The profession of psychiatry has committed to the principle of lifelong learning for maintaining competence in clinical practice (1). Engaging in ongoing educational activities over the course of one’s career, moreover, has emerged as a standard for specialty board certification, medical licensure, and credentialing in many health care organizations (2, 3). Along with this commitment to sustained professional learning has come greater attention to the notion of performance-based skills in six “competency” areas—patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning, and systems-based practice (5, 6). These two trends, taken together, have created new challenges for psychiatric educators as they seek to create continuing education resources that provide up-to-date information pertinent to competencies, are responsive to issues arising in diverse practice settings, and can accommodate the needs of psychiatrists who completed their residency programs anywhere from 1 to 50 years before.

Many empirical studies, including a few studies of residents in psychiatry, have documented the keen and sustained interest of medical students and residents in the areas of professionalism and ethics (6–12). However, little is known about the educational needs of practicing physicians regarding this competency. A comprehensive literature search revealed no systematic studies of practicing psychiatrists regarding learning preferences or needs in the areas of professionalism and ethics. A recent study of practicing physicians who had undergone disciplinary action for unprofessional conduct by their state boards revealed that the vast majority had had documentation of unprofessional behavior during medical training (12). Psychiatric educators are actively and increasingly involved in the provision of continuing education for practicing health care professionals. For these reasons, we undertook a preliminary study to understand the preferences of psychiatrists in two U.S. states regarding professionalism and ethics training.

Participants

This study was conducted as part of a larger project funded by the National Institute on Drug Abuse (NIDA), which sought to characterize ethical and practice issues in Alaska and New Mexico. Data for this study were collected from 97 psychiatrists (61% men; 89% White with 6% of Hispanic/Latino origin; 5% Native American/Alaska Native; 3% Asian American; and 2% African American; 77% married or living with partner; average age 52 years). The participants had been in practice for an average of 17 years (range: 0–48 years) and spent most of their time (76%) providing direct patient care. Their main work situations varied, with 34% in private individual or group practices, 25% in nonprofit organizations, 17% in federal facilities, 9% in county facilities, 8% in for-profit settings, and 2% in tribal programs or entities, with 12% unspecified. On an 11-point scale that ranged from none (0) to a great amount (10), respondents reported an average rating of 5.3 (SD = 2.6) for the amount of ethics-related coursework or training.

Survey

Data were collected from participants through a 21-page survey exploring ethical challenges, perceptions of illness stigma, ethics training needs, resource needs, experiences in providing health care, barriers faced in providing care, adaptations to barriers, treatment issues related to providing care to minority groups, and provider practice characteristics. To identify ethics-related training needs, survey respondents were asked to indicate to what extent additional training in each of 28 topics would help them provide more effective care (range: not at all = 0, very much = 10). The topics were clustered into two areas, namely, general practice issues (17 items) and ethical issues with specific populations (11 items).

Procedures

Potential participants in eight provider groups were identified through licensing lists obtained in Alaska and New Mexico. All psychiatrists in Alaska and New Mexico were invited to participate in this study. After obtaining institutional review board approvals, surveys were delivered following Dillman’s procedures (13). These procedures included sending a letter notifying respondents of the impending survey, two mailings of the survey, and two reminder letters. Study volunteers received $50 in compensation.

Response rates were calculated based on the following decision rules: 1). potential respondents with undeliverable addresses were removed from the denominator; 2). those indicating ineligibility due to practicing less than half time in New Mexico or Alaska during the previous year were removed from the denominator; and 3). only respondents returning completed surveys were counted in the numerator. Of the 324 psychiatrists surveyed, 26 were undeliverable, 49 were ineligible, and 97 returned usable data. Thus, the overall response rate for psychiatrist respondents was 39.0%.

Preferences for Training Topics Pertaining to Ethical Clinical Practice

Table 1 provides participants’ average scores for the 17 training topics related to ethical issues confronted in clinical practice, sorted from most to least interest based on overall scores. Topics of most interest were related to identifying and addressing clinical mistakes, allocation of health care resources, dealing with issues arising with professional colleagues, and balancing personal and professional needs. Of least interest to participants were topics related to personal relationships with clients/patients, handling of information release, and managing overlapping personal and professional roles.

To determine whether women and men differed in their responses to the training topics related to ethical issues confronted in clinical practice, a one-way multivariate analysis of variance (MANOVA) was calculated, using gender as the independent variable and the 17 topics as dependent variables. Results revealed significant differences between women and men, F (17, 74) = 2.39, p<0.005, with women providing higher ratings on 11 of the 17 items. A comparison of the rank order of the items by gender revealed few differences.

To evaluate the relationship between years in practice and overall training needs, a composite score was calculated by summing the 17 ethical items related to practice issues. A Pearson product-moment correlation revealed a significant negative relationship between this composite score and the length of time participants reported having been in practice, r (97) = −0.22, p<0.05. This finding indicates that the longer an individual is in practice, the less interest is reported in training in ethical issues related to clinical practice.

Preferences for Training Topics Pertaining to Distinct Patient Populations

Table 2 provides participants’ average scores for the 11 topics related to distinct populations, sorted from most to least interest based on overall scores. Participants expressed most interest in topics related to dealing with individuals with substance abuse, and coexisting problems and other stigmatizing disorders, and individuals from diverse cultural heritage. Participants expressed least interest in topics related to individuals living in urban areas and individuals with sexually transmitted diseases, mental illnesses and serious chronic illnesses.

To determine whether women and men differed in their responses to the topics related to distinct clinical populations, a one-way MANOVA was calculated, using gender as the independent variable and the 11 topics as dependent variables. Results revealed a significant gender difference, F (11, 83) = 1.95, p<0.05, with women providing higher ratings on nine of the 17 items. A comparison of the rank order of the items by gender revealed few differences.

To evaluate the relationship between years in practice and overall training needs, a composite score was calculated by summing the 11 ethical items related to distinct clinical populations. A Pearson product-moment correlation between this composite score and the length of time participants reported having been in practice approached statistical significance, r (97) = −0.18, p = 0.08. This finding indicates that the longer an individual is in practice, the less interest is reported in training in ethical issues related to distinct clinical populations.

In this initial study of licensed practicing psychiatrists in two rural states, we found mild to moderate endorsement of a preference for training focused on professionalism and ethics issues in clinical practice and, especially, in the care of distinct patient populations. Interestingly, we found that the number of years in practice negatively correlated with the reported need for ethics training. Consistent with prior empirical work on ethics education preferences of physicians-in-training, including psychiatry residents, the women in this study indicated greater interest than their male colleagues (6–11). In contrast with the findings of previous studies was the relatively low level of enthusiasm for formal ethics preparation, which more commonly is highly endorsed as both valuable and necessary (6–11).

Lifelong learning is predicated on the idea that professionals assume active responsibility for enhancing their knowledge base and skill set over the course of their careers. Continuing medical education is one avenue for professional learning, and attunement to the interests and needs of learners is important in creating valuable educational initiatives for practitioners. Our data suggest that certain topics, such as identifying and addressing clinical mistakes, equitable allocation of health care resources, challenges in dealing with colleagues (e.g., resolving conflicts, dealing with misconduct or impairment), scope of practice issues, and ethical considerations in the care of diverse patient populations, are of greater relative interest to practicing psychiatrists. On the other hand, topics pertaining to managing personal and professional boundaries (e.g., gifts from patients, avoidance of sexual relationships with patients) were not educational topics endorsed by the psychiatrist-participants surveyed.

The psychiatrists in this study clearly did not endorse enhanced educational opportunities as a means of providing “more effective care.” Better access to continuing education was endorsed only mildly for its benefits, and professional leave for vacation was seen as more important than time off for additional training. The reasons for this response are uncertain. It may be that past educational experiences were not conducive to ethics learning; alternatively, their prior experiences may not have been engaging or relevant to their ethical practice experiences. These results suggest that creating ethics-oriented educational activities for practitioners that are valuable, useful, and interesting poses significant challenges. In the future, as requirements for specialty board certification, medical licensure, and credentialing begin to incorporate competencies, it may be that practicing psychiatrists will express greater interest in and need for training, particularly in nontraditional areas such as professionalism or practice-based skills. They may, however, offer greater resistance unless the relevance and value of these competencies are made clear, as suggested by our finding that preference for training diminished with progressive years in practice.

The female psychiatrists in this study more strongly affirmed their interest in 19 of the 28 ethics-related topics. A comparison of the rank ordering of the topics by gender showed very few differences, however. There are two possible explanations for this pattern. First, it raises the likelihood that women have a response style in which they report higher scores than men but that their actual needs are equivalent. Second, it is possible that women recognize and report the need for training more so than do men. Further inquiry is needed to clarify the pattern of gender differences identified in this work.

The strength of this study is its unique focus on continuing education needs and its sample of all licensed psychiatrists in Alaska and New Mexico. Our response rate is typical of social scientific work with diverse groups (14–15). Nevertheless, it may introduce bias and our findings should be interpreted accordingly. Further, our study does not attempt to document actual ethics training needs or to measure the caliber of practitioners’ ethical conduct. These will be, we hope, the topics of future studies in this field.

The psychiatrists in this study indicated some interest in professionalism and ethics training, but did not express the level of enthusiasm documented in many studies of earlier career colleagues. Creating continuing medical education initiatives that are attuned to the distinct needs and preferences of psychiatrists in clinical practice thus poses many challenges. This may be particularly true for certain aspects of practice, such as ethics and professionalism, which have long been recognized as vital to clinical care and now are viewed as core competency areas.

This research was supported by grant 1RO1DA13139 from the National Institute on Drug Abuse. Dr. Laura Roberts also acknowledges the support of a Career Development Award (1KO2MH01918) from the NIMH.

The authors gratefully acknowledge the contributions of Ginger Mongeau, Marcine Mullen, and David Neal at BHRS in Alaska; Pamela Monaghan Geernaert, Alexis Kaminsky, Audrey Solimon, and Katherine Green Hammond in New Mexico; and Lee Sechrest and Patrick McKnight in Arizona.