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.

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.

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.

General and Child and Adolescent Psychiatry Resident Training in Integrated Care: a Survey of Program Directors.

OBJECTIVE: Integrated care models are an evidence-based approach for integrating physical and behavioral health services. The American Association of Directors of Psychiatric Residency Training Integrated Care Task Force sought to describe current practices for providing training in integrated care to general and child and adolescent psychiatry residents. METHODS: Directors of US general and child and adolescent psychiatric residency training programs were anonymously surveyed to examine current practices in educating their residents in integrated care. Based on themes that emerged from the survey, the authors make recommendations for integrated care education of general and child and adolescent psychiatry residents. RESULTS: Fifty-two of 197 (26%) general and 36 of 111 (32%) child and adolescent program directors responded. Results demonstrate that a majority of responding general psychiatry (78%) and child and adolescent psychiatry (CAP) (72%) training programs offer integrated care rotations, many of which are electives for senior residents. The Veterans Health Administration (VA) and Federally Qualified Health Centers are common venues for such rotations. Sustainable funding of these rotations is a concern. Fewer than half of programs offer integrated care didactics. CONCLUSIONS: This report is intended to help program directors consider options for starting or optimizing their own integrated care curricula. Future research should examine the educational value, and the overall value to health care systems, of training in the integrated care model.

Ownership of patient care: a behavioural definition and stepwise approach to diagnosing problems in trainees.

In medical education, behavioural definitions allow for more effective evaluation and supervision. Ownership of patient care is a complex area of trainee development that crosses multiple areas of evaluation and may lack clear behavioural definitions. In an effort to define ownership for educational purposes, the authors surveyed psychiatry teaching faculty and trainees about behaviours that would indicate that a physician is demonstrating ownership of patient care. Emerging themes were identified through analysis of narrative responses in this qualitative descriptive study. Forty-one faculty (54 %) and 29 trainees (52 %) responded. Both faculty and trainees identified seven core elements of ownership: advocacy, autonomy, commitment, communication, follow-through, knowledge and teamwork. These seven elements provide a consensus-derived behavioural definition that can be used to determine competency or identify deficits. The proposed two-step process enables supervisors to identify problematic ownership behaviours and determine whether there is a deficit of knowledge, skill or attitude. Further, the theory of planned behaviour is applied to better understand the relationship between attitudes, intentions and subsequent behaviour. By structuring the diagnosis of problems with ownership of patient care, supervisors are able to provide actionable feedback and intervention in a naturalistic setting. Three examples are presented to illustrate this stepwise process.

A peer mentoring group for junior clinician educators: four years' experience.

PURPOSE: To study the effect of a peer mentoring group (PMG). METHOD: Six junior clinician educator faculty and one senior faculty at the University of Washington Medical Center's Department of Psychiatry formed a PMG in 2006. The PMG had 30 meetings during 2006-2010. Group format, goals, and meeting agendas were determined solely by participants. Feedback about positive and negative outcomes of participation in the PMG was determined by open-ended response to three sets of questions; qualitative analysis was performed by an outside research consultant. RESULTS: Program evaluation revealed benefits and undesirable or unintended outcomes. Reported benefits were increased workplace satisfaction; improved social connection; increased professional productivity and personal growth/development through accountability, collaboration, mutual learning, support, and information sharing; synergy, collaboration, and diversity of thought; increased involvement in professional activities; opportunity for peer discussions in a safe environment; and increased accountability and motivation. Undesirable or unintentional outcomes were exclusivity, lack of hierarchy, scheduling of meetings, absence of an intentional curriculum, diverse and competing interests, personal-professional enmeshment, and occasional loss of focus due to overemphasis on personal matters. Every member of the PMG was retained, and scholarly productivity increased, as did collaboration with other group members. CONCLUSIONS: Participants in this PMG experienced qualitative benefits and perceived advantages in career advancement and scholarly productivity. Negative consequences did not deter participation in the PMG or outweigh benefits. The self-sufficient and low-cost structure makes it particularly portable.