Child and adolescent psychiatry (CAP) has been recognized as an underserved specialty in American medicine for decades (1). Since 1980 at least four national reports have emphasized the need to increase the number of child and adolescent psychiatrists, and it has been estimated that up to 80% of children with emotional disturbances do not receive any kind of mental health care and even fewer can access the services of a child and adolescent psychiatrist (2). The American Academy of Child and Adolescent Psychiatry (AACAP) began to examine the work force issues in 1999 and projected the need for a 100% increase by 2020 (2). At that time AACAP made recruitment into the field its highest priority, embarking on a 10-year mission to increase the child mental health workforce (3).
One of the strategies for increasing recruitment into CAP involves improving the retention of residents entering psychiatry training at the postgraduate year 1 (PGY-1) level who express an interest in child psychiatry. In one survey, 30% of medical students entering psychiatry training expressed interest in CAP, but this fell to 18% among PGY-4 psychiatry residents (4). Others suggest that the attrition rate for interest in CAP training during psychiatry residency may be as high as 75% (2, 3). One way to address this challenge is to develop integrated training in psychiatry and CAP, allowing applicants to designate CAP as a career goal from the start of their residency training. By providing interested residents with CAP experiences throughout the 5 years of combined training, interested residents may actually maintain interest and complete training in CAP, thereby improving retention (5). Early experiences in the field may also promote interest among other residents (5). Integrating CAP training with psychiatry training is not a new idea. An integrated training program has been in place at the University of Pittsburgh for over three decades. California Irvine reports a modified integration potential in their training sequence since 1968. Still most of the self-identified integrated models do not actually designate trainees as both CAP trainees and psychiatry trainees early in the training, a necessity if early experiences in child psychiatry are to be counted toward their ACGME approved training.
ACGME requirements for training in both psychiatry and CAP have at times limited the ability to integrate training, sometimes even hindering resident entry into CAP training after the third year of psychiatry training. Recent revisions in psychiatry requirements have decreased these obstacles (6). Up to 12 months of the 4 years of psychiatry training can be counted toward both adult and child requirements. However, to be counted toward CAP training, the resident must be formally identified as a CAP resident. Specific requirements that can be double counted include: 1 month of child neurology; 1 month of pediatric consultation-liaison; 1 month of addiction psychiatry; and CAP, forensic, or community psychiatry experiences. Additionally up to 20% of the required 12 months of outpatient psychiatry can be with children and adolescents and can count toward the CAP training. The new reduced inpatient requirement in psychiatry to a minimum 6 months allows greater flexibility in an integrated training schedule as does the ability to “begin” CAP experiences during the first year. With these more flexible training requirements, programs seeking to implement an integrated psychiatry and CAP training track will find it easier to meet all of the requirements.
In 2005, the American Academy of Child and Adolescent Psychiatry (AACAP) conducted an e-mail survey of ACGME accredited CAP training programs to ascertain how many had an integrated track. At that time 93 (out of approximately 115 [81%]) CAP programs responded and 33 indicated that they had “integrated” training. These 33 programs were then contacted individually by telephone or e-mail to elicit specifics about their integration. The interview focused on eight questions, the first of which clarified whether the program offered a more formal program of integrated training. Only seven programs responded positively to this question, reporting that they identify psychiatry residents in the first year as on a specific track for training in CAP. This group of seven programs was then queried with seven additional questions (see Table 1). The 26 programs that said they did not offer a formal program of integration which identified residents early in the program reported that they offered some expanded opportunities for incoming residents interested in CAP, such as exposure to pediatrics during the primary care portion of the program, earlier opportunities to see child and adolescent patients in the outpatient rotations, or possibilities to elect some inpatient experience on adolescent psychiatry units. No further information is available regarding these 26 programs. However, in retrospect, we question whether some of these programs may have offered an informal increase in exposure to CAP that was at least as intense as some of the programs described as offering “minimum exposure.” This article focuses on the seven programs that identified themselves as offering a formal integrated track (see Table 2).
The overarching finding from the in-depth interviews with the program directors is that there is much variability in the programs and a lack of consensus as to what integrated training entails. The first question determined when the program started; the range was from 1968 to 2006. Only one program reported having designated match positions while the others identified interested residents after the match and then assigned these residents to some degree of child and adolescent psychiatry (CAP) training. Formal structure for integration varied among the programs with increasing formality of the program over the 5 years. Not all programs identified the trainees formally as CAP trainees in the first 3 years. Most offered some pediatrics in the first year as part or all of the primary care requirement. Some offered pediatric neurology as part of the neurology requirement in the first year. Increasing intensity was common in the second year, although that too ranged from as little as adding some child or adolescent cases in the outpatient clinic to up to 6 months of inpatient CAP experience. The third year typically integrated more CAP outpatient experience, often a continuous experience of one day a week for six or more months. Fourth and fifth years appeared to be more focused on CAP although some continuity with psychiatry outpatients was indicated through this period. Two programs created individual training tracks for residents entering integrated training.
The telephone survey also focused on the issue of establishing collegiality, that is, providing peers in a CAP training track with interactions crucial to mutual support and learning. Some programs tried to have more than one resident in the integrated track and sought to schedule them together on various rotations. Others started child didactics early in training to bring the residents together. Additional tactics included separate program director meetings with integrated trainees and early CAP supervision. Another possibility was combining psychiatry and CAP resident group meetings to foster collegiality across programs for all residents.
All of the surveyed programs considered their programs successful. However, estimates as to how many of the trainees actually completed training in CAP varied markedly. One program reported 25% completion for residents on this track, a percentage that may be lower than other traditional programs in which higher percentages of PGY-3 psychiatry trainees move into CAP training in the PGY-5 year. The higher ranges, from 50% to 95%, seem to be associated with more formally integrated programs and may reflect a sampling bias since those trainees willing to participate in fuller integration already may have been more committed to training in CAP. Further study is needed in this area and should also include direct responses from residents regarding reasons for choosing these programs, staying in the program, completing training, or leaving training before completion.
Programs identified some barriers to optimal integration. The top barriers cited included coordinating with psychiatry, particularly balancing service demands for psychiatry with efforts to provide CAP experiences; losing residents after PGY-4 when they withdrew, having completed their psychiatry requirements; and recruitment. All program directors agreed on three critical components to facilitate the integration of psychiatry and CAP training: support from the chair as well as the psychiatry program director, close communication with the psychiatry program director, and the development of formal rotation/sequences to protect early CAP experiences.
Models of Integrated Training: Factors for Consideration
There is no one best way to integrate training as every program will differ in the resources and opportunities available. For the purpose of discussion and planning, the integration of training can be viewed as a continuum, with full integration of the psychiatry and CAP experience representing one end of the spectrum and opportunities for earlier exposure to the field representing the other end. In considering which model of integration might be most feasible for an institution, there are several factors to be considered, including institutional factors, programmatic factors, and resident considerations. Most important is how residents are identified or designated as part of any integrated or combined training experience. Prior to entry, child psychiatry training programs must inform applicants considering alternative tracks and differences from psychiatry residency training. Variations can include the timing of completion for psychiatry training, which may affect the timing of resident eligibility to apply for ABPN certification or to alter credit that can be given should the resident decide to transfer to another program. The ACGME requires that applicants be informed of goals and objectives and expectations of training, but it is also critical that potential residents understand all the implications of selecting an alternate pathway.
Relationship between Psychiatry and CAP Training Programs
A central consideration in planning any integrated training track is the relationship between the psychiatry and CAP residency training programs, including faculty, residents, training coordinators, and administration. The necessary collaboration and coordination in recruitment, scheduling, supervision, and support with residents requires good communication and a shared commitment to the success of the program. Very few programs could afford to have a completely separate and self-contained training program for an integrated track; therefore, resources and responsibilities for an integrated training track must be shared between the psychiatry and CAP residency programs. Problems with the integrated training track and issues for residents need to be identified quickly and handled without delay, both of which can occur if administration is poorly organized or if lines of authority are unclear. Integrated training creates an opportunity to forge a stronger relationship between related CAP and psychiatry residency programs. With a formalized process and recognition of residency education as an integral part of CAP training, entry from psychiatry training is no longer seen as “raiding” or “seducing” residents into a different career path.
A crucial issue is how positions will be supported. If there are only minor modifications to clinical rotations with little impact on stipend support, then integrated training would be funded in the same fashion as any psychiatry resident support for PGY-1–3 coupled with CAP resident support for the final 2 years. It must be decided if the integrated track will require additional positions or if those will be designated from existing resident slots. The opportunity offered in providing different rotations and the support afforded should not be overlooked in planning integrated programs.
Contractual Obligations and Availability of Training Sites
The contractual obligations of training agreements with clinical facilities usually determine whether the integrated program will be created from existing positions or represent new resident positions. Current program support may require review in order to determine the options in funding as well as in clinical rotations. Rotations through CAP must be assessed to ensure adequate clinical material and supervision to accommodate any increase in positions or allotted time.
The formality of an integrated program refers to the degree to which integration has been institutionalized within the training program. Factors affecting the relative formality of the program include the presence of an individual track to which trainees match, the presence of an established curriculum and series of rotations that all trainees in the integrated track follow, the existence of contracts with training sites for integrated trainees, and the existence of a formal agreement between the psychiatry and CAP training offices with respect to integrated trainee responsibilities and compensation.
There are advantages and disadvantages to formalizing an integrated training program. The advantages include certainty from year to year with respect to scheduling, meeting contract obligations, and financial planning. The disadvantages are the loss of flexibility in responding to changes in the training environment, including recruitment success, loss of residents, changes at training sites, and changes in faculty.
Intensity of the Integrated Training Experience
Another factor is the intensity of exposure to child and adolescent psychiatry (CAP) throughout the training years. Within the framework of the new Residency Review Committee requirements, there is a lot of latitude for programs interested in offering an integrated training experience. Intensive exposure may facilitate retention of the resident in CAP but requires a larger commitment from the psychiatry training program in making time available as well as a commitment from the CAP program to allocate training slots. More limited but earlier exposure to CAP training might expose the program to a greater number of residents and would avoid the need for the trainee and the program to make an early commitment. However, program directors must remember that trainees must be designated officially as CAP trainees if experiences are to be double counted for both general and child psychiatry training.
Timing of the Integrated Training Experience
Timing of the integrated training experience refers to the onset of exposure to official CAP residency experiences, which, under July 2007 RRC guidelines, can begin within the first year of training (6). There is some evidence that medical student interest in CAP is correlated with interest in pediatrics (4). Therefore, for some trainees the possibility of pediatric experiences in the first year may be a draw for students likely to choose pediatrics directly out of medical school. Early exposure to CAP training may awaken an interest in a resident and provide motivation to seek out additional experiences. On the other hand, the early months of training can often times be overwhelming, which might only be exacerbated by the additional expectations of working with children and families. Frequently, early exposure may occur in busy emergency departments where new residents assess CAP patients, an experience which may have a negative impact on sustaining interest in the field. Further, if exposure occurs too early in training in an isolated event, trainees may not sustain their interest.
Residents who begin an integrated training program may decide not to complete child and adolescent psychiatry (CAP) training or may decide to transfer to another training program. With this in mind, residency training programs should consider how the design of clinical rotations affects training requirements for those residents who change career plans. The recent revisions of the Residency Review Committee Requirements for psychiatry training (6) permit greater flexibility for those residents pursuing CAP training, but alterations may leave a resident deficient in certain psychiatry requirements should he or she decide not to finish CAP or decide to transfer to another program. Programs may design their rotation sequence during the first 3 years of training to accommodate possible changes in career plans. However, programs that spread general psychiatry and CAP requirements throughout the five years should inform potential trainees about the possible restrictions to either transferring to another program or discontinuing CAP training.
Development of Identity: Critical Mass
One of the functions of residency training is to facilitate the resident’s development of his or her professional identity as a psychiatrist. This process involves the cultivation of relationships with faculty, practitioners, and fellow residents. Altering the rotation sequence threatens this process, especially in peer-resident interactions, so existing integrated training programs have devised ways of addressing this need. Programs can control the number of residents in the training track, utilize special didactic and supervisory sessions, and offer resident mentoring. Regular residents’ organization meetings are also available as a means of generating a sense of belonging to a group. Regardless of the approach taken, feelings of isolation and not belonging may develop. As this is a potential cause of attrition, training programs should recognize and work to foster professional and social connections. Additionally, the Residency Review Committee may look for peer interactions in these programs during site visits.
An important consideration in developing an integrated program is creating a didactic sequence that provides trainees with the information they will need as they progress through training. This poses several challenges, as trainees will also be in the process of mastering materials required to be competent adult psychiatrists. One approach has been to require trainees to attend both adult and child didactics each week. A second approach has been to develop a separate didactic sequence designed for integrated trainees. Others have followed the more traditional didactic sequence and provided “on rotation” tutorials for residents who have not had formal didactics. All of these approaches have their limitations. With the first approach, residents are apt to feel overloaded with information and they are left with less time to devote to clinical experiences. The second approach limits the time trainees will spend with other residents and may foster feelings of isolation and hamper identity formation. The third approach only works if the psychiatry didactics integrate some exposure to CAP issues earlier in the training sequence; otherwise, didactics may be provided when they are no longer relevant to clinical rotations.
We propose several models for various levels of integration of CAP and psychiatry training (see Table 3). In evaluating which model may be most appropriate for a particular training program, directors must consider the financial resources, the strength of the relationship between the psychiatry and CAP training program, and the commitment of faculty. With these considerations in mind, any integrated training program should be designed to optimally utilize the available educational resources. Programs may incorporate some components from each of the various models while not embracing the entire model.
In this model, the exposure to child and adolescent psychiatry (CAP) is limited to one to two rotations which can be offered at any point during the first 3 years of training. The advantages of this model are several. First, it requires minimal commitment of additional resources from either training program and it allows the training program to retain maximum flexibility in scheduling and responding to contract demands at different rotation sites. Likewise, it allows trainees to have the opportunity to experience CAP without having to make a formal commitment. By minimizing the demand on resources, programs are able to provide exposure to a larger number of trainees, with the potential of cultivating an interest in a larger number of residents. Some might argue that this level of integration only recognizes the resident’s interest and intended goal in training but does not alter the training experience significantly when compared to the experiences of other residents on traditional tracks. In fact, as we examined this level of integration, it appeared that many programs might qualify for this designation. Conversely, an isolated experience in CAP may not be enough to solidify a resident’s interest in the field. Additionally, the experience may have the opposite effect of being isolating or overwhelming, especially in the absence of appropriate didactic and supervisory support, such as early experiences seeing pediatric patients in the emergency department or writing admission notes and orders on inpatient CAP units when on call. Finally, these early experiences that are offered without a formal designation as a CAP trainee cannot be formally counted toward CAP training.
An example of this model is the program at the University of California, Davis School of Medicine. The program does not have dedicated slots for the integrated track. Residents with an interest in CAP are offered the opportunity to pursue this interest beginning in PGY-1, with 2 months of pediatrics replacing 2 months of medicine. In the PGY-2 year, residents take a 1 month elective in inpatient CAP. During the PGY-3 year, residents follow children in an outpatient clinic for 1 day a week for 6 months. Didactics in CAP begin in the PGY-3 year and residents are assigned a child supervisor at this time. The program is in its infancy, and data are not available to evaluate the program’s effectiveness at retaining interested residents; however, significant numbers of their incoming psychiatry residents are choosing these early experiences.
Model II: Moderate Integration
In this model, there is a greater degree of exposure to child and adolescent psychiatry (CAP) and a commensurate increase in commitment from the training program and the trainee. This model is designed to offer exposure to CAP early in training, with some degree of exposure during the PGY-2 and PGY-3 years. To achieve this level of integration, a strong working relationship between the psychiatry and CAP training programs is necessary. With increased collaboration between departments, there is a greater need for a more formalized approach to increase predictability in scheduling, financial demands, and meeting contractual obligations at rotation sites. With respect to trainees, this model would hold more appeal to a resident who is willing to make a greater commitment to this training path. If the trainee is designated as both a psychiatry and a CAP trainee then the double counting of certain experiences as previously defined is possible.
An example of a moderately integrated training program is the program at the University of Indiana, which has been in existence since 1991. Similar to the first model, the University of Indiana does not have a separate training track or designated slots for integrated training. However, unlike the first model, the amount of exposure to CAP is substantially increased. In this model, residents are first exposed to CAP beginning in the PGY-2 year. During this year, residents devote 6 months of training to CAP, with a mixture of inpatient work, consultation-liaison, and intermediate care. There is no exposure to CAP in the PGY-3 year. In the PGY-4 year, residents rotate through 2 additional months of CAP in an intermediate care setting and do an additional month of child consultation and liaison, with 3 months of elective time. Residents also complete their psychiatry requirements. The PGY-5 year is devoted to outpatient CAP. Critical mass is addressed by having two residents rotate through the integrated program at the same time. Didactics are structured to coincide with the CAP rotations and begin in the PGY-2 year, with a 6-month didactic series. Didactics begin again in the PGY-4 year. Approximately 25%–33% of participants reportedly complete CAP training.
Model III: Combined Training
The combined or fully integrated training model maximizes the exposure to CAP across the first 3 years of training. Exposure to CAP begins in the PGY-1 year and continues during the subsequent years of adult training. The combined training program is highly formalized, with rotation schedules that are established, a well-developed CAP didactic program that is integrated with the psychiatry curriculum, and a separate match number in the National Resident Match Program. To sustain this level of integration there needs to be a strong working relationship between the psychiatry and CAP training programs that extends to collaboration regarding site contracts, financial arrangements, and the recruitment of trainees. The advantages of this model from the training program’s perspective are the certainty of obligations from year to year, which facilitates planning. The tradeoff is the loss of flexibility in adapting to changes in the institutional environment such as in rotation sites, faculty, and resident career decisions. From the resident’s perspective, this model would be most appealing to someone who is committed to CAP training at the end of medical school. Thus, it is less likely to generate interest in residents who are unsure about their career path, but is more likely to retain a resident with an established interest.
An example of a combined training program is at the University of Texas Medical Branch at Galveston, established in 1993. The division of CAP is fairly large for the overall size of the department with 10 full-time and one part-time academic CAP faculty. There is also close integration between the division of CAP and the rest of the department. For example, the directors of all outpatient services and the psychiatry residency training program are child and adolescents psychiatrists. There is only one psychiatry house staff group for all psychiatry, CAP, and integrated training track residents (called “combined training” in the program) and the chief residents in psychiatry and CAP work closely on issues. All clinical and administrative services as well as faculty and resident offices for the department are located in one building, facilitating the close working relationship between the two residency training programs. Since the department has a full continuum of services, neither training program needs to negotiate contracts for essential training experiences, except for those nonclinical rotations such as school, foster care, or juvenile justice. Another critical feature that contributes to the integrated training track is that all resident stipend support comes from the university General Medical Education Office. This gives the program greater flexibility in designing clinical rotations as well as the ability to individualize the training tracks and electives since the number of residents on rotations is not set by contract. With these advantages, it was a straightforward process in 1993 to establish a combined training track.
The combined training track differs from the psychiatry track by having the greatest exposure to CAP experiences permitted under the Residency Review Committee guidelines. However, the track still allows completion of psychiatry requirements by the end of PGY-4, thereby permitting the resident to sit for Part 1 of the ABPN at the usual time. Residents in the combined training track are also able to join ongoing CAP research projects from the start of training, although this is not a requirement.
Residents applying for the combined training track are interviewed by both the general psychiatry and CAP residency training directors and at least one other child psychiatrist. Each year the general psychiatry and CAP training directors meet at the end of applicant interviews and decide on the number of combined training positions to offer. For the first 5 years only one position was offered, but over the past 9 years at least two and occasionally three have been selected. The combined track can only accommodate three residents in the clinical rotation schedule. All combined training applicants are placed on both the psychiatry and the integrated training program rank lists. This allows applicants who are interested in the opportunity but not yet certain to delay their decision until they submit their rank order list. In addition, some residents know they want to be in Galveston for personal reasons, and this allows them two chances through the National Resident Match Program.
Conclusions and Future Directions
One of the possible factors influencing workforce recruitment in child and adolescent psychiatry (CAP) is waning interest in the CAP career path during psychiatry residency training. Earlier reports have indicated dramatic drop-offs in considering CAP as a career during residency training and the number of alternative psychiatry subspecialties has only increased since those studies. As presented in this report, identifying those residents interested in CAP and providing opportunities for didactic and clinical experiences throughout psychiatry residency training may counteract decreased retention. The revised Residency Review Committee guidelines provide a means to create alternatives in psychiatry residency training that offer earlier involvement in CAP that can sustain and enhance interest. However, double counting of experiences can only occur when the resident is identified as a CAP resident. The training program survey indicates that few programs have developed such pathways, but demonstrates that there are a variety of possible opportunities ranging from earlier exposure to CAP to more fully integrated “combined” training in psychiatry and CAP. To establish integrated training, residency training programs must deal with a number of considerations in order to make best use of resources and handle any constraints unique to their situation. The examples provided show a range of options, from early exposure through medium integration to combined training tracks. Other proposed solutions to the workforce crisis in CAP require extensive regulatory changes and program development. Integrated or combined training offers the chance to address the issue of recruitment within the existing structure of training. Further evaluation and development is necessary to determine the impact and outcome of these options in CAP training pathways, but the current programs offer important examples to guide future efforts.