The Royal College of Physicians and Surgeons of Canada is the body that sets standards and guidelines for all residency training programs (RTP) throughout the country. The Royal College also reviews each program regularly, to ensure that it meets all requirements for full accreditation.
Standard B.1 of their document entitled "General Standards Applicable to All Residency Programs" addresses the administrative structuring of a residency program (6). It identifies the need for, and broadly outlines the responsibilities of, a program director (PD) and a supportive residency program committee (RPC). While the program director devises, constructs, and implements systems for effective management of the overall residency training program, the RPC is expected to analyze specific issues and provide carefully considered recommendations (4). Currently, however, it happens that most of the work falls to the program director.
The functioning of a flexible and innovative RPC, capable of providing leadership in education and setting standards of performance for residents and faculty, is a challenge for any clinical academic department. Departments of psychiatry are particularly strained in this regard because of the varied streams existing within the specialty, the multiple agencies that intersect in mental health, and the explosion of knowledge accrued from research on psychotherapies, neurosciences, neuroimaging, genetics, epidemiology, pharmacotherapies and the new psychosocial and rehabilitative interventions. In addition, the changing structures of the mental health system impose a change of venues for training as well as new skill-sets such as research and statistics to be taught. As psychiatrists move farther afield from the hospital setting and venture into multidisciplinary community-based mental health agencies and telepsychiatry, the teaching of administrative psychiatry, ethics and deontological precepts has to be reinforced and expanded.
High demands made of the RTP could easily swamp the PD and cause difficulties for him/her in meeting other clinical and academic expectations and advancement possibilities. Potential "job exhaustion" may lead the PD to make a career move due to a lack of work satisfaction (1). There is considerable variability in the term of appointment of program directors across Canada. Among currently serving directors the average length of time in the position is 3.3 years (SD=2.5 range=less than 1 to 10 years). The average total length of tenure for previous directors is 4.8 years (SD=2.5 range = 1 to 10 years) (van Zyl, unpublished). Given that PDs are responsible for all aspects of the residents’ curriculum (development, implementation, and evaluation), training and clinical competence (7), PD overload and resignation could significantly affect the residents and the RTP.
The PD position is thus in danger of being rendered ineffectual with a high turnover rate; consequently, the vision and evolution of the RTP are also at risk as incoming PDs are continually adjusting to the position. Establishing a more even spread of duties among the members of the RPC merits serious consideration as it may provide the PD with a better sense of control and lessen the possibility of burnout (5).
At Queen’s University, the traditional workload carried by the PD was being questioned. A recent assessment of the Queen’s program’s administrative structure identified inefficient processes coupled with dramatic workload imbalances. The PD was expected to run the program, make adjustments, and develop and implement changes virtually alone but required the agreement of a large RPC on any decisions. It was felt that too little time was available to the PD to adequately meet all the demands of the position, and that although a large number of persons were involved in the residency program administration in the form of the RPC, the latter body contributed little to the overall administrative work associated with the RTP. The ratio of administrative input by the PD versus the RPC was estimated to be 90:10.
In response to this situation, an innovative administrative structure was developed. Concurrently, for purposes of comparison, psychiatry residency training program directors at the other 15 Canadian medical schools were surveyed with respect to their program administrative structure and executive involvement of their training committees (t3). PDs from the various schools were also asked to estimate the percentage of work that was done by the director and by the rest of the RPC (t1). Completed surveys were received from all 15 programs. Programs were grouped according to the number of residents in the program: 5 small programs (fewer than 25 residents), 6 medium-sized programs (26 to 40 residents) and 4 large programs (more than 40 residents).
Findings indicate that the size of the RPC does not appear to be related to size of the program (t1). However, some relationship was found between the number of standing subcommittees and the size of the program. Twelve of the 15 programs reported having at least one standing subcommittee (range = 1 to 10), with smaller programs reporting fewer (average = 1.5) than medium-sized (average = 4.0) or large (average = 6.3) programs. All programs reported specific work roles for some members of the committee, but these varied between programs. Small programs had an average of 1.8 work roles, medium-sized programs 2.0 roles, and large programs had an average of 3.5 roles assigned per RPC. The overall average was 2.3. These roles included managing the review of rotation evaluation forms; psychotherapy; individual program/site matters; curriculum development; developing training objectives; funding resident activities; research; core program management; safety/security; Canadian residency matching service; PGY-1; and continuing professional development.
The role of the RPC was consistent across the sample. Thirteen of the 15 directors reported that their RPC was mainly consulting in nature and the average estimate of the percentage of the committee’s work done by the director was 82% (range=67% to 90%).
In an effort to more equitably distribute administrative workload, the entire administrative system of the Queen’s University psychiatry RTP was restructured to operate under decentralized management. The primary intent of the new configuration was to transform the residency program committee from a large advisory body into that of a smaller work-sharing entity.
Decentralization entailed the identification of specific program domains, representing each area within the training program, and the appointment of individual program domain managers (PDMs) responsible for managing those specific domains. The PDMs were to report directly to the PD who would not be involved in the direct administration of these program domains.
Eight specific program domains were created at Queen's, based on local program requirements
1. Program Accreditation, Resident Career Issues and Rotations
This position involves preparing for all accreditation surveys mandated by the Royal College of Physicians and Surgeons of Canada, or any reviews instructed by either the university or the Royal College. Another standing responsibility is to meet annually with each resident in order to discuss career and rotation issues and organize rotation placements for the following year.
2. Curriculum Development, Implementation, and Review
Identifies and appoints members of a curriculum committee to actively assist him/her with regularly reviewing the curriculum, adjusting it to emerging needs, and monitoring its implementation.
3. CaRMS (Canadian Resident Matching Service)
Arranges all aspects and associated processes of the Canadian Residency Matching Service.
4. International Medical Graduate Programs (IMGP)
Monitors constant changes to existing rules and regulations within the various IMGPs to make informed decisions about appropriate applicants. Also organizes interviewers, supervisors and evaluators in the recruiting process.
Identifies and coordinates potential members of faculty as mentors for residents within the RTP and monitors the overall ongoing process.
6. Program Promotion and Liaison
Promotes the RTP locally and across the country (to fill all available residency training positions).
Identifies, initiates and leads resident research in the field of resident education. Residents and members of faculty are recruited to assist in the research and coauthor relevant papers. The aim is to facilitate increased resident research productivity (3).
Traditionally, all administration involved in the recruitment, selection, and appointment of fellows was exclusively managed by the specific division of the psychiatry department offering the fellowship. However, the need was identified to centralise organization under one administration, and accordingly, this position was created. The PDM of Fellowship Programs is responsible for verifying credentials; liaising with the College of Physicians and Surgeons of Ontario regarding licensing issues; calling for letters of reference; setting up an on-site interview with the applicant and relevant division members; and liaising with the office of the dean of postgraduate medical education.
In order to meet RPC membership guidelines of the Royal College, the following initiatives were taken:
1. The PD serves as Chair, heading the administrative structure and linking all the PDMs and their domains. Additionally, he or she is the main administrative link between the Royal College of Physicians and Surgeons of Canada, the College of Physicians and Surgeons of Ontario (the provincial licensing authority), and the postgraduate dean at the university. While fairly autonomous, the PD reports to the head of the department.
2. No members of faculty other than the PDMs are invited onto the residency program committee. PDMs additionally represent either the training facility in which they work or the academic division of the department of psychiatry to which they belong, or both. The representative of an academic division of the department of psychiatry, in effect, represents all teaching programs within that division.
3. Corresponding members are appointed in the situation where a given division or teaching site is not represented by an existing core member (F1).
4. Although corresponding members are nonvoting members and do not attend regular RPC meetings, they receive all meeting agendas and minutes and are invited to respond to those documents.
5. The resident representatives on the RPC are the chief resident, the deputy chief resident and the junior Coordinators of Psychiatric Education (COPE) representative. All the resident representatives are peer-elected and form part of the core membership.
The new system within the Queen’s University psychiatry program was phased in over a period of 1 year; flexible adjustment to new needs has been paramount.
Since inception, one program domain has already been suspended, and two new ones instated (t2). Due to governmental initiatives, the extraordinary expansion of medical school and residency training positions has been called for, and in response to these pressures, two new program domains have been created: Family Medicine Liaison and Psychiatry Outreach. The former domain primarily requires the reviewing and adjusting of family medicine resident education in psychiatry; the latter entails developing community rotations in psychiatry. Program Promotion and Liaison was suspended as our success at filling our residency positions has improved.
With this new system, the opportunity has been created for the PD to oversee important initiatives without being directly involved in organizing the details, for example, development of new rotations in community sites.
To make it possible for the PD to rapidly implement adjustments to the program without expense to core program functions, the new nature of the PD position has ameliorated the historically disruptive event of PD switchover. In contrast to the old system, administrative processing delays due to the learning phase of the newcomer have been minimized; a recent switchover—despite occurring in the midst of the resident placement interviews and shortly after a Royal College program accreditation survey—attested to this.
Since implementation of the new system, PDMs have shown keen interest in their particular areas of responsibility. Regular communication between PDMs and the PD, and among PDMs themselves, has emerged as an interesting phenomenon that has led to a degree of cohesiveness not previously present between members of the RPC.
This, in turn, has created the opportunity for improved decision making and problem resolution by allowing the PD open and rapid communication lines with the various PDMs who are simultaneously also members of the RPC. While more weighty issues continue to be managed by the entire RPC, many decisions are now effectively and more efficiently dealt with by a small committee made up of the PD and the associated PDM. All discussions are minuted, and resulting decisions are reported at the following monthly meeting of the full committee. The net effect has been the streamlining and improved flow of administrative work associated with the RTP.
Another noticeable improvement has been the increase in the voluntary time commitment from all the PDMs. Previous members of the RPC were essentially expected to attend and advise at committee meetings and were found to be reluctant to offer any additional time if the need arose. The reluctance, thought to be based on the issue of unexpected and sporadic requests for time, seemed to vanish upon implementation of the new system, suggesting that acceptance of the position of PDM implies a requirement for increased time commitment and flexibility around it.
Time input associated with each program domain varies; for example, while the CaRMS program domain requires 6 months of intense work, other program domains—such as mentorship—require yearlong PDM involvement at much lower intensity.
Having competent PDMs provides the program director with a better sense of control and lessens the possibility of burnout (3, 5).
The overall time commitment of the PD may be, but is not necessarily, reduced. Thirteen of the 16 program directors in our survey noted that their time commitment was less than the recommended amount of about 0.5 full time equivalent (FTE), the average being 0.37 FTE (2) (t1). Following introduction of the new system at Queen’s University, the time commitment remained essentially unchanged, though an estimated shift in workload ratio of PD to RPC from 90:10 to about 60:40 was apparent. This shift allowed the PD to spend more time on development and implementation of initiatives rather than on excessive detail work and crisis management.
A potential pitfall is that a shift in time commitment may require increased compensation for RPC members spending more time on RTP responsibilities. At Queen’s this is not an issue, as we have a unique funding agreement that allows for flexibility of academic time. However, other programs may face this as a problem if specific remuneration exists for administrative and education commitments.
To circumvent the risk of a program domain becoming too independent and taking on an errant course, the PD should ensure that frequent communication occurs with all PDMs. Another associated risk is that a PDM responsible for one of the more taxing program domains might promptly resign due to overwork. To prevent this situation, part of the PDM’s role is to strike and Chair a subcommittee to help spread workload.
In this study we were not able to pursue specific reasons for program directors leaving their positions prior to completing their term of office and whether this related to job exhaustion. For this reason we needed to make certain assumptions in this regard as described in the paper. This lack of information constitutes a limitation of the current study and opens an area for further research. Another limitation lies in the way program directors were asked to estimate the ratio of PD to RPC workload. Factors to be considered in this estimate were not specified to the PDs, and accordingly it is likely that this resulted in some variability in the method of estimation between sites.
The position of program director in psychiatry is a demanding one that requires 25% to 55% (average 37%) of the program director’s time, carrying an estimated 67% to 90% (average 82%) of the administrative workload. The program domain manager administration system implemented at Queen’s University enabled the program director to be simultaneously up to date with all major areas of the program while experiencing a substantial decrease in the administrative workload, achieved through increased work contribution of the RPC. This system encourages RPC members to be closely involved in decision making and development of their own program domains and allows the program director more time for developing, implementing and overseeing innovations across the entire spectrum of the RTP. Essentially, this results in a more efficient and adaptable RPC and RTP.