Optimizing Future Roles of Psychiatrists in Public Sector Care through Changes in Residency Training

Optimizing Future Roles of Psychiatrists in Public Sector Care through Changes in Residency Training
Updated June 2002

Principal Investigator: Michael Yedidia, Ph.D., Co-investigator: Carol Bernstein, M.D.

This project, from our new academic partner - the NYU Wagner Graduate School of Public Service, addresses challenges faced in effectively integrating psychiatrists into the care of persons with severe mental disorders (PSMD) in diverse public settings. Dr. Yedidia is with the NYU Wagner School; Dr. Bernstein is director of residency training at the Department of Psychiatry at NYU Medical Center.

PROJECT GOALS

To develop a basis for fostering changes in psychiatric residency training that will improve the alignment between psychiatric resources and systems needs in the public mental health sector.

Rationale: Many diverse forces in health care delivery impact upon the roles played by psychiatrists and residency training programs. These include:

Changes in the psychiatric knowledge base (e.g., diagnostic breakthroughs, advances in neurobiology and psychopharmacology);
Proliferation of non-physician professionals licensed to provide psychotherapy;
Ascendancy of managed care with its emphasis on reducing practice variation, increasing efficiency and lowering costs;
Reductions in availability of funds for psychiatric training;
Prevalence of severe mental illness among marginalized populations in public settings; and
Emphasis on primary care providers as coordinators of health services.

This study examines future roles to be played by psychiatrists in this changing health care delivery system, and assesses the responsiveness of psychiatric residency training programs to meet new challenges posed by these forces. Study goals are to:

Generate a vision of appropriate roles for psychiatrists in this changed environment,
Survey the current status of residency programs in preparing psychiatrists for these roles, and
Inform the design of a longitudinal study of a cohort of psychiatric residents with the intent of improving the alignment among recruitment, training, and ultimate role.

The study will address these questions:

How might psychiatry adapt to changes in the health care environment in order to serve optimally the mental health needs of PSMD in the public sector? What is the appropriate interface between psychiatry and de facto treatment settings for PSMD (e.g., shelters, jails)? How do key leaders in the field envision the future role of psychiatrists?
What are the implications of these visions for the recruitment and training of psychiatrists?
What types of strategies are residency programs currently employing to address the changes in the environment and how equipped are they to mount further initiatives to achieve a more productive match between training and ultimate role?

RESEARCH ACTIVITIES AND RESULTS

Method: The project will proceed in two phases:

conduct of in-depth interviews with leaders in psychiatric education and practice, and
survey of residency program directors in psychiatry. (Inductive qualitative analysis of the interviews will identify key dimensions to be addressed in the survey questionnaire).

Visions of the Future Role of Psychiatrists: To address the first two sets of research questions, in-depth interviews will be conducted with a systematically selected sample of ten acknowledged leaders in education and practice. Structured, open-ended questions will focus on their views of the role of psychiatrists in public programs serving PSMD, challenges posed by current forces in the health care delivery system, and changes needed in residency training to meet the challenges of the new health care environment.

In addition, they will be asked their views on existing proposals for re-shaping psychiatric roles, including: re-orientation of the discipline (e.g., by merging psychiatry and neurology into a single discipline), concentrating exclusively on treating severe mental illness, developing specialized training programs in public psychiatry, redefinition of psychiatrists' roles as they relate to the broader health care workforce (e.g., training psychiatrists to be primary care providers to severely mentally ill patients, facilitating collaborative practice with generalist physicians), and incorporation of new skills (e.g., adding significant attention to management and finance in the residency curriculum).

The interviews will be audiotaped and fully transcribed, and subjected to inductive analysis using standard qualitative techniques: Recurrent themes will be identified, coded, refined and correlated with each other in a search for dominant patterns. This analysis will yield a comprehensive view of future options for psychiatrists, assessments of their strengths and weaknesses, and strategies for training residents to assume these new roles.

Strategies Pursued by Residency Training Programs to Optimize Relationships between Training and Role: A survey of directors of the 387 residency programs in psychiatry in the United States will be undertaken to document their responses to changes in the health care environment. The content of the self-administered questionnaire will be determined by the options and strategies identified in the qualitative analysis. Attention will be devoted to documenting both current and planned changes that affect recruitment as well as training. It is anticipated that such changes may be associated with reorientation of the discipline, redefinition of the role of psychiatrists in relation to the broader health workforce, and supplementing skills in key areas. As other options emerge, they will be incorporated into the survey.

Respondents will be asked to indicate which measures they are pursuing and their goals in undertaking them, and will also be given an opportunity to indicate other relevant strategies not articulated in the in-depth interviews. In addition, survey items will address their views of the anticipated roles of their graduates and the missions of their programs. Finally, selected characteristics of the programs will be incorporated in the data set from the APA's Directory of Psychiatry Residency Training Programs. A descriptive analysis will facilitate categorization of the programs with respect to their current and planned responses to changes in the environment. The emerging typology will serve as the sampling frame for selecting programs for participation in the longitudinal study described below. Descriptive statistics will be used to identify program characteristics (e.g., size, locale) that are associated with particular types of innovations.

The Impact of Changes in Residency Training on the Roles of Future Psychiatrists: Long range plans include developing a proposal for a longitudinal panel study of residents who train in programs that typify responses to changes in the environment. The first-stage of the sampling for this research will be selection of such programs, including several that embrace the strategies advocated by the leaders interviewed in the first phase of the current project. As presently conceived, residents in this sample of programs will be surveyed at three critical junctures of their careers: upon entry into the residency program, during their last year of training, and two years post-residency, when most will be in practice. The focus will be on eliciting their aspirations, attitudes toward various aspects of psychiatry, and career plans as they progress and the nature of their ultimate roles once they complete their training. An analysis plan will be developed that will assess the impact of program-level as well as individual-level variables on their roles as practicing psychiatrists. The study will yield evidence of the effectiveness of varied strategies for optimizing the relationship between the training and role of future psychiatrists, and for assuring appropriate incorporation of psychiatric expertise in public sector programs serving PSMD.

Results: Interviews with a systematic sample of national leaders in psychiatric education and practice have been completed and analyzed relying upon inductive qualitative techniques. A manuscript based on this analysis has been submitted to Psychiatric Services for review. Based upon the findings, a survey of residency directors is being designed for conduct during the second phase of the project.

Respondents posed an expansive agenda for psychiatry in public sector care and an ambitious curriculum for preparing residents for commensurate roles. Leaders envisioned roles that would address:

The mix of biological and sociological factors contributing to the etiology of mental disorder,
The mix of social and psychological forces affecting the manifestation of illness, and
The discontinuities in care resulting from uncoordinated policies regarding organization and financing of mental health services.

The leaders' proposals for training would necessarily engage residents in boundary-spanning experiences: within the mental health sector, integrating psychopharmacological and psychotherapeutic modalities; within the health care delivery system, bridging mental health and medical care services; and in the broader society, bringing mental health treatment to institutional spheres whose missions are different and sometimes contradictory.

SIGNIFICANCE OF FINDINGS/ POLICY IMPLICATIONS

Findings from this study are intended to identify appropriate roles for future psychiatrists and contribute to our knowledge of how to prepare physicians to assume new roles. Analysis of the survey data will yield a typology of program responses to changes in the environment, and will serve as the basis for selecting a panel of residents to be followed through training and into practice. This longitudinal study (to be proposed following completion of this project) will assess the effectiveness of varied proposed strategies for optimizing the relationship between training and the roles to be played by tomorrow’s psychiatrists.

The report from the interviews will delineate specific training needs for bridging the gap between the current preparation of psychiatrists and changing needs for psychiatric expertise in public sector services. The survey of residence directors will characterize the readiness of training programs to respond effectively to changes in the mental health care environment.

PLANS

During the next 12 months, project goals are to conduct a design and field survey of all psychiatry residence directors in the United States, characterizing the status of their programs in preparing trainees for effective roles in public sector care. Data will be analyzed and a report of the results prepared.

Entered: July 2000

Updated: 11/18/2002

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