Child Psychiatry Perspectives Accountability and the Future of Child Psychiatry
Larry B. Silver, M.D.
Abstract. This paper reviews the increasing pressure IIII' accountability in child psychiatry. Federal legislation has increased the request for accountability in clinical practice. Shifts in federal regulations now begin to require accountability in training. The American Board of Medical Specialties now requires each specialty organization to develop models for assessing continuing professional competence. The author discusses each of these areas and offers specific" recommendations. Accountability is believed to be appropriate and helpful to the profession.
The secure world of the physician is changing. The fields of medicine, psychiatry. and child psychiatry have been challenged and criticized from outside the field of medicine. Public and private organizations want better care for less and a better system for delivering that care. Congress feels that health care is costing too much. Everywhere, critics are commenting that if the public is to pay for health care, then the public must have accountability for the monies spent. Further, this accountability must be defined and monitored by non physicians as well as by physicians. Who are these critics? They are payers of health care: the federal government and the private third-party carriers. In 1965 the federal government became the largest health insurer in the country. By 1970 it was evident that projected costs of Medicare and Medicaid would exceed estimates made in 1967 by some 240 billion dollars over a 25-year period. The rapidly increasing costs of these programs were attributed to two factors: an increase in the unit cost of services such as physicians' visits, surgical procedures, and hospital days; and an increase in the number of services provided to beneficiaries. The primary impetus for passage of control legislation, such as the PSRO legislation, was the skyrocketing costs of Medicare and Medicaid programs and only
Dr. Silver is Professor of Psychiatry. Professor of Pediatrics, and Chief of the Section of Child and Adolescent Psychiatry. CMDNJ-Rutgers Medical School. Reprints may be requested from Dr. Silver, Department of Psychiatry, Rutgers Medical School. University Heights. Piscataway, NJ 08854. 0002-7138/79/1801-176 $00.95 e 1979 American Academy of Child Psychiatry.
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secondarily the benefits that might flow from enhanced quality review of treatment. Accountability is now the main theme. I will !ClCUS on several aspects of accountability as it affects and will continue to affect the practice of child psychiatry. I will also focus on how it has begun to affect and will in the future further influence the concept of competence. the education of child psychiatrists. and the mental health of child psychiatrists. The Practice o] Child Psychiatry Accountability now shapes our definition of quality of services provided through pur review (A .P.A .• ) 976). The critics' efforts to assure quality of care tcnd to reject the formerly held premise that physicians are fundamentally humanitarian helpers who do no harm. Peer review based on the assumption that physicians know what good medicine is and can monitor themselves is no longer acceptable. We are asked to define what "good medicine" means and to do so for each and every clinical entity and situation possible. We are to show that we are objectively and completely using these definitions of "good medicine" in all clinical situations and when judging all colleagues. This request for accountability sounds reasonable until one attempts to comply with it. As but one illustration of the difficulties faced, psychiatrists have always assumed risks ; for example. in determining whether a patient is suicidal or homicidal. In return for accepting these responsibilities of judgment, psychiatrists have. in the past. been permitted considerable autonomy. I f peer review now must be based on predefined standards. one is required to use conservative judgment. producing restrictions on the psychiatrists and . secondarily. on the patient. Since there are competing claims about the relative efficacy of psychological interventions and drugs in child ps ychiatry, it becomes a less than adequate approach to require the psychiatrists to practice on the basis of scientific evidence. Unclear therapy choices leave the professional vulnerable. He or she is hesitant to use abstract rules or standards. yet is cautious about not using them. Under thesc circumstances the psychiatrist may feel restricted in making decisions and may be in no position to pass critical judgment on his or her peers. Accountability now also shapes our definition of types of service through utilization review. The payers for health care now choose to influence the choice of service facilities as well as the length of stay in these facilities. Many psychiatric facilities must now "cure" schizophrenia in 21 days! Recently a major insurance coverer sought a cutback in psychiatric benefits not only secondary to the rising costs but also out of a concern for the relative lack of scientific rigor in regard to psychiatric diagnostic and treatment decisions (Schulberg. ) 976). Accountability now shapes our definition of quality and quantity of
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service through a federal program related to utilization review and peer review, PSRO (Silver, 1976). Admit someone to the hospital or, in the future into outpatient therapy, and a non physician will match the physician's criteria for decisions with an established set of criteria. If they match, the physician's services will be approved for funding. If they do not, the physician will have to justify his or her decisions before a peer review group before the payers of care will agree to pay. In quality of care, types of care, and length of care, then, we are now accountable for our judgments and decisions based on various types of standards. But accountability docs not stop here. It is having an impact on the concept of competence to be licensed to practice medicine and on the training of child psychiatrists.
Competency and Licensure Licensing has been the model of controlling standards for the practice of medicine in the United States. Shryock (1967), in his monograph on medical licensing, notes that licensing began as early as 1650 in Massachusetts. Except for the formality of paying a renewal fee, licensure has been essentially for a lifetime and accepted as evidence of a general level of safety and clinical competence in the practice of medicine. During the last 10 years state licensing boards have questioned the concept of automatic renewal of license. At this time almost half of all states require evidence of continuing medical education as a prerequisite for reregistering individual physician's licenses, Other states will probably take similar action. This focus on mandatory continuing education suggests that voluntary continuing education alone was not seen as sufficient. There is concern as to whether mandatory continuing education will be sufficient. Continuing certification and recertification models arc now considered as the answer to accountability. Many of the efforts toward recertification have come under the umbrella of the American Board of Medical Specialties. This Board began in 1930 as the Advisory Board of Medical Specialists, a forum for the developing specialty boards to discuss common goals and problems. In 1970 the Advisory Board was reorganized and renamed the American Board of Medical Specialties; the independent boards agreed to follow the guidelines and requirements of this new unified body. The old Advisory Board recommended the consideration of recertification as early as 1940. However, it was not until 1973 that the American Board of Medical Specialties adopted the principle that all boards should pursue a policy of recertification. At the annual meeting of the American Board of Medical Specialties in March 1973 the membership approved the following action on recertification: It was moved, seconded and carried that ABMS adopt, in principle, and urge concurrence of its member boards with policy that voluntary,
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periodic recertification of medical specialties become an integral part of all national medical specialty certification programs and, further, that ABMS establish a reasonable deadline when voluntary, periodic recertification of medical specialists will have become a standard policy of all member boards [American Board of Medical Specialties, 1976, p. 9r.]. All 22 primary and conjoint boards have now endorsed the principle of recertification: 13 boards have established dates for recertification; 4 boards have made recertification a mandatory requirement. Child psychiatry is represented on the American Board of Medical Specialties by the American Board of Psychiatry and Neurology. The members of this board established a steering committee to develop the format whereby psychiatry will assess continued competence. The committee consists of representatives from the American Board of Psychiatry and Neurology, the American Psychiatric Association, the American Neurological Association, the Academy of Child Neurology, and the American Academy of Child Psychiatry. This committee will develop guidelines which must first be approved by each organization represented within the committee, then by the American Board of Psychiatry and Neurology, and, finally, by the American Board of Medical Specialties. Within a few years psychiatrists and child psychiatrists will be accountable throughout their professional life to show their continued competence.
Child Psychiatric Education The pressure for accountability has already been felt by general psychiatric and child psychiatric educators. As an example, one can no longer submit a generally written grant to NIMH's Psychiatry Education Branch and expect funding. The days of almost assured funding are gone (Silver et aI., 1977). The grant application must now define educational goals and objectives, note how the educators plan to reach these goals and objectives, and clarify how the educators will evaluate whether they have truly reached such stated goals and objectives. One can no longer say that he or she will provide a good training experience and be taken on faith. Now one must be specific and be held accountable for delivery of that which he or she promised. How will this move toward accountability influence or try to influence child psychiatric education? In addressing this question I would like to share the frame of reference used by Neil Waldrop (1976), who attempts to explain the trends of the 1970s and the possible directions of the 1980s. The traditional model of education was faculty-oriented. The faculty of the university medical centers trained specialists as they felt they should be trained. They trained as many as they chose to accept into their programs. These specialists went out to live where they chose to live and established a practice in the manner they chose to practice. The public then consumed what these specialists had to offer, where they chose to
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offer it, and within whatever delivery system the specialist chose to use. In 1974 Congress concluded that adequate medical care was necessary for the well-being of all citizens; thus, it was a "natural resource." As a natural resource, Congress was justified in regulating the field of medicine (Committee on Labor and Public Welfare, 1974). This view reversed the traditional model of medical education. Under the new model, the public, through its government, decides what types of health care it needs. Based on these data, the government decides how many of what types of physicians are needed where and what type of training they will need to provide the necessary care. The government then establishes a system for delivering this health care to all parts of the country. Further, it informs the medical centers how many of what types of specialists and generalists are needed, what skills they will need, and what type of system they will practice in. The faculties of the medical centers comply. The Health Professions Educational Assistance Act of 1976 started this process (U.S. Congress, 1976). Given this reference, what are the specific influences on child psychiatric education that now exist and that will increase in the future? Peer review education. At this time we have a peer review system of accreditation. The American Medical Association and the Association of American Medical Colleges approve facilities to provide training. Once approved, peer review is most likely done by the faculty of that facility. This faculty may ask for feedback from trainees. They rarely ask, or dare not ask, for feedback from peers, whether in the same department or, worse, in other departments. If asked, one might say that he or she taught what "intuitively" or through experience one felt needed to be taught. It is assumed that it was learned. Most, if not all, programs use a time-based system. Every trainee starts on one date and, regardless of individual differences or needs, each becomes a qualified child psychiatrist 24 months later. This type of informal or selective or nonexistent peer review is increasingly unacceptable. It is anticipated that in the near future, approval for training or reapproval for continuing to train will be based on accountability. Training directors will be asked to list definable goals and objectives for each unit of training, to explain exactly how they plan to reach these goals and objectives, and to describe the type of evaluation procedures to be used to document that the trainees really do reach these stated goals and objectives. Time-based training may be replaced by competency-based training. Trainees progress and complete their education when they document competence, not just when they become one or two years older. Most child psychiatric educators are rewarded for their efforts by academic promotions, bigger titles, and increases in pay. These advances often are not based on any assessment of competence as educators. In most places they are based on research, publications, or other evidence of scholarly pursuits. In the future, these factors may no longer be consid-
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ered valid and reliable ways of assessing educators. Student feedback will be requested. Should not the products of a training program be the best measure of success? It is possible that continued approval as a training facility will be based on the success of the trainees from that facility in passing their certifying boards or on other evidence of proven competence. Other external pressures for accountability will influence child psychiatric education. They will also influence practitioners in child psychiatry. Peer review and utilization review require outcome studies. To determine whether patients have actually benefited from psychiatric efforts one must have criteria for measuring outcome success. Child psychiatry trainees will be placed increasingly under this pressure. They must learn to think through treatment goals and why they chose to use a specific therapeutic intervention to obtain these goals. They must outline in what ways they will judge closeness to or attainment of these goals as therapy progresses or is redefined. Often this is done during supervision or in case conferences. In the future such exercises in clear thinking may not be only for the benefit of the supervisors who base their teaching on some generally agreed-upon philosophy; such exercises will also be for non physician reviewers using more broadly defined standards. How does one teach goal-attainment measurements in child psychiatry? The federal government and third-party carriers do not address the fact that this model of evaluating psychiatric efforts-whether prospectively. concurrently, or retrospectively-is based on standards; and that these standards rest upon the premise that prescribed levels of clinical activity produce predictable outcomes. This premise is untested or possibly untenable in psychiatry. Given this situation, conformance to standards such as these may be meaningless and possibly misleading. What, then, will we teach our trainees? The wish by these nonprofessionals to establish standards and to be able to review therapy objectively has led to the problem-oriented medical record and to goal-attainment scaling. Such a forced orientation is difficult to apply to the more long-ranging and intensive treatment orientations such as psychoanalysis or psychoanalytically oriented psychotherapy. Yet. these methods are taught and practiced. Accountability will influence another aspect of training. Supervision has been the mainstay for teaching clinical skills. But the growing trend toward the use of explicit evaluation procedures based upon empirical standards will, if it continues, require direct observation of patient care practices rather than assumptions based upon clinical reporting. The supervisor will have to do live supervision rather than remain in his or her office and hear the case via process notes. What does this do to privacy and confidentiality, to time and scheduling? What will be the effect of the new Health Professions Educational Assistance Act (U .S. Congress. 1976)? After child psychiatric training most of
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our new specialists will have to join the National Health Service Corps for two to four years of pay-back time, serving in health manpower shortage areas. These shortage areas are defined in three ways: (I) an urban or rural area where there is a shortage of child psychiatrists; (2) a population group which has a shortage (e.g., Indian Reservation, Watts, Harlem); and (3) a public or nonprofit private medical facility or public facility with a shortage (e.g., a community mental health center or state hospital). This law raises several issues of concern: (I) Will training programs have to modify the training objectives to provide the types of skills, knowledge, and attitudes needed for practicing in such shortage areas? (2) Will it be necessary to develop, through continuing education, a continuation of learning experience while these new child psychiatrists are practicing in professionally and possibly geographically isolated areas? (3) If we assume that the future flow of academic child psychiatrists will come from trainees who do not have to join the Service Corps, trainees assigned to research settings, or trainees returning from two to four years of clinical experience, will it be necessary to develop a "phase-in" training experience similar to the career teacher programs of the recent past? Mental Health of Child Psychiatrists
Separate from the influence that the demand for accountahility will have on child psychiatric education, what will be the psychological impact of these demands on the mental health of future child psychiatrists? There is a sociological premise that professional work suffers when detailed directives are passed down by administrators. Individuals who are unable to control their work tasks are frequently found to be less satisfied with their jobs than persons who possess this power. Our future child psychiatrists may have little of this power. Psychiatrists and child psychiatrists learn to be comfortable dealing with uncertainty. The clinical problems handled are often multidimensional and complex. With the longer forms of therapy, often it is not until the therapeutic interventions are almost complete that one can outline all of the issues involved. What then will be the effect of having to be more certain? What may be best for accountability of monies spent for mental health care may not be best for treatment or for the mental health of the patient or the physician. A final concern about the future. Child psychiatry has been unique in its efforts to bridge medicine and the social sciences. Child psychiatrists initiated much of the multidisciplinary team efforts so common to psychiatry today. Will the requirements for competency and funding force us to prove that we are more competent, thus more able to make the major decisions, or more justified in charging higher fees than our colleagues? Will this force us to retreat back onto the bridge or totally onto the safety of medicine's grounds? Perhaps this has already happened. Will our future child psychiatrists be hospital-based, primarily medically
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oriented, or a backup for primary care physicians? Will they find themselves competing with our colleagues, the social workers, psychologists, and psychiatric nurses; undoing the trust and relationships that have taken us so many years to build?
Personal Views: The Challenge I believe that the increasing expectation of accountability is appropriate and that many aspects of this movement have had and will continue to have a positive influence on child psychiatry. With the increase in knowledge in the clinical and behavioral sciences and with our expanded experiences with different models of therapeutic intervention we should be able to establish broad, flexible standards for quality of care, types of care, and length of care. To accomplish these goals will require the continued willingness of child psychiatrists to work on professional and governmental task forces to clarify and then to write such guidelines. We cannot afford to let people who are not child psychiatrists develop such standards. It is appropriate to expect all psychiatrists and child psychiatrists continually to maintain and expand their knowledge and skills. Professional societies and organizations will have to assist the clinician by providing improved programs in continuing education, an annual review syllabus, and regional review programs. It will not be enough to require continuing certification; it will be necessary to provide the programs and opportunities for each clinician to maintain his or her competence. There are more training programs in child psychiatry today than ever before. Yet, the absolute number of physicians going into child psychiatry has remained constant or slightly below previous levels. Thus, many programs are having difficulty filling all positions. Some ofthe newer programs are in medical centers with three or fewer full-time child psychiatrists; many of these are young faculty recently out of training. Some of the older, established programs have not been able to maintain their previous level of quality. Our trainees are our future. We must insist on quality of training. To help the younger or weaker programs we need to develop ongoing continuing education programs for faculty. Senior faculty must help develop junior faculty. National workshops on child psychiatric education are needed. Perhaps the field of child psychiatry has now reached a level of maturity that permits some basic, minimal standards for all training programs. A core curriculum outlining didactic and skill areas can be finalized. We can establish a minimal baseline for a program and yet permit enough flexibility to allow each program to develop its own special areas of strength. Some may question the validity of the child psychiatry boards in measuring competence; no one has yet suggested a better model for assessing basic competence. No one needs to be more competent than the director of a training program. He or she sets the standards for training
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and is the role model for the trainees. I feel that it is appropriate to establish that all directors of training programs be board certified in child psychiatry. Further, the faculty of training programs should be accountable for their products. The time-based model for completion of training is the easiest; but we do have the option of making our programs competencybased. No trainee should be permitted to complete training and start to practice child psychiatry until he or she is competent. To measure competence will require the establishment of goals and evaluation techniques. It would be helpful if the general and child psychiatry boards were established so as to allow trainees to take their boards toward the end of their last year of training. Feedback to each training program from the American Board of Psychiatry and Neurology on the performance of each trainee would be valuable in identifying areas for improvement. The future requirement for child psychiatrists just out of training to serve in the Health Service Corps in an area of shortage presents a challenge. We must develop appropriate programs during their training as well as continuing education programs for them to participate in during their service time. I share the concern that many of the newer pressures for competence and for funding place us in a competitive stance with our other mental health colleagues. In some areas psychologists are requesting permission to admit patients to hospitals and psychiatrists are opposed. Social workers are asking for equal funding for clinical services. I do not know of an answer to this problem. I can only hope that a solution can be found that does not undo the trusting relationships that now exist among the many mental health professionals. The profession of child psychiatry is able to be accountable for its training and clinical activities. Such a focus on accountability is appropriate. We must continue to work together in establishing models and standards for assessing accountability that are compatible with the practice of our specialty. Our profession and our patients will benefit.
REFERENCES AMERICAN BOARD OF MEDICAL SPECIALTIES (1976), Annual Report: 1975-1976. Evanston, III. AMERICAN PSYCHIATRIC ASSOCIATION (1976), Manual of Psychiatric Peer Review, prepared by Peer Review Committee of the American Psychiatric Associaton in cooperation with the Joint Task Force on Diagnostic Criteria for Analyzability of the American Psychoanalytic Association, and the Peer Review Committee of the American Academy of Child Psychiatry. Washington, D.C. COMMITTEE ON LABOR AND PUBLIC WELFARt: (1974), Health Professions Educational Assistance Act of 1974, Senate Report No. 99-1133, 92nd Congress, 2nd Session. Washington, D.C.: U.S. Government Printing Office. SCHULBERG, H. C. (1976), Quality-of-care standards and professional norms. ArneI'. J. Psychiat.. 133:1047-1051. SHRYOCK, R. H. (1967), Medical Licensing in America, 1650-1965. Baltimore: Johns Hopkins University Press.
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S.I.Vt:R. L. B., cd, (1976), ProJrJJ;01UlI Standards Rruino ()rgall;zal;O/u : A Handbook [or Child PJyrhill/ri.~/J . Washinglon. D.C .: Ameriran Academy of Child Psychi at r y. - - - BRUNSTt:rn:R, R. , Rt:NSHAW. D.. & COMER,.J. P. (1977) , Covernnu-nral peer review of tr aining prograllls in child ps ychiat ry . Am,r. J. Psyrhiat .. 134 : 11-14 (supplement), U.S. CONGRESS (1976), Public Law 94-484, 94th Congress , Health Pro!' ....i01111l~ Educational A .,-,i.~lllllrl' Art o] 1976 . Washingtou , D.C. : U.S. GoveJ'llllll'nt Printing Office . WAI.UROP, N . (1976) , Personal commuu icar ion .
Larry B. Silver, M.D.
Abstract. This paper reviews the increasing pressure IIII' accountability in child psychiatry. Federal legislation has increased the request for accountability in clinical practice. Shifts in federal regulations now begin to require accountability in training. The American Board of Medical Specialties now requires each specialty organization to develop models for assessing continuing professional competence. The author discusses each of these areas and offers specific" recommendations. Accountability is believed to be appropriate and helpful to the profession.
The secure world of the physician is changing. The fields of medicine, psychiatry. and child psychiatry have been challenged and criticized from outside the field of medicine. Public and private organizations want better care for less and a better system for delivering that care. Congress feels that health care is costing too much. Everywhere, critics are commenting that if the public is to pay for health care, then the public must have accountability for the monies spent. Further, this accountability must be defined and monitored by non physicians as well as by physicians. Who are these critics? They are payers of health care: the federal government and the private third-party carriers. In 1965 the federal government became the largest health insurer in the country. By 1970 it was evident that projected costs of Medicare and Medicaid would exceed estimates made in 1967 by some 240 billion dollars over a 25-year period. The rapidly increasing costs of these programs were attributed to two factors: an increase in the unit cost of services such as physicians' visits, surgical procedures, and hospital days; and an increase in the number of services provided to beneficiaries. The primary impetus for passage of control legislation, such as the PSRO legislation, was the skyrocketing costs of Medicare and Medicaid programs and only
Dr. Silver is Professor of Psychiatry. Professor of Pediatrics, and Chief of the Section of Child and Adolescent Psychiatry. CMDNJ-Rutgers Medical School. Reprints may be requested from Dr. Silver, Department of Psychiatry, Rutgers Medical School. University Heights. Piscataway, NJ 08854. 0002-7138/79/1801-176 $00.95 e 1979 American Academy of Child Psychiatry.
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secondarily the benefits that might flow from enhanced quality review of treatment. Accountability is now the main theme. I will !ClCUS on several aspects of accountability as it affects and will continue to affect the practice of child psychiatry. I will also focus on how it has begun to affect and will in the future further influence the concept of competence. the education of child psychiatrists. and the mental health of child psychiatrists. The Practice o] Child Psychiatry Accountability now shapes our definition of quality of services provided through pur review (A .P.A .• ) 976). The critics' efforts to assure quality of care tcnd to reject the formerly held premise that physicians are fundamentally humanitarian helpers who do no harm. Peer review based on the assumption that physicians know what good medicine is and can monitor themselves is no longer acceptable. We are asked to define what "good medicine" means and to do so for each and every clinical entity and situation possible. We are to show that we are objectively and completely using these definitions of "good medicine" in all clinical situations and when judging all colleagues. This request for accountability sounds reasonable until one attempts to comply with it. As but one illustration of the difficulties faced, psychiatrists have always assumed risks ; for example. in determining whether a patient is suicidal or homicidal. In return for accepting these responsibilities of judgment, psychiatrists have. in the past. been permitted considerable autonomy. I f peer review now must be based on predefined standards. one is required to use conservative judgment. producing restrictions on the psychiatrists and . secondarily. on the patient. Since there are competing claims about the relative efficacy of psychological interventions and drugs in child ps ychiatry, it becomes a less than adequate approach to require the psychiatrists to practice on the basis of scientific evidence. Unclear therapy choices leave the professional vulnerable. He or she is hesitant to use abstract rules or standards. yet is cautious about not using them. Under thesc circumstances the psychiatrist may feel restricted in making decisions and may be in no position to pass critical judgment on his or her peers. Accountability now also shapes our definition of types of service through utilization review. The payers for health care now choose to influence the choice of service facilities as well as the length of stay in these facilities. Many psychiatric facilities must now "cure" schizophrenia in 21 days! Recently a major insurance coverer sought a cutback in psychiatric benefits not only secondary to the rising costs but also out of a concern for the relative lack of scientific rigor in regard to psychiatric diagnostic and treatment decisions (Schulberg. ) 976). Accountability now shapes our definition of quality and quantity of
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service through a federal program related to utilization review and peer review, PSRO (Silver, 1976). Admit someone to the hospital or, in the future into outpatient therapy, and a non physician will match the physician's criteria for decisions with an established set of criteria. If they match, the physician's services will be approved for funding. If they do not, the physician will have to justify his or her decisions before a peer review group before the payers of care will agree to pay. In quality of care, types of care, and length of care, then, we are now accountable for our judgments and decisions based on various types of standards. But accountability docs not stop here. It is having an impact on the concept of competence to be licensed to practice medicine and on the training of child psychiatrists.
Competency and Licensure Licensing has been the model of controlling standards for the practice of medicine in the United States. Shryock (1967), in his monograph on medical licensing, notes that licensing began as early as 1650 in Massachusetts. Except for the formality of paying a renewal fee, licensure has been essentially for a lifetime and accepted as evidence of a general level of safety and clinical competence in the practice of medicine. During the last 10 years state licensing boards have questioned the concept of automatic renewal of license. At this time almost half of all states require evidence of continuing medical education as a prerequisite for reregistering individual physician's licenses, Other states will probably take similar action. This focus on mandatory continuing education suggests that voluntary continuing education alone was not seen as sufficient. There is concern as to whether mandatory continuing education will be sufficient. Continuing certification and recertification models arc now considered as the answer to accountability. Many of the efforts toward recertification have come under the umbrella of the American Board of Medical Specialties. This Board began in 1930 as the Advisory Board of Medical Specialists, a forum for the developing specialty boards to discuss common goals and problems. In 1970 the Advisory Board was reorganized and renamed the American Board of Medical Specialties; the independent boards agreed to follow the guidelines and requirements of this new unified body. The old Advisory Board recommended the consideration of recertification as early as 1940. However, it was not until 1973 that the American Board of Medical Specialties adopted the principle that all boards should pursue a policy of recertification. At the annual meeting of the American Board of Medical Specialties in March 1973 the membership approved the following action on recertification: It was moved, seconded and carried that ABMS adopt, in principle, and urge concurrence of its member boards with policy that voluntary,
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periodic recertification of medical specialties become an integral part of all national medical specialty certification programs and, further, that ABMS establish a reasonable deadline when voluntary, periodic recertification of medical specialists will have become a standard policy of all member boards [American Board of Medical Specialties, 1976, p. 9r.]. All 22 primary and conjoint boards have now endorsed the principle of recertification: 13 boards have established dates for recertification; 4 boards have made recertification a mandatory requirement. Child psychiatry is represented on the American Board of Medical Specialties by the American Board of Psychiatry and Neurology. The members of this board established a steering committee to develop the format whereby psychiatry will assess continued competence. The committee consists of representatives from the American Board of Psychiatry and Neurology, the American Psychiatric Association, the American Neurological Association, the Academy of Child Neurology, and the American Academy of Child Psychiatry. This committee will develop guidelines which must first be approved by each organization represented within the committee, then by the American Board of Psychiatry and Neurology, and, finally, by the American Board of Medical Specialties. Within a few years psychiatrists and child psychiatrists will be accountable throughout their professional life to show their continued competence.
Child Psychiatric Education The pressure for accountability has already been felt by general psychiatric and child psychiatric educators. As an example, one can no longer submit a generally written grant to NIMH's Psychiatry Education Branch and expect funding. The days of almost assured funding are gone (Silver et aI., 1977). The grant application must now define educational goals and objectives, note how the educators plan to reach these goals and objectives, and clarify how the educators will evaluate whether they have truly reached such stated goals and objectives. One can no longer say that he or she will provide a good training experience and be taken on faith. Now one must be specific and be held accountable for delivery of that which he or she promised. How will this move toward accountability influence or try to influence child psychiatric education? In addressing this question I would like to share the frame of reference used by Neil Waldrop (1976), who attempts to explain the trends of the 1970s and the possible directions of the 1980s. The traditional model of education was faculty-oriented. The faculty of the university medical centers trained specialists as they felt they should be trained. They trained as many as they chose to accept into their programs. These specialists went out to live where they chose to live and established a practice in the manner they chose to practice. The public then consumed what these specialists had to offer, where they chose to
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offer it, and within whatever delivery system the specialist chose to use. In 1974 Congress concluded that adequate medical care was necessary for the well-being of all citizens; thus, it was a "natural resource." As a natural resource, Congress was justified in regulating the field of medicine (Committee on Labor and Public Welfare, 1974). This view reversed the traditional model of medical education. Under the new model, the public, through its government, decides what types of health care it needs. Based on these data, the government decides how many of what types of physicians are needed where and what type of training they will need to provide the necessary care. The government then establishes a system for delivering this health care to all parts of the country. Further, it informs the medical centers how many of what types of specialists and generalists are needed, what skills they will need, and what type of system they will practice in. The faculties of the medical centers comply. The Health Professions Educational Assistance Act of 1976 started this process (U.S. Congress, 1976). Given this reference, what are the specific influences on child psychiatric education that now exist and that will increase in the future? Peer review education. At this time we have a peer review system of accreditation. The American Medical Association and the Association of American Medical Colleges approve facilities to provide training. Once approved, peer review is most likely done by the faculty of that facility. This faculty may ask for feedback from trainees. They rarely ask, or dare not ask, for feedback from peers, whether in the same department or, worse, in other departments. If asked, one might say that he or she taught what "intuitively" or through experience one felt needed to be taught. It is assumed that it was learned. Most, if not all, programs use a time-based system. Every trainee starts on one date and, regardless of individual differences or needs, each becomes a qualified child psychiatrist 24 months later. This type of informal or selective or nonexistent peer review is increasingly unacceptable. It is anticipated that in the near future, approval for training or reapproval for continuing to train will be based on accountability. Training directors will be asked to list definable goals and objectives for each unit of training, to explain exactly how they plan to reach these goals and objectives, and to describe the type of evaluation procedures to be used to document that the trainees really do reach these stated goals and objectives. Time-based training may be replaced by competency-based training. Trainees progress and complete their education when they document competence, not just when they become one or two years older. Most child psychiatric educators are rewarded for their efforts by academic promotions, bigger titles, and increases in pay. These advances often are not based on any assessment of competence as educators. In most places they are based on research, publications, or other evidence of scholarly pursuits. In the future, these factors may no longer be consid-
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ered valid and reliable ways of assessing educators. Student feedback will be requested. Should not the products of a training program be the best measure of success? It is possible that continued approval as a training facility will be based on the success of the trainees from that facility in passing their certifying boards or on other evidence of proven competence. Other external pressures for accountability will influence child psychiatric education. They will also influence practitioners in child psychiatry. Peer review and utilization review require outcome studies. To determine whether patients have actually benefited from psychiatric efforts one must have criteria for measuring outcome success. Child psychiatry trainees will be placed increasingly under this pressure. They must learn to think through treatment goals and why they chose to use a specific therapeutic intervention to obtain these goals. They must outline in what ways they will judge closeness to or attainment of these goals as therapy progresses or is redefined. Often this is done during supervision or in case conferences. In the future such exercises in clear thinking may not be only for the benefit of the supervisors who base their teaching on some generally agreed-upon philosophy; such exercises will also be for non physician reviewers using more broadly defined standards. How does one teach goal-attainment measurements in child psychiatry? The federal government and third-party carriers do not address the fact that this model of evaluating psychiatric efforts-whether prospectively. concurrently, or retrospectively-is based on standards; and that these standards rest upon the premise that prescribed levels of clinical activity produce predictable outcomes. This premise is untested or possibly untenable in psychiatry. Given this situation, conformance to standards such as these may be meaningless and possibly misleading. What, then, will we teach our trainees? The wish by these nonprofessionals to establish standards and to be able to review therapy objectively has led to the problem-oriented medical record and to goal-attainment scaling. Such a forced orientation is difficult to apply to the more long-ranging and intensive treatment orientations such as psychoanalysis or psychoanalytically oriented psychotherapy. Yet. these methods are taught and practiced. Accountability will influence another aspect of training. Supervision has been the mainstay for teaching clinical skills. But the growing trend toward the use of explicit evaluation procedures based upon empirical standards will, if it continues, require direct observation of patient care practices rather than assumptions based upon clinical reporting. The supervisor will have to do live supervision rather than remain in his or her office and hear the case via process notes. What does this do to privacy and confidentiality, to time and scheduling? What will be the effect of the new Health Professions Educational Assistance Act (U .S. Congress. 1976)? After child psychiatric training most of
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our new specialists will have to join the National Health Service Corps for two to four years of pay-back time, serving in health manpower shortage areas. These shortage areas are defined in three ways: (I) an urban or rural area where there is a shortage of child psychiatrists; (2) a population group which has a shortage (e.g., Indian Reservation, Watts, Harlem); and (3) a public or nonprofit private medical facility or public facility with a shortage (e.g., a community mental health center or state hospital). This law raises several issues of concern: (I) Will training programs have to modify the training objectives to provide the types of skills, knowledge, and attitudes needed for practicing in such shortage areas? (2) Will it be necessary to develop, through continuing education, a continuation of learning experience while these new child psychiatrists are practicing in professionally and possibly geographically isolated areas? (3) If we assume that the future flow of academic child psychiatrists will come from trainees who do not have to join the Service Corps, trainees assigned to research settings, or trainees returning from two to four years of clinical experience, will it be necessary to develop a "phase-in" training experience similar to the career teacher programs of the recent past? Mental Health of Child Psychiatrists
Separate from the influence that the demand for accountahility will have on child psychiatric education, what will be the psychological impact of these demands on the mental health of future child psychiatrists? There is a sociological premise that professional work suffers when detailed directives are passed down by administrators. Individuals who are unable to control their work tasks are frequently found to be less satisfied with their jobs than persons who possess this power. Our future child psychiatrists may have little of this power. Psychiatrists and child psychiatrists learn to be comfortable dealing with uncertainty. The clinical problems handled are often multidimensional and complex. With the longer forms of therapy, often it is not until the therapeutic interventions are almost complete that one can outline all of the issues involved. What then will be the effect of having to be more certain? What may be best for accountability of monies spent for mental health care may not be best for treatment or for the mental health of the patient or the physician. A final concern about the future. Child psychiatry has been unique in its efforts to bridge medicine and the social sciences. Child psychiatrists initiated much of the multidisciplinary team efforts so common to psychiatry today. Will the requirements for competency and funding force us to prove that we are more competent, thus more able to make the major decisions, or more justified in charging higher fees than our colleagues? Will this force us to retreat back onto the bridge or totally onto the safety of medicine's grounds? Perhaps this has already happened. Will our future child psychiatrists be hospital-based, primarily medically
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oriented, or a backup for primary care physicians? Will they find themselves competing with our colleagues, the social workers, psychologists, and psychiatric nurses; undoing the trust and relationships that have taken us so many years to build?
Personal Views: The Challenge I believe that the increasing expectation of accountability is appropriate and that many aspects of this movement have had and will continue to have a positive influence on child psychiatry. With the increase in knowledge in the clinical and behavioral sciences and with our expanded experiences with different models of therapeutic intervention we should be able to establish broad, flexible standards for quality of care, types of care, and length of care. To accomplish these goals will require the continued willingness of child psychiatrists to work on professional and governmental task forces to clarify and then to write such guidelines. We cannot afford to let people who are not child psychiatrists develop such standards. It is appropriate to expect all psychiatrists and child psychiatrists continually to maintain and expand their knowledge and skills. Professional societies and organizations will have to assist the clinician by providing improved programs in continuing education, an annual review syllabus, and regional review programs. It will not be enough to require continuing certification; it will be necessary to provide the programs and opportunities for each clinician to maintain his or her competence. There are more training programs in child psychiatry today than ever before. Yet, the absolute number of physicians going into child psychiatry has remained constant or slightly below previous levels. Thus, many programs are having difficulty filling all positions. Some ofthe newer programs are in medical centers with three or fewer full-time child psychiatrists; many of these are young faculty recently out of training. Some of the older, established programs have not been able to maintain their previous level of quality. Our trainees are our future. We must insist on quality of training. To help the younger or weaker programs we need to develop ongoing continuing education programs for faculty. Senior faculty must help develop junior faculty. National workshops on child psychiatric education are needed. Perhaps the field of child psychiatry has now reached a level of maturity that permits some basic, minimal standards for all training programs. A core curriculum outlining didactic and skill areas can be finalized. We can establish a minimal baseline for a program and yet permit enough flexibility to allow each program to develop its own special areas of strength. Some may question the validity of the child psychiatry boards in measuring competence; no one has yet suggested a better model for assessing basic competence. No one needs to be more competent than the director of a training program. He or she sets the standards for training
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and is the role model for the trainees. I feel that it is appropriate to establish that all directors of training programs be board certified in child psychiatry. Further, the faculty of training programs should be accountable for their products. The time-based model for completion of training is the easiest; but we do have the option of making our programs competencybased. No trainee should be permitted to complete training and start to practice child psychiatry until he or she is competent. To measure competence will require the establishment of goals and evaluation techniques. It would be helpful if the general and child psychiatry boards were established so as to allow trainees to take their boards toward the end of their last year of training. Feedback to each training program from the American Board of Psychiatry and Neurology on the performance of each trainee would be valuable in identifying areas for improvement. The future requirement for child psychiatrists just out of training to serve in the Health Service Corps in an area of shortage presents a challenge. We must develop appropriate programs during their training as well as continuing education programs for them to participate in during their service time. I share the concern that many of the newer pressures for competence and for funding place us in a competitive stance with our other mental health colleagues. In some areas psychologists are requesting permission to admit patients to hospitals and psychiatrists are opposed. Social workers are asking for equal funding for clinical services. I do not know of an answer to this problem. I can only hope that a solution can be found that does not undo the trusting relationships that now exist among the many mental health professionals. The profession of child psychiatry is able to be accountable for its training and clinical activities. Such a focus on accountability is appropriate. We must continue to work together in establishing models and standards for assessing accountability that are compatible with the practice of our specialty. Our profession and our patients will benefit.
REFERENCES AMERICAN BOARD OF MEDICAL SPECIALTIES (1976), Annual Report: 1975-1976. Evanston, III. AMERICAN PSYCHIATRIC ASSOCIATION (1976), Manual of Psychiatric Peer Review, prepared by Peer Review Committee of the American Psychiatric Associaton in cooperation with the Joint Task Force on Diagnostic Criteria for Analyzability of the American Psychoanalytic Association, and the Peer Review Committee of the American Academy of Child Psychiatry. Washington, D.C. COMMITTEE ON LABOR AND PUBLIC WELFARt: (1974), Health Professions Educational Assistance Act of 1974, Senate Report No. 99-1133, 92nd Congress, 2nd Session. Washington, D.C.: U.S. Government Printing Office. SCHULBERG, H. C. (1976), Quality-of-care standards and professional norms. ArneI'. J. Psychiat.. 133:1047-1051. SHRYOCK, R. H. (1967), Medical Licensing in America, 1650-1965. Baltimore: Johns Hopkins University Press.
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S.I.Vt:R. L. B., cd, (1976), ProJrJJ;01UlI Standards Rruino ()rgall;zal;O/u : A Handbook [or Child PJyrhill/ri.~/J . Washinglon. D.C .: Ameriran Academy of Child Psychi at r y. - - - BRUNSTt:rn:R, R. , Rt:NSHAW. D.. & COMER,.J. P. (1977) , Covernnu-nral peer review of tr aining prograllls in child ps ychiat ry . Am,r. J. Psyrhiat .. 134 : 11-14 (supplement), U.S. CONGRESS (1976), Public Law 94-484, 94th Congress , Health Pro!' ....i01111l~ Educational A .,-,i.~lllllrl' Art o] 1976 . Washingtou , D.C. : U.S. GoveJ'llllll'nt Printing Office . WAI.UROP, N . (1976) , Personal commuu icar ion .
