Iindividuals over the age of 65 years currently represent about 12% of the general population (1, 2). When the postwar baby-boomers reach their senior years, they will comprise 25% of the general population. Up to 15%—20% of older adults have significant depressive symptoms, and it is estimated that as many as 45% of persons age 85 years and older have significant cognitive impairment and dementia (3). Currently, physicians in general and psychiatrists in particular are not meeting this demand (4, 5). The determinants of this discrepancy between the demand for elderly psychiatric services and the provisions for these services is not known.
Although all graduates of Canadian psychiatry residency programs have received training in geriatric psychiatry since 1987 (6, 7), it is not clear whether this training has contributed to eventual decisions of whether to see geriatric patients. Some literature suggests that mandatory training, particularly if this occurs early in the residency period and includes positive clinical and supervisory experiences, contributes favorably to trainees eventually choosing to see geriatric patients (8—10). Others have shown that almost one-half of trained geriatric psychiatrists in Britain did not go on to practice geriatric psychiatry (11). Clearly, training in geriatrics is not the only influence on trainees’ choice of practice.
A number of studies have reported high rates of interest in practicing geriatric psychiatry among trainees (12, 13). In our own pilot work, 80% of last-year psychiatry residents reported that they planned to devote some of their practice time to geriatric patients (14). They described the most influential factors in their interest as: 1) positive clinical experiences with seniors, 2) competent, enthusiastic or charismatic, supervisors who were role models, and 3) comfort and interest in the medical and neurological nature of the field. We found similar findings in a study of psychiatrists who had significant geriatric practices (15). Our study examined the contribution to geriatric practice of educational, personal and environmental factors and their interaction and looked specifically at aspects of the training program that may have been influential. The subjects for this study are hospital-based community psychiatrists who see geriatric patients.
A focus group methodology was selected because of its demonstrated suitability in the study of attitudes and experiences of physicians (16, 17). Participants in the study were hospital-based community psychiatrists who see geriatric patients and received residency training in geriatric psychiatry. This population was selected because we assumed that they would be able to comment on their training experiences. Three focus groups were planned with a membership of four to eight participants and the flexibility to do a fourth if three focus groups did not exhaust the themes generated.
Focus group participants were recruited in the following manner. All members of psychiatry departments at nonteaching (no psychiatric residents attending) hospitals in the Greater Toronto Area were contacted to determine if they saw geriatric patients. If they answered yes, they were interviewed on the telephone to confirm that they saw geriatric patients outside of the emergency setting and to determine whether they had residency training in geriatric psychiatry. Suitable respondents were invited to attend one focus group to discuss the influences that contributed to their seeing geriatric patients. They were offered dinner, an honorarium and a continuing education session with a geriatric expert following the focus group.
Participants gave informed consent and completed a demographic questionnaire. The focus groups, which lasted for 90 minutes, were conducted according to the guidelines described by Krueger (18). Following the explanation of ground rules and goals of a focus group, participants were asked to respond to how they came to view geriatric patients and what factors influenced their decision to treat these patients. Global and specific attitudes were elicited as well as intensity and reasons for the attitudes. Once these issues had been adequately explored, they were asked to comment on how their training in geriatric psychiatry related to their current practice, if at all, and the same methods applied. SL facilitated the groups and another investigator observed the interactions and took notes of the process. The focus group discussions were audiotaped and transcribed.
Transcript based analysis, which includes reading the transcripts coupled with field notes and the discussion from the debriefing of the moderator team, was the analysis method applied (19). Preliminary coding categories were derived directly from the questions asked and the unit of analysis was thematic (a thought unit or idea). Each iteration consisted of all three coders assigning codes to the same six pages of text separately. They then compared their code assignments and discussed differences until they could be reconciled and codes revised, forming the rules of a growing codebook. All three coders engaged in four iterations of this process, at which point, 100% agreement was reached. The final codes were then applied to all the transcripts and themes that consistently occurred in all three groups were identified for reporting.
General hospital-affiliated psychiatrists (N=151) were identified in the Greater Toronto Area. Sixty-eight of these hospital-affiliated psychiatrists returned the calls (45%). Of these 68 psychiatrists, 51 treated geriatric patients. Of the 17 who did not treat geriatric patients, six had training in geriatric psychiatry. Their reasons for not seeing geriatric patients were as follows: two were child psychiatrists; two reported that the geriatric psychiatrists at their hospitals treated all the geriatric patients; and one was only willing to do consultations without follow-up, so he was not getting referrals. Of the 51 who did see geriatric patients, 34 had had residency training in geriatric psychiatry. Eighteen of them agreed to attend one of three focus groups. Ultimately, three withdrew because of inclement weather or illness, leaving a total of 15 focus group participants. The focus groups were conducted in the fall of 1999.
Ten men and five women with a mean age of 39 years (range=29—52) represented 12 different hospitals. They had been in practice for an average of 5.8 years (range=0.5—11). The proportion of patients in their practices that were geriatric is displayed in F1. All had received mandatory training in geriatric psychiatry and four had done additional training during their residency. Fourteen out of 15 had trained at the University of Toronto. This geriatric psychiatry program is the largest in the country with 15 FTE faculty at eight teaching hospitals. It trains 20 to 30 psychiatry residents annually, in required rotations of 3—6 months duration. This is consistent with the Canadian Academy of Geriatric Psychiatry’s recommendations for a minimum of three months of gero-psychiatry during residency, which have been widely adopted nationally (7). Themes were organized into two major categories corresponding to the two major questions that were asked: perceived influences on their choice to see geriatric patients and how their training in geriatric psychiatry fit into their current practice, if at all. The following is a description of the major themes within each category. Relevant quotes from the focus groups are offered for illustration.
Variables That Influence Geriatric Practice?
All three groups identified the following seven influences with great consistency:
Participants reported that there is a great demand for this type of work because of the ageing of the population, local demands, employment opportunities and opportunities to develop clinical services. Some had made a conscious decision to see geriatric patients; others felt that they had no choice but to see geriatric patients because of local demand.
"Not until I really got out into practice did the reality hit me, how much of a shortage there was and how much of the load others would have to take."
"I see that it’s just part of the job… it’s not a choice… There’s certainly going to be an endless supply of work in this sort of area."
The group perceived that geriatric psychiatry involved complex and challenging patients and system issues. Some participants felt comfortable and even stimulated with this complexity while others found it discomforting and overwhelming. Their perception influenced whether they were encouraged or discouraged from treating this patient population.
"Very challenging actually… I always like to start in the dark… that’s probably one of the reasons why I chose geriatric psychiatry because it’s more three dimensional, like physical, intellectual, emotional, all that stuff."
"You have to deal with the families. You have to deal with the caregiver. You have to deal with the medical people. So there are layers and layers of complex systems around the patient as part of the care. That’s part of the hassle."
Another factor that contributed to their willingness to see geriatric patients was their feeling of efficacy. Feeling helpful or personally rewarded encouraged them; feeling helpless or ineffective discouraged them. This category also included negative feelings resulting from having to do work that they did not enjoy, such as competency assessments.
"I feel good about the idea of giving a portion of my practice to people who are medically ill and in a geriatric age group because there’s a need… it’s important to give back."
"The amount of change that I can effect no matter what I do is limited because they have chronic problems… if they’re demented, they’re demented… what am I going to do?"
The groups endorsed the perspective that those interested in seeing geriatric patients saw them as interesting people. They actually enjoyed hearing the patients’ stories and interacting with them. Others found that they either were not interested in the stories, or their feelings of respect interfered with their ability to care for these patients and made them feel uncomfortable.
"The most powerful thing when talking to elderly people is you, in time, hear more about the war and people struggling to get out of different areas and how they survive… it’s just amazing."
"Particularly with elderly, I feel very respectful of elderly people and the losses they’ve incurred… I don’t get those strong negative feelings toward elderly people."
Comfort with or anxiety about the combination of medical and psychiatric illnesses that often present in the elderly either encouraged, or discouraged, the participants from seeing geriatric patients.
"That adds to my practice. It keeps you on your toes. You’ve got to be aware of all the systemic illnesses that older people get more often… and all the medications that they need… how they interact with our stuff."
"I think that for a general psychiatrist, that’s one of my anxieties about geriatric patients is sometimes their medical frailty or medical instabilities."
The multidisciplinary team approach to care that involved paramedical and medical disciplines had the potential to make the psychiatrists feel supported and connected with medicine as well as making their work easier. Others felt helpless if they could not find a meaningful role for themselves in the team. If it was not available, they felt isolated and unsupported.
"I like dealing with family docs and neurologists and geriatricians. You sort of feel collegial in a way I think you don’t necessarily in other forms of psychiatry."
"I realized that I need a team to really function effectively and a support system and I’m probably the least important part of it. What am I doing there? I think there was a fair bit of helplessness and uselessness."
The residency training program stimulated their interest or gave them a comfort level dealing with geriatric patients even if they had not chosen to do geriatrics. Inadequate training made them avoid it.
"If I didn’t have adequate training I think approaching geriatric psychiatry would be very daunting and I think that it would be something that’s hard to learn on your feet."
"I believe that had I been able to get the proper training or get myself to go and get that training that I need, I think that I would be more aggressive about doing a proportion of geriatric work."
How Has Their Training in Geriatric Psychiatry Contributed to or Discouraged Their Current Practice?
The groups were able to identify a number of features in their training programs that they believed had contributed either positively or negatively to their interest in geriatric patients. These features were organized into three themes.
Teachers in training programs were felt to have had a significant influence on their current practice. A number of attributes were described including teacher’s competence, skill and knowledge. The participants identified with the teachers and their practices. Their modelling of approaches to care made the resident feel secure that the problems could be managed. Such teachers were passionate about, and interested in, what they were doing and had excellent teaching ability. They were supportive, encouraging of and interested in the resident’s learning and were able to form a teaching-learning alliance with their students.
"What fascinated me about the person with whom I had my training… that he is very knowledgeable… very interested and enjoys what he’s doing. Actually, I felt this enjoyment… he was very interested in teaching me and very keen to provide me with clear material… I still now have his papers."
"If either you have a teacher who is disrespectful or unenthusiastic or just not very interesting then you can feel hopeless about the topic"
"I think I internalize ___ a bit… and find myself thinking what would __ do in this case?… a bit of modelling too."
Teaching programs that provided exposure to many and diverse patients generated comfort and therapeutic optimism, challenged ageist attitudes and consequently encouraged later work with geriatric patients. Participants valued the exposure to a variety, diversity, and volume of patients as it maximised the opportunity for generalizability to other contexts. Participants who had limited exposure felt limited in their ability.
"Unfortunately, I did my training at a chronic facility so I don’t think it was really representative of geriatric psychiatry… I wasn’t aware that I was missing out… You don’t realise until you get out into the real world that it’s a little more complicated and I don’t think that I was properly trained"
"I think it’s just comfort level through seeing people over time, I mean repetition… to get early exposure and familiarity with it you’ll be more likely to see them afterwards"
The groups also highlighted aspects of the teaching program that they thought were important. These comments communicated that the program had taught or not taught them approaches, skills and attitudes towards the geriatric patient, which provided them with a grounding to deal with any geriatric patient. A teaching program with clear, relevant goals was perceived as useful.
"I especially think the things that I learned the most from was when the teaching was very clear."
"It modelled an approach to patients diagnostically and treatment-wise that really helped me… there was an effort to make sure important core things that you should know… you do know."
"My approach to interviewing and gathering information hasn’t changed so that early training was vital."
Our findings support the hypothesis that geriatric practice is influenced by a complex interaction of educational, personal and environmental factors.
Personal themes that emerged included the unique aspects of caring for geriatric psychiatric patients such as the complexity and mix of medicine and psychiatry in the kinds of problems that are seen. Geriatric psychiatry was perceived to require an integration of medicine, psychiatry, family and society in every patient that one sees. Respondents’ feelings may have reflected their sense of mastery of this skill. It may be that some chose to do psychiatry because of a lack of interest or confidence in the medical aspects of patient care; others were challenged by it. For some subjects training was able to facilitate comfort and an ability to manage these issues. This raises the question as to whether geriatric psychiatric clinicians are born or bred. Does the effective teacher identify and channel interest or influence de novo?
Participants also felt that it was important to feel helpful in the care of these patients. It is interesting to note that the multidisciplinary aspect of geriatric care could influence trainees or psychiatrists or practitioners in either way. For some, multidisciplinary care decreased their isolation and allowed them to feel that they were able to provide better care. It left others feeling less effective and helpless. This is a very significant and probably overlooked aspect of team care on the professional identity of a psychiatrist. Often psychiatrists work in isolation from other colleagues and have not had a need to question their utility or role in their patient care. The team approach may, therefore, feel more threatening. Geriatric psychiatry curricula need to ensure that trainees are educated about their team role in order to assist in the development of this identity and feeling of efficacy and reward.
The final personal influence was whether physicians enjoyed seeing geriatric patients and hearing their stories. Themes of wisdom, strength and respect for people who have lived to an old age emerged from those participants who enjoyed them. This effect of enjoyment on practice choice intuitively makes sense and needs to be further examined in the context of training.
Environmental factors included the perception or reality of demand for service influenced whether psychiatrists would be seeing geriatric patients. Trainees who anticipate working in hospital-based settings need to be aware of the value of geriatric training in order to feel comfortable and skilled in such practice.
With regard to the educational factors, three essential components of training programs seem to influence practice: teachers, diversity of patient exposure, and other aspects of the program. Consistent with our pilot work, this group identified the teacher qualities of competence, role modelling and enthusiasm as important influences in their decision to see geriatric patients. The need to idealize one’s teacher capabilities and see them as role models is a necessary aspect of the learning process and has been discussed in the psychotherapy supervision literature (20, 21). It may be that these types of experiences allow for an internalization of certain knowledge, skills and identity that can be drawn upon when seeing a geriatric patient. Role models have not been described previously as influencing practice patterns of generalist physicians such as this group (22). The need for teachers to be responsive, form a teaching alliance and be driven by the student’s learning needs is relevant for student learning (23). Exposure to a variety, diversity and volume of patients seems critical to an effective teaching program. Themes of comfort, optimism and anti-ageism were associated with this need. This type of exposure, incubated by an enthusiastic teacher, may be sufficient for trainees to become "desensitized" to this patient population. Once their ageist attitudes have been challenged, they may begin to find a comfortable and enjoyable role for themselves in geriatric care.
Other aspects of the teaching program that encourage geriatric practice include clear teaching goals that emphasize approaches, skills and attitudes, with a mandate to prepare future community psychiatrists to care for the elderly. Respondents felt that if their training program had equipped them with skills that they could apply to geriatric patients, these skills influenced their willingness or comfort with geriatric patients. In settings where the educational program was primarily driven by the clinical service needs, the participants felt ill prepared and subsequently were reluctant to see geriatric patients. This suggests two main considerations in the development of educational objectives for geriatric psychiatry. One is to define clearly what essential skills are generalizable to the care of geriatric patients in most community settings. The other is to pay attention to the specific context in which the trainee anticipates that they will ultimately practice, so that individualized learning objectives can be fulfilled. A study such as this provides a window on the general psychiatric community that can assist in identifying "appropriate" geriatric psychiatric objectives for the training of future psychiatrists. Our findings also support the requirement for geriatric training within general psychiatry (24, 25).
This study is limited because it focused on hospital-based community psychiatrists and cannot necessarily be generalized to other professionals. The sample was small, but participants did reflect 12 different hospitals and a full range of geriatric practice. The high level of redundancy in themes across the three groups suggests that the sample was adequate for this methodology. It is not clear whether the participants who came were unique in any way from those who refused. The majority of subjects trained in the same residency program, albeit over an 11-year period during which substantial changes have taken place. Finally, issues related to access, managed care and reimbursement were not relevant to these psychiatrists, but may be important in non-Canadian contexts.
This methodology is well suited to generating themes for further research. Future studies of graduates of other training programs, those who practice in differing reimbursement systems and similarly trained psychiatrists who choose not to see geriatric patients, would add clarity and generalizability to these findings. Nonetheless, given that the themes themselves do not seem program unique, we think that our conclusions may be relevant to settings beyond our own. In particular, those training programs wishing to bolster the number of graduates who eventually choose to see the under-served elderly population might consider the themes identified here in augmenting the training experience.