And I think if you're able to connect offline, you're able to ask really specific or personalized questions to your unique needs and circumstances. Connecting with residents at different points throughout the residency process as well was really helpful for me. I think if you perchance only get residents in their first year of Psychiatry who are all on Internal Medicine, their experiences might be a little different than a third or fourth year Psychiatry resident who has a lot more experience from the program, living in the city, and it has some of that institutional knowledge about changes, wellness programs, things like that, that I think are really impactful.

And in what Maya said, in being honest, I think being honest with your friends and family as well, I think they're able to maybe point out some things that we as applicants may have kind of the rose-colored glasses and the excitement of thinking about what our lives could look like, having some of those ominous conversations with people who know you. Not just as a medical student, but as a person, were really impactful and helpful for me in crafting that rank list.

Daniel Knoepflmacher, MD: Great advice. I want to ask another aspect of this. And this could be even early in the process when you're looking at places that you want to apply to, but also after you've interviewed, how do you go about assessing the culture of the different programs where you're applying? I mean, I think Nathan, you alluded to talking to residents. Obviously, that's one way. But also, thinking about commitment to diversity, equity, and inclusion, and belonging at different programs, how do you get a sense of what it's like there, if at all?

Nathen Spitz, MD: Yeah. Maybe I put too much effort into this. I feel like a common refrain from residence is, "Oh, it's just the vibes," or that there's this kind of ethereal nature, unspoken things about programs that people are able to assess. But I think I took a multi-pronged approach. One is a general just kind of purview of the program's websites. I think clicking on almost every every link just to see how they talk about support for residents, how they talk about what programs they have in place for diversity, equity, inclusion, whether they have institutional supports, whether they have opportunities to connect and to grow and build outside of the residency program. I think seeing how a program talks about itself, and what it has in place can tell you a lot about what's to come in the future.

Social media is a growing force and presence, whether it's Instagram, Twitter-- oh, I guess now it's called X-- I don't know of any programs that are on TikTok. Maybe it's a thing. Maybe we can explore that avenue next. But checking social media is, I think, in the social media frame. There's a lot more of the kind of organic opportunities, or you can maybe see some behind the scenes of what life looks like in the residency program, highlighting bios of different residents, highlighting ways that they connect and engage outside of the program.

I was fortunate to be able to do some away rotations as well. I know that they're not necessary for psychiatry, maybe like some other specialties, where they're more heavily encouraged, but I found those extremely valuable, especially coming from Iowa, to see how Psychiatry, one, what the culture is like; two, how Psychiatry can be practiced, how it can be practiced in different settings. It was really valuable for me to get those experiences or exposures having lived most of my life and trained in the same institution. So if that is available for you, it's something I think to consider, or if there are a few programs that you're really interested in, if you can't make an away rotation work, I think Second Look days or programs you're interested in are a great opportunity as well.

Maya Graves, MD: I second Nathan on everything as always. Second Look was a great opportunity to get a better feel of the culture because program directors are not involved. Everyone's a little more relaxed. The residents are able to speak from the heart and really, you know, highlight both strengths and weaknesses of a program. I think a really telling sort of marker to see where a program is actually asking them like, what areas don't you have? Where do you think there is room to grow? Especially in terms of DEI, I think with DEI, everyone wants to create an idealist community where everyone is welcome and heard and valued equally.

But let's be real, it's just not reality. And no matter where you go, there are going to be issues. There are going to be interpersonal conflicts between people of color, residents of color and older attendings that are more conservative. There are going to be mess ups, people miscalling names. I mean, it's inevitable.

What really made a difference for the schools I was seriously considering and where I thought I would be supported best as a Black woman were those schools that were like, "Yeah, we've got problems, but these are X, Y, and Z initiatives that are either in the works or about to happen that we are trying to implement.

Additionally, I think when you talk to Program Directors or anyone from a program about how they take resident feedback and integrate it, I think when I saw programs that had resident activities that were actually resident-initiated, that said a lot. It said that the program actually listens and tailors their training to what their residents want.

And then, I also think that having not only affinity groups or spaces for open conversation and talking about, you know, the intersectionality that we all have. Not only having those, but having funds behind them. Because at the end of the day, funds really show what programs and hospitals value. And if they're willing to fund travel to the NMA or willing to fund diversity luncheons or, you know, just little things that allow students the space to be themselves and be supported as an individual that may not be highly represented in medicine.

Daniel Knoepflmacher, MD: Thank you guys. Well, you said so much there. And I think, thinking about a culture by seeing how the places you're looking at answer those questions or is there some humility about the work that has to be done and so much there. So, the good news, of course, was that fortunately both of you matched here in 2023, along with your awesome classmates and who are now on the second year of residency.

So, I want to end for like the last 10 minutes that we have left to ask you about life now as a resident. So, let's start with what were the biggest surprises about residency? You know, you come in as a medical student applying, you have all these ideas. What were the biggest surprises in reality of being a resident?

Maya Graves, MD: I think the biggest surprise was that when you go home, the work is actually done. Like, as a medical student, you come home and there's always something more you can be studying, always something more hanging over your head, you never feel adequate. But as a resident, you have a job, it's very clearly defined, you do it. And when you're done with your job, there's someone that you sign out to and they take over and you can wash your hands and leave for the day and have an evening without feeling that you're not doing something you're supposed to do. So, I think that was one of the biggest surprises. I also think that taking ownership for patients feels completely different as a resident than it does as a medical student. Like, you are the doctor. The patients and the patient's families really look to you and value you and your opinion and your advice.

So, there is just this actual sense of responsibility and neededness by the team. You know, it's nice to feel needed in addition to wanted, but needed is really nice. And, you know, if you don't do your work, a lot of people are going to suffer. And so, that was a really nice feeling about residency.

Nathen Spitz, MD: And maybe this is program specific, I know everybody will have different experiences as they navigate residency, especially at this program coming in as somebody who particularly enjoyed psychiatry and wasn't really swayed throughout it. I was really nervous or fearful about doing rotations as a resident or having that ownership that Maya talked about in rotations that I hadn't done for two to three years. And I was so pleasantly surprised at how supportive, how engaged, how welcoming, even like the off-service residents, offservice attendings, where I was always made to feel a part of the team, that I was an integral and vital part of the team. I was never made to feel less than. And I think that was really such a like positive surprise, especially coming from the medical student perspective where you're constantly evaluated and scrutinized or you have that fear that people are always judging you. So, that was a really welcome surprise. And maybe this is program specific as well, but I also feared, and this is not to minimize the financial struggles that other people have navigating the transition from medical school to residency, I have been so pleasantly surprised at my ability to live a quality life outside of the hospital and to still be able to do the things that bring me joy and that help fill my cup up and help make me be a better resident.

I know everybody has unique financial circumstances and each program has different benefits and things like that. But that was a big surprise coming from medical school, being almost entirely reliant on student loans and like tutoring on the side to try and make ends meet that, like Maya said, I can sign out and put my feet up or put my feet down and go out and explore the city and live the life that I dreamed of.

Daniel Knoepflmacher, MD: It sounds like both of you were kind of surprised by the work life balance. And that's not to say that you guys don't do a lot of work. I will vouch for that. so that's nice to hear. I do want to ask you though about challenging things. What would have been the most challenging parts of being a Psychiatry resident?

Nathen Spitz, MD: In general, I think there's like a common theme of, and maybe this is not Psychiatry, I'll try and answer both residency and Psychiatry specific, I think in residency the restriction on your time, so we're talking about living life outside of the hospital, you work way more weekends and nights than you do as a medical student, and it is very difficult, although most of my family and friends are very understanding to have to say no, or to try and make it work, but to not have the flexibility of taking entire weekends off or weeks off at a time or having predetermined vacation, I think, is something that can be difficult for a lot of other people who don't work in healthcare and may not understand the restrictions that we have.

And then, I think a challenging aspect in Psychiatry is I feel like, in this shift from the medical student to resident responsibility, and maybe this is Psychiatry specific, there's a whole unique tool or toolbox in Psychiatry in terms of providing psychotherapy that I feel woefully unprepared for as a medical student, and that's no fault of medical school. But I think there is such a unique entire realm of practicing as a psychiatrist, vis a vis the providing psychotherapy or different forms or modalities of psychotherapy. That's really challenging. And as a medical student, most of our Psychiatry knowledge is Pharmacology-based. And here we are now as residents who are serving as people's primary prescribers and maybe therapists as well, and that's a lot to take on, especially coming in from that medical student perspective.

Maya Graves, MD: I would say in Psychiatry specifically, I think a challenging aspect that seems like it'll never happen to you, but it's inevitably going to happen to everyone, is losing a patient. I think in Psychiatry specifically, it weighs on you more, I think, than someone who has a physical terminal illness. So, you know, I always was told it's not a question as to if, it's a question as to when. Unfortunately for me, I've lost my first patient. Some people go through an entire four years of residency without losing one, but that was a remarkably challenging experience for me, but I was so surprised by how supportive and overwhelmingly there everyone was because, you know, it can be really isolating and really a weird sort of thing to carry and it's not something that people in your outside life can really resonate with or understand the amount of responsibility you feel for these people you're taking care of.

So, I think specifically to Psychiatry residency, that is an inevitable, very challenging aspect. And it's very important in choosing a program that you do feel that you choose somewhere where you can approach people and talk about emotional difficulties and how to cope with something that is really impactful on someone's life.

Daniel Knoepflmacher, MD: Thank you both for sharing those challenges. And having gone through Psychiatry residency myself, I can attest to all of that. And again, thank you, Maya. I mean, that is one of the hardest things that I think many people go through for the first time in residency, and it's something where you definitely need support.

Nathen Spitz, MD: How unique it is to psychiatry, I'm not sure, but it often feels like what we're battling is like the systemic presence and social determinants of mental health and that the tools that we have as psychiatrists. We can try and provide as much CBT or SSRIs to somebody, but if they don't have a home, if they don't have an income, if they don't have supports behind them. I oftentimes, or something that I've struggled with is knowing our limits or knowing what we as psychiatrists or we as a system can provide for a person. And that I think maybe it's something unique and not that the social determinants of health don't affect every other specialty, but I feel like we are really presented with some of the utmost extremes of what systems can do to a person. And I feel like we are oftentimes, you know, trying to uplift or uphold or provide resources, which is pretty challenging.

Daniel Knoepflmacher, MD: Absolutely. And that's where, you know, you have to think about what can you do? You have to set limits for yourself, because there's an endless amount of need, but where are the differences that you can make in individuals' lives or even in the system, whether that's, you know, through organizations, whether that's through individual care. It's an important part of the field, but that's challenging. But it's also, I imagine, a bit of why you both went into Psychiatry, right, is because those things exist and there are people suffering and you wanted to help them. To that end, I want to talk about the other side. What about rewarding aspects of being a psychiatrist or a Psychiatry resident?

Maya Graves, MD: Seeing someone do well is the most rewarding thing ever, but I also think seeing someone through a really hard time and being a constant when maybe they have not always had a constant in their life is a really special role we're able to play. I often think like, "Wow, I cannot even remember the names of half of my patients, but I remember the really intimate interactions we have, and I'm sure they remember me, and that's a really unique position to hold in life where others think fondly of you or remember you, and you may not have the same sort of ability to actively think about people as often as they might think about you.

I think another rewarding aspect is just getting to know and hang out with your co-residents. You get a whole batch of friends that are decided for you who are really your rocks for about four years or however long your residency program is. So, I feel remarkably lucky to have the group of 12 that we are now, and it's just a starting point for a really, really good career network ahead.

Nathen Spitz, MD: To build on what Maya said, and this advice I think applies to every medical student is to find your people. To find the people in the resident work room that you've really enjoyed those conversations or that you're able to talk about also things outside of the hospital as well. To be a psychiatrist specifically, to be surrounded by people who are curious, who are adventurers who love to get to know other people. I think just burrs such a unique, caring, supportive, loving environment that makes coming to work fun. And speaking of work being fun, I think within Psychiatry that our work using ourselves as the intervention, although oftentimes we do hear very traumatic, harrowing stories about the human existence, to also get to really connect with somebody on a personal level to hear, to learn about their joys, their unique experiences throughout life, I think is really rewarding and something that I really valued and found myself, and this is not to talk badly about other specialties. But, you know, spending your days talking about bowel movements or abscesses or foot wounds weren't things that really filled my cup up or sparked joy for me. And I want everybody to find something that sparks joy for them. But in Psychiatry to have my day to day really getting to know people, their lives, their stories, their families, is something that just continued to keep me excited about Psychiatry residency.

Daniel Knoepflmacher, MD: Well, thinking about you guys and your classmates definitely, most of the time, sparks a lot of joy for me with the vast majority of the time. And it's just the amazing things that you guys are doing, the amazing work, and what you describe, like that sort of camaraderie that you build with each other is just such a great part of my job.

So, I want to end with a pearl that if each of you could share one piece of advice that you were going to give to medical students who might be listening and are considering Psychiatry as a career or applying to residency in Psychiatry, what do you guys wish was something that someone told you back when you were in medical school considering this specialty?

Nathen Spitz, MD: I think they're starting to maybe to paraphrase that question is that I wish, and if they did, I must have ignored it, I wish more people would have had conversations about saying no. I think that the prevailing wisdom is to say yes to everything. And I talked about this earlier, the amazing opportunities to continue to explore and try new things, for a novelty seeking. Like an experience-oriented person like myself, I think medical school can be dangerous in that there are so many opportunities. Like Maya was saying, there's always something next. There's always something that you can be doing. And I think I took that say yes to everything, you can peel it back later a little too literally, and oftentimes found myself really overwhelmed.

And although, you know, you can always peel back, you can always back out, I felt like I personally couldn't do that. Maybe it was how I was raised that if you say yes, you finish it to completion. And I found myself oftentimes exhausted or exasperated. And by learning to say no, I think, one, you're able to say yes to yourself more. I think I wish I would have said no so that I could have said yes to myself and my life outside of medical school and the hospital more. And by saying no to the extensive opportunities ahead, I think you can dive deeper when you're able to invest more, to learn more about maybe a few topics or aspects that you're extremely interested in. I think could have saved me a little grief in the end, but that is something that I wish people would've had more honest conversations with me about.

Daniel Knoepflmacher, MD: So, knowing when to stop at the buffet.

Nathen Spitz, MD: Which I can't, I have no idea. I am team sweatpants all the way. Maybe I need to start wearing jeans so that I know when to stop.

Maya Graves, MD: I think we're all so guilty of saying yes to everything, because you feel like if you say no, you'll never get the opportunity again. But I think my pearl of wisdom I will leave with students is, as medical students, we feel like we have to be perfect. We have to know all the answers. We have to perform at our highest capacity 24/7, and that is all false. It is okay not to know things. It is okay to make mistakes. It is okay to ask for help. And I think when you understand your own limitations, are willing to be vulnerable and make a mistake, and also just flat out ask for frank help, it only makes you more of a person that someone can, one relate with because we all have felt like impostors. We've all felt like we're just putting on a coat and playing doctor every day. And it's more common that we don't know than I think people, or at least med students, perceive. And it's really liberating also to be asked a question and to just say, "I don't know. Can you tell me? Or can I have five minutes to figure it out?" It takes a lot of pressure and stress off of just every interaction every day, because who knows everything? And you're not perfect.

Daniel Knoepflmacher, MD: Great advice. And so now, the people listening have been told this while they were in medical school. So, thank you both. Maya, Nathan, I'm just so grateful to both of you for coming on this podcast today and speaking with me. As you both know, I've been looking forward to this episode for a while. It's fun to speak with you guys whenever I connect with you, whether I see you in the halls or we're on Zoom together. I'm just grateful to you for sharing very, I think, vulnerably, your experiences and really your wisdom from those experiences to those who are interested in learning about what it's like to get into Psychiatry residency and to be a Psychiatry resident.

So, thank you, thank you, thank you. And I hope that all of your co-team members. You guys are both on inpatient Psychiatry right now. I completely understand that it was just so important for me to pull you away from that important work, but I'm really grateful to you guys. Thank you for coming on.

Maya Graves, MD: Thank you so much, Dr. K, for having us. It's been a real delight.

Nathen Spitz, MD: And like you said, there are more conversations to be had. There's so much that we can talk about in terms of applying to medical school and residency so we can continue the conversation for all the things that are on the mind.

Daniel Knoepflmacher, MD: Well, maybe people will be reaching out to you guys. I don't know. I also want to thank everyone who checked out this special episode of On The Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on all audio streaming platforms, including Spotify, Apple Podcasts, YouTube, and iHeartRadio. Please tell everyone you know about us, give us a rating, and subscribe so you can stay up to date with all of our latest episodes, like Nathan was saying, on a lot of fascinating topics that will be ahead. We'll be back soon with another episode of On The Mind next month, so be sure to give us a listen.

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