Psychotherapy Tracks in US General Psychiatry Residency Programs: A Proxy for Trends in Psychotherapy Education?

OBJECTIVE: The authors studied the goals and design of psychotherapy tracks in the US general psychiatry residency programs and the perceived barriers to psychotherapy tracks in programs without them. METHODS: The authors emailed 226 US general psychiatry residency program directors, asking them to complete an anonymous, online, Qualtrics survey about psychotherapy training and tracks in their program. RESULTS: Seventy-nine programs (35%) participated. Of these, 22% (n = 17) reported having a psychotherapy track, 4% (n = 3) reported currently developing a psychotherapy track, and 74% (n = 56) reported not having a psychotherapy track. Of those without a psychotherapy track, 81% (n = 44) reported not wanting one. Time, personnel, resident interest, and funding were the most common reasons for not having a track, but programs with tracks generally reported additional personnel and funding were not needed. Most programs with a track reported being satisfied with it. A sizeable minority of reporting programs (overrepresented by those without psychotherapy tracks) did not require supervision or didactics for all three Accreditation Council for Graduate Medical Education required psychotherapy modalities. CONCLUSIONS: Commonly perceived barriers to having a psychotherapy track may not be as limiting as they seem, and the diverse types of psychotherapy tracks may offer flexibility for programs seeking to design one. The finding that not all programs offer a full complement of supervision and didactics in core psychotherapy modalities is concerning for the future of psychotherapy training in residency programs. The presence of a psychotherapy track may be a proxy for the value a program places on psychotherapy education.

Beyond Informed Consent: Talking to Patients About Therapeutic Action.

Psychodynamically oriented psychotherapists are faced with the question of what to say to new patients about the therapy they are beginning. This article reviews historical attitudes about early treatment discussions with patients in psychoanalysis with an emphasis on how these discussions have evolved as informed consent became a standard of care. Approaches to talking to patients about therapeutic action in psychodynamic psychotherapy are discussed, including the development and application of a psychoeducational document that is being used to facilitate these discussions in the outpatient residents' clinic of a large urban academic medical center. Finally, qualitative data are presented to describe residents' experiences with this document. The overwhelmingly positive responses suggest that this intervention is helpful for patients and residents and can serve to deepen the treatment relationship through mutual trust and understanding.

Thinking Outside of Outpatient: Underutilized Settings for Psychotherapy Education.

OBJECTIVE: Although psychiatry residents are expected to achieve competency in conducting psychotherapy during their training, it is unclear how psychotherapy teaching is integrated across diverse clinical settings. METHODS: Between January and March 2015, 177 psychiatry residency training directors were sent a survey asking about psychotherapy training practices in their programs, as well as perceived barriers to psychotherapy teaching. RESULTS: Eighty-two training directors (44%) completed the survey. While 95% indicated that psychotherapy was a formal learning objective for outpatient clinic rotations, fifty percent or fewer noted psychotherapy was a learning objective in other settings. Most program directors would like to see psychotherapy training included (particularly supportive psychotherapy and cognitive behavioral therapy) on inpatient (82%) and consultation-liaison settings (57%). The most common barriers identified to teaching psychotherapy in these settings were time and perceived inadequate staff training and interest. CONCLUSIONS: Non-outpatient rotations appear to be an underutilized setting for psychotherapy teaching.

Smartphones, Smart Feedback: Using Mobile Devices to Collect In-the-Moment Feedback.

OBJECTIVE: The goal of this study was to streamline the collection of resident feedback in order to support faculty development and program improvement in psychiatry training. METHODS: The authors developed and implemented a brief, free, mobile survey to track resident feedback and class attendance. RESULTS: Prior to instituting this system, resident feedback was obtained semi-annually for each course (n = 90) and not each individual class. In comparison, this new system allowed the authors to collect feedback on 477 of the 519 classes held over the 2014-15 academic year (92 %). Written comments about the curriculum increased over tenfold from 42 in 2013-14 to 541 during a comparative time period in 2014-15. One year after instituting this new system, resident participation increased to 81 % on average (compared to 64 % previously). CONCLUSION: Mobile devices may provide an inexpensive and relatively untapped mechanism for improving the process of collecting resident feedback and tracking class attendance.

Teaching Dialectical Behavior Therapy to Psychiatry Residents: The Columbia Psychiatry Residency DBT Curriculum.

OBJECTIVE: Dialectical behavior therapy (DBT) is an evidence-based psychosocial treatment with efficacy in reducing self-harm behaviors in borderline personality disorder (BPD). This study describes and evaluates a clinical curriculum to teach DBT to psychiatry residents, developed at a large urban university hospital. The curriculum objectives are to (1) have psychiatry residents achieve basic understanding of DBT theory and clinical skill, (2) increase residents' ability and confidence in treating self-harm behaviors (both suicidal behavior and non-suicidal self-injury), and (3) enhance residents' willingness to treat individuals with BPD. METHODS: In addition to a 6-week didactic course on DBT offered to all residents (n = 62), 25 elected to enroll in a year-long DBT clinical training curriculum over the course of a 5-year period. The DBT clinical training consisted of 15 h of additional didactics, ongoing conduct of individual therapy and group DBT skills training, videotaping of individual therapy sessions, and weekly supervision meetings utilizing videotape to provide feedback. Residents participating in the clinical training program videotaped baseline and later sessions, which were rated for DBT adherence. All 62 graduates of the program were surveyed regarding the impact of the training on their practice of psychiatry. RESULTS: Upon graduation, a high percentage (87 % in the curriculum and 70 % in the didactic course only) reported incorporating DBT into their psychiatry practice, as well as willingness and confidence in treating BPD and self-harm behaviors. Residents participating in the clinical training demonstrated significant improvement in their ability to utilize DBT interventions, particularly in structuring sessions, problem assessment, problem solving, and using validation and dialectical strategies. CONCLUSION: This DBT curriculum was effective in preparing psychiatrists-in-training to incorporate evidence-based practices for effective treatment of BPD and self-harm behaviors and can serve as a model for teaching DBT during psychiatry residency training. Limitations include a small sample size and lack of baseline survey measurement of attitudes for pre- and post-curriculum comparison.

Special-"T" Training: Extended Follow-up Results from a Residency-Wide Professionalism Workshop on Transgender Health.

OBJECTIVE: Transgender people face unique challenges when accessing health care, including stigma and discrimination. Most residency programs devote little time to this marginalized population. METHODS: The authors developed a 90-min workshop to enhance residents' ability to empathize with and professionally treat transgender patients. Attendees completed pre-, post, and 90-day follow-up surveys to assess perceived empathy, knowledge, comfort, interview skill, and motivation for future learning. RESULTS: Twenty-two residents (64.7 %) completed pre- and post-workshop surveys; 90.9 % of these completed the 90-day follow-up. Compared to baseline, there were statistically significant post-workshop increases in perceived empathy, knowledge, comfort, and motivation for future learning. However on 90-day follow-up, there were no statistically significant differences across any of the five domains, compared to baseline. CONCLUSIONS: This workshop produced significant short-term increases in resident professionalism toward transgender patients. However, extended follow-up results highlight the limitations of one-time interventions and call for recurrent programming to yield durable improvements.

A Qualitative Study of Factors Affecting Morale in Psychiatry Residency Training.

OBJECTIVE: Resident morale is an important yet poorly understood aspect of the residency training experience. Despite implications for program quality, resident satisfaction, patient care, and recruitment, little is known about the variables influencing this complex phenomenon. This study sought to identify important factors affecting morale in psychiatry residency training. METHODS: The authors conducted four semi-structured focus groups at a moderately sized, urban, psychiatry residency program during the 2013-2014 academic year. They used qualitative data analysis techniques, including grounded theory and content analysis, to identify key themes affecting resident morale across training levels. RESULTS: Twenty-seven residents participated in the focus groups with equal distribution across post-graduate years (PGY) 1-4. Five major conceptual categories affecting resident morale emerged: Sense of Community, Individual Motivators, Clinical Work, Feeling Cared For, and Trust in the Administration. CONCLUSIONS: Morale is an important topic in residency education. The qualitative results suggest that factors related to a Sense of Community and Individual Motivators generally enhanced resident morale whereas factors related to a lack of Feeling Cared For and Trust in the Administration tended to contribute to lower morale. The authors describe the possible interventions to promote stronger program morale suggested by these findings.

Impact of the information age on residency training: communication, access to public information, and clinical care.

Access to technology in practice helps physicians manage information, communicate, and research topics; however, those in training receive almost no formal preparation for integrating web-based technologies into practice. One reason for this is that many faculty-aside from junior faculty or those in recent generations-did not grow up using Internet communication, may use it minimally, if at all, in their own practices, and may know little about its forms and varieties. This report presents a case to illustrate how these disparities may play out in the supervisory situation and makes suggestions about helping supervisors integrate technology-awareness into their teaching.

Using learning objectives for psychotherapy supervision.

Although learning objectives, often in the form of competencies, are now standard for training mental health professionals, they are not generally used to guide psychotherapy supervision. Nevertheless, when learning objectives are not used to guide supervision, supervisors and supervisees often remain uncertain about the goals of supervision, how those goals should be attained, and how they should be assessed. In this paper we review the literature on learning objectives for psychotherapy training and supervision, outline reasons for using learning objectives in psychotherapy supervision, and suggest ways to use learning objectives in training.

Training psychiatry residents in quality improvement: an integrated, year-long curriculum.

OBJECTIVE The authors describe a curriculum for psychiatry residents in Quality Improvement (QI) methodology. METHODS All PGY3 residents (N=12) participated in a QI curriculum that included a year-long group project. Knowledge and attitudes were assessed before and after the curriculum, using a modified Quality Improvement Knowledge Assessment Tool (QIKAT) and a QI Self-Assessment survey. RESULTS QIKAT scores were significantly higher for residents after participating in the curriculum when compared with pretest scores. Self-efficacy ratings in QI improved after the course for each item. Residents demonstrated gains in QI skills through participation in the group projects in which they increased rates of depression-screening and monitoring in an outpatient clinic. CONCLUSIONS Combining didactic and experiential learning can be an effective means for training psychiatry residents in QI.

A curriculum in measurement-based care: screening and monitoring of depression in a psychiatric resident clinic.

OBJECTIVE: The goal of this curriculum was to train residents in measurement-based care (MBC). METHOD: Third-year psychiatry residents were educated in MBC through didactic seminars and a quality-improvement (QI) initiative with the goal of implementing the Patient Health Questionnaire Depression Scale (PHQ-9) to screen and monitor patients for symptoms of depression. RESULTS: Residents suggested strategies for integrating the PHQ-9 into the clinic. Over the first 6 months, residents showed an increase in rate of depression screening from 4% to 92% of patients. Also, they increased monthly monitoring of outpatients with a diagnosis of depression from 1% to 76%. Residents who used the PHQ-9 to monitor patients with depression were significantly more likely to use additional standardized assessments. CONCLUSIONS: Combining an educational intervention with QI strategies can significantly affect residents' use of standardized assessments in an outpatient setting. Using standardized measures allows residents to assess their own clinical effectiveness, an emerging priority in training.

Recruiting researchers in psychiatry: the influence of residency vs. early motivation.

BACKGROUND: The declining numbers of clinician-researchers in psychiatry and other medical specialties has been a subject of growing concern. Residency training has been cited as an important factor in recruiting new researchers, but there are essentially no data to support this assertion. This study aimed to explore which factors have influenced motivation to conduct research among senior psychiatry residents. METHODS: The authors surveyed senior residents, inquiring about their level of interest in research, demographics, background, research experiences, and factors influencing motivation for research. The authors had confirmed participation from 16 of 33 residency programs with a class size of 10 or more. They received 127 responses, a 67% response rate, from participating programs. RESULTS: Residents with high stated interest in research differed from those with low and moderate interest in their research-intense post-residency plans. They were more likely to have graduate degrees. Those planning research careers had a consistent pattern of interest and involvement in research, starting well before residency. The majority of residents had had research exposure in college, but research involvement of those with very high versus lower interest diverged sharply thereafter. Those with high research interest were overwhelmingly male and tended to have lower debt than those with less interest. CONCLUSION: The great majority of residents appear to have decided whether or not to pursue a research career by the time they reached residency, and few of those with less than the highest research interest were enrolled in research tracks. Efforts to increase recruitment into research should center on identifying early developmental influences, eliminating barriers specific to women, and ensuring adequate funding to provide secure careers for talented potential researchers.

Documenting Educational Impact in the Promotion Dossier with an Enhanced Curriculum Vitae.

ABSTRACT: Faculty with a career focus on education in the health professions often have difficulty representing their academic accomplishments for due consideration in promotion decisions at their respective institutions. This problem occurs because the traditional curriculum vitae (CV) format which is most often used tends to focus on peer-reviewed accomplishments easily presented in lists, such as grants and publications. In some institutions, an educator portfolio is required in place of or in addition to the CV. However, creating or reviewing such a narrative-oriented document takes large amounts of time-time that most faculty or reviewers do not have. Having to use an educator portfolio also calls out the educator as different from the traditional research faculty member. To address this problem, we propose the solution of an Enhanced CV. The Enhanced CV includes much of what is presented in an educator portfolio but in a format closer to the traditional CV. Unlike a traditional CV, the Enhanced CV includes categories inclusive of educational contributions (eg, teaching, mentoring, and course leadership) and includes brief descriptions and/or impact statements to clarify the significance of the listed accomplishments. The Enhanced CV has been adopted at two very different institutions, where evidence is accumulating regarding the viability of the Enhanced CV as a solution to educators' problem of presenting their accomplishments for promotions. The lessons learned from these institutions illustrate how the Enhanced CV can increase the ability of educators to present their accomplishments and advance in rank in their academic careers.

Points of contact: using first-person narratives to help foster empathy in psychiatric residents.

OBJECTIVE: The authors aimed to determine if writing narratives in psychiatric training can foster empathy for severely and persistently mentally ill patients. METHODS: One resident wrote first-person narrative pieces about three different patients at a community mental health clinic. She reviewed these pieces with a writing supervisor weekly. The supervisor and resident examined the style of writing, choice of words, and story line to help the resident learn about her feelings about the patient. RESULTS: In each narrative, different choices were made that provided clues about that particular resident-patient relationship. These writing exercises helped the resident become more connected to her patients, develop interviewing skills, and engage in more self-reflection. CONCLUSION: Narrative writing effectively fostered empathy in a PGY-1 psychiatric resident working with severely and persistently mentally ill patients. This exercise also fostered understanding of countertransference and improved psychiatric history-taking skills. Psychiatry training programs may want to consider incorporating narrative writing exercises into their curriculum.

Growing Teachers: using electives to teach senior residents how to teach.

OBJECTIVE: Many physicians teach but few are taught how to teach, particularly through pedagogical interventions. The authors describe a method for teaching curriculum development and classroom skills to psychiatric residents using an elective in the fourth postgraduate year. METHODS: An elective in pedagogy provided a framework for the planning, teaching, and evaluation phases of developing a new course. RESULTS: The elective resulted in four new, well-received courses and encouraged two participants to pursue careers in academic psychiatry. CONCLUSION: The elective helped residents achieve essential teaching skills, foster mentoring relationships with senior teaching faculty, and develop as future junior faculty members.