It is with great pleasure that we introduce this collection of Academic Psychiatry, which contains three key papers providing an international perspective on the future of psychiatric education (1–3). Authors well placed within the field of psychiatric education discuss current issues facing psychiatric educators in the United States, Canada, and the United Kingdom. In our commentary, we highlight many of the main issues discussed in these papers.
One of the most significant changes identified across all papers is the shift from an apprenticeship, time-based model to competence-based outcomes in medical education and residency training. In the late 1990s, David Leach, Executive Director of the Accreditation Council for Graduate Medical Education (ACGME) introduced a competency model of instruction in postgraduate education that included six Core Competency domains: patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practices (4). The next accreditation rendition is developing the six core competencies into numerous core milestones. This milestone-oriented model is a new system, designed to help us realize the promises of the outcome approach to psychiatric training.
In Canada, the CanMeds physician competency framework was developed to better respond to the needs expressed by society, specific populations, and the individual patient. This innovative model identifies competencies in seven roles: communicator, collaborator, health advocate, manager, scholar, and professional, with an emphasis on serving society, and patients within the context of populations (2). Key competencies are discussed in the Royal College documents at different levels: introductory knowledge, working knowledge, and proficiency. In Canada, these requirements are reached within a 5-year residency system, although the first year of training focuses on other medical specialties (2).
Similar shifts toward outcomes occurred in the United Kingdom, with greater attention being given to assessment of specific competencies throughout training. The path to attaining specialty status as a psychiatrist is clearly different in the United Kingdom. After 5 years of medical school, trainees enter a 2-year Foundation Training Program. After completion of this training, an additional 6 years is required to obtain psychiatry specialty status. Carney and Bhugra describe specific requirements in the U.K., where trainees must undergo an Annual Review of Competence Progression (ARCP) to determine level of competency and fitness, before moving to the next level (3).
The United States, Canada, and the United Kingdom have become more specific regarding outcomes of training. In Canada, the CanMeds Roles have outlined specific outcomes for each level of competency, so the trainee is evaluated according to these guidelines (2). These changes have demanded changes in assessment methods that require more observation, accurate assessments, and a focus on ongoing formative assessment, rather than high-end, summative evaluation. Starting in 2014, United States psychiatry programs will be required to demonstrate resident proficiency in the attainment of numerous milestones, repetitively measured as training progresses. Residents will also be required to pass (show competency) in three Clinical Skills Evaluations (CSE) physician–patient examinations. Clinical Skills Evaluations focus on competency in 1) the physician–patient relationship; 2) the psychiatric interview, including the mental status examination; and 3) case presentation (1). Similar competencies have also been outlined for trainees in the U.K., which, in addition to clinical competencies similar to the above, include participation in research, journal club attendance, and other academic activities (3).
The last decade has also witnessed changes to the end-of-training examination, primarily in North America. This shift began initially in Canada, with the Royal College of Physician and Surgeons of Canada. Saperson notes a move away from the high-stakes, long case evaluation, to multiple OSCE stations (Objective Structured Clinical Examinations) (2). This shift in assessment was made to deal with the low reliability and validity of the high-stakes, long case, summative assessment method. The current practice of multiple shorter assessments with multiple examiners, using the OSCE format, has been incorporated to provide a more reliable and valid assessment in a high-stakes examination. As Saperson notes, many examiners objected to the change in this format because it was felt that the long case provided more information about the candidate’s clinical skills with an actual patient. Despite these objections, the Royal College proceeded with the changes, which have now been in place for many years (2). Bernstein also discusses changes to the end-of-training exam in the United States (1). The new board-certification process requires that each psychiatric residency-training program must administer and document successful resident completion of three Clinical Skills Evaluations (CSE). Upon graduation, residents apply for American Board of Psychiatry and Neurology (ABPN) certification. Initial resident applications for ABPN certification must be made within 7 years of graduation.
After 10 years of ABPN certification, board certification has to be renewed in a new process called Maintenance Of Certifications (MOC). MOC requirements include 1) self-assessment, 24 Continuing Medical Education (CME) credits every 3 years; 2) 30 CME credits/year, totaling 300 CMEs over 10 years; 3) a written/cognitive examination; and 4) Performance in Practice activities, which includes a clinical practice improvement project and standardized feedback from patients and peers over 10 years.
Given the shift in the RCPSC end-of-training exam, programs are now responsible for assessing a trainee’s ability to carry out a psychiatric interview (long case) in the training program. In Canada, programs vary with respect to how this is carried out. One method, known as the STACER (Standard Assessment of a Clinical Encounter Report), places responsibility on the program with the supervisor, who carries out a formal assessment with a resident conducting a 50-minute clinical interview with a patient with an accompanying presentation (2). The emphasis of the assessment of the long case to now be carried out in residency training leads to more formative assessments conducted throughout the training program.
In the United Kingdom, assessment has also been emphasized in training. Carney and Bhugra discuss the importance of resident logs, portfolios, and other methods that track the resident’s assessments across training (3). This has shifted the burden of assessment to the supervisors in core training and has put increasing pressure on training directors to ensure observation measures are carried out. As discussed above, in the U.K. residents must complete the Annual Review of Competence Progression before they can proceed to the next level.
The goals of psychiatric training have been clearly outlined by the United States, Canada, and the United Kingdom with the end-point of psychiatric residency being the graduation of the competent general psychiatrist. The RCPSC (Canada) emphasizes graduating the “sophisticated generalist,” the Royal College of Psychiatry (U.K.) emphasizing the generalist, and the Accreditation Council for Graduate Medical Education (U.S.) focusing on the attainment of milestones for the general psychiatrist. All three papers discuss the emergence of “specialty training” in psychiatry in several areas. Psychiatrists in the United States are able to specialize with additional fellowship training in Child-Adolescent, Addictions, Forensic, Geriatric, Psychosomatic, and Pain Medicine (1). A Sleep fellowship may also be developed as an additional psychiatric subspecialty. Recent trends in U.S. fellowships indicate that fewer than half of U.S. psychiatric residents pursue any fellowships (5). There has been the greatest decline in residents pursuing geriatric and addiction fellowships, whereas child and adolescent fellowships remain the most popular. The future of all U.S. psychiatric fellowships is not clear and will likely depend on the evolution of the new U.S. healthcare system.
In Canada, specialty training is offered in Child and Adolescent, Forensic, and Geriatric psychiatry (2). In the U.K., psychiatrists are able to obtain specialty training in six areas: Community (which includes Liaison, Addictions, and Rehabilitation), Child and Adolescent, Medical Psychotherapy, Geriatrics, Forensics, and Psychiatry of Learning Disabilities (3). Canadian and American training programs do not offer specialty training in medical psychotherapy or Learning Disabilities. The recent demand for specialist training has added an increase in burden to training programs to create more advanced programs that will graduate specialists that have greater proficiency and skill in their respective areas. How they will assess proficiency in these domains is yet to be determined.
Perhaps one of the most significant issues facing North American training programs, and discussed by both Bernstein and Saperson, is the recent attention given to resident duty-hours. The U.S. requirement of an 80 duty-hour work-week began in 2003 and was revised with additional restrictions in 2011. Duty-hour restrictions were designed to improve patient safety and reduce errors caused by residents’ sleep deprivation. In a resident opinion survey (6), residents were highly ambivalent about the likely effects of these new changes; 36.9% felt that the duty-hour changes would improve overall patient safety, but 37.5% felt it would not improve safety, and 27.4% were neutral on this topic. Also, residents raised additional concerns, which included 1) problems in the continuity of patient care because of more frequent resident shift changes and sign-outs; 2) loss of faculty, resident, and medical student education and teaching time; and 3) increased financial expense as additional medical providers would have to be added to most hospital systems. It also appears that the actual effects of duty-hour restrictions has not yet been fully determined and that results will be highly dependent on the outcomes measured.
This issue has only recently emerged in Canada. The issue of decreasing resident duty-hours has significant implications for training, teaching, and lifestyle for residents and supervisors, and will no doubt affect the operation of hospitals and academic institutions alike. This will be one of the major issues that will dominate the field, as it will deal with how to balance education and service in the United States and Canada. Typically, in these countries, residents see patients in the emergency departments on call, and staff play varying roles in teaching through the supervisory process. In the United Kingdom, recent issues around “duty-hours” have not emerged; however trainees are required to work less than 48 hours per week and must have time off after every night on call (personal communication: D.K. Bhugra, 2013).
Another common theme expressed by all authors is the importance of the connection between primary care and psychiatry (1–3). This has been a dominant theme in the United States, Canada, and the United Kingdom and continues to pose challenges for our practice of psychiatry in the future. The need to train family physicians to recognize and treat patients with psychiatric illness continues to be a significant issue, because they are on the front line, and see the greatest number of patients with psychiatric disorders. At the same time, psychiatrists must collaborate and work closely with family physicians through a variety of creative models. How this is carried out will be determined by the different healthcare delivery models in each country, and approaches are well articulated in each of these papers. All three authors emphasize the need to recognize mental illness as chronic in many cases, and cite the need for patients to maintain a close relationship with their family physician, with opportunities for consultation and treatment as needed by the collaborative-care psychiatrist. Our connection with other medical specialties is also crucial if psychiatry is to maintain its place in medicine and provide ongoing consultation to these areas of medicine. Each of these papers clearly emphasizes the importance of maintaining this connection.
Along similar lines, the critical connection between psychiatry and undergraduate medical education is of paramount importance, and is discussed here by all authors. Bhugra very clearly articulates the importance of psychiatry in the undergraduate medical education experience in Britain, and underscores its role in medical students’ career selection (3). Although less attention was given to psychiatry in previous undergraduate medical education programs, recent trends in the United Kingdom indicate that this is changing. Similarly, Bernstein and Saperson, in North America, identify an upward trend in medical students’ selecting psychiatry as a career (1, 2). There is still a need to improve psychiatric training in the undergraduate medical education curriculum in all three countries, and this should be an important issue in the future of psychiatric education in medical education.
Perhaps the most challenging issue identified by all authors is the pressing need to integrate the extensive research from related disciplines into the current psychiatric training curriculum. Psychiatry has evolved considerably over the past 10 years, with many influences from within and outside the field exerting pressures for new directions in education. Ten years ago, psychiatry residents were mainly trained in psychodynamic therapy, and received very little exposure to cognitive-behavioral, interpersonal, and other evidence-based therapies. The neurosciences were not part of the general training curriculum. Today, training programs are searching for innovative methods to introduce these exciting areas to trainees. Research in cognitive science has also pointed to effective methods of instruction; these methods are very gradually being introduced into training programs. It is difficult to know how to incorporate these new developments into residency education.
The authors identify significant social, economic, and political issues, which will affect the delivery of health care and postgraduate education. How these issues will shape the future of psychiatric education remains to be seen. These three papers offer their own perspective on these issues and illustrate that, although there are differences between us, there are many more similarities when we examine what we consider the essential issues for the future of psychiatric education.
Despite the challenges described above, it is the authors’ opinion that psychiatric education is evolving in a positive direction. A shift from time-based to competence-based training will, we hope, ensure that we are graduating psychiatrists who are skilled and ready for safe, independent practice. A shift to “competence-based” training increases the demand for better assessment methods both in training and at the end of the residency program. Significant effort has been expended to advance upon existing assessment methods. Also, improving our connection with primary care and developing specialized training will help with primary prevention, early detection, and providing more specialized services to specific population groups. The challenge will be to integrate these areas into our training programs. We would hope that, through an international dialogue, educators can share ideas and begin to arrive at novel solutions to the common challenges ahead. Some countries may have already expended considerable time in one area and can offer and receive guidance in others. Curriculum development also varies considerably from program to program and continent to continent. Sharing these ideas can only benefit our educators, residents, and, most importantly, our patients.