Insight Matters
Summer, 2003

A Paradigm Shift in Evaluating the Clinical Competence of Psychiatry Residents
by David Bienenfeld, M.D., Director of Psychiatric Residency Training
Wright State University School of Medicine

The philosophical shifts that have profoundly affected management across many types of institutions have not left residency training unaffected. The fad of "Management by Objective" has faded, but the centrality of outcome measurement in defining the quality of an organization and its function has earned a permanent place in the minds of managers and leaders.

This shift has made itself evident in the assessment of graduate medical education: both the assessment of individual trainees and the evaluation of program quality. Almost since the inception of psychiatric residency training, we have promoted residents based on their satisfactory completion of assigned rotations. Our certifying body, the Accreditation Council for Graduate Medical Education (ACGME) has granted us the right to run our programs based on our adherence to nationally-defined curriculum templates.

As recently as 1995, for example, the ACGME outlined broad educational objectives, e.g.
Clinical training should provide sufficient clinical experience in:
…4. the major types of therapy, including short- and long-term individual psychotherapy, psychodynamic psychotherapy, family therapy, group therapy, cognitive and behavioral therapy, crisis intervention, pharmacologic and other somatic therapies and drug and alcohol detoxification.

Program requirements were specific as to curriculum outline, e.g.
Outpatient. An organized, continuous supervised clinical experience in the assessment, diagnosis, and treatment of outpatients of at least one year…

This paradigm of regulating the process itself had drawbacks that became evident to both teachers and the certifying bodies, especially as the volume of material and the variety of educational modalities multiplied. Idiosyncratic programs were required to stifle their creativity in pursuit of national uniformity. At the same time, residents were graduated without any guarantee of their ability to perform certain vital tasks. Imagine an auto plant in which the manager decided the number of lug nuts an assembly line worker had to insert per day; such was the educational and regulatory setting less than a decade ago.

Since the latter half of the 1990s, the ACGME has chosen instead to act more like a plant manager who defines the quality of cars his plant produces, and lets the experts decide how to achieve the goals. Across specialties, ACGME is now focusing on competencies, i.e., measurements of how well trainees perform the tasks central to their respective fields. Representative criteria read like this:

The residency program must demonstrate that it has an effective plan for assessing resident performance throughout the program and for utilizing assessment results to improve resident performance.
1. This plan should include use of dependable measures to assess residents' competence in
a. patient care
b. medical knowledge
c. practice-based learning and improvement
d. interpersonal and communication skills
e. professionalism, and
f. systems-based practice
2. The program must demonstrate that residents have achieved competency in at least the following forms of treatment:
a. brief therapy
b. cognitive-behavioral therapy
c. combined psychotherapy and psychopharmacology
d. psychodynamic therapy, and
e. supportive therapy
Supervisors who used to be asked to rate globally a resident's ability to assess a patient on a hospital service, are now asked instead to certify that a PGY-I resident has performed a basic mental status exam; that a PGY-II on the same service has performed a detailed cognitive exam; that a PGY-III can present a comprehensive psychodynamic case formulation. The training program determines how many times each skill must be demonstrated for advancement to the next year, and for graduation.

Competency based measurement allows individual training programs more leeway in using the particular strengths of their own faculty and clinical sites. The curricula at Ohio State University and NEOUCOM no longer need to be identical; each can use most what is does best. In the end, the graduates of all programs will be certain to have met minimal competency criteria so that a potential partner, employer or insurer can be confident of the doctor's capacities.

The forms you fill out as a supervisor will be changing as programs adopt these measures. It will undoubtedly be a minor inconvenience. The payoff is a system that nurtures the individuality of residency programs and ensures the quality of our graduates.

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