Down to Earth
The Transition to Practice in Psychiatry:
A Practical Guide
Ryan J. Van Lieshout, M.D., FRCP(C)
James A. Bourgeois, O.D., M.D.
A lthough the transition from residency training to in-
dependent practice is an exciting time in one’s life,
without preparation it can be unnecessarily stressful (1, 2).
Many psychiatry residents feel that although their training
programs prepare them well for the rigors of clinical work,
the same cannot be said for the provision of information
on career options and supporting decision-making around
selecting a post-residency position and starting a practice
(2).
Below, we provide a brief guide that outlines the
career options available to new psychiatry graduates,
factors relevant to selecting a position, steps that may
be taken to qualify for independent practice, and how to
start a thriving career. We describe these from the per-
spective of the transition to practice in the province of
Ontario, Canada.
Practice Options
Making informed career decisions requires familiarity
with the options available. In many contexts, numerous
non-academic possibilities exist; these include private of-
fice practice, general inpatient or outpatient psychiatry in
a hospital setting, providing care in shared-care models,
working for the pharmaceutical or insurance industries, or
a combination of these. Within the academic environment,
one can take a position as a fellow, a clinician-educator,
clinician-administrator, or clinician-researcher.
Each type of position provides the psychiatrist with a
different mix of payment models and patient populations,
each with specific advantages and disadvantages. Often, it
is helpful to ask practicing psychiatrists why they chose
Received, accepted February 9, 2011. Dept. of Psychiatry and
Biobehavioural Neurosciences, McMaster University, Hamilton,
Ontario, Canada. Send correspondence to Dr. Van Lieshout; Drvanlierj@
mcmaster.ca (e-mail).
Copyright © 2012 Academic Psychiatry
142 http://ap.psychiatryonline.org
their type of practice, what they consider important in
selecting a position, and what they would have done dif-
ferently were they in the resident’s position at the present
time.
Making the Practice-Choice Decision
Borus (3) has outlined the steps that residents com-
monly take in making a practice-choice decision (Table 1),
and these will provide the framework for our discussion of
the optimization of this process. It is of value to initiate
this transition by the beginning of the last year of resi-
dency and to consult colleagues, mentors, and loved ones
frequently.
The first, and potentially most anxiety-inducing stage of
making a practice-choice decision is undertaking the task
itself. The second stage involves the definition of impor-
tant professional and personal issues that will affect the
practice choice. Important professional factors to consider
include intellectual stimulation and preferred practice
style. Remuneration, workload, and protected time for re-
search, teaching, and administration are also important. In
an academic department, clinician-researchers should have
50%– 80% of their time allotted to research with salary
support for the first few years. A clinician-educator should
expect 10%–20% of his or her time to be protected for
scholarship indefinitely (4). Important personal and family
considerations should also be considered (Table 2).
Developing an “ideal job” profile can help to establish
the qualities a desired position should possess. A helpful
technique is visualizing the ideal career and personal life
“5 years down the road.” Discussions with decision-facil-
itators, including family members and professional men-
tors, can aid in this process. It is at this stage, when
important issues are prioritized, that feelings of depression
often emerge (3). However, this is generally considered to
be normative and is usually self-limited.
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 VAN LIESHOUT AND BOURGEOIS

Next, the resident prepares a “professional presentation”
by updating the curriculum vitae and creating a cover
letter describing qualifications and special skills to poten-
tial employers. Having these reviewed by senior col-
leagues is a helpful exercise.
The resident then explores practice opportunities. This
can involve perusing the classified sections of journals,
web pages of hospitals and academic departments of psy-
chiatry, contacting department chairs and chiefs of clinical
service, and networking with colleagues and mentors. A
number of websites list local, national, or international job
opportunities. HealthForce Ontario (www.HFOjobs.ca),
medicalemployers.com, mdsearch.com, mdjobsite.com,
and mentalhealthjobs.co.uk are just a few of the online
resources that can help connect residents to potential em-
ployers.
The resident then visits and/or interviews at potential
work settings. Site visits allow for assessment of “good-
ness of fit.” Speaking with other residents, recent gradu-
ates, and senior faculty members can help the resident put
his or her marketability into perspective. As relationships
with colleagues are important determinants of professional
satisfaction (5), it is important to meet potential future
TABLE 1. Steps for Practice-Choice Decision-Making
1. Acknowledging and undertaking the practice choice
2. Defining personal and professional issues
3. Establishing reward priorities and minimal requirements
4. Professional presentation
5. Inquiring about opportunities
6. Interviewing
7. Negotiating
8. Committing
9. Preparing for practice
10. Using decision-facilitatorsa
a
Affects Steps 1-9.
coworkers. Discussing these experiences with decision-
facilitators can be useful.
Next, the process of contract-negotiation begins. Suc-
cessful negotiation relies on preparation and bargaining.
Developing clear professional goals that are congruent
with those of the proposed employer and having the means
to achieve these can be very persuasive. The resident
needs to be aware that there is a power differential
between him/her and departmental chairs. Taking a po-
sition of courteous assertiveness is generally the best
approach to negotiation in this setting. By the end of the
negotiation process, the resident should understand the
balance between clinical and academic expectations rel-
evant to a position. Because there is no such thing as a
“standard contract,” a lawyer should review this docu-
ment before signing (6). After selection and commit-
ment to practice, a decrease in anxiety and depression is
expected.
Preparing for Practice
The last phase of practice-choice decision-making in-
volves formally preparing for practice. In Canada, this
begins with the completion of the Royal College of Phy-
sicians and Surgeons of Canada (FRCP(C)) fellowship
examinations and is followed by the acquisition of an
independent practice license from the College of Physi-
cians and Surgeons of their province or territory. Since
most psychiatric services rendered by psychiatrists in Can-
ada are covered by government-paid health insurance
plans, acquiring a billing number is vital. Other pragmatic
professional issues that should be addressed before start-
ing a new position are obtaining hospital privileges, com-
pleting facility orientations, and the acquisition of security
passes and dictation numbers. For residents training in
Canada, updating professional liability coverage requires a

TABLE 2. Factors to Consider in Selecting an Independent Practice Choice

Personal Factors Professional Factors

Location Salary
Community size Protected time (research/teaching/administration/CME)
School quality Clinical and clerical support
Spousal employment prospects Office and lab space
Access to leisure activities Non-clinical responsibilities
Potential for maintaining privacy Collegiality of the work environment
Housing cost and availability Opportunities for promotion
Potential for intellectual stimulation Call frequency
Mentorship availability Benefits
Vacation coverage
Scope of practice

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PRACTICAL GUIDE TO PRACTICE TRANSITION
change of the Canadian Medical Protective Association
code. Because these steps can take months to complete,
the resident should initiate this process well in advance of
graduation. At this stage, seeking guidance from recent
graduates can be of value.
During residency, it is wise to become familiar with
local billing codes. This can be facilitated via billing-
tutorials provided by residency-training programs or by
residents’ completing “exercise” billings for patients and
comparing these with their supervising faculty’s billing
submissions (i.e., “shadow billing”). Faculty members
who have private practices can provide important infor-
mation to residents on topics ranging from setting up a
practice and office, to scheduling, medical-record manage-
ment, and professional incorporation. The Canadian Med-
ical Association (www.cma.ca) has produced a series of
online documents that can aid trainees in navigating the
complexities of setting up an office.
Optimizing Health During the Transition
The end of residency is an exciting time that is marked
by new challenges and losses. Leaving the resident peer-
group and a familiar clinical system can be difficult. Un-
derstanding the emotions associated with these changes
and utilizing supports can be helpful. Coping mechanisms
listed by new psychiatrists as very helpful in adapting to
early psychiatric practice include emotional support from
spouse, play and recreation, ad-hoc consultations with col-
leagues, relationships with peers, vacation or time off,
reading, creative activities, hobbies, and exercise (2).
Avoiding isolation is very important to one’s success.
Professional isolation is associated with increased levels
of work-related stress and dissatisfaction with one’s posi-
tion (7). As a result, many new physicians in independent
practice find it helpful to join a practice-group, where
knowledge and experiences can be shared with other psy-
chiatrists and the transition normalized. Unfortunately,
physicians are often not very good at prioritizing and
managing their personal health. In addition to attending to
one’s own psychological health, Puddester recommends
that early-career physicians get their own primary-care
physicians, participate in recreational activities, get ade-
quate rest and proper nutrition, and nurture professional
and personal relationships (8).
The early-career psychiatrist should consider retaining
the services of an accountant, lawyer, and financial adviser
as a means of easing the transition to practice. These
professionals can help physicians optimize their earnings,
144 http://ap.psychiatryonline.org
review contracts, advise on legal issues relating to starting
an office, and help construct a financial plan.
Coping With the Challenges Faced by the Early-
Career Psychiatrist
New psychiatrists will face myriad challenges in their first
years of independent practice. Although by no means exhaus-
tive, the following list is intended to help the trainee antici-
pate these issues and develop ways of managing them.
The stress of independent decision-making is a chal-
lenge faced by many new psychiatrists. However, adher-
ence to the principles of diagnosis, treatment, risk-man-
agement, and documentation learned during training can
mitigate these risks. The newly-graduated psychiatrist
must realize that he or she is not alone and is encouraged
to discuss cases with colleagues and/or ask for help.
Understanding one’s limitations can also be helpful in
easing the transition. New graduates often try to live up to
the impossible standards set by the over-idealized “triple-
threat” academic psychiatrists they encounter in training
(9). Attempting to live up to these standards early on is
unreasonable and can lead to feelings of inadequacy.
Setting limits can help to guard against one’s tendency
to work too much or too long. Educating patients and
referral sources on the scope of available services can help
promote an enjoyable workplace. Setting a reasonable
number of work hours per week and guarding this closely
may also help. Factoring extra time into one’s day for
administration and paperwork can save headaches and late
home-arrivals, and maintain a healthy set of order and
boundaries.
It is inevitable that psychiatrists will receive patient
care-related complaints during their careers. These can
feel hurtful, but it is important to remain calm and, if
possible, take some time before responding to them. Doc-
umenting complaints and one’s responses is sound, from a
medico-legal perspective. If it is appropriate, one should
not be afraid to apologize to the patient (and/or family
member(s)). Under the Apology Act in Ontario, apologies
cannot be used as evidence of liability against a physician
(10), and disclosure may actually lessen the risk of being
sued (11).
Conclusions
The transition to independent practice in psychiatry is
an exciting time in a physician’s life. Knowledge of the
transition and its impact can be helpful, as can the nurtur-
Academic Psychiatry, 36:2, March-April 2012

ance of familial and collegial relationships. Consultation
with decision-facilitators is vital throughout the transition
process and beyond and can help ease the transition to
independent professional life.
Manuscripts authored by an editor of Academic Psy-
chiatry or a member of its editorial or advisory board
undergo the same editorial review process, including
blinded peer-review, applied to all manuscripts. Also, the
editor is recused from any editorial decision-making.
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