General Psychiatry Training Research Articles

Guidelines for the General Psychiatry Application Process and for Inter-Residency Transitions

Selecting a psychiatry program is a seminal event. There is often not enough guidance about this process. The American Association of Directors of Psychiatric Residency Training (AADPRT) recognized that this was a high-stakes process and that there was the opportunity to provide input about the process and promoting fairness and consistency, which could help provide the best opportunity for applicants to select where they will train and for programs to accept trainees who are well qualified for what a program offers and will best fit into the learning environment. A workgroup created guidelines included herein for the application process to begin general psychiatry training and to transition from one program to another, including transfer from one General Psychiatry program into another and entry into Child and Adolescent Psychiatry Residencies as well as subspecialty fellowships in psychiatry.

Inconsistency Hinders Progress in Psychotherapy Training

Back to table of contents Previous article Next article Education & TrainingFull AccessInconsistency Hinders Progress in Psychotherapy TrainingMark MoranMark MoranSearch for more papers by this authorPublished Online:19 Oct 2012https://doi.org/10.1176/pn.47.20.psychnews_47_20_10-aAbstractResidency training in cognitive-behavioral therapy (CBT) has become much more consistently developed, and while psychodynamic therapy is widely taught, there is a lack of consensus regarding its content and a need for more rigorous evaluation of “competence.”Those were the principal findings from a nationwide survey of psychiatry residency training directors regarding training in psychotherapy in the September 1 Academic Psychiatry.Authors Donna Sudak, M.D., and David Goldberg, M.D., surveyed U.S. general psychiatry training directors about the amount of didactic training, supervised clinical experience, and numbers of patients treated in the models of psychotherapy (psychodynamic, CBT, and supportive) mandated by the Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME).Sudak is acting director of residency training and director of psychotherapy training at Drexel University College of Medicine. Goldberg is residency training director and chair of psychiatry at California Pacific Medical Center.Sudak and Goldberg received 82 valid returned surveys out of 185 sent, for a total response rate of 45 percent. Not all respondents answered all questions, but almost all (76) answered the questions about required seminar and supervised clinical hours and minimum number of patients.The researchers found that the largest amount of didactic training occurs in psychodynamic psychotherapy. Approximately 70 percent of programs provide more than 30 hours, with nearly 25 percent reporting 70 hours or more. Almost one-third offer less than 30 hours over the course of residency training.Less time is devoted to CBT didactics, with two-thirds of programs offering less than 30 hours; one-third, more than 30 hours. But Sudak and Goldberg noted that this marks a significant increase from 2001, when only 13.1 percent of programs offered more than 30 hours. About 85 percent of programs reported less than 30 hours of supportive-therapy didactics, but it is not possible to know whether they were included as part of psychodynamic or CBT training.The findings regarding didactic training are largely encouraging, suggesting that residency programs have responded to a mandate from the ACGME for psychotherapy training. Psychodynamic therapy is widely taught, but establishing consensus regarding its content and more rigorous evaluation strategies would improve resident competence, they wrote.And supportive therapy, the most widely practiced form of treatment, needs better definition and pedagogy development.In an interview with Psychiatric News, Sudak, who is president of the Academy of Cognitive Therapy, said that following the ACGME mandate for training in psychotherapy, CBT educators worked hard to develop curricula and educational tools and measuring instruments that have helped training directors adopt CBT training. Psychodynamic psychotherapy and supportive therapy training would benefit from the same approach, she said.“Training directors are incredibly busy, and training requirements are extremely rigorous,” Sudak said. “The more psychotherapy educators can help training directors by providing defined methods by which they can train their residents to a high level of proficiency, the more likely will psychotherapy training be adopted.”Regarding supervised clinical experiences, responses indicated wide variability: Most programs (73.3 percent) indicated they offer more than 30 hours of supervised clinical psychodynamic therapy, and half of those require greater than 70 hours of supervised training. However, one-quarter of programs offer less than 30 hours total.CBT supervised clinical experiences have dramatically increased over this decade, to 46.8 percent of programs with over 30 hours and only 6.5 percent with no hours. Approximately half of the programs report more than 30 hours of supervised clinical work in supportive therapy.“Effective psychotherapy training requires suitable patients,” Sudak and Goldberg stated. “We did not assess how long patients are treated, but residents often provide therapy in settings where treatment can be brief, inconsistent, or incomplete. Furthermore, there are no clear guidelines as to what the optimal didactic and supervised clinical experiences are to produce ‘competent’ residents.”They concluded that there has been considerable progress over the past decade in psychotherapy education, but inconsistencies remain in the amount and quality of training experiences offered to residents. “There is enormous variation from program to program in how much training is offered, and it’s always a lot easier to have 20 sessions of didactic class than it is to have a clinical service with available patients and faculty to supervise,” Sudak told Psychiatric News. “That remains the challenge of psychotherapy education. But psychotherapy is a core discipline of psychiatry that needs to be attended to by training directors, and the more we can make it an efficient thing to do, the more training programs will respond.” “Trends in Psychotherapy Training: A National Survey of Psychiatry Residency Training” is posted at http://ap.psychiatryonline.org/article.aspx?articleID=1359984. ISSUES NewArchived

A3 Studying and managing the behavioural phenotypes of Huntington's disease

Honorary Consultant in Neuropsychiatric Genetics. David graduated in Medicine from London University (St. Bartholomew9s) in 1976 and moved to Manchester to study Psychiatry in 1979. After completing his training in general psychiatry, he arranged a temporary secondment to Clinical Genetics in 1986 to pursue an interest in the genetic aspects of psychiatric disorders, and ended up “going native”. He is now a senior lecturer and honorary consultant in neuropsychiatric genetics. His research interests are concerned mainly with the neuropsychiatric aspects of Huntington9s disease (HD), and with the psychological and social impact of predictive DNA testing for late-onset genetic disorders. He set up the UK9s first multidisciplinary management clinic for HD, currently the largest contributing site to the European HD Network (EHDN) case registry, and is actively involved in a number of European and worldwide research projects and clinical trials. He is a member of the Scientific Review Committee of the EHDN, leads the EHDN Behavioural Phenotype Working Group and is a former Secretary-General of the World Federation of Neurology Research Group on HD. He is co-Director of the MSc programme and teaches on the Clinical Genetics and Advanced Genetic Counselling modules. Behavioural symptoms have been recognised as a key component of the clinical phenotype of HD ever since the first description by Huntington in 1872, but remain a relatively under-researched aspect of the condition. Depression has received more attention than other psychiatric symptoms, but factor analysis of several large datasets has revealed that apathy and irritability are more common, and arguably cause more distress and disability. Longitudinal analysis of behavioural symptoms has confirmed that these three symptom clusters follow different trajectories over time, suggesting that each has a different neurobiological basis, and recent imaging studies lend some support to this hypothesis. It has long been recognised that many affected individuals display characteristic behavioural changes for some years before the onset of motor symptoms, and there has been considerable recent interest in the possibility of using these early manifestations as end points for clinical trials of disease-modifying interventions in known gene carriers prior to diagnosis. However, it has proved difficult to detect substantial changes in well-conducted longitudinal studies of pre-manifest subjects such as PREDICT and TRACK-HD. One reason may be the emergence of impaired insight (or denial) as the behavioural symptoms begin to occur, a phenomenon which has been noted by clinicians for many years; another is likely to be the use of concomitant medication for symptomatic treatment. Mood disturbances, anxiety, irritability and perseveration all respond to treatment with serotonin reuptake inhibitors, but apathy may be exacerbated by the use of neuroleptic medication for symptomatic treatment of involuntary movements or aggressive behaviours.

Clinical Skills Verification in General Psychiatry: Recommendations of the ABPN Task Force on Rater Training

The American Board of Psychiatry and Neurology (ABPN) announced in 2007 that general psychiatry training programs must conduct clinical skills verification (CSV), consisting of observed clinical interviews and case presentations during residency, as one requirement to establish graduates' eligibility to sit for the written certification examination. To facilitate implementation of these requirements, the ABPN convened a task force to prepare training materials for faculty and programs to guide them in the CSV process. This article reviews the specific requirements for the CSV experience within general residency programs, and briefly describes the recommendations of the task force for faculty training and program implementation. Materials prepared by the ABPN Task Force include background information on the intent of the observed interview, a literature review on assessment methods, aids to train faculty in direct observation of clinical work, directions for effective feedback, notes regarding special issues for cross-cultural trainees, clarification of performance standards, and recommendations for structuring and conducting the assessments. Recommendations of the task force include the use of a variety of clinical settings for CSV assessments, flexibility in the duration of CSV interviews, use of formative and summative feedback after each CSV assessment, and frequent use of the CSV across all years of training. Formal faculty training is recommended to help establish performance parameters, increase interrater reliability, and improve the quality of feedback. The implementation of the CSV process provides psychiatry training programs with an excellent opportunity to assess how interviewing skills are taught and evaluated. In the process, psychiatry educators have an opportunity to establish performance parameters that will guide the training of residents in patient interaction and evaluation.

Trends in Psychotherapy Training: A National Survey of Psychiatry Residency Training

The authors sought to determine current trends in residency training of psychiatrists. The authors surveyed U.S. general-psychiatry training directors about the amount of didactic training, supervised clinical experience, and numbers of patients treated in the RRC-mandated models of psychotherapy (psychodynamic, cognitive-behavioral therapy [CBT], and supportive). Questions regarding other models of psychotherapy and about challenges in training were also included. The results demonstrate a wide range of experiences in psychotherapy education. Psychodynamic training is the most robust, but has the greatest variability. CBT training has advanced significantly over the past decade. Supportive psychotherapy is the most widely practiced, but receives the least amount of didactic time and supervision. The authors discuss next steps in the evolution of psychotherapy education for psychiatrists.

Editorial introductions

Editorial introductions

Training in forensic psychiatry: comparative issues towards a rethinking of the Portuguese model

Forensic psychiatry has experienced a significant development in the last few decades. Several mechanisms underlie this shift, including deinstitutionalization of mental health patients and extraordinary progress in neurosciences, imaging technologies and psychology, just no name a few. This development has put in evidence specific needs for training and education. A review and comparison of forensic psychiatry training in several European countries, U.S.A. and Brazil is made. A mixed approach was used, including a) systematic literature review (Pubmed search, 1989-2009) and cross-reference search and inclusion; b) specific online sites search (e.g. medical associations or scientific societies responsible for forensic psychiatry training); c) direct contact with psychiatrists and forensic psychiatrists. Forensic psychiatry training is still a heterogeneous field. While not all countries have specialization, subspecialization or competency certification in forensic psychiatry, there has been, however, a definite shift towards its individuation as a specific technico-scientific area. This contributes to an improvement in quality standards and promotes research. Notwithstanding, forensic training in general adult and child psychiatry's residencies should continue to be strengthened as it is likely that most forensic activities will remain at their care in the near future.

P01-265 - Child and adolescent psychiatry training in Europe: Views of trainee representatives for 2009 – 2010 to the European federation of psychiatric trainees

Background and objectivesThe European Federation of Psychiatric Trainees (EFPT) is an independent federation of psychiatric trainees’ associations. Previous studies have shown that up to 1/3 of countries surveyed did not have separate CAP training We surveyed trainees to gain insights regarding current training within the member countries of the EFPT.MethodsTen item Survey of Trainee representatives from 32 countries- using surveymonkey questionnaire.Industry standard encryption technology utilisied.Results27 respondent countries. Response rate 84.4% In many countries CAP and General Adult Psychiatry training were not separate Variable availability of training posts (surplus posts 23%, no posts/ long waits 19.2%) Duration of training: 3 years (19.2%),4 years (23.1%), 5 years (26.9%). In 35% of countries CAP training was entirely separate from commencement of training. In 40%, entry to CAP training occurred after training in general adult psychiatry. Trainees in 61.5% of respondent countries indicate their intention to specialise in CAP before entering training in psychiatry; 15% of trainees can indicate this at any time.ConclusionsThis is a survey of trainee representatives to the EFPT of ten items related to CAP training experiences. It highlights significant differences in training experiences in 27 respondent countries. From 2010 the EFPT aims to record detailed information on CAP training yearly. CAP trainees are an integral part of EFPT, and there are specific areas of needs in CAP training.

Geriatrics Education in Psychiatric Residencies: A National Survey of Program Directors

The authors describe the current characteristics of geriatrics training within general psychiatry training programs. In the fall of 2006, a survey was mailed and made available online to all U.S. psychiatric residency program directors (N=181). The response rate was 54% (n=97). Of the responding psychiatry programs, 96% (n=93) required a clinical experience in geriatrics, with a mean of 54.9 half days of required clinical training. The predominant training sites were inpatient geriatric psychiatry acute care units, ambulatory care experiences precepted by one or more geriatric psychiatrists, and outpatient geriatric psychiatry assessment centers. The mean number of physician faculty per residency program available to teach geriatrics was 2.8 full-time equivalents, and the mean number of physicians certified in geriatric psychiatry was 3.2 per program. Conflicting time demands with other curricula was ranked as the most significant barrier to expanding geriatrics training. Variability in the amount of time devoted to geriatrics training exists across general psychiatric residency programs. Some residents spend very little time in specific required geriatric psychiatry clinical experiences and have limited exposure to well-trained geriatric psychiatrists. Therefore, some psychiatrists who will take care of older patients in the future may be ill prepared to do so.

Choosing and Instructing the Mental Health Expert Witness: A Lesser Known Aspect of Trevorrow

Apart from its significance as the first case to recognise that a member of the “stolen generation” had a cause of action against the government, Trevorrow v State of South Australia (No 5) [2007] SASC 285 is also a pertinent reminder of the extent to which a court will be assisted by an expert, especially when the expert is providing evidence that, whilst within their general training in psychiatry or psychology, is nonetheless outside the expert's clinical or academic experience. The situation becomes worse when experts are inadequately instructed. This article will consider the responsibilities of lawyers when choosing and instructing mental health experts. It will be argued that if the civil jurisdiction rules of court in relation to expert witnesses are followed, then there should be no real need on most occasions to call mental health experts to give oral testimony, except where a pre-trial conference does not lead to the resolution of differences of opinion between the experts.

Innovative Training in Pediatrics, General Psychiatry, and Child Psychiatry: Background, Outcomes, and Experiences

The authors describe the history, rationale, and outcomes of combined training programs in pediatrics, psychiatry, and child psychiatry ("triple board"), including narrative feedback from graduates and reflections upon the important components of the program. This article reviews the background and experiences of triple board graduates and programs using published data regarding triple board history and outcomes, reflections and follow-up information collected from triple board graduates as part of a national triple board network development, and direct experiences with triple board training programs. The triple board training program provides a unique training background for physicians who serve children and their families. The programs train physicians who seek out additional training opportunities, succeed in passing board certification examinations, and earn national recognition. Additionally, feedback from graduates reflects satisfaction with training experiences. The outcomes from this experiment in integrated training in child psychiatry support the consideration of expanding triple board training programs and introducing new innovations in training.

A 4-Year Curriculum on Substance Use Disorders for Psychiatry Residents

The authors describe an addiction psychiatry curriculum integrated in a general psychiatry training program to demonstrate comprehensive and practical approaches to educating general psychiatric residents on the recognition and treatment of substance use disorders. The Massachusetts General Hospital/McLean Hospital adult psychiatric residency training program provides training in addiction psychiatry in multiple treatment settings during the 4 years of residency. Addiction specialists, nonspecialty psychiatrists, and residents and fellows provide training. Adult psychiatric residencies can provide comprehensive addiction psychiatry training that spans multiple treatment settings and postgraduate years by training general staff psychiatrists, senior residents, and fellows to assist core addiction faculty in providing addiction psychiatry education. Substance use disorders are common among patients presenting to general psychiatry treatment settings, and thus it is important that all psychiatric residents be well trained in the screening, diagnosis, and treatment of outpatients with these problems.

Training in Cognitive Behavioral Therapy in Psychiatry Residency

In January 2001, Accreditation Council of Graduate Medical Education accredited general psychiatry training programs were charged with the requirement to train residents in cognitive-behavioral therapy (CBT) to a level of competence. Programs were given the responsibility to delineate standards for trainees, to determine measures of competence, and to provide remediation for deficiencies in performance. Effective education in CBT in general and child and adolescent psychiatry residency training can be more successful when educators understand the barriers to implementation of empirically supported therapies (ESTs). Robust training programs in CBT must take into account cultural barriers to psychotherapy training and the educational demands placed on residents in adult and child and adolescent psychiatry. Resources for training and evaluation materials are available to training directors and teachers.

The teaching and training of psychiatry in Thailand

In Thailand, we have only two programmes for residency training in psychiatry: one is general or adult psychiatry, which takes 3 years to complete; the other is child and adolescent psychiatry, which takes 4 years. There are nine institutes that offer residency training but only three medical schools have the capacity to offer training in both general and child psychiatry (Table 1).

Residency Program Combines Child, General Psychiatry

Residency Program Combines Child, General Psychiatry

The Making of A Psychiatrist

The Making of A Psychiatrist

Psychiatric aspects of the assessment and treatment of sex offenders

Training in general and forensic psychiatry in the assessment and treatment of sex offenders is in need of considerable improvement. Although most sex offenders are not mentally ill, many are subject to substance misuse, abnormal personality traits, personality disorder, learning disability or dysphoric mood, and in some organic factors will be involved. Comprehensive assessment of sex offenders includes a full history and mental state evaluation, obtaining a collateral history from other sources, observation, psychometric testing, and psychophysiological methods of assessment, including penile plethysmography. Trials of the use of the polygraph are also under way. The treatment of sex offenders, especially those with paraphilias, may include medication with selective serotonin reuptake inhibitors or anti-libidinal agents. Ethical considerations can be problematic, but a balance can often be found between the welfare of the offender and the safety of the public.

Specialist registrars' views on the proposed reform of the Mental Health Act (1983)

AIMS AND METHODA postal questionnaire was sent to specialist registrars (SpRs) in the Wessex Region to evaluate senior trainees' reactions to information about the proposed changes in mental health legislation and to ascertain if the information had adversely affected their view of their future careers as consultants.RESULTSA high level of concern about the proposed changes and their potential impact on consultants was revealed. A majority of SpRs took a more negative view of their future career, especially those preparing a single Certificate of Completion of Specialist Training in general adult psychiatry, who were more likely to have adverse perceptions and to have thought of opting out.SERVICE IMPLICATIONSThe legislative proposals have the potential for considerable impact on recruitment and retention of psychiatrists.

The Exeter half-day release psychotherapy training scheme – a model for others?

Training in psychotherapy is a mandatory part of general professional training in psychiatry. The College produced guidelines in 1993 outlining the breadth and depth of training required (Royal College of Psychiatrists, 1993).

Fellowship: A Road Too Seldom Taken Taken

Back to table of contents Previous article Next article Residents' ForumFull AccessFellowship: A Road Too Seldom Taken TakenAvram Mack, M.D.Avram MackSearch for more papers by this author, M.D.Published Online:21 Sep 2001https://doi.org/10.1176/pn.36.18.0024Unlike our colleagues in internal medicine and general surgery, residents in psychiatry infrequently move on to fellowship.This situation has had detrimental effects on the profession’s ability to provide needed psychiatric services in the four areas for which there exist both a public need and American Board of Psychiatry and Neurology (ABPN) board certification—child and adolescent, addiction, forensic, and geriatric psychiatry (we also can formally subspecialize in pain management).The APA Board of Trustees’ recent vote to support the Academy of Psychosomatic Medicine’s wish to establish ABPN certification in consultation-liaison psychiatry suggests that there is general support for subspecialization. Also, good job opportunities await trainees who get added training.If public health needs, job opportunities, and specialized knowledge are not inspiring residents to enter such fellowships, I would offer another reason to do a fellowship—to complement the training in general psychiatry that one receives in residency.Readers may consider me a masochist for urging such a course. After all, as long as the future general psychiatrist passes the ABPN board-certification exam in general adult psychiatry, there should be no need to enhance his or her general psychiatric knowledge, right? My answer: Maybe.The inevitable fact is that institutions of graduate medical education vary in their intellectual approaches to psychiatry. Thus, graduation from residency or passing the board exams might belie the fact that the residency graduate was schooled in an academic institution that had its own focus, interests, or purview of the body of knowledge of general psychiatry.These variations likely result from fundamental differences in the institution’s philosophies of science or psychology. For example, in the institution in which I was a resident, we learned a great deal about dialectical behavioral therapy (DBT); it was an approach that was compatible with the institution’s intellectual foundation in Winnicotian object relations. But in three years of residency we had only one lecture on interpersonal therapy (IPT). In contrast, in the institution in which I am now a fellow, there is little emphasis on DBT, but tremendous interest in IPT, which is compatible with the department’s focus on evidence-based medicine.Thus, variations do exist. The recently enacted Residency Review Committee’s (RRC) requirements for residency programs that require residents to demonstrate competency in five types of psychotherapy may ensure that all programs teach both IPT and DBT comprehensively. I think, however, that variations will persist in the future to the same extent that they do for internal medicine and general surgery programs.These variations are not bad. As humans, we all need a model of the mind and brain to organize the facts of psychopathology and its treatment. But who today would claim to have all the answers about what mental illness is?If variations will exist, then perhaps it is the responsibility of the trainee who wishes for a comprehensive general psychiatric education to seek it, and one can find it in fellowship.Thus I encourage the open-minded psychiatry resident to consider fellowship not simply for the actual specialized knowledge base (methylphenidate versus extended-release methylphenidate versus dexedrine versus clonidine?) that he or she would gain, but for the experience in a different intellectual environment.The field would gain, too, by having more physicians trained in more places, sharing information with each other more easily, fomenting a more general appreciation of the many interesting areas of psychiatry. I realize that debt burdens seriously diminish residents’ interest in fellowship. If the trainee is willing to moonlight or delay gratification just a little longer, however, there might be many rewards later.This is not to say that residency programs should not be held to standards for providing a comprehensive general education in psychiatry. But even when meeting such standards—for instance, those of the ACGME, the RRC, or the ABPN—programs differ today in various ways, and these variations are sometimes positive and sometimes not. I think the psychiatrist-in-training may be all the better for having lived among many, rather than few, approaches to psychiatry, its scientific bases, and its methods of treatment. It will aid the individual physician, the public health, and the profession as well. ▪Dr. Mack is APA’s member-in-training trustee. He can be reached by e-mail at [email protected]. ISSUES NewArchived