Canadian Geriatric Psychiatrists: Why Do They Do It? A Delphi Study

Susan Lieff, MD, FRCPC¹, Diana Clarke, BSc, MSc²

Objective: To generate hypotheses regarding influential factors that have contributed to the practice of geriatric psychiatry by geriatric psychiatrists.

Method: Using the Delphi technique, designed to generate ideas and consensus, a sample of members of the Canadian Academy of Geriatric Psychiatry (CAGP) were asked to provide ideas on what factors were influential in their decision to devote a significant part of their practice to geriatric patients. These items were then synthesized into a questionnaire and rated for their degree of influence by the same group of psychiatrists.

Results: A total of 41 items were rated according to their degree of influence. The most influential items were related to geriatric psychiatry residency training experiences that were perceived to be positive or adequate. Supervision characteristics and interest in the medical psychiatric nature of the field were also deemed influential.

Conclusions: This study generates the hypothesis that the nature of the educational experience during psychiatry residency has a significant influence on the practice of geriatric psychiatry.

(Can J Psychiatry 2002;48:250–256)

Clinical Implications

The clinical and supervisory aspects of geriatric psychiatry residency training, as well as an interest in the medical and psychiatric nature of the field, are influential in stimulating a commitment to practise geriatric psychiatry.
We need further studies to determine what constitutes optimal training and supervision.

Limitations

The study sample was small and not randomly selected, which facilitated participation but limited the generalizability of the findings to other groups of geriatric or general psychiatrists.
Social acceptability bias may have inflated the reported influence of educational items.

Key Words: geriatric psychiatry, postgraduate education, recruitment, residency training, practice

Résumé: Les gérontopsychiatres canadiens : pourquoi en être? une étude Delphi

Canadians who are 65 years or older represent 12.3% of the population (1). It is more difficult to determine accurately the number of geriatric psychiatrists because it is not a recognized subspecialty, and the Canadian Academy of Geriatric Psychiatry (CAGP) has existed for 10 years only. When the post war, baby-boom generation reaches its senior years in 2030, it will comprise approximately 25% of the general population. As this segment of the population grows, there will be an increasing demand for psychiatric services. The Ontario Ministry of Health, while describing the preferred functions of specialized geriatric mental health services, recognized that currently there are insufficient numbers of geriatric psychiatrists to provide the necessary psychiatric care to the elderly (2). Similarly, Small noted issues in the US and concluded that a geropsychiatrist for every geropsychiatric patient is not a feasible task (3). Our low recruitment rate into the field has generated interest in understanding what the issues or factors are that contribute to, or influence, the practice of geriatric psychiatry by psychiatrists.

Herrmann, in a 1992 study of 16 graduates at the University of Toronto, suggested that supervisors and positive clinical experiences early in training strongly influenced those psychiatrists who decided to commit their entire practice to geriatric patients (4). Chan, in a study of older physicians, concluded that the age of the physician might also play a role in the proportion of geriatrics in a physician’s practice (5). In fact, Colenda’s survey of psychiatrists indicated that older psychiatrists were likely to have more patients over 65 years in their practices (6).

In a 1980 survey of US psychiatrists, Ford found that psychiatrists in general perceived elderly patients to be less ideal and viewed them as having a poorer prognosis than do younger patients (7). Burack, in his qualitative study of the decision-making processes of graduating medical students, found that role models influenced career choice and had exceptional influence in disproving negative stereotypes (8). In a parallel study, which we completed in 1998, of a sample of 20 final-year psychiatry residents, 16 (80%) reported that they planned to devote some of their practice time to geriatric patients (9). They described the most influential factors in their interest: positive clinical experiences with seniors, psychiatry supervisors who were enthusiastic and competent role models, and comfort and interest in the medical psychiatric and neuropsychiatric nature of the field. Although certain training experiences during residency may contribute to practice, other factors clearly impinge, because these high rates of interest do not translate into high rates of practice.

The purpose of this pilot study is to generate hypotheses that identify what influential factors contribute to the practice of geriatric psychiatry by psychiatrists who devote a significant part of their practice to geriatric patients.