Community Psychiatry Tracks for Residents: A Review of Four Programs
Many psychiatry residency graduates end up practicing at least in part in community settings. However, declining funding and other issues prevent many residency programs from offering robust community psychiatry training to all of their residents. Accordingly, some residency programs have developed Community Psychiatry Tracks, with the goal of developing future leaders in public sector psychiatry. We cataloged US psychiatry residency programs offering Community Psychiatry Tracks by reviewing the literature and surveying training directors and members of the American Association of Community Psychiatrists. Authors from each of the four programs found to be actively offering such tracks describe their track curricula, from which we elucidated common and variable elements as well as strengths and weaknesses and then make recommendations for other programs wishing to start a track. A Community Psychiatry Track preliminarily appears to be a well-received way to offer enhanced Community Psychiatry training to interested residents, to recruit medical students to residency programs, to offer opportunities for collaboration between residents and faculty members, and to expand opportunities for scholarly work by residents.
KeywordsPsychiatry residencyCommunity psychiatryCommunity psychiatry trackMedical education
Psychiatry residents are spending increasing amounts of time working in the public sector upon completion of their training (Ranz et al. 2006). It has been true for a long time that many residents spend some time in these settings after graduation, but in the past this was often just until they found a “real” job, i.e., public sector work was considered sub-optimal (Factor et al. 1988). Recent surveys have demonstrated that early- and mid-career psychiatrists now spend more time in publicly funded organizational settings than in private practice settings, and no longer with the intention of it being temporary (Ranz et al. 2006). Accordingly, it has been suggested that residency training needs to include further emphasis on systems of care, organizational dynamics, multidisciplinary collaboration, and funding of psychiatric services (Ranz et al. 2006).
Another recent survey showed a discrepancy between the priority verbally given to residency training in public sector psychiatric care and the extent to which that training is actually provided (Yedidia et al. 2006). Reasons for this discrepancy may include increasing time demands for a variety of residency experiences based on new Accreditation Council for Graduate Medical Education requirements, which leave less time for each core experience, including community psychiatry. Moreover, there is ever-decreasing funding available to residency programs. Many residency programs are only able to offer experiences to their residents at sites affiliated with the home (often academic) institution, unless other (community) sites are willing and able to pay for residents’ time. Such funding has become less feasible for community sites.
To meet the educational needs of residents particularly interested in public sector work, some psychiatry residency programs have developed Community Psychiatry Tracks. Analogous Research Tracks (Back et al. 2011) and Clinical-Educator Tracks (Jibson et al. 2010) have been developed as well. Since more psychiatry residents probably end up practicing in public sector settings than as researchers or clinical-educators (Ranz et al. 2006), dedicated tracks in Community Psychiatry might make even more sense.
Specific reasons for the development of Community Psychiatry Tracks include that they allow programs to focus their limited community psychiatry training resources on those residents most likely to enter the public sector. Additionally, even residencies with rich community training may wish to offer even richer experiences to residents most interested in this type of work. Community Psychiatry Tracks may also serve as a recruitment tool for 4th year medical students, many of whom profess a great interest in working with underserved populations. Moreover, they may offer a structured curriculum through one’s residency training, especially during the often-unstructured post-graduate year (PGY)-4.
The aims of this paper are to describe several institutions’ Community Psychiatry Tracks and to make recommendations for residency programs looking to start such a track based on the strengths and weaknesses of the described tracks.
We conducted a literature review, Internet search with the Google search engine, and review of residency websites to compile a list of the US psychiatry residency programs that offer Community Psychiatry Tracks as of January 2012. Our literature review consisted of a Pub Med search using the following terms: psychiatry, residency, residents, community psychiatry, public sector psychiatry, community psychiatry track, and public sector psychiatry track. The Internet search used the term community psychiatry track.
We sent email via the American Association of Directors of Psychiatric Residency Training and the American Association of Community Psychiatrists (AACP) list-servs, asking if anyone’s institution had a Community Psychiatry Track, or if they knew of any such tracks.
Our hypotheses were that: (1) only a small number of programs offer Community Psychiatry Tracks, (2) most such tracks would be in their infancy, and (3) funding for these tracks would be limited.
Comparative features of four community psychiatry tracks
University of Washington community leadership pathway
St. Luke’s-Roosevelt hospital center community psychiatry track
University of Wisconsin community psychiatry track
University of Louisville community service track
Started with funds from the State Mental Health Division
In 2011, the state cut funding for the track. The University of Washington School of Medicine now provides financial support, allowing residents to continue rotations at several community sites
Usual residency $250 per resident per year for books, travel, or conference attendance may be applied to community psychiatry books or meetings
Up to $500 per resident per year if making a presentation at IPS or American Association of Community Psychiatrists (AACP) meetings
Hospital provides extra funding for rotations at community sites that are not funded for other residents
Up to $1000 per resident per year if making a presentation at IPS or AACP meetings
Usual residency $500 travel budget may be applied to attendance at IPS or AACP meetings
How/when residents selected
Residents submit a written statement of interests and goals to the track director
Residents join anytime in residency (earlier is encouraged), with no limit on number of residents at a time in the track
Course Director for PGY-2 community psychiatry course solicits interest, and then interested residents meet with Track Director. Track and Program Directors meet to discuss suitability of each resident applicant
Up to 2 residents per year join as PGY-3 s
PGY-3 s submit a personal statement that addresses: what they would like to accomplish from participation in the track and how participation might impact their future careers; how they see the role of the physician in an interdisciplinary community psychiatry team of providers; and who they would like to have serve as their track mentor. The Community Psychiatry Track Committee (Program Director, Associate Program Director, PACT Medical Director) meets annually to review all applicants
Up to 2 residents per year join as PGY-3 s
Residents apply by March of their PGY-1 or -2 years with a letter outlining their interest in community psychiatry. The residency training office reviews the applications, and the Chair has the final decision on acceptance
No limit as of yet on number of residents who may join on July 1 after their acceptance into the track
Pairing with a mentor in the community to observe clinical work and discuss career issues
Quarterly meetings with an assigned faculty mentor
Pairing with a faculty mentor within the university with specific experience in community psychiatry as well as with a mentor from one of the community psychiatry services
Many clinical experiences at community sites with severely mentally ill populations are available to all residents, with preference given to track members in PGY-3 and -4 year(s). Sites include community mental health centers with a focus on sexual minorities or Asian or Latino populations, county jail, juvenile correctional facility, prison system, PACT team, psychiatry consultation at Community Health Centers where patients receive primary care services, rural community rotations in Alaska, Wyoming, and Montana, the county hospital, and VA
In last quarter of PGY-3 year, residents participate in 4 h per week of selectives (mobile crisis team, ACT team, Fountain House clubhouse, outpatient addictions day program, halfway house)
In PGY-4 year, residents use their 4 months of elective time exclusively for community psychiatry electives (selective options above plus inner city shelter for dual diagnosis patients, family clinical team that uses interdisciplinary approach to work with families afflicted with serious mental illness, and needle exchange program)
Community rotations required of all PGY-3 residents (psychiatric consultation at a federally qualified health center, and VA neuroleptic clinic)
12-month 20 % time PGY-4 rotation at PACT
Optional PGY-4 experiences at VA Community Support Program or jail diversion Community Support Program
Time as a PGY-3 and -4 at a psychiatry clinic for homeless persons run by medical students and staffed by volunteer psychiatrists
Residents given preferential assignment to community based rotation sites during the normal scheduling of PGY-2 and -3 rotations, which include the state mental hospital and community outpatient psychiatric clinic
Longitudinal Board experience with one of several community agencies that are willing to have residents experience how their organizations run
Evening presentations on community psychiatry topics every other month with speakers from the community (e.g., state legislators, peer counselors, medical directors of mental health centers) Field trips based on interest (e.g., shelters, state hospital, state capitol)
Monthly tutorials consisting of readings on community psychiatry topics that are discussed with an assigned mentor beginning in PGY-3 year
Teaching/scholarly project requirements
Members complete at least 1 scholarly community psychiatry activity: present a community psychiatry topic in medical student or resident didactics, incorporate a community psychiatry theme into other required residency activities, or complete a journal article or poster/presentation at the Institute on Psychiatric Services (IPS)
Encouraged to make oral presentation at IPS or AACP annual meeting
Precept and provide psychiatric education and consultation to a medical student-run primary health clinic for homeless patients
Teaching 1 PGY-1 and 1 PGY-3 community psychiatry seminar
Informal teaching of medical students at a psychiatry clinic for homeless persons
Presentation of statewide teleconference to non-medical mental health professionals
Poster or oral presentation at IPS or AACP meetings encouraged
Grand Rounds on community experiences as a PGY-4
Participate in a community education project
Attendance at IPS or AACP encouraged
Evaluation of residents
Faculty complete evaluations of residents on their community psychiatry rotations, but not overall in the track
Faculty complete evaluations of residents on their community psychiatry rotations, but not overall in the track
Protected time for residents
None beyond that required for rotations
4 h per week in PGY-3 year to complete selectives, and elective time in PGY-4 year
Residents excused for quarterly meetings with mentor
Residents excused for 2 h per week to attend mentor meetings, and for quarterly meetings with residency training office to monitor progress toward track goals
Recognized for successful completion of track with an Area of Distinction in Community Psychiatry at graduation
Recognized for successful completion of track at graduation
Since 2008, 75 % of track graduates have worked in community psychiatry or in academic position working with severely mentally ill populations
Our hypotheses were partially validated. It is true that only a small number of programs offer Community Psychiatry Tracks. Three of the four are relatively new, but one (University of Washington) has been in existence since 1990. As expected, funding for such tracks is limited, as compared to many residency Research Tracks in which research dollars can be used to fund residents. This requires creative methods of providing meaningful experiences for Community Psychiatry Track members. Additionally, some programs have been able to convince their administration to invest a small amount of money into clinical experiences and rewarding of scholarly activity by track members with travel stipends.
Common and Variable Elements
The Community Psychiatry Tracks described have several common features. Many of these elements are analogous to those seen in Research Tracks (Back et al. 2011) and Clinical-Educator Tracks (Jibson et al. 2010), so this is not surprising. Similar to Clinical-Educator Tracks but different from several Research Tracks is that residents apply to the tracks during residency (variable between PGY-1 and PGY-3 years). This makes sense in that Research Track applicants may have envisioned their career earlier, for example, by completing a Medical Scientist Training Program in medical school. An additional similarity to Clinical-Educator Tracks, and what is potentially a barrier, is the consistent lack of any significant protected time.
Common and variable elements of four community psychiatry tracks
Application to track during residency
Encouraged scholarly productivity
Participation in professional/community organizations
Formal evaluation of residents in track
Minimal protected time
Extra funding for residents to attend meetings
Preferential selection of community-based rotations/electives
Recognition at graduation/on diploma
Recommendations for Starting a Track
Faculty members who wish to start a Community Psychiatry Track first must garner support from their department and other faculty members. Departmental support should include that of the Chair and faculty administrators. Such support generally will be predicated on showing administration “what’s in it for them”. This includes use of the track as a recruitment tool, opportunities for residents to disseminate scholarly work at the national level, and opportunities for residents to help out with “teaching burdens”. Departmental support ideally would consist of money, protected time for residents and faculty, and recognition for involved residents and faculty.
Support from other faculty members beyond the Chair is necessary in a number of ways. Faculty members are important as track mentors and, for faculty members already involved in such groups, for help with involvement of residents in community/national organizations. Additionally, faculty members may be critical in offering community psychiatry-related teaching opportunities to residents. For example, if faculty members are already teaching community psychiatry didactics to other residents in the program, it may be an efficient way to offer community psychiatry-related experiences to track member-residents by having them participate in those teaching opportunities. Similarly, faculty members may be able to help with alignment of other pre-existing elements of the residency program with a community focus for track members. Of note, little ancillary staff support has been needed in the authors’ programs for development and maintenance of these tracks, since a small number of residents is involved. However, residency program coordinators may play a helpful role.
In critiquing the strengths and weaknesses of the four programs described, we make preliminary recommendations for content of a Community Psychiatry Track. A Track mentor is offered by three of the four programs and has been a well-received element such that this should be prioritized. Regarding clinical components, the University of Washington and St. Luke’s-Roosevelt Hospital Center offer the widest array of choices. These programs as well as the University of Louisville offer priority to track members in choosing these clinical components, though assuming spots remain open, all residents have the option of selecting these sites. In contrast, the University of Wisconsin only offers certain clinical sites to track members, as those sites are the costliest for the hospital to fund and cannot be made available to everyone. Individual programs will need to find a balance between number of options offered, quality of those options, and extent to which those options are only available to track members to cut down on cost and incentivize track involvement. PACT/ACT teams have proven among the most popular of our clinical offerings to track members, and should be made available if feasible.
In further comparative critique, a didactic component is offered by two of the four programs, including at the most longstanding program. This component may be more feasible at a program such as the University of Washington that has up to eight or more track members at a time, as compared to the University of Wisconsin or University of Louisville, which at this point have only one to two members at a given time. Thus, programs with smaller tracks may wish to develop a recommended reading list that the mentors can review with the track members, as opposed to incorporating a separate didactic component with separate instructors. The theme of teaching/scholarly project requirements across the four programs is that most take advantage of already-existing infrastructure. For example, many programs encourage presentations at IPS or AACP meetings. For example, at the University of Wisconsin, it has proven quite feasible for residents to present a poster at IPS on such topics as an interesting case series of community patients, or to co-present an oral topic along with one of their faculty members at IPS or AACP. None of the programs offer formal evaluation of residents’ participation in the track. This is different, for example, from Research Track residents who often have ample opportunities to receive feedback on their research. More formal feedback may help track members to take their work seriously and to maintain motivation. Likewise, formal resident recognition at graduation or on diplomas for successful completion of track requirements could prove motivating.
Programs may find it challenging to find highly motivated candidates who would excel in public psychiatry, and to keep those candidates motivated. The authors have found it useful to look for potential candidates at the time of interviews for positions within their residencies. If such candidates are successfully brought into the residency, they should be mentored and encouraged along the way to apply for the track. Many residency programs have mentorship programs in which all residents are assigned faculty mentors and/or upper-class resident mentors for the duration of residency. Mentors for track candidates can be chosen as faculty members who can serve as role models in community psychiatry leadership, and this would occur even prior to official membership in a Community Psychiatry Track.
Strengths and Limitations
This report is the first to provide guidance for residency programs looking to start a Community Psychiatry Track. However, it is possible that we have missed programs that currently have active Community Psychiatry Tracks, such that this may not represent a complete representation of all such tracks. Additionally, outcomes of the tracks are very preliminary, given that only one of the tracks has been in existence long enough to have graduates of it and of any further fellowship training. Third, the authors of this paper represent the tracks described, such that they may be biased in not seeing the flaws in their own programs in the same way a neutral observer might. Finally, this paper does not include programs that do not offer designed Community Psychiatry Tracks but that offer rich training in community psychiatry for all residents. Such programs may have no need for such a track, and may actually offer overall more comprehensive community psychiatry training for more or all of their trainees.
From the experience of four psychiatry residency programs, Community Psychiatry Tracks are preliminarily a reasonable way to offer enhanced community psychiatry training to interested residents, to focus limited resources on residents particularly interested in this work, to recruit medical students to residency programs, to offer opportunities for collaboration between residents and faculty members, and to expand opportunities for scholarly work by residents. The authors’ tracks may serve as blueprints for other programs looking for a starting point for their own such track.