Unraveling of Forensic Psychiatry fellowships makes participants paranoid on both sides of the market

 Where lawyers speak naturally about rules, psychiatrists don't shy away from talking about feelings, and the current disorder in the market for forensic psychiatry fellowships is making many participants miserable.

The Fellowship Application Process Must Be Reformed  by Octavio Choi, Journal of the American Academy of Psychiatry and the Law Online September 2021, 49 (3) 300-310; DOI: https://doi.org/10.29158/JAAPL.210088-21

"These are unhappy days in the world of forensic psychiatry fellowship programs. Here is the crux of the problem: too much product, not enough customers. Agapoff and colleagues report that for the 2016–2017 academic year, forensic psychiatry fellowships achieved a 56 percent fill rate, with 65 residents spread over 44 programs offering a total of 116 positions.1 Since then, the number of forensic programs has continued to grow, up to 48 ACGME-accredited programs offering 127 positions in 2018–2019. Seventy-three of those positions were filled, equating to a 57.5 percent fill rate.2 Things were better in the older days. According to ACGME records, in 2012–2013 there were about the same number of active residents (70) in just 36 programs.3

"The implications are clear: forensic fellowship programs are increasingly desperate to recruit a small number of applicants. From the perspective of program directors such as me, the rational strategy to pursue in this situation is to identify promising applicants early and try to sign them up before anyone else can get to them. Indeed, in recent years, fierce competition has led programs to make earlier and earlier offers that are time-limited (also known as the “exploding offer”). Paranoia is high. Given the nontransparent nature of most transactions in the applications process (no one really knows what anyone else is up to), and lack of objective referees, it only takes the slightest hint of malfeasance for outrage and fear of missing out to amplify.

"The overriding fear of many program directors is that they will not fill their available positions. In addition to bruised egos, being left with open positions means contracts will be left unfilled, possibly leading to cancellation and, ultimately, reduction or elimination of programs. Literally, to not fill risks death (of the program). The imperative, then, is to avoid not filling at all costs.

"On the other side is a paradox. For applicants, low fill rates should translate into a buyer's market, yet because the market is unregulated, the current system inflicts much suffering on them. As one recent applicant succinctly described the process: “it's a hot mess.” Competition by programs for the limited number of applicants has led to earlier and earlier offers being made with shorter and shorter times to decide; too short to adequately assess and receive offers from other programs. Indeed, the whole point of an exploding offer, from the program's point of view, is to curtail assessment of other programs by forcing applicants to make decisions before they might otherwise be ready. In marketing parlance, the idea is to pick up a bargain by taking a good off the market before it can be fairly priced.

...

"The failure of the current system is not about program directors being bad people. It is about the fragile nature of voluntary agreements during difficult times. The math is simple. If each program director has a 95 percent chance of behaving ethically over the course of the applications cycle, and there are 48 programs, there is only a .95 to the forty-eighth power probability (=8.5% chance) that all 48 directors will behave ethically in any given year. A single program director acting less-than-fully ethically is enough to kickstart a paranoid feedback loop that devolves into chaos: “If program X isn't playing by the rules, I don't see why I need to keep playing by the rules, especially if it's going to hurt me.”

"But note that system failure does not even require any actual unethical behavior; all that is required is the perception that others are behaving unethically, a perception that is encouraged to flourish in the context of desperation and lack of transparency"