Integrated Care Training in Canada: Challenges and Future Directions.

Abstract

To the Editor: The August 2015 series of articles on educating residents for the practice of integrated care is timely and important [1, 2]. In Canada, all psychiatry residents are exposed to an integrated care rotation (also known as “shared care” or “collaborative care”) during their senior years as a result of a mandatory training requirement by the Royal College of Physicians and Surgeons of Canada (RCPSC) in effect since 2011 [3]. This is congruent with broader shifts in medical education that aim to increase physicians’ responsiveness to population and community health needs and contribution to healthcare system sustainability [4]. However, Canadian psychiatry residency programs have faced challenges in interpreting and implementing the new training requirement. We conducted a national survey of Canadian psychiatry residency program directors in Spring 2011 (n=13, a 81 % response rate) [5]. They identified a lack of guidance regarding the intended outcomes of integrated care training and implementation barriers, including lack of training sites (70 %), lack of supervisors (70 %), and the need for faculty development (62 %). Unsurprisingly, a 2013 curriculum evaluation at one residency program revealed substantial discordance between the curricula planned by educators, implemented by teachers, and experienced by residents. The RCPSC responded to the program directors’ concerns in 2014 by reducing the training requirement from a minimum of 2 months to 1 month (or longitudinal equivalent). Although the revision may alleviate program directors’ concerns about maintaining their programs’ accreditation, a time-based requirement was and still is merely an outcome of convenience, and there remains a gap in guiding programs on how best to promote resident attainment of competence in integrated care. At present, programs offer experiences that vary widely in duration, format, and setting, based on idiosyncratic interpretations of the goals of training and local feasibility considerations. Given the identified challenges in implementing nationwide training, the RCPSC is now questioning the quality and consistency of integrated training in Canada in its current forms. However, integrated care models are complex, inherently context sensitive, and evolving over time—traits that do not lend themselves well to standardization of training. If we are to continue with this important innovation in psychiatric education, then we will need to clearly define the purpose and intended outcomes of integrated care training and suitable settings for a workplace curriculum in integrated care. Indeed, this may facilitate resident training in diverse settings while still demonstrating a common standard of competence. Canada has a publicly funded healthcare system with a strong foundation of primary care and public health. Residents require exposure to community and primary care settings during training in order to understand the continuum of acute and community-based services. Integrated care training affords an ideal opportunity for such exposure in a variety of settings, through which residents can contribute to mental health care delivery and capacity building beyond academic hospitals. Residents may attain competencies in multiple domains concurrently, for example, through working with nursing homes, schools, child protection services, hospices, or case management agencies. Such experiences enable residents to learn how to communicate effectively and form collaborative interprofessional relationships to support co-management of patients. Residents will develop skills in knowledge * Nadiya Sunderji sunderjin@smh.ca