The third year brings new challenges associated with more independent clinical work and higher expectations for self-directed learning. Residents grapple with such issues as the inequalities in mental health service delivery, the relapses and recurrences of mental illness seen in their patients over time, and the effect of their own countertransference reactions on their patients. Understanding and managing individuals in complex systems, beginning with families, adds a new level of sophistication to residents' clinical framework. Process becomes as important as content as many residents engage in their own psychotherapy and become increasingly reflective about themselves as physicians and therapists. And in all settings, residents are challenged to demonstrate a higher level of clinical decision-making and to cultivate their critical reading skills.

Because the third year is devoted to learning and practicing skills in outpatient psychiatry, rotations are scheduled as longitudinal experiences throughout the year, rather than in concentrated blocks. Twenty hours per week are spent in an outpatient clinic of the residents' choosing, either at Duke or the VA. Another eight hours per week are spent learning couples and family therapy in the Duke Family Studies Program. In addition, residents spend one half-day in neurology clinics that treat neuropsychiatric and related conditions, such Movement Disorders, Behavioral Epilepsy, Traumatic Brain Injury, Memory Disorders, Headache, Pain, EEG, Sleep Disorders.

The remaining time of the third year is structured flexibly on an individual basis to allow residents the option of pursuing special interests, scholarly projects or research prior to their fourth year of training. Residents may choose to spend their unscheduled time doing electives, or they may choose to complete one or both of their remaining outpatient requirements: four hours per week of child psychiatry and four hours per week of community psychiatry. Many residents have taken advantage of this flexibility in the program to develop special expertise in an area of interest over their third and fourth years of training.

For those wishing to participate in the NIH loan repayment program , residents may satisfy the eligibility requirement of 50% research time for 2 years by scheduling this during the PGY-3 and PGY-4 year.