In Canada, the Royal College of Physicians and Surgeons (RCPSC) has adopted a new framework of core competencies for all specialists, called the CanMEDS roles (1). The CanMEDS framework includes the roles of medical expert, professional, communicator, scholar, collaborator, advocate, and manager.
The physician-manager role has been identified as one of the most difficult to integrate into postgraduate medical education (2). The RCPSC (1) has defined this role as encompassing four key competencies:
1. To participate in activities that contribute to the effectiveness of their health care organizations and systems.
2. To manage their practice and careers effectively.
3. To allocate finite health care resources appropriately.
4. To participate in administrative and leadership roles.
Within psychiatry, the concept of “physician-manager” emerged during the past 20 years, in the context of an increasingly complex mental health care environment (3). As managers, practicing psychiatrists feel deficient in several administrative knowledge and skill areas (4–6). Similarly, surveyed psychiatric residents feel unprepared in several system-based roles, and more than one-third of residents in our program feel unprepared to fulfill 12 of the 23 CanMEDS-defined competencies, notably in the manager, scholar, and advocate roles (7).
The Canadian Psychiatric Association has acknowledged these gaps in training and endorsed the importance of the physician-manager role in a position paper, highlighting the need for specific residency training (8). To date, however, the literature suggests a generalized lack of structured residency training in administration in Canada (8, Lieff S, personal communication, 2005). In the United States, where the Accreditation Council for Graduate Medical Education (ACGME) recently launched a training framework of six competencies, including that of expertise in systems-based practice (9), there has been a longer tradition of teaching and learning administrative psychiatry (10). Yu-Chin and Talbott (11, 12) have described administrative psychiatry curricula for senior residents, using both didactic and experiential learning. Despite these isolated efforts, because most training programs have only recently started to focus on physician-manager education and development, there is considerable work to be done to develop teaching programs that are contextually relevant to psychiatric residents’ learning needs.
This article describes the development and implementation of a pilot physician-manager curriculum at the University of Toronto to address gaps in physician-manager training at our institution. Resident feedback will be reviewed and recommendations for further development in this important area will be discussed.
The University of Toronto offers the largest psychiatric residency program in Canada, with over 700 faculty and 124 residents training in one of the seven main affiliated sites. Until 2006, there had been no formal training in the role of the physician-manager. Few among the faculty have formal management or leadership training.
Psychiatric residents’ perceived needs and teaching preferences were central to our curriculum development efforts (13). A survey of University of Toronto psychiatric residents was undertaken in 2005 to identify perceived gaps in administrative training and educational preferences. Residents identified gaps in several areas, including program evaluation, leadership and change management, physician compensation, and self and career development (13). With regard to educational preferences, 79.6% of residents favored workshops (n=39), 73.5% small groups (n=36), 61.2% mentorship (n=30), and 57.1% lecture formats (n=28), delivered at a centralized location (13).
Curriculum development was informed by the RCPSC competency framework (1), review of other curricula (Waddell C, personal communication, 2005, 11, 12, 14), and perceived needs of residents (12). A 10-member committee, consisting of our project team, one additional resident representative, administrators, and content and education experts, reviewed the needs assessment findings and guided the development of a pilot curriculum framework, including suggested learning objectives and teaching methods. The selected topic areas included teamwork, conflict resolution, quality improvement, program planning and evaluation, leadership and change management, mental health reform, organizational structures, and self and career development (Table 1
). In the absence of any consensus in the literature regarding length or structure for such a curriculum (11, 12, 14), we opted for a junior and a senior toolkit, consisting of four half-day workshops each. The class sizes were a maximum of 25 participants to allow for group interaction. The choice of topics for each toolkit was based on rotation-specific needs to make learning contextual and to match residents’ stage of professional identity development. Workshop leaders were encouraged to use as much interactive teaching as possible (15–18).
Four junior workshops were offered to PGY-2 (n=24) and four senior workshops to PGY-4 (n=28) residents, as a mandatory part of training, between December 2006 and May 2007. Each workshop followed the same general format of didactic teaching and small groups or other interactive techniques. The sessions were augmented with handouts and slides. The workshop leaders provided references and reference materials to the residents for use in their daily practice. Clinical illustrations were used throughout.
Interactive techniques included buzz groups, brainstorming, think-pair-share discussions, a debate, and clinical case studies (17, 18). The educational strategies used in each workshop and a list of all readings are available upon request. The interactive components of selected workshops are further detailed below in following sections.
Case studies focused on clinical and educational challenges faced by residents at our institution and were developed for the workshops on quality improvement, program planning and evaluation, leadership and change management, and organizational structures in mental health.
In advance of the workshop on self and career development, residents were asked to prepare a framework of their autobiography as it would be written at the time of their retirement. During the workshop they engaged in storytelling and interviewing colleagues about their careers, which they then shared with the group.
The buzz groups technique (17) was utilized in three of the workshops: teamwork, conflict resolution and negotiation, and mental health and addiction reform. The groups were divided in clusters of three to six students who answered specific questions on positive teamwork experiences, previous conflict interactions, and positive and negative experiences with the mental health and addiction systems, respectively.
At the end of each workshop residents were asked to complete anonymous standardized workshop evaluation forms, available upon request. Evaluation questions included statements about the importance and clinical usefulness of the objectives, rated on a 5-point Likert scale, as well as open-ended comments about the strengths and weaknesses of the workshops and suggestions for improvement. The information was found to be exempt from review by the school’s institutional review board. Descriptive data were analyzed using Microsoft Excel 2002 SP3 software.
Participation rates averaged 54% overall, with a range of 13 to 20 PGY-2s and 10 to 13 PGY-4s attending each workshop. These figures are very close to those for the program’s other teaching activities during the same period. Residents’ workshop ratings and qualitative feedback on objectives and teaching strategies are described in following sections.
summarizes resident ratings of individual workshops. All statements had a mean rating of 3 (average) or above. With the exception of two workshops, program planning and evaluation and mental health and addiction reform, which residents found less relevant for their level of training, all statements regarding the remaining six workshops were rated 4 (above average) or above. Because our evaluations were confidential, the influence of variables such as age or gender on residents’ perceptions of the workshops could not be determined.
Residents’ comments on the Junior Toolkit were extremely positive. Residents found the assigned readings relevant and interesting. They appreciated the reflective and interactive components of the workshops and valued the hands-on exercises and the use of case studies and “real life” examples. They commented that they would favor more emphasis during the workshops on “being a resident on a team” and “implementing changes in poor team environments.” They suggested that future workshops use role play to illustrate the difficulties in addressing conflict and offer them an opportunity to obtain feedback on their interpersonal style during negotiations. They also suggested placing more emphasis on resident-supervisor conflict. They suggested that more time from the core curriculum be dedicated to quality improvement and medical error and that residents be given an opportunity to take part in administrative committees and quality improvement projects at their hospital sites. They recommended that the Program Planning and Evaluation workshop be refocused in subsequent years with more basic concepts taught. Alternatively, they proposed that this workshop be offered to more senior residents. They also suggested that more presentations on program planning be included in grand rounds and other educational activities, so that they can gain more comfort and familiarity in this area throughout their residency.
Residents found the Senior Toolkit workshops “relevant, informative, and thought provoking” and the readings “accessible and interesting.” They appreciated the clinical illustrations, case studies, and interactive components of the workshops and found the opportunity for reflection “very fresh.” They would like to reinforce learning about leadership, organizational structures, and mental health reform in several ways, including opportunities to shadow change leaders, participate in administrative projects and hospital committees, and access web-based cases and regular, detailed feedback from supervisors. In terms of curriculum improvements, residents suggested that case studies be used throughout for greater relevance to their daily work. They also suggested that the workshop on mental health and addictions reform focus on current reform efforts such as system-level integration and collaborative mental health care, rather than a historical overview. Finally, although they found the workshop on self and career development valuable, “providing an approach to challenging and amorphous and potentially overwhelming questions,” they suggested that this workshop be offered earlier during residency to allow for early recognition of strengths, values, and career paths.
Although isolated attempts to provide leadership and management training to psychiatric fellows and residents have been undertaken in both Canada and the United States, there is a paucity of information about how to best teach the essential administrative knowledge and skills to psychiatric trainees and evaluate these competencies. The pilot curriculum developed at the University of Toronto aimed to provide psychiatric residents with a broad spectrum of leadership and management concepts to aid them during their formative practice years. Curriculum development was the result of an active partnership between learners and experts in content and education. Workshop leaders utilized a student-centered focus and interactive techniques to promote active learning and reflection and to support changes in professional practice (16, 18).
The residents’ largely positive surveys and engaging discussions during the workshops suggest that this new curriculum succeeded in meeting its objectives. Residents valued interactive teaching methods, clinical illustrations, and case studies drawing from resident experience and clinical rotations to make learning contextual. They suggested several approaches for longitudinal reinforcement of learning, including mentorship opportunities, quality improvement projects, participation in administrative committees, and regular feedback from supervisors.
To address residents’ comments and suggestions, we are currently offering quality improvement projects to PGY-3 residents, as well as elective opportunities for those who wish to pursue more advanced training. We are also offering the workshop on program planning and evaluation as part of the Senior Toolkit and the workshop on self and career development as part of the Junior Toolkit, to better match curriculum content to residents’ knowledge, skills, and stage of professional identity development. Finally, we are planning faculty development activities to facilitate resident-supervisor discussions and feedback.
The lessons learned during this process of curriculum development are multiple and will help guide further development efforts in this area. It had previously been suggested that didactic teaching of administration should be added to the curriculum during senior years, when residents have more administrative duties, to make the information more immediately practical (11, 12). However, both our resident feedback and our resident needs assessment highlight that psychiatric residents as early as their PGY-2 year find the role relevant to their current practice. Innovative, multifaceted training approaches, combining theoretical and experiential components, may allow several topics to be introduced earlier in training such that trainees can start conceptualizing topics earlier and have a theoretical understanding before they are thrust into administrative roles.
We have previously described the process we undertook to actualize the curricular change and the associated barriers and facilitators (19). In summary, several factors contributed to the success of this program. First, it addressed a pressing need to integrate the CanMEDs roles into postgraduate training. Second, this project enjoyed the support and shared vision of the department chair and the program postgraduate director, who made this pilot a mandatory training experience. Third, workshop leaders were active collaborators in the development of individual workshops, allowing for innovative approaches, creativity, and commitment (19).
Curriculum implementation has not been without its challenges, specifically multiple competing demands on resident time, scarcity of experienced supervisors to reinforce learning during clinical rotations, and scarcity of physician-manager role models (19). Some of these challenges are being addressed by faculty development efforts, resident electives and mandatory quality improvement projects as outlined above. We hope that resident participation in the revision and refinement of the curriculum and incorporation of the workshops into the formal curriculum will encourage higher resident attendance in the workshops, and identify strategies on how best to integrate the curriculum into clinical rotations.
Our work has several limitations. Because this was an exploratory pilot curriculum, there was no formal hypothesis testing and we only made use of descriptive data. We did not measure resident acquisition of knowledge or skills, which is a direction of our future research. Furthermore, our residency program is the largest in the country, limiting generalizability to small, less well-resourced programs, which may face additional implementation challenges. Despite these limitations, it is our belief that interactive training approaches can be implemented successfully in the majority of programs.
We have outlined a new curriculum addressing the learning needs of psychiatric residents in the physician-manager role. Experience with the curriculum has been promising. The main strengths of the curriculum lie in the use of multiple educational strategies, its contextual relevance, and the emphasis on active learning. Future educational research in this area will require a more formal research design to evaluate the curriculum longitudinally and to develop tools for resident evaluation of physician-manager competencies.
We would like to thank the Director of Postgraduate Education, Dr. Ari Zaretsky, and the Chair of our Department, Dr. Don Wasylenki, for their administrative and financial support of this project. We would also like to thank all workshop leaders, including Drs. Howard Book, Ian Dawe, Janet Durbin, Sarah Jarmain, Molyn Leczsz, Susan Lieff, Elizabeth Lin, Ms. Tina Martimianakis, Drs. Peter Prendergast, Brian Rush, and Don Wasylenki for their contribution to the development of the curriculum.
This work is supported by a Royal College of Physicians and Surgeons CanMEDS Development Grant.
At the time of submission, the authors disclosed no competing interests.