An estimated 1 in 5 children (22%), which is about 20 million young people, have severe psychiatric disorders and are in need of expert evaluation and treatment (1). At this time, there are only 7,000 child and adolescent psychiatrists. Beyond the clinical needs that child and adolescent psychiatrists must address, child and adolescent psychiatry (CAP) training directors are under tremendous pressure to train other allied health professionals, largely pediatricians and general psychiatrists, to meet this need. Additional increasing demands on training programs from the Accreditation Council for Graduate Medical Education (ACGME), combined with the tremendous social demands, have resulted in a crisis in CAP training and the service needs of its graduates.
This issue of Academic Psychiatry addresses these topics in the spirit of looking forward to the challenges of a new era in residency training and the transition to an uncharted system of care. In this editorial, we outline the forces within and outside residency education that are shaping the future of our training programs and how authors in this issue contribute to meeting the challenges ahead to better care for patients.
Graduate Medical Education (GME) is currently in the midst of a conceptual and pragmatic crisis. First, the institution of the Competency Movement framework changed GME with an emphasis on a developmental model of training; evidence-based care; an “outcomes” requirement for reliable and valid measures of knowledge, skills, and attitudes; and a new emphasis on safety and quality improvement. The model began with a conceptual formulation of competence and asked each field, through the Residency Review Committees, to develop their own variations on the six core competencies (2). Also, new Common Program Requirements were developed for the medical school and hospital-based institutions within which GME training took place.
Despite the initial shock and dread of program directors and institutions that now required Directors of Institutional Organizations (DIOs), the end result was gradual acceptance, approval of the new need for rigor in medical education, and a wealth of data-driven educational research. However, there were major criticisms of the ACGME and its promotion of the competency system. Although the Dreyfus brothers’ (3) developmental model of a continuum of knowledge, skills, and attitudes from novice (medical student) through competent (residency graduate working independently at the level of a new practitioner), to master (seasoned practitioner), was accepted, nowhere were these benchmarks delineated by the ACGME in order to incorporate them within programs in a sophisticated, developmental fashion. Another critique was that the community of educators was left to devise and prove the efficacy of their own outcome measures as unfunded mandates, without sufficient, nationally organized, funded assistance. Others noted that the ACGME continually added requirements for programs and institutions—requirements that profoundly affected the funding, educational models, and healthcare delivery systems within GME programs and on the service arms of departments and hospitals—such as the inclusion requirements for duty-hour restrictions, quality-improvement projects that must include participation of all residents, new instructional mandates such as fatigue and sleep-deprivation training, and demonstration of the effectiveness of faculty as educators. Many of these new requirements fell into the “law of unintended consequences,” resulting in additional time and effort on the part of program directors and faculty and experienced as even more unfunded mandates.
The new evolutionary advance of the Competency Movement is the Next Accreditation System (NAS), developed by Thomas Nasca and colleagues (4). This model also provides conceptual and pragmatic advances, promise of continued growth of educational systems, newer and more effective means of evaluation—and, alas, as before, new unfunded mandates and complex consequences with potential burdens on institutions and programs. Its milestones advance the previous model by requiring each field to define the key knowledge, skills, and attitudes at specific developmental levels for all residents and fellows. The NAS promotes the development of better evaluation instruments, with the clear expectation that faculty development and education will be instituted and demonstrated. And it requires that assessments, including feedback and evaluations of residents and faculty, will be ongoing and at least twice a year, in large measure, to counter previous models in which competencies were evaluated only periodically. Now, residents would be required to have ongoing, real-time assessments that would be delivered to the ACGME such that a longitudinal profile of residents, programs, and faculty could be described. This would provide relief from the previous snapshots of programs and “episodic” site visits of up to 5 years, with site visits extended to 10 years. Hence, a truly developmental and longitudinal model of residents, programs, and faculty would evolve. Perhaps the most common criticism of the NAS at this time is that a practical means of delivering what is required is not known to all programs. Although national standards for assessment are going to be required by each Review Committee, they inevitably will demand the additional time-consuming process of revamping instruments and of educating faculty and residents, thus imposing new burdens on program directors and faculty. We are facing another, and much larger, unfunded mandate.
Interestingly, both models (Competency Movement and NAS) were introduced to the field without any piloting on how education and care would be affected. The Competency Model has still not been thoroughly evaluated in this sense, which is an interesting and surprising limitation, in this era of evidence-based medicine and best-evidence medical education.
However elegant these conceptualizations of education are, they occur at a time of particular hardship and change for the healthcare system and GME. The upcoming Healthcare Reform will require modifying the healthcare delivery system, using Accountable Care Organizations (ACOs) and Medical Homes as the loci of patient care, and will most probably result in a considerable shifting of the training sites for residents. There will likely be dramatic decreases in GME funding and perhaps a 33% reduction of GME programs nationally (5) and/or a shortening of medical training by 30% (6). This may lead to a reduction in the number of teaching faculty, as well. The implications for patient care, given the current shortage of many physicians, particularly in general psychiatry and CAP, are very worrisome. Thus, for both patient care and education, we will all have to do more with less.
CAP education and training is under particular pressure at this moment in time. It is already the greatest shortage specialty in the United States, and prospects for its growth are limited (7). Much of the burden of the mental health needs of children now fall on pediatrics, which also has been very concerned about how it can manage its GME and provide a standard of excellence in healthcare delivery for the future. As a result, the American Academy of Pediatrics has advocated for increased training in mental health (8). Moreover, if quality improvement in healthcare delivery is a goal for youth, all physicians, particularly primary-care physicians, will need greater knowledge and skills in mental health and a greater knowledge of families and systems of care for serving children, adolescents, and families. There is little taught now, and improved education and skills of the workforce will be needed.
The healthcare system has long been known to foster burnout, stress, and decreased empathy in its practitioners. With fewer physician graduates, the prospect for increased stress on healthcare providers looms large. CAP is no exception, and its practitioners may be at increased risk. The medical “home”—a site providing multidisciplinary, patient-centered primary care—will require innovative models for teaching the integration of systems-, family-, and patient-based care. Also, all psychiatrists will need to have greater expertise in understanding families and will need to be trained in family interventions. Child and adolescent teams in medical homes will become a necessity, far more than they are now in the healthcare system. Currently, although certain forms of family therapy have been shown to be sound, evidence-based models of treatment, general psychiatry programs have no ACGME requirement for training in family therapy, and, although CAP programs do, the training is insufficient to meet the clinical needs of its graduates. This will be particularly true in future medical homes. Finally, training programs today produce a paucity of physicians pursuing research and scholarship.
Despite these grim concerns for the future, CAP educators appear more vibrant and resilient than ever! In this issue, we can see that many of the above-noted problems are being actively studied and piloted. McGinty et al. (9) outline the American Academy of Child and Adolescent Psychiatry (AACAP) Toolkit for Systems-Based Practice in Child and Adolescent Psychiatry. This model provides a means to promote the use of patient- and family-centered care in a systems-based perspective. McGinty et al. describe a pilot study in which 15 CAP residencies used variations of the toolkit as part of a core curriculum in their programs (9). In concert with the need for a patient- and family-centered model for the future, two articles (10, 11) focus on the rationale and need for improved family therapy/intervention training in general psychiatry residencies and CAP programs. Heru et al.’s (10) commentary provides a substantial argument for the rationale for increased family therapy training, and Rait (11) describes a pilot study of the deficiencies of family therapy training in seven CAP programs, while providing potential avenues for improvement.
These articles are clearly relevant to the current and future shortage of CAP providers and may give us a means to construct new models for training that can meet our professional and social obligations within the infrastructure of a wide range of training institutions. Similarly, Hall and Warren (12) argue for CAP training in Parent and Child Interaction Therapy (PCIT) as one model for an effective, family-centered psychosocial intervention, particularly for externalizing behavioral disorders. Rait, in his Snap Shot article (13), using the same cohort as in his family-therapy training article, indicates that although CAP has ACGME Essentials for training, we have little information as a field about which primary models of treatment are being taught, what levels of expertise fellows achieve in each model, and what they wish to have augmented in their training. Further studies of this kind may help us determine how to proceed in CAP training in order to meet the demands of a new healthcare system and perhaps help in an ongoing revision of the ACGME Milestones.
Krasner (14) and others (15) have demonstrated the role of mindfulness-training and reflective practice in promoting physician well-being, decreasing burnout, improving empathy, and fostering the quality of care. Chien et al. (16) note that although burnout is ubiquitous in medical training and practice, it is extremely high among mental health clinicians, especially in emergency psychiatry. They describe a model of reflective team supervision, in line with the informal or hidden curriculum, that provides excellent supervision for residents and other members of the team while resulting in observations that improve the quality of the healthcare system. Although Krasner and others have promoted the use of mindfulness training, narrative medicine, and the hidden curriculum in other medical specialties (14, 15), the contribution of Chien and colleagues is unique in the CAP literature.
Fox and colleagues (17) argue that the workforce shortage in CAP is going to require increased education and training of all physicians in CAP, that must begin in medical school. The positive effect of early exposure to psychiatry was advocated and tested in the 1970s by Weintraub et al. (18), who introduced the Baltimore model when medical students started psychotherapy training and continued it through residency. In a similar manner, early exposure to child and adolescent psychiatry may improve recruitment into the field. Fox and colleagues initiated the new Child and Adolescent Psychiatry in Medical Education (CAPME) Task Force, sponsored by the Association for Directors of Medical Education in Psychiatry (ADMSEP), which has developed a systematic means of enlisting most stakeholder national organizations in psychiatry to develop and implement a model that may be flexibly introduced into medical school curricula in a wide range of methods and settings (17). The five CAPME objective and action plans are indeed creative, practical, and well-conceived. This appears to be an extraordinary educational outreach program for future implementation.
Finally, we must not forget our mission as physicians to promote knowledge. Providing the means to teach research and scholarship within residencies, and particularly within the 2 years of CAP training, is a formidable task. Mezzacappa et al. (19) consider a number of integrated research programs in general and child psychiatry residency training. In line with keeping costs down, streamlining education, and integrating new curricula into the fabric of an existing training program, they demonstrate how their program tackled the problem of introducing research training in an effective manner and tracked the tremendous increase in scholarly work of their residents over the course of 4 years (19). It will be most interesting to see how other programs use existing funds and resources to expand research interests.
No doubt many unforeseen challenges and opportunities will arise in the future of psychiatric education. This cluster of CAP articles demonstrates that the leaders in education and training have their eyes focused on the future. They have aptly developed models that will foster recruitment, promote models of care for both CAP and general-psychiatry clinicians, foster new interest and expertise in evidence-based research, meet the needs of medical homes in the new healthcare system, and support the resilience of our teams in times of stress, while developing measures for quality-improvement. The energy, enthusiasm, and creativity of these authors have lifted our spirits, given that we are already working productively as a field to test and promote education and training for the next generation of residents and the patients they will treat.