U of T program includes admin training

Residents at one Ontario university are happy the program integrates the CanMEDS role of physician manager into its residency curriculum

by Vicky Stergiopoulos, MD, MHSc, FRCPC;
Julie Maggi, MD, MSc, FRCPC; Sanjeev Sockalingam, MD; and Ari Zaretsky, MD, FRCPC
Department of Psychiatry, University of Toronto

As CanMEDS roles are integrated into postgraduate medical education, teaching and evaluating trainees in these roles has become a priority.

The CanMEDS framework includes the roles of professional, communicator, scholar, collaborator, health advocate, manager and medical expert. It has been challenging to integrate these seven different roles into the curricula, but none more so than the roles of physician manager and health advocate.

As managers, physicians “function as integral parts of health care organizations, organize sustainable practices, allocate resources and contribute to the overall effectiveness of the health care system�?.(1)

Despite the importance and relevance of this role, there is a paucity of psychiatry residency programs offering administrative training in Canada. Not surprisingly, psychiatry residents surveyed in our program felt unprepared in several system-based roles and more than one-third felt unprepared to fulfill 12 of the 23 CanMEDS defined competencies, notably the manager, scholar and advocate roles.(2)

The Canadian Psychiatric Association has acknowledged these gaps in training in a position paper, which highlighted the need for psychiatric residency training in several areas, including organizational structures in mental health; models of mental health care delivery; quality assurance; program development; the ability to communicate with stakeholders; skills for team building; conflict
management; finance; leadership in administration; lifestyle management; and organizational change.(3)

In response to this position paper and the Royal College of Physicians and Surgeons of Canada (RCPSC) mandate to integrate CanMEDS roles into training, our program has undertaken physician manager curriculum development efforts over the past three years. The program of study has been informed by the RCPSC guidelines, review of other curricula, and our residents’ perceived needs.

In 2005, we conducted a survey of PGY-2 to PGY-5 psychiatry residents at the University of Toronto to elicit their current and desired level of knowledge and skill in selected areas of administrative psychiatry. Educational preferences on teaching methods were also obtained. The main outcome measures were gap scores (GS), calculated as the difference between ratings of resident desired knowledge and perceived current knowledge (GSk) or skill (GSs) in selected areas.(4)

Residents identified physician compensation, program planning, quality improvement, health care reform, organizational structures and program evaluation as the knowledge areas with the largest mean GSk.

Mean skill gap scores were greatest for self and career development as well as innovation and leading change.

More than 60 per cent of respondents preferred learning through workshops, small groups and mentorship opportunities.(4)

A 10-member committee of residents and content and education experts reviewed the needs assessment findings and developed a pilot curriculum framework, which consisted of a junior and senior toolkit, each of which comprised four half-day workshops.

The junior toolkit offered to PGY-2 residents includes workshops on teamwork, conflict resolution, quality improvement, and program planning and evaluation. The senior toolkit introduced PGY-4 psychiatry residents to leadership, organizational structures, mental health and addictions reform, and self and career development. The curriculum framework is supplemented with supervised, longitudinal quality improvement projects during the PGY-3 year (see Table 1).

Both toolkits were implemented as a mandatory component of training during the 2006/07 academic year. Workshops included short didactic presentations and shared an emphasis on active learning through clinical illustrations, case studies and other interactive techniques. PGY-3 residents have also embarked on quality improvement group projects to build on resident learning from the previous year.

Resident feedback on the curriculum has so far been extremely positive.(5) Their suggestions have helped refine the curriculum framework, individual workshop content and will inform further efforts to better integrate the curriculum content into clinical rotations, match content to residents’ stage of professional identity development, and facilitate longitudinal reinforcement of learning.

In the process of curriculum development and implementation, we faced several barriers and facilitators.6 Main challenges included the multiple and competing demands on resident time, as well as the scarcity of experienced supervisors to reinforce learning
during clinical rotations.(6)

On the other hand, many factors contributed to the success of this effort.

First, this project enjoyed the support of the department chair and the postgraduate program director, who championed the curriculum since its inception. Second, curriculum development and implementation was an active partnership between learners and content and education experts, allowing for ownership, creativity, and commitment. Third, the project was managed by a core team that adhered strictly to principles of change management, including frequent communication with all stakeholders.(6)

In addition to addressing the challenges mentioned above, especially the need for faculty development, the broader vision of our team is to collaborate with other residency programs in future efforts, and contribute to the development of tools that can be used by smaller, less well resourced programs throughout the country. Included in this vision is a research component to evaluate the effectiveness of the curriculum, as well as to develop tools to evaluate residents’ performance in the physician manager role.

As a first step towards this vision, we have recently undertaken a formal evaluation of the physician manager curriculum at our program. We also recently initiated a national survey of psychiatry resident perceived training needs, whose findings parallel those of the resident needs assessment at the University of Toronto, suggesting that psychiatry residents across the country identify significant gaps in several knowledge and skill areas relating to the physician manager role.(7)

Ultimately, we hope that our work will assist other residency programs’ efforts in offering physician manager training to better prepare future psychiatrists to function effectively in today’s complex mental health care environment. Given the central role that collaborative mental health care has assumed in training, it is important that we equip our trainees to function effectively in team settings and lead reform efforts to optimize psychiatric care for our clients.

References
1. Frank J.R., ed. The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada, 2005.

2. Sinai J, Hodges B. An evaluation of CanMEDS roles with psychiatry residents: a pilot study. Annals RCPSC 32:398-402, 1999.

3. Somers J.L., Goldner E.M., Lesage A.D., et al. Filling gaps in psychiatric education: skills in administrative psychiatry and knowledge of mental health systems, services and policy. Can J Psych (insert) 49(6):1-6, 2004.

4. Sockalingam S., Stergiopoulos V., Maggi J. The Physician as a Manager: Psychiatry Residents’ Perceived Gaps in Knowledge and Skills in Administrative Psychiatry. Academic Psychiatry 31:304-307, 2007.

5. Stergiopoulos V., Maggi J., Sockalingam S. Teaching the Physician Manager Role during Psychiatric Residency: Development and Implementation of a Pilot Curriculum. Canadian Psychiatric Association Annual Meeting, Montreal, November 17, 2007.

6. Maggi J.D., Stergiopoulos V., Sockalingam S. Implementing a New Physician Manager Curriculum into a Postgraduate Psychiatry Training Program: The Change Process, Barriers and Facilitators. Psychiatric Quarterly, December 22, 2007.

7. Sockalingam S., Stergiopoulos V., Maggi J. Developing Future Leaders in Psychosomatic Medicine: Perceived Gaps in Canadian Psychiatry Residents’ Physician-Manager Training. Academy of Psychosomatic Medicine, Amelia Island, Florida. November 15, 2007.

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