The Hippocratic Oath says nothing about reimbursement. The practice of medicine, however, necessitates business knowledge. Nowadays, physicians must navigate through a sea of business terms during their busy workday all without obtaining a secondary business degree. While attempting to do their best for each patient, physicians must also attend to the financial aspects of their careers. The question that arose for me was how well are psychiatric residency programs teaching residents business management knowledge and skills given the realities of a 21st century medical practice? Additionally, if residency programs and residents did not believe the training was adequate, what might be done to improve this aspect of training?
In order to identify relevant literature on teaching practice management knowledge and skills to psychiatric residents, a search was conducted using PubMed and the Academic Psychiatry journal search engine. Once possibly relevant articles were identified, an additional hand search through each paper’s references was conducted. Search limits included: English language, all publication types, and within 10 years. Search terms included: business, insurance, practice management, reimbursement, training, and psychiatry.
The search found no published controlled trials on teaching practice management to psychiatric residents. This seemed surprising since psychiatry as a specialty has been greatly affected by the pressures of managed care. More recently in the psychiatric literature, Stubbe et al. (1, 2) published two companion articles examining residents’ and recent graduates’ exposure to practice management knowledge and skills. The surveys’ findings were consistent with previous surveys indicating that these residents felt three things:
1. Their training programs were not adequately addressing these issues.
2. Postgraduates surveyed felt ill-prepared to manage certain business aspects of their work and this created the majority of their career dissatisfaction.
3. Both recent graduates and current residents felt that training programs should more aggressively teach practice management knowledge and skills (1, 2).
As a consequence of this lack of information in the psychiatric literature, publications relating to other medical specialties were reviewed using the same search criteria outlined above. Most other medical specialties have more thoroughly researched the issues involved in teaching practice management skills utilizing surveys and descriptive studies. There were, however, no randomized controlled trials on practice management topics. In general, across many specialties, trainees and program directors felt similar to the residents in the Stubbe et al. (1, 2) surveys that programs are still not adequately preparing physicians for the new business realities of medical practice (3–7).
Two articles deserve special mention: Bayard et al.’s article “An Interactive Approach to Teaching Practice Management to Family Practice Residents” (6) and Babitch’s “Teaching Practice Management Skills to Pediatric Residents” (7). These articles describe unique programs that taught practice management knowledge and skills by integrating the didactics into their respective clinical rotations. Residents responded quite favorably to this approach.
Building a Private Practice: An In Vivo Experience
As with the residents in the previous studies, our residents voiced complaints that there was not enough focus in training on how to survive in independent practice. Residents would most often voice this concern during resident meetings, the annual spring retreat where residents met without faculty members to compile feedback on the training program, and in written annual feedback regarding their experience with the program.
Given the residents’ concerns, our program decided to implement changes to improve our teaching of practice management knowledge and skills. In considering what changes to make, I reached out to other academic clinicians and mentors to see if there was prepackaged course material that I could introduce as part of the practice management training. I was referred most often to the American Medical Association (AMA), APA, and American Academy of Child and Adolescent Psychiatry (AACAP) websites, which have free manuals for their members on practice management (8–10). However, the fact remained that utilizing them primarily in a didactics program would not be new (as our program already had didactic time allotted for practice management). Furthermore, additional didactics did not address the residents’ request for more direct exposure to practice management during training.
Therefore, the major shift in creating the reformatted clinic was that it be converted to an in vivo experience. Didactics, while important, were only one aspect of the new clinic. A more explicit shift needed to occur in order to immerse the residents—residents needed to experience this as if the clinic was their own newly started independent practice. In order to heighten this idea at the beginning of each year, residents are instructed to consider this half-day clinic as “their independent practice.” Each resident would have his or her own patient population to manage, as clinically indicated, while also running the business aspects of an independent practice. Each resident had an income goal and received quarterly productivity snapshots with gross and net incomes and projected yearly gross and net incomes. Additionally, the residents were expected to draft a business proposal for their posttraining aspirations. Each month the residents had a didactic hour on different aspects of medical business practices. Residents also met individually with me quarterly to review their independent practice’s progress for assistance in formulating their posttraining business goals. As an additional motivating measure (one that is commonly seen in the independent practice arena), one resident won a “productivity award” for her contributions to the clinic based on her overall gross productivity for the year. Gross productivity was employed as it is an easily calculated number (unlike net productivity, which is linked to insurance reimbursement factors). Although issues with insurance reimbursement factors were discussed in the didactics and informally during clinic time, net productivity was not considered a fair value on which to base the productivity award, as the residents did not have any direct control over which insurance type their patients utilized.
Residents’ feedback regarding this experience was consistently high. All of the graduating residents (2006–2007) considered the clinic to be a “novel” experience for learning about practice management. As part of the clinic revisions, graduating residents and current child and adolescent psychiatric residents were asked to complete an anonymous survey regarding the entire Baylor Child and Adolescent Psychiatry program’s practice management curricula (Table 1
). Three out of four graduates returned the survey and seven out of eight current residents returned the survey. Although the number of respondents was small, there appeared to be a trend toward improved practice management knowledge (Figure 1
). Clearly, the biggest limitation is the small number of residents involved in the training program. An additional limitation is the fact that the survey does not actually test the resident’s competency in the practice management topics. A final limitation is that the survey did not directly ask how much the Baylor Clinic was responsible for the improvement. The survey does ask residents to rate how much time each individual clinical site focuses on practice management (1=not at all; 5=most days). This item has relevance only for graduating residents who have completed all of the clinical rotation sites. Our goal is to repeat the survey yearly so that we can gather more data to:
1. Compare how well overall the program is addressing this important aspect of training.
2. Compare how well the Baylor Outpatient Clinic meets its educational goals and objectives for practice management training.
3. Gather additional suggestions residents may have for improving the practice management training experience in the program as a whole.
Discussion and Conclusions
Practice management is an increasingly vital skill base that physicians must be able to understand and apply. The psychiatric residency review committee does require, albeit vaguely, practice management exposure and knowledge (10). Most medical specialty program directors and residents indicate a need for improved teaching of this special topic (1–7). Yet despite the requirements and desire for more practice management exposure, psychiatric training programs have been slow to respond (1–2). Despite the limitations of our small sample size, our residents concurred with the larger desire of other medical specialty program directors and residents to have practice management be more fully incorporated into the training experience. Additionally, the graduating residents felt the newly reformatted child outpatient experience in the Baylor Psychiatry Clinic offered a novel method to increase their practice management knowledge and skills. In the literature review and in our experience with our newly reformatted clinic we recommend that program directors should:
1. Whenever possible work to incorporate learning practice management into clinical work in addition to didactics. Including items such as productivity measures and gross and net revenue appeared to make a positive impact on our small group of trainees and had the added benefit of not requiring too much additional time for the faculty member to prepare.
2. Having outside experts (insurance, contracts, ethics, etc.) lecture can assist residents in gaining practical knowledge and advice on practice management issues. As it is likely many programs already offer didactics on practice management we recommend that these lectures be associated with a continuity clinic so issues discussed in lecture could be directly applied and discussed during the clinical rotation.
FIGURE 1. Practice Management Knowledge based on Self-Evaluation after Residency Program
See Table 1 for questions. Scoring based on Likert-scale: 1=not at all prepared, 5=very well prepared.
At the time of submission, the author disclosed no competing interests.