Much attention has been paid to the reduced lengths of stay in psychiatry inpatient facilities, with primary goals being rapid diagnosis, resolution of the crisis, and discharge (1, 2). This results in the release of patients only partly compensated, who require more complex ambulatory care. The primary locus of treatment has shifted from inpatient to outpatient care. Because of this, residents experience greater anxiety and obstacles to learning which include both the very brief inpatient exposure and the acuity of the outpatient population. In fact, they may become demoralized by the pace of these rapid treatment units and learn little about the continuum of care available in contemporary behavioral health systems (3).
There is, without question, a need to adapt training experiences to the demands of changes brought about by managed mental health systems. Inpatient psychiatry, by itself, may no longer provide the resident with the opportunity to develop a therapeutic relationship and to learn about the effects of treatment intervention over time (1). An alternative approach, to permit longer-term involvement with patients, is important if we are to preserve the patient-oriented traditions of psychiatric practice.
The program requirements for outpatient experience established by the Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education (ACGME) for psychiatry mandate
an organized, continuous, and supervised clinical experience in the assessment, diagnosis, and treatment of outpatients of at least one year (or its full-time equivalent if done on a part-time basis) that emphasizes a developmental and biopsychosocial approach to outpatient treatment. At least 80% of this experience must be with adult patients. A minimum of 20% of the overall experience (clinical time and patient volume) must be continuous and followed for a duration of at least one year. (4)
Though most programs encourage residents to follow a few psychotherapy patients for longer periods, the usual outpatient requirement is arranged with a combination of rotations in 1-year blocks of ambulatory clinics or a combination of rotations consisting of specialty clinics and medication clinics. Our own program was structured along these lines with most of the third year and part of the fourth year containing such block assignments.
Jackson Memorial Hospital (JMH) and the Miami Veterans Hospital are primary sites for the University of Miami Miller School of Medicine’s Department of Psychiatry Residency Training Program. Each has its own faculty and outpatient clinic and a somewhat different gender and ethnic patient mix. Otherwise, the population reflects what is typically seen at a large urban county hospital and VA that serves a county of 2.2 million. The population includes recently discharged patients and patients followed over the long term to prevent relapse. The opportunity to achieve competency in the required psychotherapies is also provided. Patients are seen weekly or less often for well-stabilized individuals.
In response to patient complaints of yearly doctor changes and the often limited resident contact with patients, a small committee of faculty and residents designed a model program that would provide 3 to 4 years of continuous care experience for the residents and their patients. Using the facilities at both the JMH County Hospital and the Miami VA Hospital, half-day continuity clinics were organized. These began with a half day in the PGY-1 year and expanded by an additional half day each post-graduate year. They were maintained with an increasing but continuous caseload of patients until the completion of the fourth post-graduate year. By that time, residents conducted 2 full days of such clinics.
In order to meet the RRC ACGME requirement for a full year of outpatient training, additional month-long blocks of walk-in clinics were planned. The integration of the clinic half-days taken away from the block rotations and other services required more time allotted to services like consultation/liaison and child psychiatry to meet the RRC ACGME minimum requirements of 2 months (e.g., a consultation/liaison 4-month block minus three half-day continuity clinics and one half-day didactics=2.8 months). A coverage schedule was created with residents assigned to teams. In that way, the block-assigned services would be covered by half of the residents while the other half were attending their continuity clinics.
Many meetings with faculty and residents were held to overcome initial concerns and the logistical difficulties presented by this program change. In July of 2000, the changes were implemented. A limit was placed on the number of patients that a resident might see in a half-day assignment. All outpatient activity, other than individual psychotherapy supervision, was confined to these clinics and included new patient intakes, brief medication visits, psychotherapy cases, and even group therapy. Attending supervisors were available on-site to see or review all patients. Psychologists, social workers, and nurses were included in the treatment team as well. Tweaking the system over the next 2 years made the experience more manageable. By the PGY-3 level, one of the three half-days was set aside for psychotherapy cases alone. New patient intakes were limited to two per session and scheduled for half a day once a month to provide sufficient time for the resident to evaluate and discuss the patient in detail with the attending supervisor. The faculty anticipated that these changes would better prepare the trainees for the realities of present-day practice as reported by our graduates.
Utilizing some of the recommended approaches to survey instruments by Sierles (5) and survey research by Scholle and Pincus (6), we devised a survey questionnaire about our continuity clinics for residents using a Likert scale.
The 10 anchor points ranged from 1 (totally disagree) to 10 (totally agree). The 15 questions were provided to the available separate groups of PGY-2, -3, and -4 residents. In June of 2004, they completed them anonymously on the same day. In March of 2006, the PGY-4 residents were again asked to complete the survey. They had been the PGY-2 residents in 2004 and had participated in the original survey. In an effort to avoid type I error due to the small group size, the training level difference and the absence of ordinal data led us to display the means for each PGY level.
The scores were averaged and means for each year for each question are displayed in Table 1. The scores that registered above “more positive than negative, or 7” in the PGY-4 group were those endorsing the opinion that the continuity clinics allowed the residents to follow their patients over the entire program, that this was more of what real practice would be like, that it permitted the residents to learn more about the evolution and progress of mental illness, and, most importantly, that it improved the therapeutic alliance (Questions 1, 3, 14, and 15). In each of the above items the PGY-2 residents were less likely to agree, but once residents reached the PGY-3 level they were much more in agreement. Supportive of this trend were the items worded in a negative fashion, which included preference for a 1-year rotation (Question 2) and the suggestion that patients get better care in regular block clinics (Question 13), which scored lower as residents moved toward completion of the program. Over time, residents also showed a trend to become more satisfied with greater ownership of their clinics (Question 4) and more neutral about interruptions to their regular block rotations (Question 5). Questions 6 through 10 were included to elicit residents' perceptions of available help during their clinic experience. The results support the residents’ impressions that patients are satisfied with the continuity clinics as the overall rating improved following the establishment of these clinics. Repeating the survey with the PGY-4 residents 2½ years after their original participation as PGY-2 residents revealed results almost identical to those of the original PGY-4 residents surveyed in 2004.
The doctors’ responses to the question about patient satisfaction were indirect and led us to examine available data obtained by the nurse administrator over the previous 4 years using Professional Research Consultants (7), a private organization hired by Jackson Memorial Hospital to survey patient satisfaction. A telephone survey of randomly selected patients over the previous 4-year period revealed improvement in all parameters of the doctor-patient relationship. This improvement has been sustained in repeated surveys.
The reorganization of our residency training program by establishing continuity clinics in an effort to enhance patient care and resident training has been successful. Resident survey information reveals that as residents advance and become more familiar with the program and the importance of the continuous experience, they appreciate the benefits of such an arrangement. With time they experience less disruption of the block rotations as they learn to multitask. For some residents this is an easy transition; for others it is more difficult.
Assignment patterns are more complex, and those responsible for making such assignments must consider many additional factors. These include service coverage by additional team arrangements, protecting clinic time from block rotation service demands, and providing suitable didactic and case conferences. Necessary contacts with patients while away from the clinics must also be managed with adequate telecommunication and backup.
Though patients reported increasing satisfaction over the same time period, other changes in the ambulatory setting may also be responsible for this. All faculty have had to adjust to this very different resident assignment pattern. Those in charge of the outpatient clinics must keep track of all residents in the training program as all require supervision and evaluation as well as instruction of a more didactic nature. Faculty responsible for the traditional block assignments must organize their service to accommodate the periodic absence of the residents assigned to them.
Colleagues in medicine, pediatrics, and family medicine have recognized the benefits of continuity clinics (8). However, because visit frequency in those specialties varies (9), unless patients are in a crisis their experience is somewhat different. As is true for others, clinic resources, time in clinics, and faculty supervision affect the quality of the continuity clinic experience (10). Our experience can serve as a useful model. It is a practical alternative to the traditional block approach to psychiatry training as demonstrated by our survey findings and the overall acceptance of continuity clinics by the residents and faculty.