Over the years, the number of months of inpatient training required for general adult psychiatry residents has gradually declined. Recently, the Psychiatry Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) proposed a further reduction to a minimum of 6 months of inpatient psychiatry (1). General adult psychiatry residents have 4 years (sometimes 3, depending on career and fellowship plans) to develop basic skills in interviewing, assessment, and treatment planning, as well as to understand the scientific and theoretical bases of human psychopathology. In addition, residents are expected to develop and hone the requisite personal and collegial qualities that make up the broad arena of “professionalism.” When one considers the goals of psychiatry training as summarized by the ACGME’s core competencies, an argument can be made that for training purposes, an inpatient setting may be the most conducive site for mastering these core competencies. In that context, we believe that a reduction from the current minimum of 9 months of training in inpatient settings threatens to seriously undermine the quality of training for psychiatry residents.
This commentary is based on our own teaching experiences—one of us is an academic inpatient psychiatrist (S.L.) and decided to pursue inpatient psychiatry because of her positive experiences during residency, and the other (R.R.) has long taught biopsychosocial formulation to PGY-1 residents on their first inpatient rotation. We first review the existing literature on psychiatry training in inpatient settings and then discuss the potential depth and scope of the critical foundation that residents develop during inpatient rotations by discussing how inpatient training critically contributes to attaining competency in the six general medical competencies established by the ACGME. Finally, we discuss factors that training programs should consider before decreasing the inpatient training requirement.
The literature on inpatient rotations and training in current times is sparse. Crowder and Jack (2) discuss this lack of literature in their article on educational opportunities on inpatient units, and discuss many of the advantages to training in inpatient settings. They note that, among other benefits, severe and often refractory psychopathology and comorbid medical illnesses are seen most frequently and most clearly in inpatient settings. Exposure to such presentations early in residents’ training, when inpatient rotations usually occur, allows residents to develop a fundamental model of illness presentation which can be modified and expanded over their subsequent course of training. Houghtalen and Guttmacher (3) provide a detailed description on the changing nature of inpatient care and its impact on psychiatric education. They also point out that inpatient work provides a stable foundation upon which outpatient treatment can be built.
There is also a limited body of research directly comparing the differences in knowledge and skills acquisition in inpatient versus outpatient settings. Key differences were found in one study (4) that looked at the differences in the sequence of inpatient rotations between a group of residents who had first started in an inpatient rotation as PGY-2s and a group of residents who first started in an outpatient rotation. Compared with residents starting on inpatient rotations, PGY-2 residents who started with outpatient rotations underestimated the severity of symptoms; misinterpreted symptoms of Axis I disorders as Axis II pathology; had greater difficulty utilizing a biopsychosocial model of understanding patients; were more hesitant to use psychotropic medications; had difficulty making rapid decisions and interventions; and, notably, had greater difficulty developing a professional identity (4). Although the study sample size was small and the purpose was to examine sequencing of rotations rather than the length of inpatient rotation, the results suggest the fundamental role that inpatient rotations play in attaining general medical competency in psychiatry. Future educational research should develop effective measurements for the ACGME general medical competencies and determine the effects of decreased time in inpatient settings on resident competency.
The ACGME has established six general competencies that psychiatry residents must demonstrate: 1) compassionate, appropriate, and effective patient care; 2) medical knowledge; 3) practice-based learning; 4) interpersonal and communication skills; 5) professionalism; and 6) systems-based practice (2). We will review each of the competencies and demonstrate the important contributions of the inpatient setting to the development of residents into competent psychiatrists.
Patient Care and Medical Knowledge
All clinical rotations provide opportunities for residents to learn medical knowledge from their supervisors and practice the application of this knowledge while caring for patients. Inpatient supervision, however, is quantitatively and qualitatively different from supervision on outpatient rotations. During inpatient rotations, supervisors observe, assess, and discuss patient care with residents in a real-time setting, and provide opportunities for immediate feedback and intervention, which are generally not possible with outpatient supervision. Inpatient settings may also promote the formation of more comprehensive patient assessments. No other setting promotes gathering the quantity and quality of information obtained during a patient’s hospitalization, not only from the patient, but from his or her family, friends, and other clinicians. Residents learn not only from their own interviews but also from observing and hearing about their patients’ interactions on a 24/7 basis. This contrasts with the different boundaries and time constraints of outpatient settings, where residents see their patients less frequently and may rarely observe them interacting with others. Some may counter that patients’ behaviors are altered by being in a hospital and that inpatient settings are “not the real world.” Ironically, because residents obtain such a rich variety of information from collateral sources, it may be on inpatient units where residents understand their patients’ “real world” in most depth. This may allow residents to develop the critical ability to make hypotheses about patients in all settings, including patients whom they see less frequently and in the limited context of outpatient settings.
Inpatient settings often provide residents exposure to patient populations with acutely florid and classic presentations of illness. These and other groups may not be seen as frequently in outpatient settings. Such groups include treatment-refractory patients, patients with multiple comorbid psychiatric conditions, and patients whose cultural and social backgrounds delay presentation for treatment until the development of the most severe stages of illness. Rotations on subspecialty units like addiction psychiatry, geriatric psychiatry, or research units further expand resident exposure to patient presentations and therapeutic interventions. Residents can work with inpatient supervisors to compare and contrast these patients with those patients who present with classic presentations, and evaluate and apply the literature. An evidence-based mental health approach can be a formative component of the resident’s lifelong approach to the management of patients who fall outside standard diagnostic schemata or treatment regimens. Another component of practice-based learning and improvement is tracking patient outcomes. Residents will encounter utilization review staff who measure the need for inpatient level of care and length of stay. Residents can learn about criteria for continued inpatient coverage, how length of stay affects their patients and the hospital overall, and discuss with their supervisors how to balance clinical care in the face of financial and administrative constraints.
The crux of our field is based on sophisticated interpersonal and communication skills for competent assessment and treatment. Such skills are difficult to teach in didactic settings and may be best learned by observation. With appropriate supervision, residents in inpatient settings have multiple opportunities to observe, practice, and discuss the nuances not only of physician-patient communication but communication with colleagues from other disciplines. Because of their many interactions with severely ill patients and the challenges of working closely with other staff, residents on inpatient units will invariably be confronted with their own strong emotions (5). This provides opportunities to teach basic skills of self-reflection and the management of strong emotions during difficult interpersonal communication with patients, families, or others in the system of care.
Professionalism and Systems-Based Practice
The first 2 years of residency training may be the most crucial years for the development of a professional identity (3). The importance of role modeling in medical education and professional development has been increasingly noted in the medical literature (6). Effective inpatient attendings serve as effective role models: the words and demeanor they use to talk to and then discuss the most challenging of patients; their interactions with individuals at all levels of care both within and outside of psychiatry; and their work ethic that sets the standard not only for the resident but for the unit. Even the most professional and sophisticated residents can have a breakdown in such skills and behaviors under the duress of the inpatient unit milieu. It is crucial for residents to learn how to communicate effectively when the need for successful communication and professionalism is at its highest (and at the greatest risk of failure). We believe this is best learned by observation and internalization of such behaviors and attitudes on a daily basis, and by having opportunities for residents to process with their supervisors immediately when there is a failure in communication or lapse in professional behaviors and attitudes.
The inpatient unit may also be a rich setting for residents to learn about and interact with the patient’s system of care. Residents have the ability to work in systems within the unit, within the hospital, and outside the hospital as they interact with families and the outpatient system of care. Residents on inpatient units have the opportunity to observe group dynamics not only between patients, but also within the unit staff. Effective supervisors can also help residents understand that interacting with the system of care, often denigrated as “social work,” is actually fundamental to comprehensive patient treatment. After all, if patients cannot afford prescribed medication, or if follow-up care is inadequate, the patient may be readmitted shortly after discharge.
We acknowledge the difficulty of determining the correct amount of inpatient training time during residency. However, a useful comparison may be drawn by examining inpatient requirements in other residency programs. In internal medicine, the ACGME requires a minimum of 12 months of inpatient rotations during 3 years of residency (7). During their 3-year residency, pediatric residents spend a minimum of 5 months in noncritical inpatient settings and an additional 5 months in critical care inpatient settings. They must also have inpatient experiences in their 7 months of subspecialty rotations (8). Even family medicine residents must spend a minimum of 6 months on general adult inpatient rotations, in addition to the separate inpatient experiences they must have during subspecialty rotations in gynecology, neonatology, pediatrics, surgery, and geriatrics (9). Our colleagues in these primary care disciplines, which traditionally emphasize outpatient care, may well understand that inpatient settings may provide the best environment to develop competent residents. Although some of the additional inpatient time in other specialties may be necessary for the acquisition of various procedural skills, one can argue that our fundamental diagnostic “procedure,” the psychiatric interview, is also best learned in an environment with ample opportunities for directly supervised skill acquisition.
Since colleagues in other medical specialties continue to require more inpatient training, what is the rationale for decreasing the amount of time residents spend in inpatient psychiatry? One stated reason is to accommodate greater opportunities for residents interested in research careers. Current ACGME requirements provide up to 17 months of time free of “timed requirements” during the 48 months of psychiatry residency. For most programs, the major obstacle to maximizing resident research opportunities is funding this time and covering clinical services during those months of research training. We wonder whether another, perhaps unconscious, rationale is the increasing financial pressures on inpatient units. Minimizing time in inpatient training may silently represent acceptance of these financial pressures, to the great detriment of future generations expecting high quality clinical training in psychiatry.
In our opinion, we are left with the following facts: 1) training on inpatient units provides outstanding opportunities for residents to develop the foundation for attaining competency in the six general competencies; 2) although data are limited, they suggest that inpatient rotations do play critical roles in residents attaining competency; 3) there are no data to determine the effect less time on inpatient units will have on attainment of competency; 4) our colleagues in some other medical specialties believe that inpatient training does contribute to attainment of competency; and 5) a major rationale for decreasing the number of inpatient months, improving research opportunities, is limited more by funding issues than by inpatient requirements.
Whether or not the minimum inpatient time requirement is further decreased, we welcome the opportunity to think about the need to consider carefully how to maximize and utilize inpatient time to its full advantage. Those of us working and teaching on inpatient units must take on the responsibility to maximize the tremendous potential for learning that inpatient settings can provide. Therefore, we believe residency programs should give careful consideration before decreasing time in inpatient settings, which provide residents with critical, invaluable training for attaining competency as board-eligible psychiatrists.