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Psychiatry residency training programs in Canada have a principal responsibility to train young physicians to meet the psychiatric health care needs of the population through high-quality patient care and innovative research. This mandate requires that training programs be aware of and respond to the community’s changing clinical and academic needs. We can reasonably assume continued rapid expansion in our understanding of the biology of mental illness, an increase in effective psychotherapeutic interventions, a strong demand for more educational and clinical accountability, and application of innovative technology to teaching—all in the context of a worsening physician shortage. Each of these factors requires significant revisions to our current approaches to training. Training programs face the dilemma of attempting to provide new knowledge, skills, and models for practice while tied to an apprenticeship model of training and often-inefficient models of health care delivery. This dilemma can be overcome if programs develop more carefully thought-out, conscious training models that focus principally on the attainment of core competencies. To achieve these core competencies, they must be clearly articulated. Longitudinal programs to teach them and tools to measure their attainment must be developed. Further, the apprenticeship model of training, which emphasizes sequential training blocks (rotations), must be modified to incorporate longitudinal tracking of skill development through logbooks and regular, standardized assessments. The current apprenticeship model does not include such accountability and currently provides inadequate supervision: the average supervised time in patient care is 1 hour weekly (1), and junior residents in psychiatry spend less time working directly with their supervisors than do trainees in any other medical specialty (2). The single clearest statement of the general roles required of physicians is that made by the CanMEDS 2000 project (3), now being incorporated into each residency program in Canada. The CanMEDS framework provides a useful structure for reviewing the changes that programs must undertake if they are to provide relevant training. Our discussion will centre on the core competencies of medical expert, collaborator, communicator, and scholar—the roles comprising the greatest portion of resident training. Programs have been developed to enhance professional (4), as well as managerial and administrative (5), competencies, but we will not discuss them here. Training for Greater Expertise in Clinical Care: The Role of Medical ExpertAs knowledge expands regarding the biology of major mental illness and the interplay between mental and physical illness, it becomes imperative that programs require residents to have a firm grasp of medical fundamentals related to psychiatry. Competency as a psychiatric medical expert must ensure fundamental knowledge and skills in such domains as neurology, endocrinology, immunology, pediatrics, geriatrics, genetics, imaging techniques, and pharmacology. The basic clinical training (BCT) year should therefore evolve from a general year to a year providing essential grounding in medical skills and knowledge relevant to psychiatry. Most Canadian training programs now offer or require neurology in the BCT year, but if relevant medical expertise is to be obtained, programs or the Royal College of Physicians and Surgeons of Canada (RCPSC) will need to revisit the view of the BCT year as a simple rotating internship. Perhaps more important, they will need to resist pressures to push psychiatry core training down further, into the BCT year. More elective time within the PGY years 2 to 5 will also need to be available for rotations in medical subspecialties, particularly for those interested in research, geriatrics, and consultation-liaison psychiatry (6). In the US, residency programs exist that combine psychiatry with neurology, pediatrics, or family medicine. Some have seen this trend toward an increased marriage of psychiatry and medicine as a threat to psychiatry; others have seen it as a recognition of the interwoven nature of physical and mental illness (7). Regardless of one’s viewpoint, the brain and body will play a far more central role in psychiatry in the years ahead, and programs must prepare residents for this inevitability. Competency in Psychotherapy An important deficit in resident training is the lack of emphasis on achieving competency in evidence-based psychotherapies. Across Canada, the dominant focus of psychotherapy training remains long-term psychodynamic psychotherapy, despite the relative lack of evidence for its effectiveness in treating acute or severe psychiatric illness. Although guidelines have now been set for minimum hours in psychotherapy training, the RCPSC does not clearly mandate training in evidence-based treatments. In the US, accreditation now depends on programs’ providing training in 5 psychotherapies, including cognitive-behavioural therapy (CBT) (8). It was noted at the 2002 national meeting of postgraduate psychiatry program directors (COPE) (9) that few Canadian programs require residents to train in evidence-based psychotherapies such as CBT or interpersonal therapy (IPT). Moreover, if psychiatry is to demand expertise in effective psychotherapeutic treatment, planners will need to rebalance their psychotherapy programs to place greater emphasis on effective shorter-term treatments so that treatment can be provided to as many as possible (10). Without such focus, psychotherapy risks becoming irrelevant and unfunded, the domain of the fortunate few. Training in evidence-based psychotherapies is complicated by a relative lack of faculty preceptors; however, if training is competency-based, residents can acquire a significant portion of their evidence-based psychotherapy training from psychologists, nurses, and social workers who have the required expertise (11). Competency in Psychopharmacology As the shortage of psychiatrists becomes more severe, psychiatrists will be providing consultations on, and limiting their caseloads to, the more complex and refractory patients. Training programs therefore have a fundamental responsibility to ensure that residents acquire a comprehensive grasp of psychopharmacology: sophisticated knowledge and experience in psychopharmacology must not be seen as the domain of the subspecialist but, rather, as a core competency. To date, training in psychopharmacology has been left to core academic lectures and apprenticeship on rotations (13). It is now essential that programs expand training to ensure competency in psychopharmacology through delineation of the knowledge and experience required, longitudinal tracking with logbooks of residents’ use of psychopharmacological treatments, and evaluation (14). An organized psychopharmacological curriculum can also be linked to quality-assurance training (15), a chronically neglected area. Residents do not generally welcome such monitoring, and programs will need to be clear that the purpose of such tracking is not punitive but formative and to guarantee comprehensiveness and quality in training. Medical Expertise and Subspecialty Training As proposed, the PSM will radically alter resident training and threaten the viability of all but the largest training programs. When this matter was discussed at the 2002 COPE meeting (9), most of the smaller programs acknowledged that they would not be able to provide comprehensive formal training in at least 1 of the 4 subspecialties under consideration. If a program cannot offer training in all 4 areas, it will be markedly less attractive to recruits and thus less likely to fill its Canadian Resident Matching Services (CaRMS) quotients. As we know, the consequence tends to be fewer CaRMS positions allocated to psychiatry, with a net effect of fewer trainees in the smaller programs and training, particularly subspecialty training, consolidated in the major urban centres. Graduates tend to work where they train; we can thus assume that this move to formal subspecialization will result in fewer graduates working in underserviced areas and markedly worsen the current severe shortage of child and geriatric psychiatrists in rural areas. Subspecialization enriches our skills and knowledge; however, formal recognition of only 4 such domains, and the resulting fragmentation of psychiatry into 4 separate specialties, will not. Conversely, maintaining the current focus on core general training, permitting subspecialization through electives, and continuing to support fellowships as vehicles for subspecialization, will produce none of the problematic consequences noted above. Training for the 21st century means finding flexible ways for subspecialists to acquire the core competencies of their subspecialty. If the particular subspecialty competencies are articulated, most can be provided in any training program; competencies that cannot be provided locally can likely be met through electives or fellowships taken in larger centres. Thus, the integrity of smaller programs can be preserved. As with core training, the central issue for subspecialties is to clearly articulate the competencies required and then to evaluate the attainment of these competencies. Training for Expertise in Underserviced Domains The shortfall in geriatric psychiatrists is especially concerning, because the aging of the overall population will increase the demand for psychiatrists with expertise in mental illness in the elderly. In Ontario, for instance, the population over age 65 years will double in the next 25 years (19). The relatively poor recruitment into geriatric psychiatry is somewhat surprising, given the extent to which new resident recruits are anxious to maintain their medical skills and the degree to which those medical skills are required within geriatric psychiatry. As with child psychiatry, funding that appropriately compensates geriatric psychiatrists is required to make the subspecialty more attractive. As well, programs must seek more vigorously both to identify residents interested in geriatric psychiatry and to establish strong mentoring relationships between them and their senior colleagues. Addiction psychiatry also has critical shortages. Owing to the tremendous shortage of addiction psychiatrists, residents have a difficult time accessing high-quality, medically focused training, although they express interest in addictions. Residents are now required to have exposure to addiction psychiatry, at the least. Again, if residency programs are to address this critical need, they must have clearly articulated statements defining the core knowledge and skills expected. For training, they will need to draw on nonmedical experts in addictions; until a critical mass of local faculty can be developed, they may need to encourage rotations in the 24 addiction residency programs in the US (20). Further areas of profound shortage exist: in the year 2000, the Canadian Association of Psychiatry and the Law (CAPL) had only 77 members, although many patients seen on forensic services have chronic psychiatric illness. Where rehabilitation programs are part of the forensic service, they could support resident interest in this essential subspecialty by accepting rotations as RCPSC-mandated chronic care core rotations. Similar recognition for rotations that focus on individuals with developmental disabilities would likewise help to expand interest in this drastically underserviced domain (21). Role of Collaborator–ConsultantThe ratio of psychiatrists to the general population is recommended to be 1:8400. In fact, it is 1:22 773 in Saskatchewan and 1:20 925 in New Brunswick, based on 1998 data. With 3.5% of psychiatrists leaving the field each year (22) and fewer than 100 residents graduating each year, the shortages will only get worse. Therefore, training programs must ensure that residents are experienced in efficient clinic- and team-based treatment models. General outpatient psychiatric training must shift from a private-office model that is disconnected from other mental health professionals and focus on a model that develops the role of the psychiatrist as a consultant to family physicians, as the medical lead on treatment teams, and as the supervisor of clinicians who are providing direct patient care (23). Consultation skills can best be learned in a shared care model where residents work on-site in a family physician clinic and learn first-hand what family physicians want and need from a consultation. The government is committed to shared care, models have existed for many years, and objectives for such rotations have been developed (24,25). However, few training programs include such work, and none require it. This issue needs urgent attention if residents are to be prepared for future practice. In addition to gaining experience in shared care, residents must become comfortable supervising clinicians in what is called the physician-extender model of care (26). In the first author’s experience, a single psychiatrist in a single office seeing patients in a 1-to-1 model will carry 40 to 80 patients, whereas a physician supervising 2 nurses will be able to effectively manage the mental health needs of an additional 100 to 120 patients, assuming that each nurse follows 50 to 60 patients. One of the central jobs for residency programs in the next 5 years is therefore to integrate this supervisory model as an essential feature of general outpatient rotations so that, on graduation, residents are familiar and comfortable with this more effective model of mental health care. CanMEDS also directs that training should take place in actual settings; in this context, programs should provide residents with the skills required to practise in underserviced areas. Several programs have added mandatory and elective rotations in rural or underserviced areas, and the University of Toronto has recently created a CaRMS position specifically for a Northeast Ontario rural resident. Virtually every training program in Canada has elective rural rotations available to residents. The University of British Columbia (UBC) has a well-developed program—a potential template for programs across Canada—that requires residents to complete a selective rotation in a community or rural setting. Developing programs such as the Ontario Psychiatric Outreach Program (and the associated Ontario Psychiatric Education Network) has been costly, requiring site visits, faculty appointments for rural supervisors, development of telepsychiatry links, and considerable transportation and housing costs. These placements can have significant impact on call schedules, on the viability of the core academic program, and on participation in research by residents pursuing longer blocks of time in underserviced areas. That said, the programs have provided experiences that are highly valued by residents and have shown initial effectiveness in attracting residents to underserviced regions. They deserve universal replication. However, rural rotations cannot be mandated until adequate supervision is available in underserviced areas; even then, mandatory rotations are probably unwise, as there is little point in forcing an uninterested resident into a nonurban setting. Role of CommunicatorCommunication skills are particularly poorly taught in other medical specialties (27). Psychiatry, which values communication skills above all else, should take the lead in developing communication skills programs. Such skills are essential to psychiatric practice but, as with many other fundamentals, are neither taught nor evaluated systematically: they are generally assessed on rotation evaluation forms, usually with a single tick box. Evaluations do not identify, for instance, whether a resident can clearly and empathically convey to patients their diagnosis and treatment options; or clearly ask a question to a colleague when seeking a consultation; or write clear, concise progress notes; or dictate a focused, relevant consultation letter with clear treatment options. The backbone of diagnosis and care is the psychiatrist’s interview skill, yet here as well, according to resident feedback, there appears to be no agreed-upon interview structure or process. The diagnostic interview that is the basis for the RCPSC oral examination is to be learned by observation of one’s supervisor; however, few such interviews are actually observed, and resident feedback often varies highly among supervisors. Beyond the general diagnostic interview, developing skill in subspecialty interviewing depends on the will of the resident and the availability of subspecialists. Greater consistency could be achieved with new technologies: it is already technologically feasible to offer a catalogue of sample diagnostic and subspecialty interviews to all trainees via the internet, using streaming video. Providing sample interviews and agreed-upon feedback concerning the interviews will help set a common national standard and has the potential not just to enhance the examination but also to improve interview skills across the country. Role of ScholarAttaining competency as a scholar requires developing critical appraisal skills, a plan for lifelong learning, and for those pursuing research careers, investigational skills. Of these, only investigational skills are evaluated and only through the uncompromising school of grant acceptance or refusal. The other skills cannot be assessed until they have been operationalized: it is possible to see critical appraisal skills assessed through phenomenology, diagnosis, and management stations (PDMs) or written examination, but systematic training must first be implemented. Journal clubs, the traditional method of attempting to promote critical appraisal, do not develop these skills (28); a more focused approach is required. It is unlikely that more than 10% of residents will pursue a research career, but this vital group of residents require particularly close attention: research training requires close mentorship, protected time, and participation in clinical- investigator training programs or Masters programs in research methodology. Happily, there have been notable advances in supporting young investigators, fellowships have increased significantly, and the future for career researchers is brighter than it has been for years. A significant concern for smaller programs, however, is their ability to recruit and retain an adequate cohort of researchers without compromising their work through clinical demands. Without faculty rewards for research and protection of faculty research time, the essential mentoring for residents cannot take place. Developing a critical and scholarly attitude, even for those not pursuing research careers, requires that residents become familiar with standardized assessment tools such as the Structured Clinical Interview for DSM-III-R (SCID), Brief Psychiatric Rating Scale (BPRS), and the Hamilton Depression Rating Scale (HDRS). The future will link funding to outcomes and will require physicians to be familiar with principles of continuous quality improvement and to be skilled in using standardized scales in their clinical practice. Finally, if psychiatrists are to achieve expertise as educators and managers, programs should support residents who wish to pursue, within the residency, masters degrees in health administration or education. Evaluation of CompetencyAt this time, resident evaluations are almost entirely based on rotation evaluation forms that programs are redesigning to reflect the CanMEDS competencies discussed above. Unfortunately, rotation evaluations are notoriously unreliable (29). More accurate assessment of resident competency will depend on clear description of the particular skills being assessed; on use of more standardized tools, such as Objective Structured Clinical Examinations (OSCEs), learning modules, and written examinations; and on comprehensive evaluations involving not just the immediate supervisor but also team members, patients, fellow residents, and other physicians. More comprehensive assessments can be done through Web-based evaluation software, already used in some medical programs. Such evaluation will provide more timely and anonymous feedback to residents and will be more accurate than the now-common single-supervisor evaluation. In addition, competency will need to be linked to experience. Although repetition does not guarantee competence, lack of repetition all but ensures incompetence. A near-universal concern of program directors is the shrinking amount of time residents spend in direct contact with patients as their programs focus on academic activities, as they develop more longitudinal training (such as psychotherapy training), and as they eliminate clinical service on postcall days. Where resident activity has been surveyed, the average time residents spent in direct patient contact was less than 20 hours weekly (1; L Martin unpublished data, 2002) There is a real danger that increased focus on competencies will further fragment programs and that residents will come to see themselves as students, rather than as professionals. Residents can now graduate without having prescribed tricyclic antidepressants or a depot neuroleptic, without seeing a child suffering from attention-deficit hyperactivity disorder, or withiout following a patient with obsessive–compulsive disorder. As part of identifying essential training components, program directors will need to develop ways to track resident experiences. Many surgical, internal medicine, and obstetrics programs now have residents maintain a logbook; indeed, in some jurisdictions they are a mandatory part of successful licensure (30). Psychiatry should not lag behind these programs. If competencies are to be measured, the RCPSC must identify the minimal experiences on which competencies will be based and establish a basic national logbook. Use of agents or diagnoses can be tracked with existing personal digital assistant (PDA) programs (31) or through software programs such as WEB Eval (32), currently used to provide Web-based evaluation of residents. Fundamental knowledge will require ongoing review of the RCPSC written examination, but interim assessments of knowledge can be made through the well-standardized Psychiatry Resident In-training Examination (PRITE) (33). Challenges to Implementing Competency-Based Training Implementing competency-based training and more systematic and rigorous tracking of resident training will be a time- and labour-intensive endeavour, but one that we cannot afford to delay. The greatest single obstacle to achieving this long-overdue redesign will be faculty fatigue, which in part necessitates the redesign. Making changes will require additional time and effort from faculty precisely at the point where they are already overtaxed by clinical demands caused by physician shortages. There is no clear way past this, unless departments and faculties provide concrete assistance to program directors and committed faculty undertaking these revisions. With such help, a fundamental reorientation in our training can successfully be implemented—a reorientation that will see our programs graduate more knowledgeable, highly skilled, and effective psychiatrists and that will allow Canadians to see a substantive improvement in the quality of their mental health care. References1. deGroot J, Tiberius R, Sinai J, Brunet A, Voore P, Sackin D, and others. Psychiatric residency: an analysis of training activities with recommendations. Acad Psychiatry 2000;24:139–46. 2. Daugherty SR, Baldwin DC, Rowley BD. Learning, satisfaction, and mistreatment during medical internship: a national survey of working conditions. JAMA 1998;145:796–803. 3. Societal Needs Working Group. CanMEDS 2000 project. Skills for the new millennium. Annals of the Royal College of Physicians and Surgeons of Canada 1996;29:206–16. 4. Zikos E. Professionalism in residency training. CPA Bulletin 2002;34:32–4. 5. Yu-Chin R. Teaching administration and management in residency training. Acad Psychiatry 2002;26:245–52. 6. Varan L, Noiseux R, Fleisher W, Tomita T, Leverette J. Medical training in psychiatric residency: the PGY-1 experience. Can J Psychiatry 2001;46(10). Insert. 7. Wulsin L, Cantor L. Current status of family medicine-psychiatry combined residency programs. Acad Psychiatry 2000;24:120–3. 8. Accreditation Council for Graduate Medical Education: Graduate medical education directory 2001-2002. Chicago (IL): AMA; 2001. 9. COPE National Meeting; April 20, 2002;Ottawa (ON). 10. Weeresekera P. Postgraduate psychotherapy training: incorporating findings from the empirical literature into curriculum development. Acad Psychiatry 1997;21:122–32. 11. Medical Education Committee Group for Advancement of Psychiatry. Health care reform and postgraduate psychiatry: challenges and solutions. Acad Psychiatry 1999;23:1–8. 12. Garfinkel PE, Cameron P, Kingstone E. Psychopharmacology education in psychiatry. Can J Psychiatry 1979;24:644–51. 13. Awad AG, Darby PL, Garfinkel PE. Psychopharmacology training in psychiatric residency programs: the Canadian scene. Can J Psychiatry 1991;36:21–5. 14. Glick ID, Janowsky DS, Salzman C, Shader RI. A proposal for a model psychopharmacology curriculum for psychiatric residents. Neuropsychopharmacology 1993;8(1):1–5. 15. Awad AG. Integrating a clinical review process with postgraduate training in clinical psychopharmacology. QRB Qual Rev Bull 1987;13:279–82. 16. Persad E. Discussion paper: proposal to develop primary specialties in psychiatry. CPA Bulletin 2002;34:7–9. 17. Parker Z, Steele M, Junek W, Morin L, Davidson S, Fleisher W, and others. Child psychiatry in Canada: physician resources. Position Statement of the Academy of Child Psychiatry. Available from the Canadian Psychiatric Association, Ottawa (ON) 18. Leverette J, Leichner P, Meltzer S, Flynn L. Book of abstracts, 49th annual meeting of the Canadian Psychiatric Association. Ottawa (ON): Canadian Psychiatric Association; 1999. p 30–1. 19. OMA Human Resources Committee. OMA position paper on physician workforce policy and planning.Ont Med Rev 2002;April:17–26. 20. Pichot JT, Harris JT, Jones AR. Frequently asked questions about education in addiction psychiatry. Acad Psychiatry 1998;22:253–7. 21. Lunsky Y, Bradley E. Developmental disability training in Canadian psychiatry residency programs. Can J Psychiatry 2001;46:138–43. 22. Hnatko G, Pankratz W. Human resource planning for psychiatry in Canada, the Council of Provinces. Ottawa: Canadian Psychiatric Association; Forthcoming. 23. Meyer RE, Sotsky SM. Managed care and the role and training of psychiatrists. Health Aff (Millwood) 1995;14:65–77. 24. Cowley DS, Katon W, Veith RC. Training psychiatry residents as consultants in primary care settings. Acad Psychiatry 2000;24:124–32. 25. The Collaborative Working Group on Shared Mental Health Care. Shared mental health in Canada: current status, commentary and recommendations. Ottawa (ON): Canadian Psychiatric Association and College of Family Physicians of Canada; 2000. 26. Holzman MD, Elkins CC, Neuzil DF, Williams LF Jr. Expanding the physician care team: its effect on patient care, resident function, and education. J Surg Res 1994;56:636–40. 27. DesCoteaux JG, Wallis MV. Applying theory to design of communication-skills teaching at postgraduate medical level. Annals RCPSC 1998;31:270–4. 28. Fu CHY, Hodges B, Regehr G, Goldbloom DS, Garfinkel P. Is a journal club effective for teaching critical appraisal skills: a controlled trial with residents in psychiatry. Acad Psychiatry 1999;23:205–9. 29. Hodges B, Herold J, Regehr G. Global ratings and performance-based assessment: a review. Paper presented at AAP Conference; 2002; Toronto (ON). 30. Cobb RA, Baigrie RJ, Harris P, Harries PG, Shaper K, Fox A, and others. What constitutes general surgical training? Evidence from the log books of trainees in one district general hospital. Ann R Coll Surg Engl 1994;76(3 Suppl):117–20. 31. Malan TK, Haffner WH, Armstong Y, Satin AJ. Hand-held computer operating system program for colection of resident experience data. Obstet Gynecol 2000;96:792–7. 32. One45 Software Inc. WEB Eval. Vancouver (BC): One45 Software Inc; 2002. 33. Woodman C, Schultz SK. Faculty assessment of residents and the Psychiatry Resident In-training Examination: is there a correlation? Acad Psychiatry 1999;23:137–41. Author(s)Manuscript received and accepted March 2003. 1. Associate Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario. 2. Assistant Professor, Child and Adolescent Psychiatry, Memorial University of Newfoundland, St John’s, Newfoundland. Address for correspondence: Dr L Martin, Department of Psychiatry and Behavioural Neurosciences, 301 James St South, Fontbonne 4th Floor, Hamilton, ON L8P 3B6 e-mail: martinl@mcmaster.ca
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