The graduate medical education system expects its senior trainees to lead, teach, and supervise their junior colleagues, but pays little attention to how effectively they do so (1). Emerging trends in the field of child and adolescent psychiatry indicate that the skills have been neglected for too long. The two most recent surveys of early career child and adolescent psychiatrists indicated additional training in leadership, supervision, and teaching would have been helpful in current practice (2, 3). Child and adolescent psychiatrists are increasingly likely to practice as part of a system of care, within which health care professionals with various levels of training rely on the psychiatrist for guidance, education, or supervision. Systems-based practice experts label the ability to supervise other mental health professionals as essential for success (4). Child psychiatrists, frequently on the vanguard of new trends in clinical practice, such as the evidence-based medicine movement, must understand how to disseminate emerging best practices to their colleagues (5). In addition, child and adolescent psychiatrists, as tertiary care providers, should be able to confidently teach and supervise primary care physicians (6).
The Residency Review Committee does require training programs to provide opportunities for residents to teach, but fellowships have underestimated its importance over the past 20 years. When asked to rank the most important training experiences for their fellows, child psychiatry training program directors ranked “teaching” 26 out of 29 and frequently suggested it for elimination from the Accreditation Council for Graduate Medical Education’s (ACGME) requirements (7). A survey of child and adolescent trainees’ perceptions of the ideal training program did not even provide the opportunity to rate “learning how to teach” among 20 possible responses (8). A survey that did inquire about trainees’ desire to learn to teach found that two-thirds felt it was important, but only one-half were satisfied with the opportunities their program offered them to do so (9). Historical precedent and the continued lack of literature on teaching trainees to teach indicates that, at the detriment of their graduates, child and adolescent fellowships continue to neglect this skill.
This article discusses how one child and adolescent psychiatric fellowship implemented a new rotation designed to improve its graduates’ knowledge of effective teaching methods in the setting of a focused leadership experience. We hypothesized that by creating a real leadership and academic role for the senior fellow, he or she could acquire meaningful experience in the areas of instructing, evaluating, and supervising their colleagues. We also posited that by establishing the fellow as a dedicated guide and educator for rotating medical students, a recommendation of others in the literature, the experience would increase students’ interest in child and adolescent psychiatry (10). As a tertiary outcome, we hypothesized that the fellows’ increased involvement in education would improve the general psychiatry residents’ perception of the adequacy of their rotation in child and adolescent psychiatry (CAP).
The faculty and fellows collaboratively established the Academic Chief Fellow rotation based on the premise that each fellow, with appropriate supervision, should assume real responsibility for a variety of academic activities. Each of the three second-year fellows served as the Academic Chief Fellow for a 4-month block with one full day per week designated for chief fellow duties. Faculty remained aware that, as trainees in new leadership positions, the chief fellows could be marginalized by rotators or administrative staff in favor of more experienced faculty members. The faculty, therefore, took steps to legitimize the chief fellows as integral and leading members of the teaching team. First, a faculty supervisor was assigned to instruct and monitor each fellow. Second, to prevent any erosion of the authority granted to the fellow in his or her role as chief, faculty and fellows clearly delineated the expectations and duties of each rotation. The fellows wrote a detailed rotation description, including goals in terms of knowledge, skills, and attitudes and standard operating procedures, which the program director edited and formally added to the training manual (see Appendix A
In preparation for the rotation, all fellows participated in a five-session interactive didactic seminar taught by one of the authors (AS). Each session included discussions about one to two readings and relevant personal vignettes from the faculty facilitator. Topics for these sessions included the intricacies of the mentoring relationship (11); excellence in clinical supervision and practical guidance for fellows as supervisors (12, 13); common mistakes of new therapists (14); an introduction to parallel process in supervision and understanding lying within the supervisory relationship (15, 16); and ethical issues in supervision (17). Participants were encouraged to contribute their relevant past experiences and reactions.
For 4 months, each second-year fellow assumed the role of a first-level supervisor for all trainees rotating on the child and adolescent psychiatry service. All patient cases were staffed with a faculty member, but the fellow served as the first source of guidance and as the initial point of contact for questions and problems. In the academic year 2006–2007, rotators included eight fourth-year medical students, five first-year residents (interns), one general psychiatry second-year resident, and two general psychiatry fourth-year residents. The service generally hosted one to two rotators at a time. In the initial meeting with the rotator, the Academic Chief Fellow conducted the rotation orientation and crafted an individualized weekly schedule by selecting from approximately 10 ongoing clinical activities (Table 1
). Based on the rotator’s experience and interests, the Chief Fellow created a goal, learning objectives, and standards for each clinical activity. For example, the goal for a rotating intern, who selected the Child Study Group (a multidisciplinary, multiple session diagnostic process for children under 5 years old) as one of her clinical activities, was to increase her clinical exposure to young children. Her learning objectives included becoming familiar with the presentation of psychiatric illness in young children; understanding the uniqueness in diagnostic approach in young children; and increasing her ability to distinguish normal and abnormal development. Standards consisted of her required tasks while participating in the Child Study Group, including completing the provided background readings, attending all sessions, writing progress notes, and interacting with the patient, family, and other members of the treatment team. The Academic Chief Fellow individualized the goals, learning objectives, and standards to meet the needs of each rotator.
The Chief Fellow also created and delivered a series of informative discussions, termed “Core Concept” lectures, for the rotating medical students and residents. PowerPoint slides, handouts including reference articles and outlines, video demonstrations, and open dialogue were used to communicate essential points of child and adolescent psychiatric interviewing, attention deficit and hyperactivity disorder, pervasive developmental disorders, mood disorders, and psychotic disorders.
The Academic Chief Fellow met with each rotator several times each week with 1 hour dedicated to delivering the “Core Concept” lectures and another for reviewing their experiences, addressing problems, adjusting goals, and providing guidance. The Chief Fellow also interacted with the rotators during several clinical activities, such as while conducting intake or consultation-liaison evaluations.
The Academic Chief Fellow collaborated with his or her faculty supervisor to evaluate the performance of each medical student and resident, provide mid-rotation feedback, and complete final evaluations. Through these discussions the faculty supervisor helped the fellow to consider the rotator’s strengths and weaknesses, form a general plan to address deficiencies, and outline specific techniques to deliver positive and negative feedback.
Faculty assessed the Academic Chief Fellow’s performance as a teacher and supervisor in several ways. The faculty directly observed the fellow’s initial presentation of a “Core Concept” lecture; rated him or her using a written feedback form in areas such as clarity of presentation, knowledge of the subject presented, use of audiovisual aids, ability to engage the recipient in the presentation, and overall effectiveness; and provided immediate verbal feedback. In addition, several members of the faculty took turns observing the Chief Fellow from behind a two-way mirror while the fellow and rotator conducted intake evaluations. The faculty provided feedback on all aspects of the fellow’s performance, including how he or she instructed the trainee in crucial areas including case formulation, creating a differential diagnosis, and constructing a treatment plan.
Faculty also integrated feedback from the rotators themselves into the learning process for the Academic Chief Fellow. The faculty supervisor elicited verbal feedback on the fellow’s performance as an educator during weekly individual supervision sessions with each rotator. Medical student rotators also completed a written satisfaction survey (see “Survey Method” section). The faculty supervisor incorporated data from these forms into his or her feedback for the fellow.
We administered two surveys. The first surveyed each child and adolescent psychiatry second-year fellow after the completion of their Academic Chief Fellow rotation in the 2006–2007 academic year. Two respondents were male, one was female. All were graduates of U.S. medical schools. One had completed a residency in preventative medicine, held an M.P.H., and worked for 2 years as a board-certified preventative medicine physician. That fellow then completed a general psychiatry residency prior to beginning child and adolescent fellowship training. The other two fellows completed a 4-year general psychiatry residency and immediately entered fellowship training. None had any formal training in education or academics, but all had supervised medical students, interns, and junior residents during their residency training.
Respondents were asked to rate their agreement with the following statements (1=not at all; 5=extremely):
1. The objectives of the rotation were clear.
2. The prerotation seminar readings improved my knowledge of supervision and teaching.
3. The prerotation seminar discussions improved my knowledge of supervision and teaching.
4. The rotation improved my ability to evaluate the strengths and weaknesses of junior colleagues.
5. The rotation improved my ability to deliver feedback to junior colleagues.
6. The rotation improved my ability to deliver lectures to junior colleagues.
7. The rotation improved my ability to tailor lectures to colleagues with different levels of experience.
8. The rotation improved my confidence to lead in an academic setting.
9. The rotation was applicable to my future practice.
Respondents were provided space to write any additional comments and were asked to list the best and worst aspects of the rotation.
The second paper survey was distributed to medical students who rotated on the child and adolescent psychiatry service during the academic year 2006–2007 at the conclusion of their rotation after they had received a final grade with verbal and written feedback from the Academic Chief Fellow and attending. There was no space for a name on the form, but two medical students wrote their names at the top. Only the five medical students who had rotated on our service for over 2 weeks were given the feedback form. Three medical students who rotated for 1 or 2 weeks were not included in the survey as they were not present for many of the lectures, did not receive midpoint feedback, and participated in substantially fewer clinical activities. Four of the surveyed medical students were enrolled in medical schools located in the United States and one was enrolled in an accredited medical school in Puerto Rico. All were in their fourth year of training and on elective rotations with the child and adolescent psychiatry service at our facility. Most were interested in psychiatry as a career and were considering our general residency program for training. The medical students were asked to rate their agreement with the following statements (1=not at all; 5=extremely):
1. The core concept discussions were informative.
2. The core concept discussions were taught in a way in which I felt free to ask questions.
3. The fellow thoroughly knew the material which we discussed.
4. My interactions with the fellow during clinical encounters increased my understanding of child and adolescent psychiatry.
5. I received relevant and helpful feedback on my performance at the midpoint and conclusion of my rotation.
6. This rotation has made me more likely to pursue a career in child and adolescent psychiatry.
The form also requested that respondents comment on the best and worst aspects of the rotation in the space provided.
We also reviewed the results of the residents’ evaluation of their child and adolescent psychiatry rotation that had been collected via a computer-based feedback system immediately after their rotation by the general psychiatry program director. Residents were asked to rate their agreement with the following statements (1=not at all; 5=extremely):
1. adequate educational experience relevant to clinical practice;
2. adequate numbers of patients;
3. level of diversity of patient characteristics, problems, and complexity;
4. degree to which learning objectives were met or exceeded;
5. level of well-defined and clearly stated expectations for success;
6. improved my skills in psychopharmacology;
7. level of exposure to evidence-based approaches to patient care;
8. improved my skills as a clinician, educator and leader;
9. faculty members’ involvement with patient care, decision-making, and strong interest in the quality of resident’s education;
10. faculty’s approachability for supervision;
11. faculty’s availability for back-up support to ensure quality patient care;
12. overall quality of this rotation.
Residents were asked to consider the Academic Chief Fellow as part of the “faculty” for the purposes of the rotation evaluation.
In the fellow satisfaction survey, all categories of responses averaged 4 points (definitely) or better (Table 2
). All fellows agreed that the rotation was “extremely” relevant for their future practices. In addition to enhancing several skills key to teaching and supervising, fellows felt that the rotation “definitely” (mean score of 4) increased their confidence in their leadership skills. Comments about the best part of the rotation included “independence in most activities made it a good learning experience” and “good opportunity to recruit for the residency program.” Respondents felt the worst aspects of the rotation were that “seminar discussions could have been more focused” and “additional opportunities to provide lectures to trainees in other residencies would be helpful.”
Medical student satisfaction with the teaching provided by the Academic Chief Fellow was very high overall (Table 3
). The three questions which covered the “core concept” lectures received very high responses (between 4.8 and 5). Four of five medical students also responded that the rotation made them “definitely” or “extremely” more likely to pursue a career in child and adolescent psychiatry. Comments about the best parts of the rotation included, “lots of one-to-one time with fellow and attending,” “rotation was well organized,” and “the lectures were useful.” Comments about the worst aspects included, “increase structure to eliminate downtime,” “not able to follow patients long-term,” and “would have liked more direct patient contact.”
Resident evaluations of the rotation were also generally positive (Table 4
). Notably, the three questions directly regarding the faculty’s, and therefore the Academic Chief Fellow’s, involvement scored particularly high (4.6, 4.6, and 4.8). Although not statistically significant, 11 of the 12 measures improved from the 2005–2006 academic year, during which there was no Academic Chief Fellow position.
As child psychiatrists’ practices change, so must fellowship training. We have interpreted the results of recent surveys of new fellowship graduates as a clear statement of the ineffectiveness or insufficiency of training in academic areas and described one fellowship’s attempt to meaningfully integrate greater amounts of these skills into its curriculum. To function in a practice environment increasingly tied to multidisciplinary treatment teams and systems of care, child and adolescent psychiatrists must be able to lead through teaching and supervision.
Our results indicate that the Academic Chief Fellow rotation enhances important academic skills. Fellows unanimously agreed that the experience would be “extremely” relevant in their future practices. The secondary outcome of increasing medical student interest in child and adolescent psychiatry, a national priority within the field (18, 19), has been met with near unanimity. Finally, resident satisfaction with the child and adolescent rotation was improved from the previous academic year.
Several limitations of our approach are noteworthy. Medical student feedback may have been biased because many were interested in pursuing child and adolescent psychiatry as a career. We did not conduct pre- or posttesting of rotators’ knowledge, skills, or attitudes, which would have sharpened our appreciation of the impact of Academic Chief Fellow teaching. We did not employ a standardized instrument for faculty evaluation of the Chief Fellow when providing clinical instruction to the rotator during intake evaluations. Instead, we relied on subjective faculty observations and prompt feedback. We believe that these loosely structured faculty feedback sessions identified ways for fellows to improve their teaching and allowed the faculty to make suggestions in a collegial manner and monitor improvements in subsequent evaluations. Finally, our results are based solely on one class of three fellows.
In conclusion, an experience-based rotation augmented with a focused seminar and faculty supervision provides meaningful and worthwhile training for senior child and adolescent psychiatry fellows, increases medical student interest in child and adolescent psychiatry as a career and likely improves the general psychiatry residents’ rotation in child and adolescent psychiatry.