Our healthcare system is undergoing dramatic change under the rubric of the Patient Protection and Affordable Care Act (ACA) (1). Many psychiatrists have been marginalized in the current health system, functioning primarily as medication managers. The changes required by the ACA represent an opportunity for psychiatrists to promote the integration of health and behavioral health care systems. To take advantage of this opportunity, a special focus on workforce development is needed. This development can be carried out at multiple levels, including medical school, residency, fellowship, mentorship, and early-career development (2).

This article will focus on the incorporation of Systems Based Practice (SBP), recovery, and community psychiatry into a residency curriculum developed by the Public Psychiatry Education Program at Columbia University Medical Center Department of Psychiatry.

The Accreditation Council of Graduate Medical Education (ACGME) requires SBP as one of six core competencies. SBP is defined by the ACGME as an “awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care” (3). The Psychiatry Residency Review Committee (RRC) of ACGME in 2007 added community psychiatry as a required clinical experience within the competency of Patient Care.

ACGME does not yet require the teaching of recovery principles. However, many psychiatry training programs regard recovery principles as a foundation for the teaching of SBP and community psychiatry.

Recovery is defined as the processes by which people are able to live, work, learn, and participate fully in their communities (4). The ACGME definition of community psychiatry focuses on people with “persistent and chronic” illness. The concept of recovery has now been broadened to include all patients receiving mental health care in public and community settings. Accordingly, discussions are ongoing with ACGME to broaden its definition of community psychiatry along the same lines.

Most residency programs provide limited didactic or clinical training in SBP, community psychiatry, or recovery. To address these issues, we have developed a recovery-oriented training program that incorporates SBP in community psychiatry settings. This program is informed by a study demonstrating SBP to be best conceived of as four roles performed by psychiatrists. The four roles are identified as 1) Patient Care Advocate; 2) Team Member; 3) Information Integrator; and 4) Resource Manager. In brief, the Patient Care Advocate role involves the one-on-one relationship with the patient and shared decision-making. The Team Member role includes the typical multidisciplinary team and also involves service providers, other clinicians, and family. The Information Integrator role involves the gathering, analysis, and implementation of an action plan based on the analysis of information. The Resource Manager role involves effective use of resources (fiscal, human, material, and time) available to the patient (micro) and to the system (macro). Detailed definitions of these roles were published previously (5). We have chosen to teach these principles through multiple educational modalities, including didactic classes, clinical rotations, supervision, and oral and written case presentations. Teaching in each of these modalities unfolds over the course of the 4-year training program.

The didactic lectures are designed as a continuum across all 4 years of training. Each lecture uses clinical examples to illustrate key points and recovery principles. The lectures are directly linked to residents’ clinical experiences, and residents are encouraged to participate in discussions by using their experiences to illustrate points. All lectures also emphasize SBP and highlight the roles of the psychiatrist in each of the systems presented.

The PGY1 lectures introduce the history of community psychiatry in the United States. The lectures review three of the key system changes that led to the downsizing of the state hospitals: new treatments (psychotherapy and pharmacology), the civil rights movement, and shifts in funding streams.

The PGY2 lectures focus on recovery-oriented systems and evidence-based practices (EBP). These lectures are designed to give the residents a basic exposure to the different systems that people with mental illness navigate. The lectures also set the foundation of knowledge that residents will need as they carry out the four roles conceptualized as the fundamentals of SBP. We present the following EBPs: Housing First, Supported Employment, and Wellness Self-Management in the PGY2 lectures, and Co-Occurring Substance Abuse Treatment and Assertive Community Treatment (ACT) in the PGY3 lectures. These lectures emphasize the role of the psychiatrist as Patient Care Advocate and Team Member. Residents are encouraged to identify these two roles in the inpatient systems of care to which they have been exposed as PGY1 and PGY2 residents.

PGY3 residents frequently work in outpatient settings. In these settings, residents tend to act more independently and need to work with multiple systems of care. The PGY3 lectures therefore focus on integrated systems of care to provide better continuity and access to care for patients. Lectures focus on co-occurring substance abuse, co-occurring physical health issues, involvement in the criminal justice system, ACT, and the role of peers in the workforce.

PGY4 residents often act as junior attending physicians and get more involved in management and policy-making in mental health settings. It is important for them to understand the administrative, financial, and political mechanisms that govern mental health care and to take a leadership role in molding such systems. PGY4 lectures, therefore, focus on the role of the psychiatrist in leadership and management. Lectures highlight the Information Integrator and Resource Manager roles in recovery-oriented practices.

We have developed SBP milestones to measure residents’ achievements across all 4 years of training. PGY1 residents spend much of the year on medicine rotations and are often the clinicians who are responsible for the bulk of the direct patient care. Accordingly, at the end of the PGY1, residents should be proficient in the role of Patient Care Advocate. The PGY2 is primarily an inpatient year, where residents are members of multidisciplinary teams. At the end of the PGY2, residents should be proficient as Team Members.

PGY3 residents are in the outpatient clinics and must get information from multiple systems, analyze the information, and help patients formulate comprehensive treatment plans. At the end of the PGY3, residents should be proficient as Information Integrators. PGY4 residents spend most of the year in electives, with some authority to make treatment decisions based upon available resources. At the end of PGY4, residents should be proficient as Resource Managers.

A crucial aspect of this program is a PGY3 year-long, half-day-per-week outpatient rotation. This rotation fulfills the ACGME/RRC requirement for the community-psychiatry expectation. In this setting, residents have the opportunity to learn and observe how people with mental illness live and function in the community.

Each resident chooses one patient from his/her caseload, and, during the initial assessment, reviews with the patient the various systems of care that he or she navigates. This review is broken into eight components: mental health, physical health, substance abuse/use, social/family life, vocational/educational needs, housing, legal issues, and financial issues. The project includes a home visit and culminates in a formal write-up and presentation. Residents incorporate recovery principles by helping patients prioritize these systems. Residents are encouraged to actively use all four SBP roles in working with patients. If performing one role does not help the patient achieve her/his goals, residents are encouraged to switch roles and try a different approach.

PGY2 and PGY3 residents participate in site visits to community programs. For PGY2 residents, programs are selected that incorporate specific evidence-based practices. For PGY3 residents, programs are selected that exemplify integrated systems of care.

A crucial aspect of this program is clinical supervision. The supervisor–supervisee relationship in psychiatry is generally focused on psychotherapy and medication management. The SBP and recovery approach emphasizes taking into consideration the whole person and all of the systems of care he or she navigates. To address this, we have developed in-service training for clinical supervisors. The in-service training reviews the four roles of SBP and focuses on measurable objectives and goals of the clinical rotations. The training uses vignettes and resident evaluation tools that have been developed to measure residents’ knowledge and clinical skill in carrying out the four roles of SBP. Resident and supervisor feedback has been uniformly positive. Specifically, supervisors have felt that using a milestone approach to evaluating residents’ performance of the four SBP roles is particularly helpful. The resident evaluation tool is being formally tested.

The essential elements are the 1) consistent review and emphasis on the four research-based SBP roles; 2) recovery principles of person-centered care and shared decision-making; 3) importance of having residents interact with patients in community settings and home visits; 4) integration between didactic courses and clinical rotations, taking into consideration the nuances of each site; and 5) focus on the supervisor–supervisee relationship.

This model curriculum is informing an ongoing SBP Consultation Project being carried out by the Public Psychiatry Education (PPE) program at Columbia University Medical Center Department of Psychiatry, where this curriculum has been implemented for the past 5 years. At their request, PPE is consulting with a number of psychiatry residency training programs around the country to help augment their SBP training. As part of the consultation, recommendations and guidance are offered for implementation of this curriculum. This model has been adapted to fit the needs of the participating training programs. The model curriculum is based on the systems available in any given community; therefore, this program can be adapted to fit urban and rural settings, special populations, and training programs with limited resources. This training is intended to encourage residents to pursue careers in public psychiatry, thereby meeting the workforce needs of the increasingly complex national behavioral healthcare system.