Academic Psychiatry 29:227-228, June 2005
© 2005 Academic Psychiatry
Residency Training and Homelessness Education
Richard C. Christensen, M.D., M.A. and
Lorrie K. Garces, M.D., Department of Psychiatry University of Florida College of Medicine Jacksonville, Fla.
To the Editor: We read with great interest the article, "A Survey of American Psychiatric Residency Programs Concerning Education in Homelessness," by McQuistion, Ranz and Gillig (1). Although the authors showed that a number of psychiatric residency programs have established training initiatives which address education in homelessness and mental illness, there remains the question of why are there still so few residents participating in clinical rotations dedicated to serving this highly vulnerable and underserved population. Of the residency programs that responded to the survey (106/178), 60% offered at least some training opportunities in working with homeless populations. However, only 11% of the programs rotated all their residents through these educational experiences. This is particularly confounding since the writers clearly point out organized psychiatry’s long-standing commitment to meeting the needs of those individuals who are homeless and suffering the effects of the most serious psychiatric disorders and addictions (2). Hence, there appears to be a disconnect between the profession’s public commitment to serving the homeless population and the educational curricula of training programs preparing the cadre of future clinicians to meet this glaring social and human need.
The authors cite the reported reasons for such a low rate of involvement as funding difficulties, "low program priority," which is connected to a "lack of community prevalence of homelessness," and the absence of recruiting and retaining academic community psychiatrists. We agree these factors, no doubt, contribute to the relative dearth of training opportunities for residents in homelessness education. Overcoming these barriers, however, will require commitment and action from those holding leadership positions (i.e., chairpersons, associate Chairs of education, residency training directors, etc.) within academic departments of psychiatry.
Although the clinical opportunities available to residents who work with underserved populations vary from department to department, it’s critical to remember not all training activities in homelessness education are created equal. We agree with the authors that incidental contact with homeless patients in settings like emergency departments, while valuable, is not formalized enough to address the myriad educational learning points that develop when rotating in a clinical setting devoted solely to treating the homeless. In fact, we believe the most successful residency training rotations in homeless education are developed, implemented and sustained as formalized educational commitments that are fully integrated into the residency training curriculum (3). Training opportunities that are solely resident-sponsored—as often is the case in clinical work with homeless populations—spearheaded by a single faculty member—regardless of the depth of commitment—and extracurricular in nature, run the great risk of not withstanding the test of time. Residents graduate, individual faculty persons leave, volunteer clinical opportunities for trainees come and go. It is our contention that nonmandated training initiatives, many started with wonderful intentions, are sustained on shaky ground until they become securely fixed within the matrix of a department’s articulated educational mission.
We would argue that the locus of responsibility for initiating and institutionalizing formal training endeavors in homelessness education ought to reside in the top tiers of leadership in academic departments of psychiatry. Once an academic department publicly owns an educational program providing psychiatric care to homeless persons, and links it to the general educational goals of the residency training program, there emerges the very real potential for overcoming funding barriers, "low priority" inertia, and issues of faculty recruitment.
The authors of this survey have quite successfully pointed out to those of us in academic psychiatry the gap that exists between our professional creed and our actual educational commitments to train socially responsive and responsible physicians. It now becomes our responsibility to work with departmental leadership to ensure this message does not go unheeded.
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REFERENCES
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- McQuistion HL, Ranz JM, Gillig PM: A survey of American psychiatric residency programs concerning education in homelessness. Academic Psychiatry 2004; 28:116–121[Abstract/Free Full Text]
- Lamb HR (ed): The Homeless Mentally Ill: A Task Force Report of the American Psychiatric Association. Washington DC, American Psychiatric Association, 1984.
- Christensen RC: Service-learning in medical education: Teaching psychiatry residents how to work with the homeless mentally ill. In Creating Community Responsive Physicians: Concepts and Models for Service Learning in Medical Education. Edited by Seifer SD, Hermanns K, Lewis J. Washington, DC, American Association for Higher Education, 2000, pp. 55–62.
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