Medical residency training is a developmental process of acquiring new skills and knowledge, but it is a time also for acquiring attitudes and modifying self-representations and professional identity (1). Both the profession and the professionalism of the physician are largely molded during this critical period when residents discover not only their competence, but also their limits. Although researchers have described developmental stages of medical and psychiatric residency training (1,2), few tools have been developed to educate and prepare psychiatry residents for the critical developmental transitions they will face in their training.
Donald Light, Jr., in 1975, developed a sociological calendar (3,4) as a device for condensing and analyzing data about social processes in order to describe important dimensions and stages of social and professional development in psychiatric residency training (F1). Such a device could be used as a research tool to test educational processes, a teaching tool to prepare psychiatric residents for specific transitional times in their training, and an administrative tool to assist in residency program development and quality improvement. However, Light's calendar has not been widely used by psychiatry educators. Some reasons for this might be that 1) it was written more than 25 years ago; 2) it was based on a psychoanalytic-style program that is not common in today's training paradigm; and 3) it was published in the sociology literature and therefore was not widely accessible to the psychiatric community.
Light's calendar also has not been updated for modern psychiatric training. An updated calendar would be important because of the many changes in psychiatric training necessitated by advances in biological therapies, increased use of short-term psychotherapies, and wider penetrance of managed care. Managed care has led to decreased lengths of hospital stays, decreased numbers of allowed outpatient visits, decreased use of inpatient services in exchange for increased use of outpatient and partial hospital services, and increased use of outpatient case management for the chronically mentally ill (5). There is also now a wider range of practice opportunities after graduation and a greater need to diversify professional roles (6).
The objectives of this study were 1) to develop a sociological calendar—a timeline of social and professional development—based on modern psychiatric residency training, and 2) to test the validity of the sociological calendar by using a survey of residents' attitudes toward their professional roles, supervisors, patients, and personal self-image.
Update of Sociological Calendar
The study began in 1993 in a large, eclectic, urban three-hospital system-based general psychiatry residency program. The chief residents from each of the four major teaching sites (university hospital, county hospital, Veterans Affairs hospital, and university outpatient clinic), including the first author, participated in the study.
A focus group format (7) among these chief residents was initially used to achieve consensus on the primary social and professional domains, or categories of primary focus, for the 3-year calendar of transitions that occur during residency. During a 1-hour focus group session, the participants were shown Light's original calendar and asked to discuss how they would revise or amend the focus categories. A consensus regarding the final categories was achieved.
Author J.R.F. then conducted a 30-minute semistructured interview (8) with each chief resident within a month of completion of residency training to stimulate the participants to think independently about and take notes on the salient developmental stages within each focus area of the sociological calendar. Finally, a 90-minute focus group was conducted among the participants to further explore the content of the semistructured interviews and to arrive at succinct summary statements that describe the developmental stages corresponding to each category of primary focus. Authors J.R.F. and D.D.H. then used an iterative process of clarification, categorization, and/or differentiation of the detailed field notes taken from the focus group discussion to further summarize, interpret, and refine (7) the concepts for the final calendar. The final calendar was then validated with the study participants.
The residency program consists of 12 residents in their first year, 14 in their second year, 14 in their third year, and 12 in their fourth year of training. In the first year, residents typically spend 4 months in medicine or pediatrics and 2 months in neurology rotations. Thus, the beginning of the sociological calendar for psychiatry residency training corresponds to the beginning of the first-year resident's seventh month, or to the beginning of the second year for residents who completed a full-year internship elsewhere. The first year of psychiatry training consists of 12 months of inpatient psychiatry. The second year consists of 1 month of emergency psychiatry, 5 months of consultation-liaison psychiatry (or 3 months of consultation-liaison psychiatry and 2 months of addictions psychiatry), and 6 months of outpatient psychiatry. The third year consists of 6 more months of outpatient psychiatry and at least 6 months of electives.
Osgood Semantic Differential Survey
In 1999, all psychiatry residents were asked to fill out anonymously the Osgood Semantic Differential Survey (OSD; 9) in the final month of their respective residency years. The OSD is an attitude survey instrument validated in several studies (10,11) and used previously to assess psychiatrists' professional development (12). The OSD is organized according to three basic components that contribute to an "attitude" toward a thing or object: evaluation, potency, and activity. The evaluation component of an attitude represents the desirability and value of an object. The potency component is concerned with issues such as size, weight, and strength. The activity component measures quickness, excitement, or agitation. Osgood et al. showed that our attitudes are formed by approximately 70% evaluation, 20% potency, and 10% activity. The advantage of the OSD approach to the evaluation of an attitude over the more commonly used Likert-type scale is that the OSD captures the essence of attitudes that are beyond the one-dimensional nature of the Likert scale, which generally focuses exclusively on the evaluation, or "good" versus "bad," component of one's attitude. The OSD and Likert scales use similar rating systems, for example a scale of 1 to 7 in which 1 is anchored at one extreme, such as "bad," and 7 at the other extreme, such as "good." As educators, we use the Likert scale frequently, but Osgood has shown that for more sensitive issues, such as the development of a professional identity, one needs to take into account the role that "potency" and "activity" play in the formation of an attitude. For example, one can have a relatively good attitude (evaluation component) toward a supervisor and at the same time feel that the supervisor is neither quick enough (activity component) nor powerful enough (potency component).
Using the OSD in this study, the subject is asked to respond to a trigger stimulus, such as "supervisor" or "myself," and indicate the response with a check mark within two polarized adjectives that are selected for one of the three attitude components. The stimuli used in this study were the subject's professional role (psychiatrist), the professional supervisor (residency supervisor), the psychiatric patient, and self-image, represented by the word "myself." Seven blanks represented gradations between the polarized adjectives, a structure similar to that of a standard Likert scale. Which adjective came first for each pair of adjectives was randomly determined. The polarized adjectives were selected to represent the purest form of the three attitudinal components. "Good—bad," "optimistic—pessimistic," and "positive—negative" were used to polarize the evaluation component. "Hard—soft," "strong—weak," and "lenient—severe" represented the potency component. "Active—passive," "calm—excitable," and "hot—cold" measured the activity component. Aggregate scores were determined for each component by summing scores from their respective adjectives. Lower scores represent higher evaluation, more potency, and more activity.
Analyses of variance were used to compare responses among the four residency classes for each component of the four stimuli. Two-tailed paired t-tests were used to compare residents' responses to the "myself" stimuli components with the other three stimuli for all residents and for each residency class.
The four chief residents who participated in developing the calendar were two females and two males. Two were married and none had completed a prior residency in another field.
A sociological calendar for psychiatric residency training was developed (F2), using Light's original work as a stimulus to elaborate on the similarities and differences in today's residency training. The new calendar includes more detailed descriptors of social and professional domains (primary focus). The "efficacy" focus in Light's calendar was renamed "strategies for effectiveness." Light's "focus of therapy" was renamed "focus of interaction" to emphasize the variety of interactions with patients in modern psychiatry. Light's "relation to non-medical staff" was expanded to include "relationship with peers and co-workers." A category of "relationship with supervisors" was added to examine this important component of residency training. A new category, "primary affective state," was added to examine the emotional state of the resident as he or she progresses through residency training. The importance of the resident's supervisor and the resident's emotional state in professional development were emphasized by Halleck and Woods in 1962 (13).
Osgood Semantic Differential Survey
A total of 31 residents completed the survey: 4 first-year residents, 11 second-year residents, 8 third-year residents, and 8 fourth-year residents or fellows. The mean age of the residents was 34.5 years (SD=6.0); 17 (54.8%) were male, 17 (54.8%) were married, and 27 (87.1%) had not previously completed a residency in another field.
There were no significant differences between males and females or married and single residents on any of the stimuli components. There were also no significant differences among the four residency classes among the stimuli components.
Pooling all 31 residents surveyed with the OSD revealed significant differences in their self-ratings compared with their mental constructs of "psychiatrist" and of "patient." On the activity component, they rated themselves as more active than psychiatrists (10.7 vs. 12.6; t=4.6, df=30, P<0.0001). They also rated themselves as more valuable than patients on the evaluation scale (8.3 vs. 12.7; t=8.1, df=30, P<0.0001), and they felt more powerful than patients on the potency component (11.4 vs. 12.8; t=2.6, df=30, P<0.05).
Each residency class was then examined separately. For the first-year residents, significant differences were found in self-ratings compared with their ratings of psychiatrists on the activity component (8.8 vs. 11.5; t=5.7, df=3, P<0.05).
For the second-year residents, significant differences were found in self-ratings compared with their ratings of psychiatrists on the potency component (10.8 vs. 12.6; t=2.4, df=10, P<0.05), psychiatrists on the activity component (10.9 vs. 12.7; t=2.4, df=10, P<0.05), and patients on the evaluation component (8.5 vs. 12.5; t=4.6, df=10, P<0.001).
For the third-year residents, significant differences were found in self-ratings compared with their ratings of patients on the evaluation component (7.8 vs. 12.6; t=4.2, df=7, P<0.005).
For the fourth-year residents and fellows, significant differences were found in self-ratings compared with their ratings of patients on both the evaluation component (8.5 vs. 12.9; t=4.0, df=7, P<0.005) and the potency component (11.3 vs. 13.6; t=2.6, df=7, P<0.05).
The OSD scores for the differences between "myself" and "supervisor" were particularly interesting and are displayed in F3. Here, the differences between the residents' scores for "myself" and "supervisor" are displayed for each of the residency classes. Residents in the first year rate their supervisors as more valuable and powerful, but less active, than themselves. By the fourth year of training, these differences disappear and the ratings of "myself" and "supervisor" are almost identical.
A modern sociological calendar of psychiatric training illustrates the changes in the social and professional developmental stages in psychiatric residency training over the past 20 to 25 years. The calendar reveals stages of development that are different from those in Light's original sociological calendar. These differences are in part driven by changes in psychiatric practice and mental health systems. The stages are defined in greater detail to specifically reveal the fluctuations within each primary developmental area of focus. They reflect the intensity and stress associated with the first year of inpatient work, the complexity of systems of psychiatric care, and the myriad therapeutic tools and techniques that psychiatric residents must master during their training. Despite these changes, many aspects of residents' experiences remain unchanged, such as the beginning residents' skepticism toward patients (14) and their fear of being judged by supervisors (15).
We were able to begin to validate the updated sociological calendar by using the Osgood Semantic Differential Survey. First- and second-year residents rated themselves as significantly more active than their image of psychiatrists in general, whereas third- and fourth-year residents and fellows did not. This is consistent with the calendar, which reveals that first- and second-year residents' strategies for effectiveness include taking on much more responsibility for making their patients "better." They must act more quickly and experience more negative affective states during this period, particularly during the first year. First-year residents, however, also see their supervisors as more valuable and powerful (F3) than themselves. This mismatch between high activity and low value and potency may lead to ambivalence, self-doubt, and frustration.
Second-year residents rate themselves as more potent than their image of psychiatrists in general. Having survived their first year of psychiatry residency, they have more hope and confidence in their ability to care for patients, work within the system, and interact with colleagues. Second-, third-, and fourth-year residents also rated themselves more favorably than patients on the evaluation component. This higher self-rating may represent the residents' increasing competency and decreasing sense of vulnerability.
By their fourth year, residents view themselves as more potent, or powerful, than their patients. They feel more able to balance patient care with their personal issues, to pass on their knowledge to other trainees, and to embark on independent careers. Their knowledge and confidence are also illustrated (F3) in their ratings of themselves and their supervisors as equally valuable, powerful, and active. These residents are now ready to be supervisors themselves.
Closer analysis of the supervisor/myself differences in F3 shows that in the first year residents tend to view the supervisor, in comparison to themselves, as more powerful and more valuable but less active. However, as early as the second year, supervisors are seen as less powerful. This change corresponds well with the focus group findings that second-year residents were having more skepticism about their supervisors and felt less dependent on them. By the time the residents are in their final year, however, the OSD measurements show little or no difference between the self and supervisor triggers. This corresponds with the focus group comments that in their final year the relationship with the supervisors was one of collaboration.
These findings are consistent with literature describing the stresses encountered and coping styles used by beginning psychiatry residents (16). Shershow and Savodnik (17) described the importance of the supervisor's helping residents recognize their own dynamic struggles during their inpatient training, focusing on regression as a potentially adaptive response in this setting. Some components of regression, such as competition, despair, and dependency, are succinctly noted in the sociological calendar. Yager (2) argues that in order to help psychiatry residents resolve their unavoidable identity crises during the course of training, residency programs must give an accurate appraisal of the clinical experience and help the resident master not only the skills, but also the role of the psychiatrist.
In a broader context, the experiences of psychiatric residents can be described as an example of a closed-group experience in which perceptions and behaviors of developing mental health leaders progress through predictable stages within the residency program (18). These stages may be applied to the resident—supervisor relationship at the "micro" level as well as the residency and clinical program at the organizational or "macro" level. Bion (19) assumed that group participants maneuver through basic stages of inadequacy and incompetence (dependency), denial and hostility (fight—flight), and hope and preservation (pairing). Similarly, Schutz (20) postulates that individual development and behavior within groups is characterized by human responses during one's progression through the stages of inclusion, control, and affection. Kernberg (21) emphasizes burdensome responsibility, unmet dependency needs, and reduction in other basic human needs such as freedom, privacy, support, and gratification as major causes of regression in the development of leaders within organizations. Greenblatt (22) describes three periods during the development of a leader when he or she is particularly prone to bad judgments: succession, crisis, and departure. Residents may transition through many such cycles throughout their various rotations. The universal theme beneath these group constructs is that underlying anxieties and concerns are expressed in behaviors that both affect and reflect the stability of the system and its participants (18). Identification of these "search," "conflict," and "survival" themes can be used by the organization (e.g., the residency program) to drive appropriate proactive stabilizing strategies such as clarification of expectations, provision of support, and implementation of continuous quality improvement.
Limitations of this study include the use of a small sample of chief residents to derive the updated sociological calendar and the use of a small, cross-sectional sample of residents in the validation study. The study was conducted in one training program; therefore, there may have been some bias due to the influence of training philosophy, clinical settings, and clinical opportunities. As a result of these limitations, the stages in the calendar may not be generalizable to the experiences of residents in other programs.
This calendar, or a similar one adapted for different training programs, may be used as a companion to the psychiatric resident's professional development. It can serve to help normalize expectations of residents and to help highlight times when residents are particularly prone to disillusionment and new challenges. Providing a device such as the sociological calendar to help prepare residents for their upcoming experiences may help to convey the residency program's organizational culture, which is so important to the "hidden curriculum" (23).
The sociological calendar can be useful as a research tool to increase thinking about educational process, a teaching tool to prepare psychiatric residents for specific transitional times in their training, and an administrative tool to assist in residency program development. The calendar can be used by residency supervisors as a guide to achieve interpersonal synergy with their trainees during the critical maturation/facilitation phase of the mentor-protégé relationship (24). It can ultimately help to relate current resident experiences to the general goals of modern-day psychiatric training. The Osgood Semantic Differential Survey is an effective instrument in demonstrating differing attitudes among residents in various stages of their training. The incoming resident's preexisting attitudes toward psychiatry and the type of orientation provided by the residency training program may have significant impact on subsequent professional development (25), and these factors should be studied in greater depth. Future research should continue to update and validate this sociological calendar across different psychiatry residency training programs and to test its utility in the arenas of clinical training, educational research, and quality improvement.
This work was presented in part at the annual meeting of the Association of American Medical Colleges, Washington, DC, November 2001.