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Method
The Delphi technique, which was developed by Helmer and associates
at the Rand Corporation in the early 1950s, was used to generate
ideas and consensus on what factors might influence practising psychiatrists
who see geriatric patients (10). This process provides an impersonal
and anonymous setting wherein opinions can be voiced without bringing
the experts together. Initially, we identified a group of experts.
Then, we asked these experts to provide several brief statements
about a specific issue of interest. These viewpoints are subsequently
synthesized and offered back to the group to elicit their opinions.
Generally, the narrower the range of opinions, the more agreement
there is about the answers. The goal is to gain consensus. The advantages
of this technique are that it maintains attention directly on an
issue, minimizes psychological communication barriers, and provides
equal opportunity and precise documentation. Its limitations include
difficulty with integrating cross-impacts among specific opinions,
overlooking important possibilities, and inadequate testing of the
measures generated for reliability and validity (11).
We identified the experts as a sample of academic and community-based
active members of the CAGP during the academic year 1997 to 1998
who typically attend the CAGP annual meeting. These participants
were selected for 2 reasons: 1) they were devoting a significant
part of their practice to geriatric patients and 2) we anticipated
that they would comply with the study following either a telephone
reminder, or an e-mail, or by attending the next anticipated annual
meeting of the CAGP. They were distributed across the country but
were not a random sample.
They were faxed a letter which asked, “What factors do you
think are influential in psychiatrists devoting a significant part
of their practice to geriatric patients?” Space was left on
the same page to list up to 10 points. They were asked to fax their
responses back as soon as possible (Phase 1). Then, we synthesized
the opinions into a questionnaire, in which they were asked to rate
the degree of influence of each item (Phase 2). Items were included
in the questionnaire if they appeared in more than 1 respondent’s
list. To ensure clarity of the items prior to distribution, we solicited
feedback on the questionnaire from several geriatric psychiatrists
who were not participating in the study. We obtained information
about what proportion of their practice time and patients was devoted
to geriatric psychiatry. After the questionnaires, we followed up
with telephone calls and e-mail reminders to the participants. Some
of the study participants attended the CAGP annual meeting, where
we distributed questionnaire copies to all study participants who
were present. The participants were asked to complete the questionnaire,
if they had not already done so by the end of the day. They were
given frequent reminders over the course of the 1-day meeting. Data
were entered into an Excel spreadsheet and then imported to SPSS
(12) for analysis.
Results
A total of 22 experts were identified. The composition included
11 academic (AC) psychiatrists and 11 community-based (CB) psychiatrists.
Of the 22 psychiatrists (86%), 19 completed Phase 1 of the Delphi
(11 AC and 8 CB). Of these, 6 were women, and 13 were men. We developed
a 41-item questionnaire of influential factors for rating in Phase
2. Table
1 describes these items. They could be divided conceptually
into educational, environmental, and personal influences. All 19
psychiatrists completed Phase 2. They were all devoting a considerable
amount of their practice to geriatric patients (Figure
1). The distribution of their responses is represented in
Figure
2 (educational), Figure 3 (personal) and Figure 4 (environmental).
Although the numbers in this type of study are too few to apply
statistical techniques, numerous items achieved consensus, with
most responses being “greatly” to “very greatly”
influential. The most significant items were educational. Of the
group, 99% reported that a positive psychiatry residency experience
with seniors and an adequate geriatric psychiatry residency rotation
were greatly or very greatly influential. This was followed by supervisor
qualities, which a minimum of 70% of the group rated as greatly
or very greatly influential. Supervisors’ characteristics (Table
1) included the following: role models, competent, enthusiastic
and charismatic, and mentoring. For the personal items (Figure
3), over 80% of the group felt that interest in the medical
psychiatric nature of the field was greatly to very greatly influential.
Other items that were very positive but had less consensus (68%)
were interest in aging, positive countertransference to the elderly,
and the challenge of the multifactorial nature of problems in the
elderly. However, there was less consensus for the other personal
items, except for fear of aging, where most participants felt that
this was not, or only slightly, influential. Of the group, over
80% also felt that credentialing was not, or slightly, influential
(Figure
4). A total of 68% felt clinical job opportunities were
greatly to very greatly influential, but the agreement was not as
apparent as with previous items discussed. There was no agreement
about economic factors having any significant degree of influence.
Discussion
Similar to our findings in the study of factors that influence
psychiatry residents’ interest in seeing geriatric patients
and Herrmann’s follow-up study of trainees, positive psychiatry
residency experiences with seniors strongly influence psychiatrists
to devote time to the practice of geriatric psychiatry. Virtually,
this entire group of practising psychiatrists, who committed most,
if not all, of their practice to geriatric patients, felt that positive
clinical experiences during residency contributed in a major way
to their decision to practise in the geriatric psychiatry subspecialty.
This generates the question: what does a positive residency experience
with seniors include? Is it one where the patients do well in their
treatment, or is it the nature of the training experience? Further,
an adequate geriatric psychiatry rotation was an important influence
in this study. The fact that this item was highly rated above supervisory
characteristics suggests that the clinical experience itself may
stimulate enthusiasm for practice. Perhaps, clinical exposure to
geriatric psychiatry confronts ageist biases, so trainees consider
the field to have positive outcomes (13).
In addition, our resident study generated the large degree of consensus
about supervisors’ positive influence on ultimately committing
practice time to geriatric patients. Swenson proposed that one goal
of mentorship is choosing a subspecialty (14). He describes mentors
as advisers, role models, teachers and sponsors, which resonates
with the qualities of the influential supervisor (that is, role
models, competency, enthusiasm and charisma, and mentors). The degree
to which supervisors contribute to practice choice is unclear, but
it may be relevant.
Interest in the medical psychiatric nature of the field is a theme
also shared by the psychiatry resident study and is useful when
considering who is more likely to enjoy treating elderly patients.
It may be helpful to communicate to residents during their training
that if the interface of medical psychiatry is an area of interest,
then they should consider exposure to geriatric psychiatry. This
group proposed and rated positively such items as interest in aging
and positive countertransference to the elderly.
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It is unclear whether this attitude antedated or was a consequence
of training. Clinical job opportunities, although not as influential
as some of the other items, did have some degree of consensus. The
reason practising psychiatrists would find this more relevant than
do trainees is puzzling. To understand career choice, Vaughan suggested
that we consider the social context during physicians’ training
(15). This drive for security may reflect the social values at the
time of training in this sample of psychiatrists.
Credentialing was not an issue that influenced the practice of
geriatric psychiatry. Currently, geriatric psychiatry is not a recognized
subspecialty of the Royal College of Physicians and Surgeons of
Canada (RCPSC); thus, there is no mechanism for credentialing. It
is interesting that the issue arose in the generation of the survey,
and for this reason, it may reflect anticipation of future changes,
which the CAGP hopes to achieve. In contrast to Small’s suggestion
that financial reimbursement has been a disincentive to practise
in this field, these items did not have consensus.
This study is limited in several ways. The sample of psychiatrists
was selected to maximize compliance and was not a random sample.
It may, therefore, reflect a unique group that seeks membership
and activity in this type of organization. In fact, this limits
the generalizability of these findings to other groups of geriatric
psychiatrists, unless one assumes that most practising geriatric
psychiatrists belong to such an organization. Similarly, most of
these psychiatrists completed their residency training prior to
the implementation of mandatory training in Canada. It is conceivable
that the residency experience as an influence may be inflated if
this group had selected its rotations because of prior interest
in the field. That pre-residency educational influences, as well
as personal issues, were generated by the study and did not achieve
consensus makes this concern less likely. The number of participants
in the study was small and anonymous to each other but not to the
study investigators. This may have inflated the reported influence
of the educational items because of social acceptability bias. Given
that these psychiatrists were not recent graduates (within the past
few years) and had no professional or personal relationship with
the investigators, this may have been less of an issue. Because
the participants in this study were devoting a large part of their
practice to geriatric patients, we cannot assume general psychiatrists
who see a smaller number of geriatric patients would report the
same findings.
Conclusions
This study’s findings generate the hypothesis that the educational
experience during psychiatry residency has a significant influence
on the practice of geriatric psychiatry by psychiatrists who devote
a major part of their practice to geriatric patients. The clinical
experience itself, as well as the supervisory relationship, stood
out and needs further exploration to determine what constitutes
a positive clinical experience and an optimal supervisory relationship.
That a similar, previous study of psychiatry residents also generated
these influences suggests that the interest during residency may
be a necessary precondition to practising geriatric psychiatry.
Given the RCPSC’s current mandatory training requirement in
geriatric psychiatry, this is encouraging. Despite similar findings
in the psychiatrist and resident study, most graduates do not continue
to practise geriatric psychiatry in any major way, suggesting that
there may be other unperceived reasons for practice. It may be that
exposure to the field assists trainees in countering their ageist
biases and in discovering the positive nature of the field. The
specific role of the supervisor as role model, teacher, clinician,
and mentor may then build on this interest and facilitate developing
a commitment to treating this patient population. To understand
how to encourage future geriatric practice, we need a study of practising
geriatric and general psychiatrists to examine this hypothesis in
a systematic way.
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Manuscript received January 2001, revised,
and accepted February 2002.
1 Assistant Professor of Psychiatry, University of Toronto, Postgraduate
Education Coordinator, Division of Geriatric Psychiatry, Toronto,
Ontario.
2 Research Assistant, Department of Psychiatry, Baycrest Centre
for Geriatric Care Graduate Student, Public Health Sciences, University
of Toronto, Toronto, Ontario.
Address for correspondence: Dr S Lieff, Department of Psychiatry,
Baycrest Centre for Geriatric Care, 3560 Bathurst Street, Toronto,
ON M6A 2E1
e-mail: s.lieff@utoronto.ca
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