Increasing Access To Perinatal Mental Health Care: The Perinatal Psychiatry Access Program Model.

Perinatal psychiatry access programs offer a scalable approach to building the capacity of perinatal professionals to identify, assess, and treat mental health conditions. Little is known about access programs' implementation and the relative merits of differing approaches. We conducted surveys and semistructured interviews with access program staff and reviewed policy and procedure documents from the fifteen access programs that had been implemented in the United States as of March 2021, when the study was conducted. Since then, the number of access programs has grown to thirty state, regional, or national programs. Access programs implemented up to five program components, including telephone consultation with a perinatal psychiatry expert, one-time patient-facing consultation with a perinatal psychiatry expert, resource and referral to perinatal professionals or patients, trainings for perinatal professionals, and practice-level technical assistance. Characterizing population-based intervention models, such as perinatal psychiatry access programs, that address perinatal mental health conditions is a needed step toward evaluating and improving programs' implementation, reach, and effectiveness.

Project ECHO in Psychiatric Workforce Development: the Example of a Perinatal Mental Health ECHO.

OBJECTIVE: Perinatal mental health and substance use disorders (PMHSUD) often go unrecognized and untreated. This study examined the use of the Project ECHO model to teach obstetric, primary care, and mental health clinicians about screening, diagnosis, and treatment of PMHSUD. METHODS: Participants in 3 years of the University of Washington's Moms' Access Project (MAP) ECHO program (2019-2022) completed pre- and post-program surveys. Nine participants in year 1 completed qualitative interviews. Dedoose was used for qualitative analysis of interviews. RESULTS: Of 136 participants, 62.5% (15/24) completed both pre- and post-surveys in year 1, 56% (28/50) in year 2, and 32.2% (20/62) in year 3. Most respondents agreed or strongly agreed that they were glad to have participated (96.8%; 60/62) and that they had used information learned in the program in treating a patient (95.1%; 58/61). In all years, respondents endorsed increased confidence regarding learning objectives of the program. Qualitative interviews following year 1 yielded themes of hierarchy of competence, motivation versus results of participation, connection, and politics of change: position and practice type. CONCLUSIONS: Findings supported the feasibility, acceptability, and self-reported effectiveness of the ECHO model for workforce development in PMHSUD.

What Sustains Residency Program Directors: Social and Interpersonal Factors That Foster Recruitment and Support Retention.

Residency program directors' careers follow several trajectories. For many, the role is relatively short term, lasting 3 to 5 years, during which time the program director may gain educational and administrative experience. However, a sizeable cohort of program directors have remained as program directors for a decade or more, and some have filled the role for the majority of their careers. Over the years, the role of the academic residency program director has become increasingly affected by administrative responsibilities, including scheduling, documentation, and reporting requirements, along with increasing clinical demands that may conflict with ensuring resident wellness and lead to insufficient time to do the job. Burnout in this role is understandable. Given these obstacles, why should any young faculty member choose to become a training director? The authors of this commentary have each served as a residency program director for decades, aggregating approximately 150 years of program director experiences. Based on their collective reflections, the authors describe social and interpersonal aspects of the program director role that have enhanced their professional satisfaction and well-being. These include overseeing residency cycle events from initial interviews through graduation and certification; assuming leadership and social roles in academic departments; counseling, mentoring, and assisting residents with work-personal life difficulties; and helping trainees and programs weather a variety of traumatic circumstances. These life-enriching experiences can compensate for the challenging aspects of these roles and sustain program directors through exceptionally rewarding careers.

Challenges of Assessing Resident Competency in Well-Being: Development of the Psychiatry Milestones 2.0 Well-Being Subcompetency.

Burnout and depression are major problems facing physicians, with 300-400 physicians dying by suicide each year. In an effort to address this issue, the Accreditation Council for Graduate Medical Education (ACGME) revised the Common Program Requirements for residency and fellowship programs to include a strong emphasis on well-being, and this revision has been extended to including a subcompetency on well-being in the Milestones 2.0. The Psychiatry Milestones 2.0 Work Group was convened to draft updated psychiatry milestones. As part of the open feedback period, the American Association of Directors of Psychiatric Residency Training submitted an organizational letter outlining several points to consider regarding the original draft of the well-being subcompetency. The ACGME was receptive to this feedback and allowed the Psychiatry Milestones 2.0 Work Group to revise the subcompetency. Current research indicates that burnout is largely driven by systemic factors, but well-being literature and initiatives often focus on individual factors and responsibility for burnout rather than systemic change. Program directors tasked with assessing resident well-being can additionally encounter several professionalism concerns, including how to (1) define a subcompetency within a competency that itself has not been well defined; (2) decide the appropriate balance between individual and systemic responsibility for well-being; (3) consider mental health as a parameter of well-being; (4) balance roles as physicians, psychiatrists, and training directors in thinking about the mental health of residents without overstepping boundaries and while maintaining privacy, confidentiality, and resident safety; and (5) measure well-being in a sociocultural context. This article describes how these considerations were incorporated into the revision of the Psychiatry Milestones 2.0 version of the well-being subcompetency, which has subsequently been made available to other specialty work groups for potential use as they develop their specialty-specific Milestones 2.0.

Growing the Psychiatry Workforce Through Expansion or Creation of Residencies and Fellowships: the Results of a Survey by the AADPRT Workforce Task Force.

OBJECTIVE: The USA needs to produce more psychiatrists to meet projected workforce deficits. The American Association of Directors of Psychiatric Residency Training Directors (AADPRT) sought to examine opportunities for and obstacles to expanding or creating residencies and fellowships. METHODS: In November 2019, the authors conducted a survey of residency and fellowship directors. The survey gathered information about new positions, new programs, participation in interprofessional education, and loss of residency or fellowship positions. RESULTS: The survey was distributed to psychiatry residency (N=231) and fellowship (N=194) directors, with a response rate of 33.4%. One quarter of responding residencies and fellowships reported creating new programs; 24.7% of residency and 17.5% of fellowships reported expansion. The most common reason to develop or expand programs was the shortage of psychiatrists, with the local institution as the most common funding source. Fifty-seven percent reported that they had wanted to expand, but faced barriers, primarily lack of funding. Recruitment and retention of faculty are major challenges. Psychiatry departments frequently (87.5%) participate in interprofessional education, generally perceived as positive. Unfortunately, 15.7% of respondents reported loss of positions or closure of programs. CONCLUSIONS: Creating and expanding residencies and fellowships are common strategies for addressing the shortage of psychiatrists. Barriers include lack of funding and challenges recruiting/retaining faculty. The loss of residency/fellowship positions or closure of programs is a worrisome trend.

A Review of Forensic Fellowship Training: Similar Challenges, Diverse Approaches.

OBJECTIVE: As the specialty of forensic psychiatry and the numbers of justice involved individuals with mental illness continue to grow, forensic education is receiving more attention. To add to this discussion, the authors reviewed current training practices in forensic psychiatry fellowship programs. METHODS: As part of a project funded by the state legislature looking at psychiatry and psychology training, with special focus on state hospital partnerships, the authors interviewed and surveyed forensic psychiatry fellowship program directors and conducted site visits to select programs. Given the mandate, special attention was given to programs with state hospital and psychology training affiliations. RESULTS: The literature and fellowship directors identified several key features and challenges for forensic training programs. Forensic fellowships focused primarily on evaluations and consultations but differed in their offerings related to training in treatment, scholarship, and particular types of evaluations. Common concerns included maintaining adequate funding, variety of training experiences, adequate faculty time, and adequate institutional support. Directors described cultivating institutional support by demonstrating mutual benefit as particularly important for securing resources. CONCLUSION: Forensic fellowships operational during the 2016-2017 academic year offered a range of forensic training activities, but experienced common challenges such as inadequate funding and faculty supervision. Empirical studies are needed to evaluate the relationship between programmatic offerings, the noted challenges, and acquired competencies.

Transforming Psychiatry from the Classroom to the Clinic: Lessons from the National Neuroscience Curriculum Initiative.

OBJECTIVE: Individual residency programs often struggle to keep pace with scientific advances and new training requirements. Integrating a modern neuroscience perspective into the clinical practice of psychiatry is particularly emblematic of these challenges. The National Neuroscience Curriculum Initiative (NNCI) was established in 2013 to develop a comprehensive set of shared, open-access resources for teaching neuroscience in psychiatry. METHODS: The NNCI developed a collaborative, team-based approach with a peer-review process for generating and reviewing content. Teaching resources have included interactive sessions for the classroom paired with a comprehensive facilitator's guide. Brief accessible reviews and short videos have been developed for self-study and teaching in clinical settings. Dissemination efforts have included hands-on training for educators through national workshops. All resources are freely available on the NNCI website. Outcome measures have included the number of educational resources developed, feedback from workshop attendees, the number of US psychiatry residency programs who have adopted NNCI resources, as well as analytics from the NNCI website. RESULTS: To date, the NNCI has developed over 150 teaching sessions, reflecting the work of 129 authors from 49 institutions. The NNCI has run over 50 faculty development workshops in collaboration with numerous national and international organizations. Between March 2015 and June 2019, the website (www.NNCIonline.org) has hosted 48,640 unique users from 161 countries with 500,953 page views. More than 200 psychiatry training programs have reported implementing NNCI teaching materials. CONCLUSIONS: This multisite collaborative provides a model for integrating cutting-edge science into medical education and the practice of medicine more broadly.

Creating a State-Academic Partnership to Advance a Forensic Teaching Service: Benefits and Barriers.

In Washington State, like many states, there is a shortage of forensically trained mental health clinicians to work with criminal justice-involved individuals. At the direction of the state legislature, a collaborative project was undertaken by the University of Washington, the state Department of Social and Health Services, and a state psychiatric hospital to develop a proposal for a jointly sponsored forensic teaching service. The authors reviewed the literature, surveyed and interviewed forensic psychiatry and psychology training directors, and conducted site visits of selected training programs that offer multidisciplinary training or have affiliations with state hospitals. The authors conducted focus groups of additional stakeholders, including clinicians and patients in forensic settings, to better understand the needs in Washington. The authors report on several common benefits and barriers to establishing forensic teaching services. Other states and forensic programs may find this article useful in identifying common considerations for forensic mental health teaching services.

Faculty Development for Teaching Faculty in Psychiatry: Where We Are and What We Need.

OBJECTIVE: A Faculty Development Task Force surveyed the American Association of Directors of Psychiatric Residency Training membership to assess faculty development for graduate medical education faculty in psychiatry departments and barriers to seeking graduate medical education careers. METHODS: An anonymous Survey Monkey survey was emailed to 722 American Association of Directors of Psychiatric Residency Training members. The survey included questions about demographics, the current state of faculty development offerings within the respondent's psychiatry department and institution, and potential American Association of Directors of Psychiatric Residency Training faculty development programming. Two open-response questions targeted unmet faculty development needs and barriers to seeking a career in graduate medical education. Results were analyzed as frequencies and open-ended questions were coded by two independent coders. We limited our analysis to general psychiatry program director responses for questions regarding faculty development activities in an attempt to avoid multiple responses from a single department. RESULTS: Response rates were 21.0% overall and 30.4% for general program directors. General program directors reported that the most common existing departmental faculty development activities were educational grand rounds (58.7%), teaching workshops (55.6%), and funding for external conference attendance (52.4%). Of all survey respondents, 48.1% expressed the need for more protected time, 37.5% teaching skills workshops, and 16.3% mentorship. Lack of funding (56.9%) and time (53.9%) as well as excessive clinical demands (28.4%) were identified as the main barriers to seeking a career in graduate medical education. CONCLUSIONS: Despite increasing faculty development efforts in psychiatry departments and institutions, real and significant unmet faculty development needs remain. Protected time remains a significant unmet need of teaching faculty which requires careful attention by departmental leadership.

Practical Interventions to Enhance Resident Ownership of Patient Care.

OBJECTIVE: In the modern training environment, some question whether trainees have the opportunity to develop ownership of patient care, which includes concepts such as advocacy, autonomy, commitment, communication, follow-through, knowledge about the patient, responsibility, and teamwork. Despite descriptions of what ownership is, there is little discussion of how to foster ownership during residency. The objective of this study was to solicit psychiatry resident and faculty perspectives on ways to enhance resident ownership in training. METHODS: Twenty-nine of 74 (39.2%) residents and 31 of 68 (45.6%) faculty members surveyed provided narrative responses to a voluntary, anonymous, electronic survey asking two structured, open-ended questions about what factors make it more or less likely that a resident will take "ownership" of patient care. RESULTS: The coding process produced four overarching categories of themes (attending, resident, educational program, and environment) that reflect domains for possible interventions to increase ownership, with conceptual guidance from the Theory of Planned Behavior. From these factors, the authors propose a number of practical yet theory-based interventions which include setting expectations, modeling, promoting autonomy, countertransference supervision, changing residency culture, and longer rotations. CONCLUSIONS: These interventions address subjective norms, attitudes, perceived ability and control, environment, and actual resident abilities, all of which, according to the Theory of Planned Behavior, would be likely to influence patient care ownership. Future studies could develop curricula and examine the effectiveness of the interventions proposed here in reinforcing or developing ownership in physicians.

Understanding ownership of patient care: A dual-site qualitative study of faculty and residents from medicine and psychiatry.

INTRODUCTION: With changes in duty hours and supervision requirements, educators have raised concerns about erosion of patient care ownership by resident physicians. However, the definition of ownership is unclear. This qualitative study investigated definitions of ownership in medicine and psychiatry faculty and residents. METHODS: The authors distributed an anonymous online survey regarding definitions of ownership to faculty and residents at the psychiatry and internal medicine residency programs at the University of Washington and the Harvard Longwood psychiatry residency and conducted a qualitative analysis of free-text responses to identify emergent themes. RESULTS: 225 faculty (48.6%) and 131 residents (43.8%) across the three programs responded. Responses yielded themes in five domains: Physician Actions, Physician Attitudes, Physician Identity, Physician Qualities, and Quality of Patient Care. All groups identified themes of advocacy, communication and care coordination, decision-making, follow through, knowledge, leadership, attitudes of going 'above and beyond' and 'the buck stops here', responsibility, serving as primary provider, demonstrating initiative, and providing the best care as central to ownership. Residents and faculty had differing perspectives on 'shift work' and transitions of care and on resident decision-making as elements of ownership. DISCUSSION: This study expanded and enriched the definition of patient care ownership. There were more similarities than differences across groups, a reassuring finding for those concerned about a decreasing understanding of ownership in trainees. Findings regarding shared values, shift work, and the decision-making role can inform educators in setting clear expectations and fostering ownership despite changing educational and care models.