The business of medicine is not often discussed within training programs, and many psychiatric residents are unprepared to pursue the business and contractual aspects of securing employment after graduation. Once employment is obtained, many residents lack the understanding of the management principles necessary to sustain a successful practice. A review of the literature found minimal information on training psychiatric residents in practice management. The Canadian Psychiatric Association published an article on “Navigating the Transition to Practice”; however, this focused mainly on the emotional loss of leaving one’s training program rather than the managerial and business skills needed to do well outside of a training program (1).
A 12-week course during the fourth postgraduate year (PGY-4) year at Case Western Reserve University, which covers key business topics relevant to psychiatric practice, was presented at the 2006 annual meeting of the American Association of Directors of Psychiatric Residency Training (2). An extensive review of the published curricula offered to psychiatric residents online revealed that in programs where practice management curriculum has been offered, it has been during the fourth year of training. The curricula have focused on transition to practice and ethical dilemmas or on specific concepts such as billing and coding. Providing practice management education at the end of residency does not allow residents to incorporate their learning into their training and limits the educational experience. In response to resident feedback regarding the lack of practice management education and the need for competency in systems-based practice, the authors designed a course to achieve these goals.
Prior to 2005, our psychiatric residency provided education on practice management, but the majority of the teaching was unstructured. To determine if we were providing optimal training in this area, we asked our graduates at 1 year and 5 years postgraduation whether they felt prepared for business management. In a survey of our 2000 and 2001 graduates 5 years after graduation, (n=9 with a 64.3% response rate), 89% of the responders (n=8) indicated that they felt unprepared or totally unprepared for business management. In a survey of our 2004 and 2005 graduates 1 year after graduation, (n=8 with a 57.1% response rate), 37.5% of the responders (n=3) indicated that they felt unprepared or totally unprepared for business management. Subsequently, with this information and with the feedback from our current residents, it was determined that a change in our practice management education was needed.
The course is based on the organization and integration of eight domains of knowledge as specified by the American College of Medical Practice Executives (ACMPE) and the Medical Group Management Association (MGMA). The ACMPE and MGMA represent approximately 270,000 physicians and 19,000 administrators in the field of medical practice management. It is the largest association of medical practice executives in the United States.
The eight domains as described by the ACMPE and MGMA include (3):
2. Human resources management.
3. Planning and marketing.
4. Information management.
6. Governance and organizational dynamics.
7. Business and clinical operations.
8. Professional responsibility.
The Practice Management Seminar that we developed is structured into modules with each module representing one of the eight domains; every module includes four weekly sessions occurring over a 32-week period during PGY-3. It is a logical fit to have a structured practice management course during the outpatient year, when the resident practice closely mirrors a group practice structure. The goal is for residents to apply the knowledge gained during the course to their current group practice.
The schedule is as follows:
Week 1: Lecture and introduction from a specialist on topic.
Week 2: Discussion of topic and assignment of projects to develop better understanding of topic.
Week 3: Meeting with clinical adviser to discuss the relevance of the topic to outpatient practice.
Week 4: Presentation of projects and further discussion.
During the first 2 years of the course, 5-week modules were used which included 2 weeks to work on individual projects. However, based on resident feedback, time is now dedicated to discussion about the way each topic affects their current outpatient practice. The switch from 5-week to 4-week modules also allowed us to reduce the overall length of the course without reducing the educational value.
During the first week, the domain is introduced by an expert in the field from within our institution, which includes a 1-hour lecture regarding the key concepts related to the topic (Table 1
). Experts are instructed not to get too detailed, but rather to give residents specific concepts that would be useful as medical professionals. Additionally, the speakers are encouraged to focus on general concepts that can be applied in a multitude of practices rather than the model used at our institution.
During the second week, the class meets with the group leader to further discuss the topic and develop a better understanding of the key concepts. Projects are then assigned for that domain. Project assignments are not meant to be time or labor intensive, and the goal is for residents to learn what questions to ask and whom to seek out for help in each specific domain. Furthermore, residents are encouraged to choose projects based on their own personal interests, in order for the projects to be more meaningful to them.
For week three of each domain, the group meets with a clinical adviser to discuss the topics relevance to their current outpatient practice. For the final week, the group reconvenes to discuss the residents’ individual projects and share the knowledge that they gained from completion of the projects. Wrap-up and further questions on the particular topic are discussed at that time (Table 1
Limited literature on this subject indicates that there is not an established method in educating residents in practice management (4–6). Our approach incorporates multiple learning modalities, including lecture, small group discussion, and hands-on projects. Additionally, residents develop a mentoring relationship with the course leader and faculty to discuss practice management issues that arise not only in the course, but also after completion of it. Considerations for implementation of a similar practice management course in other residency programs include time, money, personnel, and faculty.
The Accreditation Council for Graduate Medical Education (ACGME) has encouraged practical implementation of the competencies in addition to demonstrations of data-driven improvements. This course was designed in response to surveys from our graduates, in which the majority of them felt unprepared for practice management both 1 and 5 years after completion of residency. A course evaluation was e-mailed to the residents after completion of the course. Four of the six residents (66%) completed and returned the survey. All comments were favorable regarding the course content and approach to teaching. All respondents felt that the course met or exceeded their expectations. Other resident feedback from within the last year resulted in a revision of course structure. The course length was decreased to improve efficiency, while simultaneously incorporating real world learning in how the course impacts the current resident practice.
The projects within the practice management curriculum provide education to the residents regarding the development and benefit of data-driven improvements in real time. For example, during the business and clinical operations domain, a resident reviewed the no-show policies of local psychiatric practices; subsequently, this information was brought to the department access committee and no-show task force. With this information, several different strategies were implemented, allowing the department to decrease the number of no-shows of new patients in the PGY-3 outpatient clinic by half in a 12-month time frame.
The long-term benefits of this course have not yet been realized, as the first group of residents to complete it only recently graduated. Future steps will include reassessment of the graduates, at 1 and 5 years postgraduation, to determine the effectiveness of the course.
The ACGME has recognized the importance of practice management by incorporating it into the systems-based practice competency. Despite this, the majority of psychiatric residency training programs do not have a formal, structured curriculum on practice management. The practice management curriculum described here could be altered to fit any residency program and concepts learned during the course may be integrated into data-driven improvements within the residents’ clinical practice. Future studies are needed to assess the long-term efficacy of practice management education.
As a member of the Medical Group Management Association, Dr. Menaker received honoraria for presenting at the 2008 annual meeting. At the time of submission, Drs. Wichman and Netzel disclosed no competing interests.