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Commentary | September 01, 2006

Clinical Habits and the Psychiatrist: An Adult Developmental Model Focusing on the Academic Psychiatrist

James A. Bourgeois; Mark Servis

Academic Psychiatry 2006;30:365-371.

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Received July 19, 2005; revised February 16, 2006; accepted March 23, 2006. Drs. Bourgeois and Servis are affiliated with the Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento, California. Address correspondence to Dr. Bourgeois, 2230 Stockton Boulevard, Sacramento, CA 95817; james.bourgeois@ucdmc.ucdavis.edu (E-mail). Copyright © 2006 Academic Psychiatry.

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Abstract

Objective: The authors examine the development of the psychiatrist from an adult developmental perspective, focusing on the early development and consolidation of highly adaptive clinical and other professional habits. They place special emphasis on the professional development of the academic psychiatrist. Method: The authors review and use literature on adult psychological development as a formative template upon which a prototypical psychiatrist proceeds through a telescoping series of adult developmental stages. At each stage of clinical development, specific tasks are identified and outlined, and articles from the academic psychiatry literature are cited to provide content-specific examples of the development of academic and clinical habits of importance to those psychiatrists who then develop an academic career. Results: The clinical development of the psychiatrist follows either a continuous or episodic process that parallels the broader themes of adult development, allowing for optimal integration of the interests and skills of the individual in a niche within the increasingly diverse field of psychiatry. For the academic psychiatrist, a continuation of this model applies to development as a clinical instructor and researcher. Conclusions: Optimum developmental attention to clinical habits and skills begins in medical school and proceeds sequentially throughout subsequent career stages, correlating with subsequent stages of adult development. The authors describe in functional terms strategies for successful navigation of these challenges in clinical habits development. At all stages, mentorship and supervision are highly encouraged, as is attention to macrolevel changes in the clinical and administrative milieu.

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Developmental Stages Theory: Application to Physician Development

Abstract | Developmental Stages Theory: Application to Physician Development | A Chronological Model of Development for the Academic Psychiatrist | Conclusions | References

The adult developmental model we present serves as a lifelong template for the "telescoping" nature of clinical skills development, wherein each clinical skill serves as the basis for subsequently acquired ones. The psychiatrist proceeds from mastery of "individual" clinical encounters to "broader" areas of influence, paralleling the "expanding social sphere" of interpersonal influence in adult developmental stages. Academic supervisors may facilitate the development of clinical habits by taking the subordinate’s developmental stage into account. While many of the points discussed are applicable to nonacademic psychiatrists and physicians of other specialties, we focus on the academic psychiatrist. The question of what motivates a psychiatrist to pursue an academic position is not the primary focus of this article and probably is unique to each individual, warranting further inquiry. Excellent handbooks on psychiatric education and faculty development address these issues in greater depth (¹, ²).

The development of an academic psychiatrist overlaps with a series of adult developmental stages. A unifying contemporary adult developmental framework is presented by Vaillant (³) in his model of "mental health." According to Vaillant, as one progresses through the four adult developmental stages as defined by Erikson (⁴), there is an expansion of the "social radius." The expanded stages, in sequence, are: identity, intimacy, career consolidation, generativity, keeper of the meaning, and integrity, with Vaillant’s addition of the stages "career consolidation" and "keeper of the meaning" to Erikson’s original stages.

Identity encompasses separation from parents and development of the independent self, and dates approximately from ages 13 to 21 (³, ⁵). Intimacy permits reciprocal involvement and interdependency with a partner, and dates approximately from ages 21 to 40 (³, ⁵). Career consolidation requires four components: contentment, compensation, competence, and commitment. This stage is interpolated between intimacy and generativity in the Vaillant modification, and thus the ages represented, approximately 30 to 50, bridge those two stages (³). Generativity refers to the ability to personally invest in the development of the next generation, and dates approximately from ages 40 to 60 (³, ⁵). Keeper of the meaning involves passing of traditions into the future, with a sense of conservation of the collective products of the culture. As this stage is interpolated between generativity and integrity in the Vaillant modification, the ages represented bridge those two stages, or approximately ages 50 to 70 (²). Integrity is a sense of importance of one’s life products and a final sense of peace regarding one’s own life, and it dates approximately from age 60 onward (³, ⁵).

Though career development of the academic psychiatrist may take various pathways, we present a "modal" developmental model. Early career development typically occurs in early to middle adulthood (typically ages 21 to 50). This period represents the stages of identity, intimacy, and career consolidation. Later career development generally occurs in middle to late adulthood (typically age 40 onward, with some overlap with early career development). This period corresponds to the stages of generativity, keeper of the meaning, and integrity. Success in this period requires prior successful management of the earlier stages as a substrate to reorient from the "self-focus" of the early stages to the "other" focus of these latter three (Appendix 1).

Another view on academic development is provided by Colarusso and Nemiroff (⁶). They emphasize the benefits of identifying early with those with an interest in psychiatry, including the capacity for empathy and sensitivity. Allowances for differential rates of progress in adult development in trainees are important. In addition, there is a paradox in the trainee who approaches middle age while still engaged in the regressive pursuit of specialty training at a time in the life cycle when peers in other professions that do not require an extended period of training are in more autonomous positions.

Professional Competence and Clinical Habits

An inclusive definition of "professional competence" encompasses "habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served" (⁷). Specific dimensions of professional competence include cognitive, technical, integrative, contextual, relationship and affective/moral competence, and habits of mind (⁷). Ideally, "clinical habits" development will address these various dimensions in a simultaneous and balanced way. This multidimensional model of clinical competence dovetails well with the operationalized concept of the biopsychosocial model, where the clinician simultaneously considers the biological, psychological, and social aspects of the patient’s experience (⁸).

The Oxford English Dictionary defines "clinical" and "habit" as follows (⁹): "clinical" means "designating or pertaining to teaching given at the bedside of a sick person, esp. in a hospital, and (branches of) medicine involving the study or care of actual patients." "Habit" means "a settled disposition or tendency to act in a certain way, esp. one acquired by frequent repetition of the same act until it is almost involuntary; a customary practice or way of acting." The definition of "clinical" contains a prominent role for "teaching" and "study," not merely "care of actual patients." The definition of "habit" contains the evolution of a "customary practice" learned by repetition to the point of involuntary action. A scheme of clinical habits broken down by functional areas important to the academic psychiatrist is presented in Appendix 2.

Stahl (¹⁰) applied Stephen Covey’s model described in his book, The 7 Habits of Highly Effective People (¹¹) to psychopharmacology. "Begin with the end in mind" includes targeting symptom remission. "Synergize" is exemplified by combining interventions for a greater net result. "Sharpen the saw" includes targeted education to strengthen the scientific basis for clinical practice. "Put first things first" is illustrated by early management of resistance to increase adherence. "Think win/win" includes a "participative" treatment plan so that physician and patient each can gain a sense of accomplishment. "Become proactive" includes searching psychiatric conditions which may be underdiagnosed. "Understand and be understood" refers to the need for ongoing two-way communication.

Balance Among Professional Roles

Academic development is best viewed as a long, occasionally discontinuous and somewhat protean process of evolution of the self that is often highly dependent on the clinical and academic milieu (¹²). While clinical skills development is the focus of this article, additional skill sets are important to the academic psychiatrist. Mastery at administration is advantageous in career and leadership development. The balance among the often competing areas of teaching, writing/research, and reviewing/editing is a separate task within the academic realm (⁶).

A Chronological Model of Development for the Academic Psychiatrist

Abstract | Developmental Stages Theory: Application to Physician Development | A Chronological Model of Development for the Academic Psychiatrist | Conclusions | References

Psychiatry Residency and Fellowship

Important steps in the development of clinical habits and career identity take place in the psychiatry residency and fellowship. The assumption of a specialty identity is a complex process. There is an element of self-selection, wherein the residents/fellows see themselves as members of a specialty community. There is also the intrinsic appeal of the intellectual and clinical firmament of the specialty. Finally, there is the vision of oneself making a meaningful clinical contribution.

The development of sound clinical habits must be an "over-learned" process to the point that it becomes "reflexive." Cognitive theorists have described the development of clinical expertise as a progression from unconscious incompetence to conscious incompetence, to conscious competence, and finally to unconscious competence (¹³). Clinical habits are learned both explicitly from others and from one’s own experience. Ideally, clinical habits and skills are integrated into the "core competencies" assessed in academic programs (¹⁴).

Each clinical rotation provides an important developmental step in the progression toward clinical competence in psychiatry. "Off service" rotations in medicine, neurology, pediatrics, and family practice provide important opportunities to learn about illnesses at the medical, neurological, and psychiatric interface. Rotations on inpatient psychiatry services provide extended contact with patients for the direct observation of acute psychopathology. Residents and fellows learn diagnostic skills, rapid stabilization and treatment intervention, and interdisciplinary teamwork. Psychosomatic medicine rotations recapitulate some of the learning from "off service" rotations, but this time in the role of psychiatrist and consultant. Outpatient psychiatry rotations provide the core experience for developing psychotherapy competencies, including psychodynamic psychotherapy. Administrative and chief resident rotations allow the consolidation of clinical skills in the role of teacher and the acquisition of administrative and leadership skills. For those anticipating an academic career early in residency, access to mentoring that is specific to academic development is crucial. Mentors facilitate resident development with thoughtful feedback, exploration of areas of interest, and involvement in the mentor’s academic projects.

Mastery of evidence-based, manual, time-limited psychotherapy models is a necessary clinical habit in the contemporary environment (¹⁵). Structured approaches to psychotherapy supervision to address content and process issues in supervision facilitate the development of more productive use of supervision (¹⁶). The development of the Psychodynamic Psychotherapy Competency Test (¹⁷) provides a measure of knowledge about psychotherapy and may be useful as a monitoring tool. The annual Psychiatry Residency In Training Examination (PRITE) can serve as a barometer for clinical and neurosciences knowledge.

Addressing the administrative and clinical modifications driven by managed care systems is an essential clinical habit (¹⁸). Specific residency program goals to integrate an approach to managed care include defining training objectives, instilling values consistent with managed care practices, imparting knowledge about managed care systems and practices, building skills specific to managed care system needs, and selecting training sites, structures, instructors, and clinical supervisors who teach managed care models.

Early development of writing for publication is an imperative in academic psychiatry and should begin by residency. Clinical case reports and reviews of the literature are excellent academic development tools, as mastery of the organization of clinical material, review of the literature, and writing papers simultaneously reinforce the clinical learning from cases and development of communication and research skills. Faculty mentorship of residents’ initial efforts at publication (including collaboration with the faculty member in shared authorship) may be critical in the development of this skill (¹⁹).

Similarly, opportunities for psychiatry residents to participate actively in research activities facilitate academic development. Residency programs that offer a "research track" option of protected research time are an example. Departments can facilitate the acquisition of research fellowships and associated funding to encourage resident research.

A critical role for psychiatry residents or fellows is that of teacher (⁶). To teach a clinical skill forces one to solidify clinical habits and to communicate the knowledge and skills to others in clear behavioral terms. Psychiatry residents/fellows benefit most by teaching several different groups of learners: medical students, more junior psychiatry residents, physicians rotating on psychiatry services, and nonphysician therapists. The ability to tailor one’s clinical teaching to the different needs and developmental backgrounds of other professional groups serves to solidify one’s clinical habits and teaching skills. For example, training forums that address faculty psychiatrists’ responsibilities to senior residents/fellows may assist residents’ own transition to faculty positions (²⁰, ²¹). Journal clubs may consolidate specialty knowledge, encourage critical appraisal of the literature, and increase knowledge of the application of epidemiology and biostatistics (²², ²³).

An important clinical habit to develop is the adoption of appropriate advancements in information technologies (²⁴). Examples include personal digital assistants (PDAs), electronic medical records, and telemedicine. Because residents/fellows are positioned on the "front lines" of patient care activities, they are in an advantageous position when it comes to institutional adoption of information technologies.

In preparation for the American Board of Psychiatry and Neurology’s (ABPN’s) Part 2 live interview sessions, practice interviews and examinations (or "mock boards") allow rehearsal of the limited interview and examination time for the actual boards (²⁵, ²⁶). The skill to conduct a properly detailed and empathic interview followed by a case formulation within strict time constraints is an inherently good clinical habit that has benefits far beyond the successful navigation of the board examination process.

Hereafter, for residents headed toward independent practice and other nonacademic careers, the challenges of consolidation of clinical skills, pursuit of board certification, integration of lifelong learning in the maintenance of clinical currency in a dynamic practice environment, and pursuit of overall life/work balance can be facilitated by continued application of the habits learned in residency. For the developing academic psychiatrist, specific sequential challenges remain, and these are the foci of this article.

Junior Faculty (Assistant Professor)

The role of the junior faculty member can be a surprisingly stressful one for the early career academic psychiatrist (²⁷). There may be a paradoxical experience, wherein one has completed an arduous training program and earned a faculty position, while simultaneously still feeling less than fully self-confident clinically. Continued practice of the habits learned earlier in training serves both to consolidate one’s own self-confidence and to model self-assured and systematized clinical practice for junior trainees. Participation in organized faculty development programs (including structured mentoring relationships with senior faculty clinicians) may assist in developing clinical and teaching skills (²⁸, ²⁹). Junior faculty members may seek out participation on committees developing clinical algorithms and other objective clinical practice guidelines.

Junior faculty should seek to develop local and regional expertise in their specific areas of interest and should seek to participate in national-level organizations within psychiatry. This may take the form of program committee development work, participation on discussion panels, task forces, and the like. Serving as a reviewer for professional journals within one’s specific interest area allows for the development of editorial skills as well as an opportunity to review state-of-the-art papers.

For many junior faculty members, a major developmental challenge is competition for academic promotion, especially at research-intensive departments where they may need to compete for promotion with full-time researchers who have a great advantage in access to active research protocols. To develop the "habit of promotion" often requires management of competing interests (e.g., clinical duties, teaching, administration, and research), and protection of academic development time for research, and writing for publication. Research funding opportunities specifically earmarked for junior faculty may assist in research development, as may the involvement of the junior faculty member as a collaborator on more substantive funded projects where a senior faculty member serves as principal investigator.

Mid-Level and Senior Faculty (Associate Professor and Professor)

For the mid-level and senior faculty member, the maintenance of clinical habits should be a pattern of lifelong clinical learning. The academic medical environment provides a rich substrate to maintain clinical currency. Continued academic productivity may be enhanced by the provision of protected research time and research funding support. However, for the mid-level and senior faculty psychiatrist, collateral demands and distractions with nonclinical and administrative duties (including the assumption of departmental and university leadership roles) may lead to professional imbalance. Rittelmeyer (³⁰) addresses the role of academic leadership in departments in detail. Among these collateral demands is the expectation that mid-level and senior faculty serve as leaders and content-matter experts in national and international professional organizations and government advisory groups. Mid-level psychiatrists must make a final decision to continue with an academic career, especially when other models may offer greater financial reward. This commitment may be facilitated by completion of specific management training programs for senior academic leadership positions.

The senior faculty psychiatrist may be inclined to take certain structural initiatives to maintain clinical habits. Maintenance of clinical currency may be accomplished by "set-aside" time; for example, a certain day or week without administrative distraction to focus on clinical cases. Schedules where senior faculty members participate in clinical call coverage send a powerful message to junior department members that senior faculty value clinical currency.

Conclusions

Abstract | Developmental Stages Theory: Application to Physician Development | A Chronological Model of Development for the Academic Psychiatrist | Conclusions | References

The development and maintenance of good clinical habits are best viewed as a continuous process throughout the psychiatrist’s career. Convergence of one’s clinical interests with mastery of the ever-evolving scientific database will yield a clinically current and intellectually stimulated psychiatrist. At each stage of development, the relative needs for instruction, modeling, mentorship, collegiality, and communication may evolve. Clinical habits are the stock in trade of how psychiatrists treat patients and discharge their other responsibilities. Clinical habits require constant nurturance and pruning as new knowledge supersedes the obsolete. Continuous modification of clinical habits is the sine qua non of the committed clinical and academic psychiatrist.

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APPENDIX 1. Adult Developmental Stages, Training Level, and Clinical Skills

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APPENDIX 2. Clinical Habits Organizational Scheme

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Abstract | Developmental Stages Theory: Application to Physician Development | A Chronological Model of Development for the Academic Psychiatrist | Conclusions | References

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