Table 1 presents the salient characteristics of psychiatry residency training in the five countries.
TABLE 1.Summary of Key Features in Psychiatry Residency Training of All Five Countries
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|Characteristics||United States||Canada||United Kingdom||India||Nigeria|
|Total psychiatry programs aa||183||16||14 deaneries bb||132||8|
|PGY-1 positions aa||1,097 categorical||146 for Canadian medical graduates; 16 for IMGs||481 CT1(equivalent of PGY-1)||324||30–40 (estimated)|
|Regulatory board||American Board of Psychiatry and Neurology (ABPN) and Accreditation Council for Graduate Medical Education (ACGME)||Royal College of Physicians and Surgeons of Canada (RCPSC)||Postgraduate Medical Education and Training Board (PMETB) and Royal College of Psychiatrists (RCP)||Medical Council of India (MCI)||West African College of Physicians (WACP) and National Postgraduate Medical College (NPMC)|
|Duration||4 years||5 years||6 years (includes specialty training)cc||3 years (+3 years for academic position)||4–6 years|
|Duty-hours||80 hours/week||None specified||48 hours/week||No guidelines||No guidelines|
|Core competencies||Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and System-Based Practice||Medical Expert, Communicator, Collaborator, Manager, Health Advocate, Scholar and Professional||Medical Expert, Communicator, Collaborator, Manager, Health Advocate, Scholar and Professional||Not clearly defined||Not clearly defined|
|Psychotherapy||Competence required in supportive, cognitive, and psychodynamic, and some exposure to family, couples, and group therapies||Mandatory training in cognitive, psychodynamic, group, and family therapies||Training required in minimum of three short cases and one long-term individual case, along with experience of group or family therapy||Mostly theoretical training; some exposure to cognitive and supportive modalities||Mostly theoretical training; some exposure to supportive therapy|
|Research||Research and publication requirements by some programs; others require participation in a QA/QI project||Expectation to complete a QA/QI or research project at least once during residency||Strong emphasis on clinical audits (like QA/QI); case reports or a small literature review in Core Psychiatry training||Requirement to do 2 years of clinical research, followed by dissertation and submission of written thesis||Mandatory 2 years clinical research leading to dissertation|
|Evaluations||Evaluation after each rotation (usually 360-degree), patient logs, annual PRITE and CSV exams||ITERs, FITER, and passing of oral exams during residency training||WPBA and ARCP||Variable; annual in-training written and clinical exam||Annual appraisal of progress and maintenance of the trainee log-book|
|Board certification||ABPN certification, Part I (written) and Part II (clinical); (CSVs will replace Part II in Year 2013)||RCPSC exam, consisting of written and oral (OSCE) components||MRCPsych examinations consisting of three written examination papers and CASC (clinical) examination||University-based written and clinical exam and evaluation of research dissertation||WACP professional written and clinical exam and evaluation of research dissertation|
Structure of Training and Clinical Experience
In the U.S., psychiatry categorical residency training consists of 4 years of training (7). There is ample exposure to various Axis I and Axis II psychiatric disorders. Subspecialty training opportunities are available in the fields of addiction, child and adolescent psychiatry, forensic, and geriatric psychiatry, as well as psychosomatic medicine, clinical neurophysiology, pain medicine, sleep medicine, and hospice and palliative medicine (8). Medico-legal concerns and managed-care pressures sometimes affect clinical decisions.
In Canada, residency training is 5 years, divided into a basic clinical year, core training years, and a senior year (9). There are no managed-care pressures, as psychiatric care is reimbursed by the provincial health ministries. There is adequate exposure to both Axis I and Axis II psychopathology. Compared with the U.S., the threshold to admit patients is higher, which may be due to lower litigation rates (10). Subspecialty training is available in psychosomatic medicine and child, geriatric, and forensic psychiatry (9).
In the U.K., there has been a radical change in graduate medical training requirements since the introduction of ‘Modernising Medical Careers in 2005 (11). After medical school, junior doctors are required to undertake a 2-year foundation program. Psychiatry training is divided into core training (CT-1 to -3) and specialist training (ST-4 to -6) of 3 years each (12, 13). Health care is covered by the government-funded National Health Service (NHS). Whereas there is good exposure to Axis I pathology, less-severe disorders and Axis II pathology are often treated in primary care. Patients with severe and persistent mental illnesses are followed by the community mental health teams, leading to good exposure to community care during residency training (14). Specialist training is available in general adult psychiatry (subspecialties include: liaison, substance misuse, and rehabilitation), learning disability, psychotherapy, and child and adolescent, forensic, and geriatric psychiatry.
In India, training is 3 years (15). A 1-year internship in all major primary-care specialties is required before completion of medical school (16). After completion of the 3-year residency, a 3-year “Senior Residency” option is available to develop a career in academic, administrative, and research psychiatry. Trainees usually have good exposure to various psychiatric disorders, although they may have more experience with severe manifestations of Axis I disorders than do U.S. trainees. Personality disorders are less often seen. Detailed recognition of psychopathology is emphasized (15). Trainees may have more experience in the use of first-generation antipsychotics and clozapine. The quantity of clinical experience may be more intense, as there is a paucity of psychiatric services, fewer restrictions on work hours, and less pressure for record-keeping. Trainees may have less experience in patient care coordination with ancillary psychiatric services, as these services are few. Physicians usually expect greater autonomy in patient care because of the paternalistic culture in the medical system, fewer legal restrictions, and greater family influences on patient-care decisions. Subspecialty training is poorly developed.
In Nigeria, residency training has two parts: Part 1 (Junior Residency) and Part 2 (Senior Residency), each consisting of 24 to 36 months of training (17). Candidates must pass the Part 1 examination before proceeding to Part 2. After successful completion of Part 2, an individual is designated a Fellow of the West African College of Physicians (WACP) (18). Overall, the clinical experience is similar to that in India, except that trainees have less experience in the use of atypical antipsychotics, because of their unavailability.
In all five countries, residents must understand the indications of electroconvulsive therapy (ECT) (9, 12, 15, 17, 19). Trainees become proficient in the prescribing, administration, and monitoring of this treatment. In most programs, it is learned throughout the training period, and electives are also available. The use of ECT varies among these countries. It has declined in the U.S., Canada, and the U.K., but it continues to be commonly used in India and Nigeria (20).
Curriculum and Competency Expectations
In the U.S., psychiatry residents must train for a minimum of 4 months in primary care, 2 in neurology, 6 in adult inpatient psychiatry, 12 in continuous adult outpatient psychiatry, 2 in child and adolescent psychiatry, 2 in consultation–liaison psychiatry, 1 in geriatric psychiatry, and 1 in addiction psychiatry to sit for the board certification examination (19, 21). Electives are usually completed during PGY-4.
In Canada, PGY-1 includes rotations in inpatient psychiatry and primary care (9). PGY-2 trainees rotate through inpatient and outpatient services. PGYs-3 and -4 include child and adolescent, chronic care, consultation–liaison, substance abuse, and geriatric rotations. In PGY-5, residents choose elective rotations (9). Up to one-half day per week throughout PGY-2 to -5 may be spent on clinical or research electives.
In the U.K., the first 3 years of psychiatric training (CT 1–3) involve a minimum of 12 months’ experience in general-adult psychiatry and some experience in child and adolescent psychiatry, old-age psychiatry, and psychotherapy. Trainees must then choose their subspecialty (ST 4-6), in which they will eventually be awarded their certificate of completion of training (CCT) (12, 13).
In India, training comprises a minimum of 12 months of inpatient psychiatry, 6 in outpatient psychiatry, 4 in addiction psychiatry, 2 in consultation–liaison psychiatry, 2 in neurology, 1–2 in state mental hospital/community psychiatry, and 1–2 in psychotherapy/psychological evaluations (15, 22). Requirements vary from program to program.
In Nigeria, psychiatry rotations during the Part 1 program include 6 months of adult, consultation–liaison, and child-and-adolescent, and 3 months of neurology. Geriatric, forensic, addiction, community and rehabilitation, social and transcultural psychiatry, and psychotherapy are covered during Part 2 (17).
In all five countries, didactics comprise a systematic course of lectures and seminars covering basic sciences, clinical topics, communication, and interviewing skills. Teaching also occurs through grand rounds, clinical case conferences, journal clubs, and psychotherapy seminars. Table 1 outlines the competency requirements for the five countries (9, 12, 23, 24).
In the U.S., the Accreditation Council for Graduate Medical Education (ACGME) in 2003 established a maximum 80-hour work-week for residents (23). The duty-hour distribution and directives for levels of supervision, especially for PGY-1 trainees, have further changed beginning in July 2011 (25).
In Canada, resident unions, whose primary interest has been residents’ well-being, have negotiated a series of reduced duty-hours that approach those in the U.S. However, the authors were unable to find any duty-hour restrictions specified by the Royal College of Physicians and Surgeons of Canada (RCPSC) (9).
In the U.K., residents are restricted to an average of 48 hours per working week, specified by the European Working Time Directive (EWTD) (26).
In India and Nigeria, there are no duty-hour regulations. Work hours depend on the workload and the number of residents available. Typically, the work schedule varies by hospital, and junior residents work more than senior residents.
In the U.S., residents are required to develop competence in applying supportive, psychodynamic, and cognitive-behavioral psychotherapies. Residents are exposed to family, couples, group, and other individual, evidence-based psychotherapies (19).
In Canada, psychotherapy training is included in the core rotations one-half day per week (9). Trainees have 4 months of skill-building sessions with psychiatrists and psychologists. Afterward, residents fulfill competency in four modalities of therapy: cognitive-behavioral, family, group, and psychodynamic (9).
In the U.K., there are five basic requirements for psychotherapy (12): development of interviewing skills, psychotherapeutic formulation, a minimum of three short-term cases (12 to 16 sessions), one long-term individual case (12 to 18 months), and some experience in group, couples, family, or systemic therapy.
In India and Nigeria, exposure to psychotherapy is required but frequently deficient for many reasons. Psychotherapy, as practiced in the U.S, is not suitable for majority of the population because of the different socio-cultural milieu, religious beliefs, medical paternalism, and lack of psychological sophistication of patients (27). Psychotherapy is not popular, and there is a shortage of qualified therapists (27, 28). Training is mostly theoretical, and there are no set competency development guidelines. Psychotherapy training varies by program. The emphasis is usually on the cognitive-behavioral and supportive modalities. Supervision in psychotherapy is usually provided by M.D. faculty.
Research and Teaching Activities
In the U.S., residents are exposed to research to promote an atmosphere of curiosity and academic inquiry (19). Most programs require trainees to participate in at least one quality-assessment and quality-improvement (QA/QI) project. Despite opportunity, research experiences during residency are typically brief and fragmented across years of training (29).
In Canada, residents must present a quality-assurance or a research project at least once during their training (9). The PGY-3 curriculum assists residents in this with exposure to research methodology and critical appraisal skills. The optional research mentorship program provides high-quality research experiences (9).
In the U.K., opportunities are available to participate in supervised research. In core psychiatry training, research may include clinical audits (similar to QA/QI), case reports, or a literature review. In advanced training, residents may participate in original research (12).
In India, 2 years of prospective clinical research is required under faculty mentorship (15, 16). The limited infrastructure and paucity of funding may affect research quality. Candidates must present and submit a dissertation for evaluation before residency completion (15, 16).
In Nigeria, during Part 2 training, trainees must conduct research projects over a 2-year period, resulting in a dissertation (17).
Psychiatry residencies in all five countries emphasize the development of teaching skills (9, 12, 15, 17, 19). Trainees have opportunities to assist in ‘bedside’ teaching of medical students and delivering supervised small-group teaching. India offers additional training as “senior resident” for 3 years after residency for those interested in an academic and teaching career (16).
Evaluations and Board Certification
In the U.S., trainees are required to document patient logs and complete both written (Psychiatry Resident-In-Training Examination) and Clinical Skills Verification (CSV) annual examinations (7, 19). Programs must complete competency based evaluations (usually including 360-degree evaluations) upon completion of each rotation and maintain a record for various psychotherapy competencies. Graduating residents sit for the American Board of Psychiatry and Neurology (ABPN) examinations and must pass a Part I written exam and a Part II clinical skills exam to become board certified psychiatrists (7, 19). The Part II exam will soon be replaced by a minimum of three successful in-residency CSV examinations.
In Canada, there are two formal methods of evaluating residents (9). One is via in-training evaluation reports (ITERs), completed by a supervisor at the end of a specific rotation. Observed interviews are a key evaluation process, as are records of types of patients seen and therapies administered. Second, residents are must pass two long-case psychiatric interviews in their final year. Near the completion of training, a final in-training evaluation report (FITER) is sent to the RCPSC. Certification occurs upon satisfactory completion of residency and additional national written and oral exams administered by the RCPSC.
In the U.K., there is a greater emphasis on Workplace-Based Assessments (WPBA) (12, 13). WPBA focuses on evidence-based workplace performance, evaluated by different assessors during each year of training. Each trainee is subject to an Annual Review of Competence Progression (ARCP). Trainees are required to complete the Membership of Royal College of Psychiatrists examinations (MRCPsych), consisting of three written examinations and a clinical assessment of skills and competencies (CASC) examination, at appropriate training levels (12, 13).
In India, the trainee must pass the university-based exam in psychiatry, which evaluates theoretical, clinical (patient interview) and research skills (15, 16). A passing score of 50% in all areas is required. The theory exam comprises essay questions; the internal evaluation of the candidate accounts for 20% of the final evaluation, including annual or semiannual in-training exam scores.
In Nigeria, the certification examination is two parts: Part 1 and Part 2 (17). The WACP provides each trainee with a logbook in which supervisors approve all rotations and procedures. Also, the institutional training coordinator conducts an annual appraisal of each trainee’s progress. The Part 1 examination includes a written essay exam and a clinical exam. The Part 2 examinations include an oral defense of a research dissertation and an oral course examination. The resident must pass all sections of each exam.
In the U.S, Canada, and the U.K., the process of constructive feedback is an integral part of learning and teaching. But, both in India and Nigeria, it is weak and ill-defined. Often, one-to-one feedback has a negative connotation and is viewed as a punishment. (See Table 2 for a comparison of evaluation approaches in the various programs.)
TABLE 2.Comparison of the Training Evaluation Processes
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|Evaluation Type||United States||Canada||United Kingdom||India||Nigeria|
|Day-to-day||Direct feedback||Direct feedback||Direct feedback||Direct feedback||Direct feedback|
|End of rotation||360-degree (based on competencies)||ITER (and FITER at the end of training)||WPBA including ACE, CBD, and MSF||None||Log-book evaluation by supervising attending|
|Semiannual||Meeting with program director||Meeting with program director||Meeting with program director||In-training theory and practical exam aa||None|
|Annual||PRITE and CSV||Oral examinations, including STACER in the final year||Annual Review of Competence Progression (ARCP)||In-Training Theory and Practical Exam aa||Annual appraisal of progress by training coordinator|
|Psychotherapy||Evaluation based on video sessions review, case write-ups, and psychotherapy supervisor evaluations||Evaluation based on training experience and psychotherapy supervisor evaluations||Weekly CBDG in the first year; SAPE used for psychotherapy evaluation||Evaluation based on case write-ups||None|
|Research||Mostly demonstration of QA/QI project; some programs may have other specific clinical research requirement||Evaluation done by the residency training committee||Case report or small literature review in the Core Psychiatry training; original research required in ST4–ST6||Requirement to carry out a clinical research project; evaluation of dissertation as part of final evaluation||Clinical research and evaluation of dissertation as part of the final evaluation|
|Final evaluation||ABPN certification examination||RCPSC certification examination||MRCPsych examinations||University-based essay-type written and practical exam||WACP examination|
Historically, IMGs have contributed significantly to the U.S. physician workforce across all specialties, particularly psychiatry (4). If these physicians are to be successfully integrated into American medicine, conscious effort needs to be directed toward the facilitation of their training and learning (5). U.S. psychiatric educators may benefit from information on the training methods and processes in other countries. A number of potential training implications are discussed below.
In the U.S., Canada, and the U.K., the curriculum is well-planned, and emphasis is placed on the consistent meeting of core competencies. Supervision, feedback, and evaluation are well-structured in the U.S., which may cause uneasiness for those IMGs used to a more informal style of assessment. Learning and identifying psychopathology is more emphasized in the U.K, India, and Nigeria, requiring longer patient evaluations. Previously-trained IMGs may struggle to finish their evaluations in an abbreviated period of time. Moreover, lack of familiarity and communication difficulties may lead to problems in diagnosing and managing personality disorders. Previously-trained residents from India or Nigeria may have limited clarity regarding the practical applications of psychotherapy techniques, which may interfere with the acquisition of accurate psychotherapy skills. Alternatively, they may be more experienced in the use of ECT. Residents with previous training in the U.K. may have increased competence in community psychiatry. Residents from Nigeria may tend to prefer first-generation antipsychotics because of limited experience and the unavailability of second-generations in Nigeria. Finally, a prospective clinical research project requirement in Indian and Nigerian residency training may enhance trainees’ broad understanding of research methodology.
As educators, we must acknowledge some potential strengths and weaknesses of IMG trainees with previous psychiatric training. First, a wealth of knowledge and experience regarding psychiatric theory and practice is brought to their program. Motivational issues may be lessened as these trainees have a consistent and genuine interest in psychiatry. They may function at a higher level than other junior trainees, potentially serving as peer mentors and role models. Alternately, those who used to be at the top of their professional ladder may struggle with identity and role confusion. Unlike recent medical school graduates, these trainees may have well-formed professional opinions and attitudes, potentially resulting in conflict with faculty. As countries vary in their theory and practice of psychiatry, discord may arise during patient evaluations and didactics. Cultural differences in the doctor–patient relationship may contribute to further conflicts, especially regarding patient autonomy. Psychiatric educators should remain diligent in monitoring these matters so that previously-trained IMGs’ strengths can be developed and weaknesses attended to early and effectively. Further studies are needed to understand these aspects of retraining of previously-trained IMGs.
This study has some important limitations. First, we selected the countries and programs because we have trained there. The descriptions may not completely generalize to all other programs from the same countries. Second, the descriptions of the programs include the experiences and perceptions of the individual authors, although we reviewed the available literature and synthesized the information available on websites and official documents.
Nevertheless, this article provides a detailed comparison of psychiatry residency training in the U.S., Canada, the U.K., India, and Nigeria. It provides an outline of possible strengths and weaknesses of previously-trained IMGs. We emphasized systems-based aspects of training in other countries that may interfere with the integration of IMG psychiatric residents into the U.S. residency (especially those who were previously trained; Table 3). Despite numerous commonalities, there are differences in psychiatry training among the five countries. U.S. psychiatric educators’ awareness of these subtle differences in the education, values, systems, and interactions may facilitate acclimation of IMGs.
TABLE 3.Possible Systems-Based Issues in Previously-Trained IMG Psychiatry Residents
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|1.||Respect of patient’s autonomy|
|2.||Change in classification and diagnostic system (ICD to DSM)|
|3.||Experience with personality disorders|
|4.||Limitations of psychotherapeutic experience|