Medical schools and residency training programs do not as a rule teach administration and management. Nonetheless, many graduated residents will occupy in the future a variety of managerial and leadership positions—functioning as clinician executives (chairpersons of departments of psychiatry, directors of clinical research units, medical directors of inpatient or outpatient settings, or mental health commissioners)—without the benefit of formal training in management, leadership, organizational principles, finance, or politics. In this paper I describe the history of the need for residency training programs to teach administration. The paper outlines a new core curriculum used to expose residents in PGY-3 or PGY-4 to the principles of organizational theories, implemented by the author in 2001 in the Psychiatric Residency Training Program of the Department of Psychiatry, Cabrini Medical Center, an academic affiliate of the Mount Sinai School of Medicine in New York City. The results of a survey of these residents after exposure to this core curriculum are also reviewed and discussed.
Borus (1) discusses the following developments. A 1979 survey of U.S. general psychiatry residency training programs within the American Association of Directors of Psychiatric Residency Training (AADPRT) revealed that only 29% of the 143 responding programs required any learning about administration as part of their core curriculum and only 40% offered any required or elective didactic sessions about administrative issues within their curriculum. Of those who offered didactic sessions, less than one-third taught any material about quality assurance or personnel management; less than one-fourth taught about budgeting, accreditation standards, or resource allocation; and less than 30% assigned any reading about administration at any time during residency. Although 85% said they offered some clinical training in the administrative aspects of psychiatric practice, most of the training was provided in an elective chief residency experience in the PGY-4 year.
Since that time, psychiatric practice has become more complex with the emergence of systems oversight practices such as managed care, peer review, continuous quality performance improvement indicators, new government regulations, best-practice algorithms and clinical care guidelines, new prospective payment reimbursement systems, and hospital report cards. A 1989 follow-up survey (2) of the AADPRT programs revealed that 56% of the responding programs offered didactic sessions about administration to their residents and 58% offered an experiential learning module in administration. Most programs that offered administrative teaching did so in the PGY-4 year (89%), 28% offered it in PGY-3, and only 20% offered it in PGY-1 or PGY-2.
In the "Special Requirements for Residency Training in Psychiatry" (3), the Residency Review Committee for Psychiatry of the Accreditation Council for Graduate Medical Education describes the need for "requisite knowledge" to be acquired during training. This includes "familiarity with the issues of financing and regulation of psychiatric practice, including information about the structure of governmental and private organizations that influence mental health care." One of the requisite skills to be learned is "experience in psychiatric administration, especially such as leadership of interdisciplinary teams."
In the early 1980s, the AADPRT Task Force on Teaching Administration in Psychiatry made content and curriculum recommendations that apply today (4). The task force outlined 10 core areas for teaching residents about the administrative aspects of psychiatric practice and provided a guide for how to integrate the teaching in these core areas into the curriculum intertwined with clinical training. The 10 core areas were as follows: 1) theories and sociology of organizations, 2) small and large group theories, 3) systems theories, 4) impact of patient—staff and staff—staff interactions on patient behavior, 5) clinical administration of discrete psychiatric units, 6) leadership uses of power and authority, 7) personnel management, 8) practical organizational politics, 9) financial issues and third parties' relationships to psychiatry, and 10) psychiatry's relationship to local bureaucratic systems and regulatory agencies.
Ranz et al. (5) discuss the role of the psychiatrist as medical director. Their survey of alumni psychiatrists who graduated from the Columbia University Public Psychiatry Fellowship (fellowships that have supported the training of young psychiatrists for leadership positions in the public sector since 1981) and members of the American Association of Psychiatric Administrators demonstrated that medical directors perform a wider variety of tasks and experience increased job satisfaction compared with staff psychiatrists. Notwithstanding respondents' belief that clinical collaboration tasks contribute most to job satisfaction, the performance of administrative tasks is most highly correlated with overall job satisfaction.
The core curriculum covered four topics with four clinical case presentations and was presented in eight sessions. It was felt that if only theoretical material were presented, the trainees would not understand the practical usefulness of this material. Therefore, to make these lectures come alive, actual problematic case vignettes were presented to engage trainees in considering how they would diagnose the problem and strategize approaches to solutions if they were the medical director or chief of service.
The theoretical lecture was presented with use of a flip chart for clearer presentation, as recommended by the residents by the end of the first lecture (see discussion below). The case vignettes were handed out to the residents at the end of the theoretical lecture for the following week's class discussion. For the case discussion, the lecturer mapped out the case on the blackboard as a resident presented and acknowledged each resident's point of discussion with a diagram, also on the blackboard. By the end of the case analysis, the lecturer handed out the actual case solutions and answers for further comments. The uniqueness of the case vignette format is that this format engages the student to "think like a doctor": to find the "diagnosis" of the problem or conflict in the case and to come up with a "treatment plan" or solution in administrative terms.
The topics were as follows: 1) Organizational Theories in Mental Health; 2) Leadership in the Administration of Psychiatric Systems; 3) Strategies for Organizational Change; and 4) The Market for Mental Health Care. These topics are outlined in the Textbook of Administrative Psychiatry, edited by Talbot et al. (6), which is the core text used in the Administrative Psychiatry Certifying Examination by the American Psychiatric Association Committee on Psychiatric Administration and Management. The above topics, presented in the "basic concepts" section of this text, were selected to minimize overlap and maximize coverage of the major areas. The objective of this curriculum is to provide an overview of the important areas of concern to the clinician executive and engage students to think about how to solve administrative problems from the real world to improve patient care outcome.
The Organizational Theories section, based on the chapter by David and Preven (7), discusses the following: definitions of the manager, the manager's functions; the historical development of management theory: scientific, classical, behavioral (theory X , theory Y, theory Z, management by objectives); and structure of organizations (macro, micro, matrix, formal vs. informal). The objective of the lecture is to promote an appreciation for the complexity of organizational theory as well as the simplicity of the concept of operation and support system. The case vignette from Greenblatt's textbook (8) discusses a "battle between psychology and psychiatry" in a Veterans Affairs hospital on a psychiatric ward. The central teaching point of the case is that a conflict between two disciplines on a ward is a result of a problem with the organizational structure. Understanding the type of structure and the history of who has the power and authority will help in figuring out the solutions to the conflict.
The Leadership section, based on the chapter by Cozza and Hales (9), discusses the following: definitions of leadership (transforming, transactional, behaviorally oriented, dynamic); management and administration (what leadership is not); leadership traits (the Great Man theory vs. the Big Bang theory, charisma, the dysfunctional leader); leadership styles (authoritarian, democratic, dynamic, participatory management); development of leadership (not just a bag of tools—neat, "this will work every time" procedures); skills of leadership (setting goals, establishing a trusting environment, communicating effectively, making decisions constructively, delegating, managing group process, utilizing and resolving conflict, using power productively); and need for visionary leaders to nurture and promote within the ranks. The objective of the lecture is to familiarize the student with an understanding of the different types of leadership and the skills needed to change an organization. The case vignette is an actual case of a new medical director (the author) from New York City engaged to start a new Crisis Intervention Center in Connecticut and identifying and finding solutions to the practical and political challenges she faced. The "take-home" message is as follows. A new leader can be confronted with all sorts of problems (some inherited, others new) upon taking on a new job in a new system. One has to learn to use appropriate resources (personnel policy and procedure manual, human resources, table of organization, public relations, state and local governance statutes and regulations, history of local politics, supervision) to analyze problems and identify solutions. This case also engenders lively student discussions about how to motivate staff, how to handle discipline of staff, how to manage above and below one's position in the organization, how to negotiate the media if one's program is in a political fishbowl, and the question of who supports the medical director.
The Strategies for Organizational Change section, based on the chapter by Keill et al. (10), familiarizes the resident with practical organizational politics and the strategies to enhance the effectiveness of psychiatric service delivery systems. It discusses the following three assumptions concerning administrative psychiatry: 1) psychiatrists have a commitment to promote and protect mental health, and those in leadership roles should improve the organizations that deliver these services; 2) politics are considered to be the accomplishment of various goals through proper utilization of power by the clinician executive; and 3) politics are by nature adversarial. The clinician executive is usually in competition for limited resources (space, funds, personnel). Political ventures require precise measuring of existing political structures and their components of power. This analysis includes the type of power, who the players are, the location of power in one's allies and opponents, what strategies to use to win over the opposition, and the understanding that there are competing priorities. The case vignette entitled "Draconian Cuts" from Greenblatt's textbook (8) discusses the California state budget cuts of community mental health clinics in 1989 and the politics involved. The case helps the student to identify what players and which political events have power over disappearing resources and the consequences of such losses. The student starts to think creatively about how to influence power during such times to bring about change that will positively benefit patient care.
The Market for Mental Health Care section, based on the chapter by Sharfstein et al. (11), familiarizes the training resident with the economic forces affecting the delivery of mental health care, including the delivery systems for cost containment (managed care, prospective payment system, utilization management in the private and public sector), and illustrates the practical consequences in clinical care.
The case vignette is entitled "How much does it cost to keep Johnny in the state hospital versus in the community with a network of services?" This case causes the student to think about what services are needed to keep a patient ("Johnny or Jane") in a state hospital and how the services change as the patient is moved into the community. It compels the student to troubleshoot problems that will emerge from the transition to keep the patient out of the state hospital. This lecture is also visually engaging; on the blackboard, the lecturer draws a stick figure of "Johnny" inside a rectangular box entitled "state facility," then an arrow pointing from the box to a space labeled "community." As the students come up with new resources necessary to maintain "Johnny," the lecturer draws more boxes acknowledging their suggestions (group homes, day hospital, entitlements, work rehabilitation training, crisis service, case management, dual-diagnosis mental illness and chemical abuse/dependence programs, police, etc.). The final challenge is to put the question of the cost per year of each of the two systems (state hospital vs. community support services) to maintain Johnny's mental health, physical health, and quality of life. The answer is often a surprise to the uninformed student: the cost of the community system is roughly half that of the state hospital—$55,000 per year versus $110,000 per year to keep Johnny healthy, thus raising the further question of which system the government is likely to invest in. This case illustrates a powerful take-home lesson of how government legislatures think about funding appropriations.
In January, February, April, and June 2001, after each topic and case vignette presentation, a survey was handed to each PGY-3 and PGY-4 trainee. The surveys were filled out and returned to this lecturer at the end of the case vignette section. Signing one's name was optional.
In total, 5 PGY-3 residents (4 females and 1 male) and 4 PGY-4 residents (3 males and 1 female) participated in this educational program. The PGY-3 residents' countries of origin were Poland, India (2), and the United States (2); those of the PGY-4 residents were China, Burma, Dominican Republic, and the Philippines. In summary, 8 of 9 residents were foreign medical graduates and 1 was a U.S. medical graduate. Seven of the 8 foreign medical graduates had practiced internal medicine (6 for about a year, 1 for 14 years) or a medical specialty (obstetrics/gynecology), and 1 foreign medical graduate had completed a psychiatric residency and practiced 1 year of community psychiatry in Europe. The U.S. graduate was an attending physician in her medical specialty (urology) for 9 years at a VA hospital, and, as an associate coordinator of a clinic in a county medical center, spent 10% to 20% of her time in a decision-making capacity for medical residents and students. Two foreign medical graduates (1 born and raised in the United States) had completed master's degrees in public health from a New York postgraduate medical school (New York Medical College) or a school of public health (Columbia School of Public Health), one majoring in epidemiology and the executive program, the other in health policy and human services management. Two of the foreign medical graduates had been research assistants in U.S. medical centers and had had several papers published in basic sciences or public health areas. Three of the foreign medical graduates had worked either as substance abuse counselors (in Michigan or California) or as volunteers in an emergency room (in California or Florida) for 1 to 2 years. None of the above residents had any background knowledge of North American psychiatric administrative standards. The 2 residents who had completed M.P.H. programs had been exposed to U.S. health administration theories.
Respondents were asked to rate from Excellent (a score of 5) to Average (3) to Poor (1) on the following survey items: Overall Program: 1) Was the subject matter sufficiently covered? 2) Were audiovisual materials used appropriately? 3) Did subject matter have practical application? 4) Will subject matter help in your patient practice? 5) If applicable, were handouts helpful? Speaker: Was the speaker clear and effective? Personal Objectives: 1) Did the program increase knowledge in areas where greater knowledge was desired? 2) Did the program give you new knowledge, skills, or approaches? 3) Did the program meet the stated objectives? Program Improvement: 1) Would you like to see a different format to the program? 2) Is there a need for specific handouts that may enhance this type of program? 3) Other comments: Suggest future topics and/or recommendations.
Some of the residents were away during parts of this course (for example, the resident from China was away during all of the case presentations and could not complete the surveys), and therefore the author presents the results of the surveys that the residents completed.
For the Organizational Theories section, results are shown in t1. Seven of the nine survey items were scored above 4.0 (i.e., greater than "above average"). Helpfulness in patient practice scored 3.8 ("above average"), and appropriateness of audiovisuals scored 3.0 ("average").
Three comments focused on the need for more handouts. Two comments discussed need for better audiovisuals than use of the blackboard. The audience found the material to be "interesting and different." They found the use of the blackboard for the lecture theory part hindered presentation of the material. Residents felt it was cumbersome for the lecturer to illustrate new material, which included several complex diagrams of organizational structures, and talk at the same time. The class recommended either more handouts or a prepared flip chart for future lectures.
The case presentation made the theory come alive and engendered lively student involvement. The case caused the class to analyze the conflicting dynamics between two disciplines on a ward in terms of organizational theory. The lecturer diagrammed the conflict and the suggested solutions on the blackboard as each student communicated his or her point. In the end, the students felt this sort of analysis could lend itself easily to organizational issues in their own inpatient experience and was a dynamic and important tool.
For the Leadership section, results are displayed in t2. All items were scored between 4.2 and 4.8 (greater than "above average") except for speaker clearness and effectiveness, which scored 5.0 ("excellent"). There were no comments.
At this point, a prepared flip chart was used instead of the blackboard for the lecture part. The flip chart made the presentation flow easily and smoothly so that the lecturer could stop at any time to illustrate a practical point of clinical or administrative significance. For the case vignette discussion of a new medical director from New York City starting a new Crisis Intervention Center in Connecticut, the lecturer used the blackboard to illustrate the case. The lecturer put two columns on the blackboard entitled "the problems" and "the solutions." This format challenged the students to analyze the problems that he or she would face as the brand-new medical director. The fact that this was a real case that the lecturer faced 15 years ago brought it more to life. All sorts of ideas emerged from the class, including the needs to handle the media, discipline staff, envision and define the mission of the new program within the hospital as well as in the community, train staff, and be sensitive to local politics. From a final resident's comment about "who supports the medical director," the lecturer felt empathic understanding from the class. The class got the point that being a medical director is challenging not only intellectually but also emotionally, and that to bring about successful change in an organization, the medical director needs moral suport and feedback from key people such as his or her family, department chairman, supervisor or mentor, and organizational leaders.
For the Strategies for Organizational Change section, results are shown in t3. Almost all items were scored 4.2 to 4.6 (greater than "above average"). The exceptions were scores of 3.8 (greater than "average") for helpfulness in patient practice and 4.0 ("above average") for helpfulness of handouts. One respondent commented that this was a "concise review of a difficult topic."
The case vignette entitled "Draconian Cuts," discussing the California state budget cuts of community mental health clinics in 1989, engaged the class to think on a higher level. The class identified who are the players in power outside the mental health centers (state, governor, legislature) that control the disappearing resources and what is the political climate that affects patient care. This case also caused the students to think creatively about how to influence the powers to successfully negotiate change to improve patient care outcome.
For the Market for Mental Health Care section, results appear in t4. All items scored 4.5 to 5.0. The items for increase in knowledge, new knowledge and skills learned, and meeting of program objectives all scored 5.0 ("excellent").
This lecture and case presentation were very successful. The discussions were lively and engaging. Diagramming the case on the blackboard challenged the students to thoughtfully come up with creative solutions as to how to keep "Johnny" out of the state hospital and in the community. The question of cost per year of maintaining a patient in a state hospital versus in the community was a surprise to the uninformed student and a powerful teaching point on how government spends money.
The survey comments were indicative of how successful this lecture and case presentation were. New suggestions and ideas came up in the comments, including the recommendation to "teach this lecture on a simpler or introductory level to PGY-1 and PGY-2 residents"; to illustrate more practical aspects of Medicare billing, including "showing an HCFA 1500 Medicare billing form"; and to have the residents "visit more community support programs, e.g., vocational/social clubs, state hospitals, settlement houses, nursing homes, etc." Eight of the 9 residents went on at least one field trip to a nursing home with the lecturer during their community psychiatry continuing day treatment rotation (Cabrini Center for Nursing and Rehabilitation). One resident went with the lecturer to a Bowery shelter. By May 2001, 4 of the 8 residents had gone with the lecturer to visit Manhattan State Psychiatric Hospital on Wards Island.
In summary, all four sections of this administration and management course scored from greater than "above average" to "excellent" (4.1 to 5.0) for the items of increasing knowledge, learning new skills, and meeting stated program objectives. The Leadership section scored the second highest of the four sections in these categories. The case presentation was that of the personal experience of the lecturer and therefore may have evoked more lively discussion and interest. The Organizational Theories section scored slightly lower (though still greater than "above average"), presumably because the audiovisuals needed improvement to illustrate the new material. The Market for Mental Health Care section scored the highest overall, with scores of 5.0 for increasing knowledge, learning new skills, practical applicability, helpfulness in patient practice, and meeting of the program objectives. From the positive survey results and the thoughtful, lively discussions from the residents during the lecture and case vignette presentations, it is felt that this educational program teaching the new curriculum of psychiatric administration and management was extremely successful and met its educational objectives.
Competent psychiatric leadership and development of administrative and managerial skills are paramount if systems of care for patients are to survive. Psychiatric resident trainees must understand the need to develop organizational skills as they anticipate future leadership roles as clinician executives or as medical directors, all of whom must work collaboratively to lead groups of people toward a common goal. Creative decision making about the allocation and use of scarce human and fiscal resources, especially during challenging times of managed care and organizational restructuring, is important for the training resident to grasp. The exposure of residents to this concept is the first step toward the future survival of mental health delivery systems. This familiarization also begins to make the resident think on a higher level to effect the best care for patients to lead to the best clinical outcomes.
In this paper, I have described a core curriculum that familiarizes psychiatric trainees with administrative and managerial concepts. This core curriculum has begun to be implemented in our training program. The residents' unanimously positive survey and engaging discussions during the lecture and case vignette presentations illustrate that this new curriculum succeeded in meeting its educational objectives. The program will be tailored as feedback is elicited. New courses in finance, law, and other topics will be added as the curriculum develops. It is the hope of this author that other psychiatric training programs will start and continue to develop education programs in psychiatric administration and management.
The author especially thanks the following people at the Cabrini Medical Center, New York, NY: Dr. Joel J. Wallack, Director of the Department of Psychiatry; Dr. Giovanni Caracci, Director of Psychiatric Residency Training; and Dr. Madeleine Stam, Associate Director of Psychiatric Residency Training, and her family, for their wonderful support.