In Canada, the Royal College of Physicians and Surgeons identifies the physician-manager role as an essential competency for physicians and mandates its integration into postgraduate medical education.
In the CanMEDS 2005 Physician Competency Framework (1), the Royal College of Physicians and Surgeons (RCPSC) stated that physicians must be able to:
In support of this framework, practicing psychiatrists report an increased need for managerial skills, given the complexities of the current mental health system and the reality that administrative duties are a relevant part of their practice (2). Studies also demonstrate that practicing psychiatrists and fellows feel deficient in several administrative and leadership areas (2, 3). Psychiatrists perceive changing from a strictly clinical to a managerial focus as a daunting assignment; however, psychiatrists who participate in administrative duties report increased job satisfaction (4).
Canadian and U.S. universities have made isolated attempts at management and leadership training for psychiatry fellows and residents (5, 6). The University of British Columbia offers their first-year psychiatry residents a series of seminars on health policy, stakeholders, and the mental health system. Yu-Chin (6) described an organizational theories curriculum for residents at the Cabrini Medical Center in New York City, which used both didactic and experiential learning for PGY-3 and PGY-4 residents. Because of the paucity of Canadian psychiatry residency programs offering administrative training, the Canadian Psychiatric Association recently highlighted the need for specific training during residency in the following mental health care areas: organizational structures in mental health; models of mental health delivery; quality assurance; program development; the ability to communicate with stakeholders; skills for teambuilding; conflict management; finance; leadership in administration; lifestyle management; and organizational change (5). Furthermore, psychiatry residents feel unprepared for systems-based roles but their perceptions regarding management training remain unknown (7).
We conducted a needs assessment survey to involve psychiatry residents in the development of a physician-manager curriculum for the University of Toronto, Canada.
We posed the following questions: What physician-manager knowledge and skill areas do psychiatry residents perceive to be important to acquire during their training? What are residents’ preferred learning methods for a physician-manager curriculum?
The University of Toronto’s Research Ethics Board approved our request to survey all PGY-2 to PGY-5 residents (N=102) enrolled in the Department of Psychiatry. This survey excluded PGY-1 residents because they had not completed their psychiatric clinical rotations at the time of mailing. Residents received the anonymous four-page surveys and cover letter by mail in July 2005 and returned the completed surveys to independent administrative offices within 2 weeks.
The survey comprised 11 questions that asked residents to rate their perceived current knowledge or skill levels in selected areas and rate how important they think it is to further their knowledge or skills in the specified areas. A 3-point Likert scale was used to rate the responses as 0, 1, and 2. Table 1 shows the knowledge and skill areas based on surveys of psychiatric administrators (4), physician-manager curricula prepared at other institutions (6), and deficits in physician-manager postgraduate training identified by the Canadian Psychiatric Association (5). Specific Canadian examples supplemented each topic area to provide greater subject clarity. For instance, “federal and provincial roles in health care funding” elaborated on the subject heading “Canada’s Health Care System.”
The survey elicited information on respondents’ preferred methods of learning, past education in physician-manager topic areas, and preferred teaching location. Respondents’ demographics included age, gender, PGY training level, advanced degrees held, desired future practice, past committee experience, and prior medical school education in management. We assembled a focus group of PGY-1 to PGY-5 psychiatry residents at one of the University of Toronto’s affiliated teaching hospitals and asked them to review each of the questions. We incorporated changes suggested by the focus group into the final version of the survey.
We used SPSS 13.0 software to analyze respondents’ data, employing descriptive statistics, multiple regression analyses, and analysis of variance (ANOVA). We designated the difference between residents’ perceived knowledge or skill in an area and their desired level of knowledge or skill in that area as either knowledge gap scores (GSk) or skill gap scores (GSs). A higher gap score indicated a larger difference between the residents’ current knowledge/skill in a specified area and the importance they placed on furthering their knowledge/skill in the area. We calculated mean gap scores for each knowledge and skill area, then compared them using a one-way repeated, within-subjects measure ANOVA. If a mean knowledge and skill gap approached a score of 1, then we used paired t tests to compare them.
We summed the gap scores for each area to find the total gap score for all knowledge (TGSk) and skills (TGSs). We performed multiple regression analyses to determine which of these variables predicted TGSk or TGSs: gender; advanced degree; past management experience; level of training; and prior medical school education in management. We postulated that these variables could influence knowledge and skill gap scores and residents’ self-assessment. We performed two separate regression analyses using TGSk and TGSs each as the dependent variable, and the five characteristic variables as independent variables. Statistical significance was determined at p<0.05.
The response rate was 48% (N=49), comparable to similar questionnaire studies (2, 8). The mean age of respondents was 30.4 years, and 62% were men. Approximately 30% had advanced degrees, but no residents had a master’s in business administration, public health, or education. Forty-three percent of respondents had committee experience and 12.5% of respondents had participated on more than one committee during their training. A large proportion of residents (81%) envisioned working in an academic hospital setting upon graduation, either exclusively or in addition to other types of practices.
Perceived Current Knowledge/Skill Level and Its Importance
Data reflecting respondents’ perceived knowledge/skill level and their respective importance for each knowledge/skill area are summarized in Table 1. Residents rated highest perceived knowledge levels in “mental health legislation” and highest perceived importance scores for “physician compensation.” Respondents reported highest perceived skill levels in “working in teams” and placed the greatest importance on “innovation and leading change.”
Knowledge and Skill Gap Scores
Knowledge and skill gap scores are also shown in Table 1. ANOVA revealed an overall difference in mean GSk (F[11, 38]=8.495, p<0.001) between the knowledge domains. Mean gap scores for knowledge areas were significantly greater for "physician compensation (GS=1.06 [SD=0.626], p<0.01) and program planning (GS=0.98 [SD=0.854], p<0.01). ANOVA revealed a significant difference between the four skill areas (F[3, 46]=19.72, p<0.001]. Looking after yourself and your career (GS=1.27 [SD=0.811], p<0.01) and innovation and leading change (GS=0.98 [SD=0.661], p<0.01) were both significantly greater than the other skill variables.
The mean total gap scores to be used in the regression analysis were calculated for both knowledge (TGSk=6.16 [SD=6.80]) and skill (TGSs=2.57 [SD=2.66]) areas.
Multiple linear regression analysis showed no significant associations between TGSk and TGSs and each of the five respondent variables.
Fifty-three percent of respondents preferred to learn at a central teaching site with their peers, 32% at their hospital site, and 15% on the Web. When asked to select all preferred learning methods for a proposed physician-manager curriculum, residents preferred workshops (79.6%) and small group interactive (73.5%), mentorship (61.2%), and lecture (57%) formats. Only 35% of respondents chose Web-based formats as their preferred learning method, and 4% chose online discussion boards.
This is the first study to evaluate psychiatry residents’ perceived need for a physician-manager curriculum. Previous studies assessed perceived gaps in administrative and leadership knowledge and skills only in practicing psychiatrists and fellows. Our findings show that psychiatry residents have the greatest perceived knowledge gaps in physician compensation and program planning, and the greatest perceived skill gaps in innovation and leading change and looking after yourself and your career. It is possible that these findings reflect existing curricula’s failure to address these areas, and respondents’ perceived needs to increase knowledge and skills in these areas in order to be able to negotiate and secure leadership roles in an unstable health care environment undergoing both primary care and mental health care reform. Furthermore, both physician compensation and professional self-care are relevant to individual needs, which may be a motivating factor for residents to want to increase their knowledge or skills. We found no significant associations between either TGSk or TGSs and the completion of an advanced degree, participation on committees, PGY level, or prior undergraduate exposure to management education. This lack of association might be due to an incorrect assumption that there is exposure to administrative issues in these domains. There was no association between either TGSk or TGSs and gender.
With regard to preferred pedagogy, residents favored small-group interactive, workshop, mentorship, and lecture formats delivered at a centralized location. These findings are in accordance with previous surveys of administrators and fellows (3, 6). However, residents’ preferred learning methods might be influenced by their exposure to common educational methods used at the survey site, thus encouraging higher ratings for didactic as opposed to Web-based formats.
Study limitations must be considered when interpreting these results. First, the response rate was less than 50%, and despite comparable response rates in other mailed surveys of physicians (2, 3, 8), it is possible that results may not be representative of all psychiatry residents in the program. Additionally, we conducted the study at a single Canadian residency program, which raises the possibility that the results are not generalizable to other residents and programs; however, the University of Toronto is the largest psychiatry residency program in Canada, accounting for 126 of the 587 psychiatry residents in the country. Approximately 70% of residents in the program graduated from medical schools other than the University of Toronto, providing representation from 12 out of 16 Canadian medical schools. Thus, our sample represents residents who have had different preresidency experiences that may have influenced their views regarding the physician-manager role. Furthermore, data from American institutions and other countries have revealed similar perspectives regarding physician-manager education (3, 6). Lastly, a larger sample size may have provided sufficient statistical power to detect significant results among the five respondent characteristic variables in the regression analysis.
Nonetheless, our survey indicates that psychiatry residents, as early as their second postgraduate year, find aspects of administration and leadership relevant and challenging to their future practice, suggesting that this is an appropriate time to introduce the physician-manager curriculum. Residents’ responses guided the development of a pilot physician-manager curriculum at the University of Toronto, consisting of junior and senior curricula of four workshops each, geared to those areas with the highest gap scores. We consider it important to introduce these topics in residency, allowing residents to apply the knowledge and skills they learn in a training environment.
We hope that formalized physician-manager training, offered in a contextually relevant format, will help ease the transition of psychiatry trainees into their new role as physician-managers, as well as recognize and meet the needs of our complex health care environment and those of our society. Future efforts include a national survey, currently under way, to provide further information for a national physician-manager curriculum.