Episode 9 – Sean Woodward of PsychSIGN on Choosing Psychiatry and Rethinking Medical Training

This article is adapted from Episode 9 of the Future Psychiatry Podcast, first released in January 2023. Host Dr. Bruce Bassi spoke with Sean Woodward, then a medical student at Northwestern University Feinberg School of Medicine and national president of PsychSIGN, the Psychiatry Student Interest Group Network.

What PsychSIGN does

PsychSIGN is a national network, affiliated with the American Psychiatric Association, that connects the psychiatry interest groups at individual medical schools. Most schools run their own interest group with its own events, but a single group rarely gets the chance to collaborate on a larger scale. PsychSIGN fills that gap through regional chairs who stay in close contact with the schools in their region, host regional events and mixers for student leaders, and work with the national leadership on programming for students across the country.

Psychiatry is getting more competitive

Dr. Bassi noted that ERAS data over the prior five years showed psychiatry applicants holding roughly steady as a share of all residency applicants. Sean offered a different lens: the match itself. The psychiatry match rate had been falling, and international medical graduates were finding it harder to match, both signs that more U.S. students are competing for the same positions. Growth in the number of medical schools and graduates is part of the picture, but interest in psychiatry is clearly strong at the national level.

How students choose a specialty

Both agreed that specialty choice is noisier than it looks. The number of graduates entering a given field can swing sharply from one class to the next, and much of that comes down to which rotations and which mentors a student happens to meet. One supportive mentor, Sean said, can be the difference between applying to a specialty and never considering it. Departments where faculty, from the chair to the residency director, visibly stand behind the students who apply tend to produce many applicants.

The lesson for training programs is simple, if not easy: recruit and develop good mentors, because students notice.

What is changing in the curriculum

Almost every topic can claim to be under-taught in medical school, and there is only so much time. Sean described several additions he had seen:

• A data science thread that introduces students to analysis tools, a little programming, and the basics of machine learning.
• Lectures on how the health care system and insurance work.
• A longitudinal clinical experience in which students follow the same primary care patients over their four years, now paired with quality improvement and community outreach projects that consider where patients come from and what care they can realistically reach.

Telehealth exposure is uneven. Students may see it in outpatient clinics that stayed remote after the pandemic, but where the psychiatry clerkship is mostly inpatient, it includes little of the outpatient telepsychiatry that makes up much of practice today.

Communication training is shifting too. Students are now taught motivational interviewing and to ask what actually gets in the way of taking a medication or keeping an appointment, such as cost, access, side effects or circumstances, rather than simply telling patients they need to comply. Dr. Bassi connected this to the idea of contextual errors: a treatment plan can look right on paper and still fail because it does not fit the patient's life.

Why some students steer away from psychiatry

Sean described a few long-standing forces. Some students absorb the view, sometimes from their families, that a psychiatrist is not a "real doctor." Others are skeptical of psychiatric medication altogether. Dr. Bassi added that because psychiatric outcomes are harder to measure than something like blood glucose, and because much of the evidence comes from short trials, questions about industry influence feed that skepticism.

Another critique Sean had heard is that psychiatry treats the symptoms of problems society should fix, such as long working hours, low wages and other social determinants of health. He agreed those changes would be welcome, but argued that people who are struggling now should not have to wait for society to change before they get relief. Dr. Bassi described the same tension in his own practice: when depression is tied to losing a job or an income, a medication alone is rarely the whole answer, and a longer conversation about the rest of the person's life often matters as much.

The two also noted a growing public appreciation for therapy, the sense that "everyone should have a therapist," reflected in the popularity of documentaries such as Stutz.

Supporting medical students: what the research suggests

Medical training asks a great deal of students, so the conversation turned to what schools and faculty, not just students, can do. Dr. Bassi highlighted two papers.

The first, by Neufeld and Malin (2020), found that students' basic psychological needs (autonomy, competence and relatedness) were more closely tied to their stress than mindfulness or resilience were. Mindfulness helps, but it is a layer on top of the environment, not a change to it.

Sean explained why those needs are hard to meet in the clinical years. Students typically rotate every four to eight weeks and may switch services weekly within a rotation, so they are always new, rarely fluent in the local routine, and seldom autonomous. Some schools are shortening the preclinical phase to allow longer clerkships, which may help. He also stressed something students value and rarely get: protected time to recharge. As curricula add new threads such as quality improvement, data science and the business of medicine, that time is often what gets squeezed.

The second paper, by Hodgson and colleagues (2020), offers practical tips for faculty supporting students in distress. A few that stood out:

1. Build regular, formal points of contact through the year, and set an early tone of open communication that encourages self-reflection and self-care.
2. Offer open-door hours when students can drop in without an appointment.
3. Respond promptly, even briefly, to emails from students who are struggling, and offer to meet.
4. Allow enough time for those meetings, and reinforce that it is okay not to be okay.

Support like this works best when it is understanding rather than punitive.

Language, technology and mental health

Sean was interested in natural language processing (NLP) and the idea that language is closely tied to behavior. He gave a well-known example: researchers who analyzed Agatha Christie's later novels found that her vocabulary narrowed over time, consistent with the dementia they believe she developed late in life. Something as simple as vocabulary richness could be one signal among many in a screening tool. Similar work looks at the disorganized speech characteristic of schizophrenia.

Dr. Bassi pointed to a 2022 narrative review by Zhang and colleagues on NLP for mental illness detection. Most of the studies it covers analyze text, such as social media posts, interview transcripts and clinical notes, rather than the audio itself, and the field is held back by a shortage of public datasets for training models. Sean noted that telehealth therapy companies and large technology platforms are already building datasets of their own.

They closed on a paradox of consumer technology. Platforms engineered for engagement have helped create new problems, such as problematic social media use, that clinicians now treat, and the same companies now ship screen-time reminders to address them. Sean's hope was that genuine efforts to reduce screen time win out. For clinicians, the takeaway is to stay involved in how these tools are built and to keep raising the ethical questions around them.

Resources

Adam Neufeld: Basic psychological needs, more than mindfulness and resilience, relate to medical student stress: A case for shifting the focus of wellness curricula

https://pubmed.ncbi.nlm.nih.gov/33016810/

Jessica Hodgson: Twelve tips for novice academic staff supporting medical students in distress

https://www.tandfonline.com/doi/abs/10.1080/0142159X.2020.1831464

Natural language processing applied to mental illness detection: a narrative review

https://www.nature.com/articles/s41746-022-00589-7

Contextualizing Care Organization w/ Dr. Saul Weiner

https://www.contextualizingcare.org/