Mark Servis

Clinician-Educator Tracks for Residents: Three Pilot Programs

ObjectiveOver the past 30 years, clinician-educators have become a prominent component of medical school faculties, yet few of these individuals received formal training for this role and their professional development lags behind other faculty. This article reviews three residency tracks designed to build skills in teaching, curriculum development and assessment, education research, and career development to meet this need.MethodsThe residency clinician educator tracks at University of Michigan, Baylor College of Medicine, and University of California Davis are described in detail, with particular attention to their common elements, unique features, resource needs, and graduate outcomes.ResultsCommon elements in the tracks are faculty mentorship, formal didactics, teaching opportunities, and an expectation of scholarly productivity. Essential resources include motivated faculty, departmental support, and a modest budget. Favorable outcomes include a high percentage of graduates in clinical faculty positions, teaching programs created by the residents, positive effects on recruitment, and enhancement of faculty identity as clinician educators.ConclusionClinician-educator tracks in residency present a viable means to address the training needs of clinical track faculty. The programs described in this article provide a model to assist other departments in developing similar programs.

Evaluating a Lecture on Cultural Competence in the Medical School Preclinical Curriculum.

ObjectiveThe authors aim to evaluate the effectiveness of a presentation designed to increase cultural competence.MethodsA measure was developed to evaluate the attainment of knowledge and attitude objectives by first-year medical students who watched a presentation on the effect of culture on the doctor-patient relationship and effective methods of interpretation for non-English-speaking patients. The test was administered before and after the presentation and data were analyzed using a linear mixed-effects regression model.ResultsBoth knowledge and attitudes improved over the course of the lecture.ConclusionsThose who give individual presentations in multiple instructor medical school courses should supplement their course evaluations with lecture-specific surveys targeted to their specific learning objectives for knowledge and attitudes.

Expansion of the consultation-liaison psychiatry paradigm at a university medical center: integration of diversified clinical and funding models.

The perspective of the contemporary Consultation-Liason Service (CLS) psychiatrist is increasingly one of consultant to medical and surgical colleagues in models other than inpatient medical and surgical units. Simultaneously, the need for a clinically and educationally robust inpatient CLS persists despite funding pressures. The University of California, Davis Medical Center Department of Psychiatry has made use of creative organizational and financial models to accomplish the inpatient CLS clinical and educational missions in a fiscally responsible manner. In addition, the department has in recent years expanded the delivery of psychiatry consultation-liaison clinical and educational services to other models of care delivery, broadening the role and influence of the CLS. Several of the initiatives described in this paper parallel an overall evolution of the practice of consultation-liaison psychiatry in response to managed care influences and other systems pressures. This consultation-liaison paradigm expansion with diversified sources of funding support facilitates the development of consultation-liaison psychiatry along additional clinical, administrative, research, and educational dimensions. Other university medical centers may consider adaptation of some of the initiatives described here to their institutions.

The Doctoring Curriculum at the University of California, Davis School of Medicine: Leadership and Participant Roles for Psychiatry Faculty.

ObjectiveThe authors describe in detail the 3-year model of the Doctoring curriculum plus an elective fourth-year Doctoring course at University of California, Davis School of Medicine (UCDSOM) and University of California Los Angeles (UCLA) School of Medicine and the critical role for psychiatry faculty leadership and participation.MethodsThe authors present a review of curricular materials and course operations for the different Doctoring courses for first-, second-, third-, and fourth-year curriculum. The authors describe the role of psychiatry faculty in both leadership and in group facilitation.ResultsThe Doctoring curriculum offers case-based, small-group learning that relies heavily on standardized patients to teach core content around doctor-patient communication, ethics behavioral medicine and counseling approaches. There are frequent psychosocial issues woven in to these encounters. Psychiatry faculty members and other mental health professionals are well-prepared by virtue of their training to lead small group discussions and facilitate the supportive elements of the small groups in medical education.ConclusionThe Doctoring curriculum is both a biopsychosocial educational endeavor and a high-visibility leadership opportunity for the Department of Psychiatry. Other medical schools and departments of psychiatry may wish to pursue similar roles in their didactic programs.

Systems-Based Practice and Practice-Based Learning for the General Psychiatrist: Old Competencies, New Emphasis

Since the development and propagation of the six-competency framework, there has been a lack of understanding among both residents and teaching faculty of what systems-based practice (SBP) and practice-based learning and improvement (PBLI) entail [1–3]. In our anecdotal experience, these have been viewed as “soft” competencies, acquired incidentally as part of rigorous clinical training. This reflects cumbersome titles whose meanings are not intuitive to many physicians, few established teaching methods in either competency, and a lack of metrics for many of the corresponding program requirements. However, even as those metrics and training practices have emerged in other medical and surgical disciplines, psychiatry has been slow to adopt and disseminate them [4, 5]. As the Psychiatry Milestone Project began, multiple converging trends compelled our Working Group to pay particular attention to PBLI and SBP and to establish Milestones that will more closely align psychiatry with other specialties. First, the nature of medical practice is changing in ways that will impact psychiatry. New physicians in all specialties are increasingly choosing employment in large groups/ systems [6], and in these environments, they will be expected to join formal quality improvement (QI) processes. As large practices transform into Accountable Care Organizations (ACOs) under the Patient Protection and Affordable Care Act, that trend is expected to accelerate [4]. Psychiatry and allied behavioral specialties have outstanding potential for controlling costs and improving outcomes if we can appropriately prepare our trainees for that work [7–9]. Impending reforms in health care financing have also spurred interest in integrated and collaborative care as a specific practice model [10–12]. These modes of practice will demand skills that, in our experience, only a handful of departments currently teach well [13]. Atop this, the continuing presence of suicide reduction as a National Patient Safety Goal [14] highlights the need for psychiatry and psychiatric training to join the work started by our general medical colleagues. Second, an emphasis on quality and safety is woven throughout the Accreditation Council for Graduate Medical Education (ACGME)’s Next Accreditation System (NAS). The Psychiatry Milestone Project itself is an attempt to implement QI philosophies through continuous outcomes tracking in medical education [15]. Within NAS, the Clinical Learning Environment Review (CLER) replaces institutional site visits and specifically assesses “opportunities for residents to report errors, unsafe conditions, and near misses” and “how sponsoring institutions engage residents in the use of data to improve systems of care, reduce health care disparities and improve patient outcomes” [16]. Our experiences as CLER “alpha test” sites showed that ACGME site visitors are seeking evidence of resident engagement in systems-level improvement throughout the institution and that no department or service line will be exempted. Third, PBLI is increasingly important to board certification and licensure. The American Board of Psychiatry and Neurology (ABPN)Maintenance of Certification (MOC) process requires annual self-assessment, lifelong learning, and documented practice modification based on patient/peer feedback [17]. With certification potentially tied to Maintenance of Licensure (MOL) in the coming years [18], new graduates must be prepared for a career of rigorous self-assessment and improvement. J. Hunt Alpert Medical School at Brown University, Providence, RI, USA

The Chief Resident in Psychiatry: Roles and Responsibilities

ObjectivePsychiatric residency programs have had chief residents for many years, and several articles previously published describe the chief residents’ unique role as both faculty and resident. This article describes chief resident roles and responsibilities and explores trends in academic psychiatry departments from 1995 to 2006.MethodsThe authors mailed a survey about the roles and responsibilities of chief resident positions to psychiatric residency training directors using the American Association of Directors of Psychiatric Residency Training (AADPRT) mailing list in 1995 and e-mailed the AADPRT e-mail list in 2006. Data were collected by mail in 1995 and collected in 2006 by a web-based survey similar to the instrument used in 1995.ResultsJoint selection of chief resident by faculty and residents, 12-month terms protected time for administrative duties and written job descriptions were helpful features common to most programs.ConclusionOur results demonstrate that the majority of general psychiatry residency programs use the joint selection method with a negotiated job description, as well as a 12-month term.

A progress report on a department of psychiatry faculty practice plan designed to reward educational and research productivity

ObjectiveThe authors provide a progress report on a faculty practice plan that assigns a monetary value to administrative duties, teaching, scholarship, community service, and research.MethodsModifications to the original plan are described and quantifiable results in the areas of scholarship and research are summarized.ResultsDuring a 4-year period reported, the total direct costs of all grants increased 40% and the total number of publications increased 108% during this same time frame.ConclusionThe authors believe that a practice plan which assigns a monetary value to administrative duties, teaching, scholarship, community service, and research can incentivize faculty to be successful in each of these areas.

The Four General Competencies

A comprehensive assessment and outcome-based system of medical education is underway. All specialty residency programs within the Accreditation Council for Graduate Medical Education (ACGME) have specific medical knowledge and patient care requirements for professional practice. This process of defining the unique knowledge-base and patient care activities for psychiatry is discussed in another paper in this series. However, when it was time for the psychiatry milestone work group to decide how to approach the four general competencies (systems-based practice (SBP), practice-based learning and improvement (PBLI), professionalism (PROF), and interpersonal and communication skills (ICS)) shared by all physicians in training and throughout a life time of practice, we considered whether to adopt the general subcompetencies and milestones as defined by the ACGMEExpert Panel onmilestones or create specific subcompetencies and milestones applied to psychiatry. We chose to develop psychiatry-specific general competencies (table). This article will describe some of that process as well as highlight the unique aspects they bring to psychiatry. With these four general competencies, we define psychiatry’s contribution to the larger healthcare delivery system though our adherence to professional knowledge and behavior, as well as how we lead the clinical team within a system of care surrounding any given individual served. This is evident in our commitment to lifelong learning, maintaining, and enhancing our interpersonal and communication skills, and howwe know and utilize the larger system of care for the benefit of patients and their families. All this is possible when the individual psychiatrist is compelled by high ethical and professional standards. These four competencies bring the practitioner out of the individual doctor patient relationship (as rich, meaningful, and healing as it is) to membership within a healthcare delivery system with numerous multidisciplinary providers, as well as family and society. It is this context that we can best understand psychiatry training and the four general competencies. General competencies from a psychiatry perspective: The strength that psychiatry brings to the general competencies lies in our long standing participation and leadership in a multidisciplinary treatment team model of care. The inherent knowledge, skills, and attitudes in communicating with other healthcare providers, families, and patients are explicitly outlined in the general competencies (SBP, PBLI, PROF, and ICS). One could understand practice-based learning and improvement as an inherent component of professionalism. However, since lifelong learning for individual healthcare providers is so important to a vital and safe healthcare delivery system, it is a separate and distinct competency serving as a significant guide and standard for physician practice and ethos. Psychiatry is in a position to guide as well as to teach our medical and surgical colleagues what we know about the four general competencies in the evolving era of healthcare transformation through behavioral health integration.

Consultation-Liaison Psychiatry: Advantages for Healthcare Systems

Consultation-liaison (CL) psychiatry is psychiatry for the medically ill. This review describes the evolution of CL psychiatry from its origins in early 20th century general hospitals to the present era. The differences between CL psychiatry and general psychiatry are emphasized. The CL psychiatrist works in a multi-specialty and interdisciplinary environment whereas the general psychiatrist may not. Because of the CL psychiatrist’s experience with comorbid psychiatric and physical illness, he/she is skilled in the management of psychiatric comorbidity in the medically ill. Healthcare systems now require integrated models of service delivery in resource-sensitive environments. The CL psychiatrist is qualified to advise fellow physicians and other healthcare practitioners in how to manage psychiatric illness. CL psychiatrists have clinical, educational, administrative and research roles that are valuable in the delivery of comprehensive medical care in integrated, outcome-oriented systems.

The Milestones for Psychosomatic Medicine Subspecialty Training

BACKGROUND The Accreditation Council of Graduate Medical Education Milestones project is a key element in the Next Accreditation System for graduate medical education. On completing the general psychiatry milestones in 2013, the Accreditation Council of Graduate Medical Education began the process of creating milestones for the accredited psychiatric subspecialties. METHODS With consultation from the Academy of Psychosomatic Medicine, the Accreditation Council of Graduate Medical Education appointed a working group to create the psychosomatic medicine milestones, using the general psychiatry milestones as a starting point. RESULTS This article represents a record of the work of this committee. It describes the history and rationale behind the milestones, the development process used by the working group, and the implications of these milestones on psychosomatic medicine fellowship training. CONCLUSIONS The milestones, as presented in this article, will have an important influence on psychosomatic medicine training programs. The implications of these include changes in how fellowship programs will be reviewed and accredited by the Accreditation Council of Graduate Medical Education and changes in the process of assessment and feedback for fellows.