Training requirements in psychiatry residency programs have increased tremendously both in number and specificity in an ongoing effort to keep up with an expanding knowledgebase, changing patterns of healthcare delivery, and societal mental health needs (1—8). Recommendations regarding the addition of new requirements have generally been met through the consensus of postgraduate directors and chairpersons (2,3,9), but there is virtually no research that determines which training activities are educationally superior. A Canadian conference on psychiatric postgraduate education (9) led to the following recommendations: mandatory training blocks in geriatric psychiatry and chronic care; 2 years of once-weekly supervised psychotherapy experience; outpatient psychiatry, to include a variety of patient pathology, with supervision by academic psychiatrists involved in the work and who directly observe residents with patients; an initial year of a rotating internship; and a final multiple-choice written examination and case-based oral examination. By way of contrast, training requirements for addictions, quality improvement, ethics, community psychiatry, emergency psychiatry, and various psychotherapeutic modalities are decided on locally either through adding several-week training blocks, half-day clinics, seminars, and/or additional supervision into current mandatory rotations.
Teaching staff have become concerned that as residents attempt to meet the new educational requirements, too little time may be devoted to core clinical rotations. The Postgraduate Education Committee of the University of Toronto wished to investigate this concern through determining exactly how residents spend their time and what staff and residents thought about the educational usefulness of various training activities. To address this, the Resident Activities Task Force was created. For Phase I of our two-part study, the Task Force requested residents to keep a 1-week time-log to determine the composition of their daytime training activities. In a second phase, residents and staff were invited to take part in focus groups (10) to validate the time-log of current training activities and to comment on the value of various activities to their learning.
The Task Force, composed of four postgraduate coordinators, three residents, and an educational consultant, developed the format for the time-log. Demographic information included year of training, type of rotation, and training site. Included was a list of resident activities (t1) and daily time-sheets to record the major activity engaged in for each quarter-hour of 1 week from Monday to Friday. Evening and weekend on-call activities were not documented. Residents were asked to rate each activity's value with respect to current education and future psychiatric career by use of a five-point Likert-type scale (1: Not At All, 2: Slightly, 3: Moderately, 4: Very, 5: Extremely). They were also requested to indicate whether or not a staff member was present while the activity was carried out. Finally, space was provided for written comments.
The time-logs were distributed by the resident members of the Task Force by means of two mailings, timed for the midpoint of a 6-month rotation in 1996, when it was assumed the residents would have settled into their current experience. Informed consent was obtained. Participants were rewarded with a DSM-IV Casebook (11).
After analysis of the time-log data, the Task Force asked Chief Residents and Postgraduate Coordinators to invite local residents and staff to participate in focus groups.
Thirteen focus groups of 45- to 60-minute duration were convened at general and psychiatric hospitals and child and geriatric settings in an attempt to capture the spectrum of clinical rotations. All focus groups followed a specific format: the study was described, written informed consent was obtained from the participants, and each participant was given a multicolored graph displaying the results of the activity logs (F1). After reviewing these results in detail, the focus group leader facilitated an audiotaped discussion around the following questions:
These questions were used as the basis of the analysis (10) of the audiotape transcripts. Task Force members carried out this analysis in pairs. Interrater reliability between members of each pair was initially 80%, but after discussion between the coders, it reached 100%.
A group of 52 of 90 PGY2—5 psychiatry residents (57.7%) completed time-sheets for a full week. Participants included residents in core 6-month rotations during the PGY2—4 years: general hospital psychiatry (inpatient and outpatient placements), child, chronic care, consultation—liaison, and geriatrics, as well as residents in senior elective rotations in the PGY4 and PGY5 years.
F1 shows a summarized average amount of time residents devoted to each training activity weekly and their average assigned educational value. The average assignments of time and value are shown in t1. Excluding the average of 4.6 hours necessary for travel or meals, residents spent an average of 39.0 hours weekly in training activities, with a range of 30.5 to 57.0 hours.
In F1, the width of each bar indicates the average time allocated to the labeled activity. Each bar's height reflects the average educational value. Current patient care-related activities (patient care and supervision), indicated in black, add up to 26.2 hours, or almost two-thirds of an average week. The four remaining activity categories: education, teaching, research, and general administration, are indicated by different hatch marks in black and white. Because significant differences in value were found between Activities 1a to 1g in the Patient Care activities category (see t1), there are separate bars for each of these activities.
In comparing the educational value of the six activity categories, an analysis of variance revealed significant between-group differences (F[12, 1,972]=54.690; P<0.0001). With Scheffé's post-hoc comparisons, significant differences between activities revealed that supervision was valued more than direct patient care without staff present (P<0.0001) and more than education (P<0.05). Furthermore, indirect patient care—administration and general administration—were found to be significantly less valued than all other activities (P<0.0001) except emergency rounds. Additional findings were not discussed in the focus groups.
Focus group participants.
Six resident and seven staff focus groups were held at seven different sites. The gender distribution of the 36 residents and 37 staff who participated in the focus groups approximated the current gender distribution of residents and academic staff in the department. Among residents, 21 were female (59%), and 15 male (41%). Thirteen (35%) supervisors were female, and 24 (65%) were male. The seniority of staff ranged from 2 to 22 years on staff, with academic appointments from lecturer to full professor.
Most residents confirmed the accuracy of the finding that two-thirds of their time was spent in patient-related activities, including supervision. They also indicated that this proportion was reasonable. However, residents in most groups wanted more observed clinical experiences than the current average of 1 hour weekly. Staff did not comment on the total amount of time residents spend in all patient care-related activities, but focused on what they perceived to be "an amazingly small amount of time" spent by residents providing direct patient care, an activity that is "necessary for clinical … skills." Like residents, staff placed a high value on supervised, direct patient care. Others emphasized the need for residents to see patients independently in order to acquire a sense of clinical responsibility.
Residents and staff agreed that administrative work was of low educational value, but staff saw it as a necessary part of residency, providing an opportunity to learn about independent practice and legal requirements.
Residents confirmed the accuracy of the listing of 6 hours of supervision weekly, acknowledging that it accounted for time with all supervisors, not just primary supervisors. Most resident comments focused on enhancing the quality of the available supervision, rather than increasing the quantity. The most useful supervision included direct observation of resident interactions with patients. It provides opportunities for tailored feedback with suggestions to improve interviewing skills and interventions, as well as for teaching specific aspects of psychiatric diagnosis and management. As one resident suggested, "without [our] being observed regularly, we will continue to make the same mistakes and be less likely to improve clinically." Residents also found it extremely useful to observe their supervisors doing interviews or even conducting psychotherapy, but noted that "unfortunately, psychiatrists work behind closed doors." Observing supervisors' interactions with patients tended to "demystify" the process of therapy and provided opportunities to observe other interventions or styles that the residents may then attempt independently.
Additional suggestions to improve supervision included developing clear goals tailored to the resident's educational needs or level of training, flexibility of supervisory time in response to clinical load, and the supervisor's sharing the resident's clinical work through seeing patients together or seeing similar patients. Residents also valued working with experts in a field. At one site, residents expressed discomfort in feeling responsible for the supervisor's finances, noting that supervisors who are salaried provide more time than those paid only for clinical work.
Although surprised that residents participate in 6 hours of supervision weekly, staff agreed that the number of supervisors each resident has accounted for the finding. Staff emphasized the importance of observed patient care, rather than the typical supervisory practice of meeting separately from patients, because it enables "a much more active staff—resident collaboration." Staff indicated that these opportunities commonly arise with new assessments, in consultation—liaison psychiatry, and in crisis situations. Similar to residents, staff thought that the nature of the profession limits opportunities for a resident to attend a psychotherapy session with a supervisor.
Staff listed factors that might contribute to successful supervision: rapport, specific personality traits of residents, developing an individualized teaching contract at the beginning of rotations, allowing time for mentorship to grow, and modeling interactions with patients as well as with other staff.
Residents generally thought 9 hours for education, as recorded on the log, was accurate. Some residents indicated that seminars were a necessary part of residency because the seminars organize their learning, whereas other residents believed time in seminars could be reduced. Respondents stated that seminars were most useful when they were relevant to current clinical work. Additional suggestions to improve teaching included coordination of each section by one instructor and the use of "expert educators," those who are knowledgeable, stimulating, and skilled at conveying information.
The majority of the staff focus groups, like the residents, were not surprised that residents attend 9 hours of seminars weekly. Staff also believed this time could be reduced, leaving more time for clinical experiences. Generally, it was thought that contextual learning is superior to didactic teaching.
Three resident groups discussed resident teaching and concurred that teaching is an essential role for psychiatrists. Most staff groups also addressed teaching, and both they and the resident groups generally thought residents are not adequately prepared to teach. Residents suggested that protected time for teaching medical students is necessary. Staff suggestions included providing more time for and supervision of residents' teaching and broadening their teaching opportunities.
Resident and staff focus groups who did address research during residency were quite surprised with the high educational value placed on it in the time-log data. Noting the low average time per week, they speculated that the few residents who do research value it highly.
In all of the resident focus groups and five staff groups, it was asserted that any new requirements ought to be integrated into existing rotations. Residents described being pulled in many directions by all the elective and mandatory training experiences. On the other hand, residents place a high value on the many training opportunities and freedom of choice in the program, and some felt the resulting fragmentation of their training experience was worth the price.
Staff spoke at much greater length than residents of their concerns about fragmentation. They believed that the urgency and need to shift frames of reference created by going from activity to activity throughout the day could diminish the value of learning in a specific rotation and hinder the development of a resident's professional identity. Staff suggested it was important to "promote mentorship" and to focus more on process than content. Several staff groups and a few resident groups discussed the need to emphasize critical appraisal skills and self-directed learning skills instead of trying to cover everything in residency. Some staff groups suggested that residents maintain training logs and that there be regular faculty development efforts to enhance staff teaching and clinical skills.
Enhancing the Value of Training Experiences
Resident and staff focus groups concurred with the time-log data that the most valued educational experiences occur when clinical experiences are shared by working together and observing one another work. This suggests that the commonly held service and education distinctions (12,13) are not polarized experiences. The central question is not how to balance clinical service with education but how to make clinical experiences more educational.
Sufficient supervision is critical to the educational value of clinical experiences for psychiatry residents. In this regard, a previous survey of Canadian psychiatric residents reveals that high value is placed on clinical and psychotherapy supervision in an atmosphere where learning is valued (14). Furthermore, an Australian study found that educational neglect by supervisors was considered one of the five most adverse experiences during psychiatric residency and was experienced by almost 60% of psychiatric residents (15).
This study highlights the importance of the quality of supervision. By ensuring that supervision is clinically focused and occurs in the context of direct patient care, an increased amount of supervisory time may not be required. With respect to defining supervision, Alonso (16) suggests that psychiatric supervision is a process that involves four distinct entities: the patient, the therapist-in-training, the supervisor, and the training institution's administration. Our residents specifically emphasized the importance of the resident—supervisor interaction and accurate and specific feedback on their work with patients, echoing Shanfield et al.'s findings (17) regarding excellent psychotherapy supervision. Although a more extensive discussion of supervision exceeds the scope of this article, this study endorses a model of supervision that entails a teacher—learner-centered perspective that facilitates transformative learning, which may shift perspectives and paradigms to prepare for self-directed learning rather than disseminating knowledge (18). However, supervisors must ensure that clinical experiences match the residents' competence, interests, and capabilities (19). Furthermore, anticipation and discussion of clinical issues have been shown to enhance the educational value of subsequent clinical experience (20).
A teaching and learning contract is a powerful tool that can flexibly integrate the resident's educational objectives with the administration's curriculum requirements, thus reducing tension between staff and residents who may view the curriculum differently. Moreover, the process of negotiation required between staff and resident in developing and maintaining the contract can be a useful relationship-building experience and may promote mentoring. Such relationships are valuable in helping residents to develop a professional identity and deal with numerous daily professional concerns (19,21). Supervisors who need to learn the skills of interactive teaching may require faculty development experience.
Rearranging Programs to Optimize Education
Although staff were astonished at what they perceived to be the low number of hours in which residents are involved in direct patient care, there is no literature to provide a comparison from previous years or other programs. This study provides a benchmark regarding time allocation of residency training activities; however, additional studies are necessary to determine whether time in direct patient care is changing or there are differences by program.
Despite the lack of earlier data regarding time allocation of training activities, both staff and residents suggest that if one area of training is to be further limited, it should be seminar time. The quantity of seminars could be reduced in favor of patient-based supervision, thereby minimizing disruption of clinical experiences and enhancing continuity of care, areas that are considered integral to professional development. The remaining seminars would be most valuable if the content is relevant to the current clinical rotation. This could be done through a centralized curriculum providing a weekly block of seminars for residents in each mandatory rotation.
Although our study emphasized the need to enhance the quality of supervision, a recent study found that psychiatry residents spend less time with attending staff than first-year residents from any other discipline (22). Junior residents may benefit most from placements where staff tend to work alongside residents, such as in the emergency department, in consultation—liaison psychiatry, and in inpatient psychiatry. Furthermore, such frequently neglected areas of supervision as indirect patient care liaison, consulting with other colleagues, teaching, and administration could also be supervised by involving residents in the staff person's teaching and liaison work. With residents working alongside supervisors, the latter need not free up additional time.
An extremely valuable but underutilized supervisory experience is observation of staff psychiatrists doing clinical work. Although the private nature of psychiatric work has been cited as the reason for closing the therapeutic situation to residents (23), a number of our department members have successfully experimented with allowing residents to sit in for the full course of a brief dynamic therapy. In our child and family program, using a "bug-in-the-ear" approach, supervisors observing residents behind one-way mirrors can provide guidance via an earpiece speaker set-up.
Strengths and Limitations
Several features of this study have contributed to our confidence in the data. First, the average amount of time spent on various activities was determined by on-the-spot detailed log entries, since retrospective estimates of time spent in training activities are often inaccurate (24). Second, the educational value for each activity was assigned by the learners themselves and not reliant on staff or experts, although staff generally concurred with resident opinions. Finally, lengthy discussions of the findings in the focus groups provided contextual data from psychiatric residents and staff psychiatrists. Although the fragmentation described related to the numerous sites may be a concern specific to large programs, the importance of a high quality of supervision that takes place within the clinical situation has been reemphasized by this study.
This work was completed at the University of Toronto, Department of Psychiatry, Toronto, Ontario, and presented at the 47th Annual Meeting of the Canadian Psychiatric Association, September 17th, 1997, Calgary, Alberta, Canada.
We received unrestricted educational grants from Solvay-Kingswood and Pfizer for Phase I and a peer-reviewed grant for Phase II from the University Health Network Department of Psychiatry.
Thank you to Drs. L. Andermann, W.P. Fleisher, N. Herrmann, and A. Kaplan for their comments.