Q&A with a Psychiatry PGY-2 Pharmacy Resident

Julia DiNardo, PharmD, is a PGY-2 psychiatry resident at the VA Salt Lake City Health Care System in Salt Lake City, Utah. She is originally from Pittsburgh, Pennsylvania where she stayed for college and earned her PharmD from the University of Pittsburgh School of Pharmacy. She completed her PGY-1 pharmacy residency at the VA Puget Sound Health Care System in Seattle, Washington.

Q: Why did you decide to pursue a PGY-1 and PGY-2 pharmacy residency?

A: During pharmacy school, I worked at the academic medical center in the area; the longer I worked there, and the more residents and clinical pharmacists I worked with, the more I knew that I would probably pursue a residency too. Still, I seriously explored alternate career paths and spent rotations in a wide variety of settings. While I thought I could see myself going down any of those paths, I decided to pursue residency, because I felt regardless of what I ended up doing, it would never be a bad thing to have the additional clinical training that a PGY-1 residency would offer me.

It probably wasn't until my APPE rotation at a psychiatric hospital that I felt fully committed to pursuing a residency with the intent of becoming a clinical pharmacist in a patient care setting, specifically psychiatry. That was when I decided that I would also need to complete a PGY-2.

Q: What is the structure of your residency program?

A: The PGY-2 at the VA Salt Lake City offers four, 8-week core experiences and 12 weeks of elective opportunities. The core rotations include inpatient psychiatry, the Substance Abuse Residential Rehab Treatment Program, outpatient psychiatry, and primary care-behavioral health. Elective experiences are flexible depending on the interest of the resident, but options include mental health intensive case management, outpatient addiction, mental health consult team, and the Utah Poison Control Center. There are also opportunities in transitions of care, polypharmacy clinic, and academic detailing.

I should mention that the program has 3 PGY-2 spots, and we work closely with trainees in other professions. Every Friday morning there is an interdisciplinary topic discussion, and there are teaching opportunities with multiple professional programs at the University of Utah. Additional teaching opportunities exist with the local schools of pharmacy including lectures and precepting students on rotation. I must also disclose the physical "requirements" unique to our program, which may include rock climbing, hiking, skiing, as well as the annual Spartan race.

Completion of the residency also requires a longitudinal research or quality improvement project to be presented at the annual CPNP meeting, a medication use evaluation for ASHP midyear, and a CE presentation for the pharmacy department. We staff on the Inpatient Psychiatric Unit once per month.

Q: What are your day-to-day tasks?

A: Day-to-day tasks certainly vary depending on the rotation. I just completed the primary-care behavioral health rotation, which in itself has various experiences on different days. I might see patients as a part of team visits with a medical resident and attending to provide medication reconciliation and recommendations for pharmaceutical care plan adjustment, or I may have my own face-to-face or telephone appointments.

Once per week we also have Geriatric Assessment, which is when the pharmacist/pharmacy resident, medical resident, attending, as well as a social worker and psychologists all collaborate over more complicated patients. All of these encounters require documentation in the electronic medical record.

The inpatient rotations involve rounding as a member of the interdisciplinary team and completing admit and discharge med recs. The substance abuse residential program also involves leading group sessions. On any rotation, additional responsibilities include patient education, drug information questions, non-formulary reviews, and topic discussions. We also rotate responsibility for transitions of care for Veterans returning to the VA following discharge from an outside mental health facility.

Q: What are the benefits of completing a PGY-2 residency? What about the disadvantages?

A: Completing a PGY-2 allows you to build upon everything you learned in pharmacy school and PGY-1, and provides you with the tools and experiences to be able to call yourself a specialist in the area you are most passionate about. You have more time to see rarer conditions and learn from experts how to best care for your patients. There is more to being a psychiatric pharmacist than knowledge of the mechanisms and pharmacokinetics of psychotropic medications - it is important to learn how to approach what can be a sensitive and complex population, and a PGY-2 gives you extensive hands-on practice.

In my opinion, the biggest disadvantage of a PGY-2 is another year of resident salary. It can be challenging, especially if your residency is in a city with a high cost of living (my PGY-1 was in Seattle) to balance those monthly expenses on your stipend alone, particularly during the first few months. However, I do believe that it is worth it to get the experience, and eventually the job, in the area you want.

Q: How did you decide your PGY-2 program was the right fit for you?

A: I knew that the VA Salt Lake City was a good "fit" for me for several reasons. I completed my PGY-1 at another VA, which I loved, but does not have a psychiatry PGY-2. After applying and interviewing at a mix of VA and Non-VA programs across the country, I decided that I wanted to stay in the VA system and I wanted to stay in the West.

Location aside, it was really the interview that was the deciding factor. I could tell that the environment and the culture would be compatible with my style of learning, and I felt as though the preceptors just wanted to get to know me as a person. I realized through the entire interview process that it actually had a better balance of inpatient and outpatient compared to other programs than I had originally thought from my online research. I also really like having co-residents, and the then-current residents were very enthusiastic and clearly happy with their experience, which was most telling to me.

Q: What opportunities does a PGY-2 psychiatry resident have after completion of the residency?

A: Obviously a PGY-2 in psychiatry trains you to be a clinical pharmacist in a mental health setting, which means so many options it is hard to begin! I get e-mails about open positions at VA hospitals across the country for psychiatric pharmacists probably more than any other specialty. Being PGY-2-trained makes you more competitive for these positions.

There are psychiatric pharmacists who work on inpatient psych units, and those jobs can vary depending on the type of hospital - VA, state hospital, academic medical center, children's hospital, etc. You can also work on for residential programs, such as those for substance abuse rehabilitation or PTSD, within the jail system, or on the ambulatory care side in various mental health clinics. Particularly at the VA, I think a PGY-2 psych residency can be valuable in primary care and general medicine. Moreover, pain and palliative care positions are often filled by psych-trained pharmacists. There's also academia, and positions in administration, industry, policy, and I'm sure many more.

Q: What advice do you have for students looking to pursue a residency in psychiatry?

A: To anyone thinking of pursuing any type of residency I would say, first, don't limit yourself. Explore different specialties, explore nonclinical areas of practice, and if you are thinking about psychiatry, take any opportunity you have to do a rotation or shadow a pharmacist in the area.

If your school has a student chapter of CPNP, get involved. Participate in mental health-related outreach events offered by other student organizations. Volunteer in the community. Don't think you can only apply to PGY-1 programs that offer a PGY-2 in psychiatry as your perfect fit might not, but be open to the possibility of reapplying.