The decision by the Accreditation Council on Graduate Medical Education’s Psychiatry Residency Review Committee (RRC) to require competency in five areas of psychotherapy (brief therapy, cognitive behavior therapy, combined psychotherapy and psychopharmacology, psychodynamic therapy, and supportive therapy) has had many implications for psychiatry residency programs and residents (1). The American Association of Directors of Psychiatric Residency Training (AADPRT) appointed a Task Force that developed sample competencies for each of the five required psychotherapy competencies. These sample competencies were intended to serve as guides to program directors. Task Force leaders determined that assessment methods would be addressed at another time (2).
Training directors and psychotherapy supervisors have just begun to implement these competencies and revise their evaluation methods and forms to reflect the new competencies. Old methods of assessment including direct observation, process notes, audio- and videotaped interviews, and chart reviews are still the major methods used. A few new methods of psychotherapy assessment have been developed. These include the multiple-choice Columbia Psychotherapy Skills Test for psychodynamic psychotherapy; the Cognitive Behavior Supervision Checklist by Wright, Sudak, Beck and Bienenfield; the University of Missouri assessment method; and an assessment method formulated by faculty at the Texas Tech University Health Science Center—El Paso (2, 3, 4).
Despite these efforts by AADPRT, there are no clear guidelines for how to determine competency or what constitutes competence in psychotherapy. The ambiguity as to what exactly they are to strive for has impacted residency programs and residents, who are asked to determine and show competencies. It has placed new demands on training directors and their faculty who have to find resources to meet these competency requirements. Our program has been struggling with these competency criteria and their incorporation into the residency curriculum. We were curious to look at the methods used by different programs for competency determination, how these competencies have impacted these programs and how this decision has been translated into actual practice.
Resident opinions are important in the development of educational curricula. It has been recommended to incorporate opinions of those evaluated into the proposed assessment techniques (5, 6). Residency program directors using guidelines from the Accreditation Council for Graduate Medical Education (ACGME) to select preferred evaluations for measuring general competency might find that residents do not have the same perceptions (7). Chief residents are at a stage usually ahead of other residents and sometimes act as auxiliary faculty members. They are aware of the demands and intricacies of residency. Obtaining their opinion can be helpful in the development of better curricula. There have been no studies looking at what residents think about psychotherapy competencies. This survey is the first attempt to provide some insight into chief residents’ opinions about psychotherapy competencies, implications of competency criteria on residency programs, methodology used by various programs for competency determination and degree of integration of competency criteria into residency curricula.
Chief residents of psychiatry residency programs who attended a Chief Residents Executive Leadership Program (ELP) at the Institute of Psychiatric Services in Boston, October 29—30, 2003, were surveyed.
A 21-item open ended and forced choice questionnaire was developed to assess the aforementioned questions (Appendix 1). The questionnaire was self-administered; the questions evoked information on various aspects of competencies including the resident awareness, methods used for competency determination by programs, the number of patients required in the five areas of psychotherapy, opinion about the integration of competencies into the residency curriculum, time spent on psychotherapy, reading materials specifications and residents’ attitudes toward competency requirements. The study was approved by our institutional review board (IRB). No identifiers were used and responses were kept confidential.
Chief residents (N=102) who were present at the meeting were surveyed and 72 (70.58%) returned the completed survey, representing 70 residency programs. An additional three uncompleted instruments were received. Of the completers, 69 were in their PGY-4 and three were in PGY-3 level of training.
Resident Awareness of Competencies
Sixty-two (84%) of the respondents reported that they were aware of the competency requirements for residents.
The various assessment methods of competencies were queried. Psychotherapy competency is determined by global assessment by non-physician psychotherapy supervisors in 61% of programs, a committee comprised of both physician and non-physician faculty in 21% of programs, physician faculty in 15% of programs and by other methods in 3% of programs. In this study the results indicate that global assessment by psychotherapy supervisors is the main method of assessment used for competency determination by the majority (61%) of programs.
The number of patients required for competency determination varied. The majority of respondents reported a requirement of 1—4 patients (F1). Few programs require use of >10 patients for competency requirements except for combined psychotherapy and psychopharmacology which had an interesting split pattern with 45% of respondents requiring 1—4 patients and 46% requiring more than 10 patients.
About one-quarter (26%) of chief residents expressed some concerns about the faculty preparedness to teach and assess psychotherapy competencies. The results showed that 74% of chief residents thought that faculty were qualified to teach and assess competencies, 23% thought that faculty were somewhat qualified and 3% were of the opinion that faculty members were not qualified to teach and assess psychotherapy competencies. This finding is important because some programs do not have enough expertise and resources in some or all of the areas of competencies. This is an important aspect of the influence of psychotherapy competencies on residency programs, as programs struggle to develop the resources to improve in these areas.
The largest proportion of respondents (46%) reported using videos for combined psychotherapy and psychopharmacology. Only 13% of chief residents reported use of videos for psychodynamic psychotherapy. Eight percent reported use of videos for cognitive behavior therapy and 6% reported use of videos for brief therapy and supportive therapy each.
More than half (55%) of chief residents reported that reading materials for psychotherapy competencies are specified in their programs. Twenty-seven percent reported having no specified reading materials for competencies, and 20% of residents reported that the reading materials were somewhat specified.
Instruments Used for Competency Assessments
The instruments used by programs in teaching and assessing competencies varied widely across the programs. The various instruments used by programs included use of case formulations (65%), videos (45%), process notes (44%), audiotapes (21%), multiple choice exams (20%), portfolios (12%), patient outcomes (9%) and other not specified methods (5%).
Residents’ Attitudes Toward Competencies
The attitude toward psychotherapy competency determination was split among the respondents. Thirty-nine (54%) of the respondents reported they enjoy the competencies; 31 (43%) reported they were somewhat of a burden, while 2 (3%) reported they were a big burden. Twenty-four (34%) of the respondents reported that they thought the residents in their programs enjoyed the competency criteria. Forty (56%) of the respondents reported competencies were somewhat of a burden, and seven (10%) reported them as a big burden on residents. This opinion of chief residents about residents’ attitudes toward competencies is interesting in the fact that it differs from their own opinion about competencies.
Effect of Competencies on Residency Programs
A significant number of chief residents (54%) viewed a positive impact of competency determination on their programs. Forty-three percent of respondents reported a neutral impact and 3% reported a negative impact of competency determination on residency programs.
Integration of Competencies With Residency Curriculum
Only 32% of chief residents reported that competencies are well integrated into their residency curriculum. Sixty eight percent of chief residents reported that competencies were either partially integrated or not integrated at all into their residency curriculum.
Learning and being familiar with various psychotherapeutic techniques is an important aspect of psychiatry residency training. The incorporation of psychotherapy competencies into residency educational requirements underscores the fact that psychotherapy is an integral part of psychiatry training. Mellman and Beresin (2) stated that training directors must now find resources in faculty, patients, and residency teaching time to teach, supervise and assess residents so that they graduate with competency. This exploratory study provides a sample of chief residents’ opinions about the role of psychotherapy competency determination, its impact on psychiatry residency programs and how this decision has been translated into actual practice. Only 84% of chief residents were aware of the competency requirements. This implies a differential emphasis placed on competencies across various programs. We were surprised by the large proportion of respondents who reported use of videos (46%) for combined psychotherapy and psychopharmacology. Use of videos is an important tool for learning, teaching and assessing competencies. It is particularly important in the areas of psychodynamic psychotherapy and cognitive behavior therapy. The finding that highest use of videos was reported for combined psychotherapy and psychopharmacology may reflect the ease rather than the more appropriate use of this important tool in psychotherapy.
The majority of chief residents (54%) reported a positive impact of competency determination on residency programs. It may, however, not reflect the average response of residents. Chief residents are generally in their final years of residency and are presumably better adjusted in their programs and may view events that are stressful to other residents as less stressful. A significant number of chief residents (46%) thought that competency determination was a burden. The average time spent on psychotherapy was 6 hours per week. There was no correlation between the time spent on psychotherapy, patient requirements, lack of reading materials and the responses on burden. We asked ourselves what might be an explanation for this response. One possible contributor might be the preparedness of programs for competencies. There was a positive correlation between the responses on faculty qualifications and impact of competency requirements on residency programs. Those who reported that their faculty was well qualified to teach and assess competencies tended to report a positive impact of competencies on the program. Yager and Bienenfeld (8) advised programs to define precisely the levels of formative competence they expect, and design curriculum and measures accordingly. Falender et al. (9) stressed the need for training in psychotherapy supervision and suggested development of supervision competencies to ensure faculty preparedness to provide adequate training and professional development of the trainee. A significant number of chief residents (27%) reported having no specific reading materials for psychotherapy competencies, which may be indicative of poor preparedness of programs for competencies.
This survey shows that, from the standpoint of chief residents, there is little consistency in psychotherapy competency determination across various programs. It shows a wide variation in the patient requirements for each area of psychotherapy for competency determination. We speculate that the larger number of patient requirements for combined psychotherapy and psychopharmacology (46% programs requiring more than 10 patients) may be born out of the emphasis on either more frequent use of medication management type of psychiatric practice or due to the ease of obtaining such patients. Psychiatry residency programs across the country differ in the level of emphasis put on various aspects of residency curriculum. Is there a need for some level of uniformity in these areas? This survey also suggests that competency criteria are not well integrated into the curriculum in the majority of residency programs. The standard of competency determination in five types of psychotherapy is so variable in practice that it raises some questions about the validity of the requirements. Yager and Bienenfeld (8) urged the RRC to revise their requirements to address expectations more honestly and to restate the expected competencies more modestly. Is there a distinction between "being familiar" and "being competent"? How close or different are these two terms? What constitutes being familiar for one person/program may be equivalent to being competent in another program. Giordano and Briones (4) argued that if "competence" were equated with "expert," it would be impossible for training programs to achieve this goal, whereas interpreting "competence" as knowledge of the basic tenets of the five forms of psychotherapy and adequate clinical exposure to each form that will enable residents to become comfortable using them may make demonstration of competence more achievable. Experts in different areas of psychotherapy may think that their area of expertise is the best method and needs to be incorporated into competency determination. The importance of these various areas of psychotherapy should be compared to all other critically important areas of the psychiatry residency curriculum. One such approach may be reducing competencies to two areas while mandating familiarity in other areas. This survey highlights the fact that, at least in the eyes of chief residents, there is no consistent standard of integration of competencies into residency curricula.
Limitations of our survey include the bias inherent in the information collected from chief residents. We do not know to what extent this study population reflects the opinion of chief residents and residents of all the psychiatry programs. This study represents only 70 programs; consequently generalizability is limited. Viewpoints of chief residents about their programs may not reflect the exact practices of residency programs. The items under the questions about residents’ attitude toward competencies were not mutually exclusive. It might have introduced a negative bias and may not have picked up respondents who think of competencies as a burden but nevertheless enjoy doing them. Child fellows are not represented in this study. This brief questionnaire had many viable items that informed the understanding of competencies. However, further refinements could be warranted. A new study would include residents, program directors and faculty members. Consistent assessment methods and guidelines for psychotherapy competencies need to be devised, implemented and tested for their validity, scope in actual practice and their impact on psychiatry residency training.