One definition for the word "retreat" in Webster's Dictionary (1) is "an act or process of withdrawing, especially from what is difficult, dangerous, or disagreeable." These days much is difficult and disagreeable regarding graduate medical education. Residency training programs in psychiatry face major challenges: adapting to reductions in graduate medical education (GME) funding, incorporating new advances into the curriculum, meeting the demands of the Residency Review Committee (RRC) and Health Care Financing Administration (HCFA) regulations, teaching new skills and knowledge residents need to function effectively in managed care environments, and responding to shifting recruitment scenarios. These challenges must be dealt with effectively to prevent low morale and fragmentation among both residents and faculty. Departmental retreats are one mechanism to help faculty and residents analyze and plan responses to these challenges.
Retreats have been described in the literature outlining approaches for residents and faculty development, teaching humanistic skills, facilitating resident evaluation of faculty performance, fostering residents' teaching skills, teaching critical reading skills, and reducing stress (2—8). However, the literature specific to psychiatry includes only one brief letter to the editor describing the authors' use of retreats and reporting results from a survey of psychiatry department chairs across the country, indicating that 42% sponsored retreats (9).
In this report, we describe our experiences with a department-wide resident-faculty retreat developed for our training program to examine the performance of our program to date and to formulate recommendations for change in its curriculum and service rotations. Before the retreat, we assessed areas of satisfaction and dissatisfaction with our program among alumni, current residents, and faculty. We also conducted a detailed analysis of the program's contribution to the general hospital's finances. A consultant participated in planning; facilitated discussions; and provided valuable, objective assessment and comment on various issues that emerged. A follow-up plan for action was formulated and carried out.
To our knowledge, this report is the first in the psychiatric literature that describes such processes. Our report is also noteworthy in that it describes the efforts of a free-standing, community-based hospital residency training program to comprehensively assess its performance and, based on performance measures and an assessment of various external pressures and perceived strengths and weaknesses, chart a future course of action.
The psychiatric residency training program at Brookdale University Hospital and Medical Center (BUHMC) has been fully accredited since 1967. It has 20 residents, and its faculty includes 22 full-time psychiatrists and 10 consultants. The medical center is located in an underserved, inner-city section of East Brooklyn and provides medical and psychiatric services for a population composed primarily of ethnic minorities and recent immigrants. With the advent of managed care and reductions in New York State support and financing of the health care industry, BUHMC has been forced to reexamine its priorities on educational and service issues. The retreat was held in March 1998, at an outside conference center, with the full support of the department chair, the faculty, and residents, and was funded by unrestricted educational grants from pharmaceutical companies.
A committee of key members of the faculty and the chief residents met weekly starting in January 1998 and decided that several areas about the program's performance, faculty and resident morale, and the medical center's and department's finances would be carefully studied and reported on at the retreat. The following specific issues were framed for discussion and for generation of action plans at the retreat.
Service vs. Educational Conflicts
The total number of adult outpatient visits to the department rose from 22,925 in 1995 to 27,095 in 1996 to 29,543 in 1997, while the average number of available therapists dropped from 18.5 to 14.35 in those same years due to departmental downsizing secondary to the hospital's financial distress. Projected visits for 1998 were 31,473, and the number of therapists dropped further to 13.45. The two inpatient units, with a total of 57 beds, were operating at 100% census. Residents play a key role in service delivery, and faculty have less time available for training and education. How do we maintain educational quality while facing multiple demands on residents' and faculty's time for noneducational tasks?
Cultural Issues Related to Education
How can the program help its trainees, who are mostly international medical graduates (IMGs), successfully acculturate and excel as psychiatrists in the United States?
Financial Pressures on the Educational Program
Medicare is making major changes and cuts in the way GME is financed, and managed care companies refuse to pay for GME. The GME Demonstration Project launched by the Greater New York Hospital Association (10) forced BUHMC to reevaluate its educational mission and to consider downsizing. This requirement provided an impetus for our training program to evaluate its contribution to the hospital. As a "safety-net" medical center—based training program, can the program "afford" to downsize and, if so, at what cost?
What Is the Training Program's Social Mission?
Does the program have an impact on our community's, region's, and nation's delivery of quality medical care to the indigent beyond the immediate provision of care at BUHMC? What is the record of its residents in caring for poor, needy populations?
Quality of Training and Education
How successful is the program in training future psychiatrists and how satisfied are graduates with their training? What have their board certification experiences been? How satisfied are the current residents and faculty with their experiences in the program, and what changes do they recommend?
Each member of the preparatory committee took responsibility for conducting a survey that addressed one of the following areas: 1) resident satisfaction, 2)faculty satisfaction, 3) alumni satisfaction, and 4)patient satisfaction. Residents' performance in the Psychiatry Resident In-Training Examination (PRITE) and the department's annual mock board examinations were also reviewed. Alumni, faculty, and patient satisfaction surveys were developed specifically for this retreat, while resident satisfaction was measured by a 10-item survey developed by the American Association of Directors of Psychiatric Residency Training Taskforce on Quality in Residency Education (11). This survey was repeated 8 months after the initial administration in October 1998 to measure potential changes in attitudes.
Faculty responded to a 49-item survey that used Likert-type scales to estimate the extent to which requirements resulting from managed care affected various areas of their professional lives and how their professional and academic activities had changed over the past 5 to 10 years.
The alumni survey was composed of 86 items assessing demographics, training issues while at Brookdale, how well training had prepared the residents for different areas of practice, first job after residency, current position, academic and professional activities, and board-certification history. Alumni were also asked to offer comments and suggestions about their training. More detailed accounts of the faculty and alumni surveys will be reported separately. Copies of all survey forms, detailed analyses of the responses, and copies of the retreat agenda are available on request from the authors.
The retreat was scheduled as a daylong event. Various reports were presented during the morning session. The afternoon session consisted of resident, faculty, and resident-faculty group discussions that focused on the specific questions the retreat was to address. The consultant played a key facilitative role throughout the day, responding to survey results and sharing his own experiences in psychiatric education. At the start of the retreat, the participants were provided with the agenda for the retreat and with statements summarizing the key findings of each survey.
Summary of Survey Results
Every effort was made to locate all alumni since 1968 who had undertaken more than 2 years of training at BUHMC. Of 140 such alumni, addresses were located for 112, of whom 65% returned completed surveys. The responses suggested that the graduates are pleased with the training they received at BUHMC and would recommend the program to applicants. The graduates felt that the program had better prepared them to treat psychotic, affective, and substance abuse disorders than to treat personality disorders or childhood disorders. They recommended more training in briefer therapies and cognitive—behavioral therapy. More than 90% of the respondents agreed that they saw a wide range of clinical problems, that their training provided ample opportunities for learning, that they were given appropriate patient care responsibility, and that they were very satisfied with the training they received. Fewer 1990s graduates than graduates from earlier decades (only 56%) agreed with the statement that education had greater priority over service.
Foreign-born IMG alumni were significantly more likely to work with chronically mentally ill/substance abusers, patients with Medicaid or no insurance, and minority populations in their current job than were U.S. medical graduates and U.S. IMG alumni. More than 80% of the respondents attempted Part I of the American Board of Psychiatry and Neurology (ABPN) within 2 years of graduation, and 72% of those reported that they passed on the first attempt. Sixty-six percent of the respondents attempted Part II, and 62% of those passed on the first attempt. The overall rate of board certification among the respondents was 53.5%. Completed faculty surveys were collected from 76% of the faculty and consultants. The results suggested that, due to increasing administrative and clinical responsibilities, more than one-third have less time for teaching and supervision now, compared with 5 to 10 years ago. Nearly one-half reported low morale about their field, role, and lower professional satisfaction, and one-third reported less enthusiasm for teaching and supervising than they had 5 years ago. Decreased resident interest in learning was given as the principal explanation for having less enthusiasm for teaching.
The resident survey indicated general satisfaction with the training program but highlighted certain areas that could be improved. The residents perceived that, secondary to staff cuts in the recent past, service had taken greater priority over education. However, they also highly rated the quality of classroom teaching. The residents also gave high ratings to the level of support they received from their peers, indicating a sense of cohesion among them in facing these challenges.
For the residents, increased stress has been caused by increasing caseloads, shorter lengths of stay, high rates of readmission, and having to care for higher numbers of violent and substance-abusing patients. The residents also experienced as very stressful time spent on the telephone obtaining managed care approvals for clinical work and meeting increasing demands for documentation. The approximately 2 hours per day spent in didactics diminished their time for clinical work. At the same time, a comparison of PRITE scores of each PGY group of residents revealed that overall scores for each class, when compared with their cohort nationwide, improved between 10 and 21 percentile points from 1996 to 1998, except for the PGY-2 class, whose scores remained unchanged.
The patient survey showed that patients were satisfied with the care that they received from our residents.
The reports generated useful discussions in resident and faculty meetings with the consultant, which centered around stresses related to service, conflicts between service demands and time set aside for off-service didactic teaching, and strategies to deal with clinical challenges. Feelings and opinions were freely shared by all participants.
As a result of this process, we formed four postretreat work groups consisting of both residents and faculty to discuss and problem solve in the following areas: didactics, inpatient, outpatient, and consultation-liaison. The chair of each group was asked to make specific recommendations to the educational committee within 8 weeks following the retreat.
The educational committee adopted the following principles to guide efforts to reform the program: 1) holding clinical supervisors accountable for teaching clinical area-specific knowledge and skills; 2) achieving a reasonable balance between education and service; 3) requiring residents to carry a balanced caseload, with a greater emphasis on briefer therapies; 4) introducing primary care psychiatry; 5) experimenting with newer teaching techniques; and 6) consolidating managed care and community psychiatry teaching. The actual changes are described in t1.
To ensure that maximum caseloads for residents would not be exceeded, a half-time psychiatrist was added on one of the inpatient units and all of the staff psychiatrists were required to carry individual caseloads as primary therapists in contrast to their previous practices of only supervising residents' caseloads.
The new conference schedule for PGY-1s begins with an extensive orientation to psychiatry in the summer months, after which they start their rotation in internal medicine. Upon completion, the residents join the didactics of the PGY-2 class. PGY-3s have an entirely different conference schedule, as do PGY-4s. For all classes, staff psychiatrists provide coverage for any clinical emergencies when they are attending conferences.
The change in the internal medicine rotation was facilitated by a surplus in trainees. Our internal medicine department recently began to train residents from an emergency medicine residency training program, resulting in many more interns being available than are needed to cover the inpatient units. Internal medicine was pleased to assign our residents to ambulatory-care centers for 1 month of their 4-month rotation, and the shift did not pose any financial complications.
Evaluation of the Retreat
Evaluation forms were distributed to both faculty and residents immediately following the summation. The respondents were asked to evaluate the content, the process, and the perceived results of the retreat. The residents and faculty rated 17 different statements on a five-point scale. The faculty were required to rate an additional three statements about the potential impact of the retreat on their teaching, supervision, and professional activities.
Completed surveys were obtained from 13 of 20 residents (65%) and 18 of 32 faculty members and consultants (56%). Although the response rates were relatively low, the responses were overwhelmingly positive. The mean for all questions was 4.0 on a five-point scale, with the residents being slightly more positive than the faculty (4.1 vs. 3.9). The results reported are for both faculty and residents unless otherwise noted. Percentage of agreement includes subjects who rated "strongly agree" as well as "agree."
Ninety percent of the respondents agreed that the presentations were well organized; 87% agreed that presentations were interesting and presented useful information; 84% agreed that the presentations had clear objectives; and 71% agreed that the presentations met their objectives.
Seventy-seven percent of the respondents clearly understood the purpose of the retreat before it was held, and 85% stated that they would have attended even if they were not required to be there. Sixty-eight percent agreed that they learned useful information about the residency program, and 70% agreed that they learned important information about psychiatry residency training in other programs besides BUHMC. Only 61% agreed that there was sufficient time allotted for discussion. The vast majority, 90%, agreed that BUHMC should periodically undertake educational retreats.
Seventy percent of the respondents agreed that the retreat had a positive impact on the morale of residents, and slightly fewer, 61%, agreed that the experience positively influenced faculty morale. Of faculty only, 58% reported that the retreat would have a positive impact on both their teaching and supervision. Only 42% of faculty agreed that the experience would have a positive impact on their professional activities.
Only 45% of all respondents agreed that discussions led to workable solutions. However, the aim of the retreat was more to critically examine our performance and to begin the process of seeking solutions. As mentioned earlier, task forces were formed at the close of the retreat to address these problems. Overall, 84% of the respondents agreed that the retreat was a useful and worthwhile activity.
As a 6-month postretreat follow-up, the resident satisfaction survey was readministered in October 1998. The PGY-1s were excluded from the analysis, since they did not participate in the initial survey. In addition, follow-up surveys could not be obtained from the eight residents who had left the program, including five who graduated, two who continued their training in child psychiatry, and one who resigned. Of the 20 residents, surveys from only 12 were available for analysis, limiting its utility. Responses from October were compared with March responses by using independent samples t-tests. The responses could not be paired because the forms were not coded or marked in any way to help ensure that the residents would give honest feedback. A five-point scale was used; 1="very dissatisfied" to 5="very satisfied" (see t2).
The residents gave higher ratings in all areas, except for "morale in department" and "level of support from peers," which dropped slightly but nonsignificantly. Two areas that improved sufficiently to achieve statistical significance at P<0.05 are "respect of faculty for residents" and "education prioritized over service." This finding suggests that the retreat may have contributed to ameliorating residents' discontent about education vs. service priorities in the department as well as improving the respect of faculty for residents. These positive responses may be secondary to increased postretreat attention the residents have been receiving.
This report has several limitations. First, we were unable to obtain complete sets of responses for each of the surveys. This deficiency may weaken the value of the report, particularly for the surveys of resident satisfaction, as discussed earlier, and of retreat attendees. The attendees who left early and did not complete a survey may have been less interested in the process or have had more negative feelings toward the program than those who stayed until the end. In addition, this report represents the experience of only one department and may be of limited value to other hospitals with different characteristics. Finally, it is difficult to identify all of the social, political, and interpersonal factors that contributed to the success of the retreat and its implementation.
Our department had tried to address some of the issues discussed here in departmental executive committee meetings, faculty meetings, and resident's experiential T-groups. Unlike these other venues, the retreat provided an opportunity for both faculty and residents to hear each others' points of view without feeling defensive. Hearing about the experiences of other programs and finding that our predicament was not unique to our department helped both groups to be flexible and receptive. In addition, data from the surveys provided the participants with a very clear indication of the degree of seriousness of these issues at levels not available at monthly departmental meetings. Meeting at an off-site location on a Friday also contributed to a collegial rather than confrontational atmosphere that resulted in all stakeholders committing themselves to a positive outcome.
The presentations of the results of surveys were quite extensive; if we were to conduct such a retreat again, we would increase the scheduled time to 1.5 days to afford more time for discussion at the end of each survey presentation.
To determine the effects of new teaching techniques and didactic changes, we will continue to monitor the performances of the residents on the PRITE and clinical examinations as well as their rates of success on the ABPN examinations.
This article described our experiences in organizing and conducting a department-wide faculty-resident retreat to address issues of concern to our training program. This retreat enabled us to delineate some of the major strengths and weaknesses of our program and provided us with clear directions to solve the problems we identified. The joint efforts of faculty and residents in addressing our concerns and finding solutions were significant. Additionally, the outside consultant provided us with opportunities to better understand the experiences of other programs. Similar to Kling and Fost (8), we found that extensive preparation, tight management of the schedule, a clear focus, sufficient time for open discussion, and conduct of the process in an environment conducive to open exchange were vital to the success of the retreat. Finally, follow-up with concrete actions is crucial if the retreat is to have lasting benefit.