Acad Psychiatry (2015) 39:740–741 DOI 10.1007/s40596-015-0436-4
FEATURE: LETTER TO THE EDITOR
Integrated Care Training in Canada: Challenges and Future Directions Nadiya Sunderji 1 & Ruzica Jokic 2
Received: 12 September 2015 / Accepted: 18 September 2015 / Published online: 6 October 2015 # Academic Psychiatry 2015
To the Editor: The August 2015 series of articles on educating residents for the practice of integrated care is timely and important [1, 2]. In Canada, all psychiatry residents are exposed to an integrated care rotation (also known as “shared care” or “collaborative care”) during their senior years as a result of a mandatory training requirement by the Royal College of Physicians and Surgeons of Canada (RCPSC) in effect since 2011 [3]. This is congruent with broader shifts in medical education that aim to increase physicians’ responsiveness to population and community health needs and contribution to healthcare system sustainability [4]. However, Canadian psychiatry residency programs have faced challenges in interpreting and implementing the new training requirement. We conducted a national survey of Canadian psychiatry residency program directors in Spring 2011 (n=13, a 81 % response rate) [5]. They identified a lack of guidance regarding the intended outcomes of integrated care training and implementation barriers, including lack of training sites (70 %), lack of supervisors (70 %), and the need for faculty development (62 %). Unsurprisingly, a 2013 curriculum evaluation at one residency program revealed substantial discordance between the curricula planned by educators, implemented by teachers, and experienced by residents. The RCPSC responded to the program directors’ concerns in 2014 by reducing the training requirement from a minimum of 2 months to 1 month (or longitudinal equivalent). Although the revision may alleviate program directors’ concerns about * Nadiya Sunderji [email protected] 1
University of Toronto, Toronto, ON, Canada
2
Queen’s University, Kingston, ON, Canada
maintaining their programs’ accreditation, a time-based requirement was and still is merely an outcome of convenience, and there remains a gap in guiding programs on how best to promote resident attainment of competence in integrated care. At present, programs offer experiences that vary widely in duration, format, and setting, based on idiosyncratic interpretations of the goals of training and local feasibility considerations. Given the identified challenges in implementing nationwide training, the RCPSC is now questioning the quality and consistency of integrated training in Canada in its current forms. However, integrated care models are complex, inherently context sensitive, and evolving over time—traits that do not lend themselves well to standardization of training. If we are to continue with this important innovation in psychiatric education, then we will need to clearly define the purpose and intended outcomes of integrated care training and suitable settings for a workplace curriculum in integrated care. Indeed, this may facilitate resident training in diverse settings while still demonstrating a common standard of competence. Canada has a publicly funded healthcare system with a strong foundation of primary care and public health. Residents require exposure to community and primary care settings during training in order to understand the continuum of acute and community-based services. Integrated care training affords an ideal opportunity for such exposure in a variety of settings, through which residents can contribute to mental health care delivery and capacity building beyond academic hospitals. Residents may attain competencies in multiple domains concurrently, for example, through working with nursing homes, schools, child protection services, hospices, or case management agencies. Such experiences enable residents to learn how to communicate effectively and form collaborative interprofessional relationships to support co-management of patients. Residents will develop skills in knowledge
Acad Psychiatry (2015) 39:740–741
exchange, learn about organizational and team dynamics, contribute to stewardship of limited specialist resources, and become aware of how funding and practice models, as well as health professions training, influence availability of services, individual patient experiences, and population health. Residency programs should consider offering a longitudinal experience in the senior years of training, as this would be most conducive to demonstrating the relevant competencies. Teaching integrated care should include a mix of experiential learning (direct patient care and “indirect care”), supervision by a psychiatrist practicing integrated care, and didactics. Indirect care may include knowledge exchange with other health or social service providers, team-based quality improvement of mental health care, program consultation, development and/or evaluation, or interorganizational coordination activities. Assessment should include multisource feedback, review of clinical documentation, case-based discussions, a portfolio, and/ or reflective exercises that situate the experiential learning in an interprofessional, organizational, and health systems context. There remains a continuing need to (a) clearly define the competencies required for the successful practice of integrated care, (b) examine the existing evidence for effectiveness of integrated care training, (c) provide faculty
741
development, and (d) develop valid assessment tools for use in integrated care settings. We anticipate that the above recommendations may bring challenges for the psychiatry residency programs charged with implementing them; however, establishing a shared sense of direction and developing open source materials for teaching and assessment could support the residency programs in moving forward with this important area for training.
References 1. 2.
3.
4.
5.
Cowley DS. Teaching integrated care. Acad Psych. 2015;39:422–4. Coverdale JH, Roberts LW, Balon R, Beresin EV, Tait G, Louie AK. Integrated care in community settings and psychiatric training. Acad Psych. 2015;39:419–21. Specialty Training Requirements in Psychiatry. Royal College of Physicians and Surgeons of Canada. 2009. http://www. royalcollege.ca/cs/groups/public/documents/document/mdaw/ mdg4/~edisp/088025.pdf. Accessed 12 September 2015. The Future of Medical Education in Canada Postgraduate Project: a collective vision for postgraduate medical education in Canada. The Association of Faculties of Medicine of Canada. 2012. https://www. afmc.ca/future-of-medical-education-in-canada/postgraduateproject/phase2/pdf/FMEC_PG_Final-Report_EN.pdf. Accessed 12 September 2015. Sunderji N, Zaretsky A. Shared care education: results of a national survey. Meeting of the Coordinators of Psychiatric Education (COPE). 2011.
FEATURE: LETTER TO THE EDITOR
Integrated Care Training in Canada: Challenges and Future Directions Nadiya Sunderji 1 & Ruzica Jokic 2
Received: 12 September 2015 / Accepted: 18 September 2015 / Published online: 6 October 2015 # Academic Psychiatry 2015
To the Editor: The August 2015 series of articles on educating residents for the practice of integrated care is timely and important [1, 2]. In Canada, all psychiatry residents are exposed to an integrated care rotation (also known as “shared care” or “collaborative care”) during their senior years as a result of a mandatory training requirement by the Royal College of Physicians and Surgeons of Canada (RCPSC) in effect since 2011 [3]. This is congruent with broader shifts in medical education that aim to increase physicians’ responsiveness to population and community health needs and contribution to healthcare system sustainability [4]. However, Canadian psychiatry residency programs have faced challenges in interpreting and implementing the new training requirement. We conducted a national survey of Canadian psychiatry residency program directors in Spring 2011 (n=13, a 81 % response rate) [5]. They identified a lack of guidance regarding the intended outcomes of integrated care training and implementation barriers, including lack of training sites (70 %), lack of supervisors (70 %), and the need for faculty development (62 %). Unsurprisingly, a 2013 curriculum evaluation at one residency program revealed substantial discordance between the curricula planned by educators, implemented by teachers, and experienced by residents. The RCPSC responded to the program directors’ concerns in 2014 by reducing the training requirement from a minimum of 2 months to 1 month (or longitudinal equivalent). Although the revision may alleviate program directors’ concerns about * Nadiya Sunderji [email protected] 1
University of Toronto, Toronto, ON, Canada
2
Queen’s University, Kingston, ON, Canada
maintaining their programs’ accreditation, a time-based requirement was and still is merely an outcome of convenience, and there remains a gap in guiding programs on how best to promote resident attainment of competence in integrated care. At present, programs offer experiences that vary widely in duration, format, and setting, based on idiosyncratic interpretations of the goals of training and local feasibility considerations. Given the identified challenges in implementing nationwide training, the RCPSC is now questioning the quality and consistency of integrated training in Canada in its current forms. However, integrated care models are complex, inherently context sensitive, and evolving over time—traits that do not lend themselves well to standardization of training. If we are to continue with this important innovation in psychiatric education, then we will need to clearly define the purpose and intended outcomes of integrated care training and suitable settings for a workplace curriculum in integrated care. Indeed, this may facilitate resident training in diverse settings while still demonstrating a common standard of competence. Canada has a publicly funded healthcare system with a strong foundation of primary care and public health. Residents require exposure to community and primary care settings during training in order to understand the continuum of acute and community-based services. Integrated care training affords an ideal opportunity for such exposure in a variety of settings, through which residents can contribute to mental health care delivery and capacity building beyond academic hospitals. Residents may attain competencies in multiple domains concurrently, for example, through working with nursing homes, schools, child protection services, hospices, or case management agencies. Such experiences enable residents to learn how to communicate effectively and form collaborative interprofessional relationships to support co-management of patients. Residents will develop skills in knowledge
Acad Psychiatry (2015) 39:740–741
exchange, learn about organizational and team dynamics, contribute to stewardship of limited specialist resources, and become aware of how funding and practice models, as well as health professions training, influence availability of services, individual patient experiences, and population health. Residency programs should consider offering a longitudinal experience in the senior years of training, as this would be most conducive to demonstrating the relevant competencies. Teaching integrated care should include a mix of experiential learning (direct patient care and “indirect care”), supervision by a psychiatrist practicing integrated care, and didactics. Indirect care may include knowledge exchange with other health or social service providers, team-based quality improvement of mental health care, program consultation, development and/or evaluation, or interorganizational coordination activities. Assessment should include multisource feedback, review of clinical documentation, case-based discussions, a portfolio, and/ or reflective exercises that situate the experiential learning in an interprofessional, organizational, and health systems context. There remains a continuing need to (a) clearly define the competencies required for the successful practice of integrated care, (b) examine the existing evidence for effectiveness of integrated care training, (c) provide faculty
741
development, and (d) develop valid assessment tools for use in integrated care settings. We anticipate that the above recommendations may bring challenges for the psychiatry residency programs charged with implementing them; however, establishing a shared sense of direction and developing open source materials for teaching and assessment could support the residency programs in moving forward with this important area for training.
References 1. 2.
3.
4.
5.
Cowley DS. Teaching integrated care. Acad Psych. 2015;39:422–4. Coverdale JH, Roberts LW, Balon R, Beresin EV, Tait G, Louie AK. Integrated care in community settings and psychiatric training. Acad Psych. 2015;39:419–21. Specialty Training Requirements in Psychiatry. Royal College of Physicians and Surgeons of Canada. 2009. http://www. royalcollege.ca/cs/groups/public/documents/document/mdaw/ mdg4/~edisp/088025.pdf. Accessed 12 September 2015. The Future of Medical Education in Canada Postgraduate Project: a collective vision for postgraduate medical education in Canada. The Association of Faculties of Medicine of Canada. 2012. https://www. afmc.ca/future-of-medical-education-in-canada/postgraduateproject/phase2/pdf/FMEC_PG_Final-Report_EN.pdf. Accessed 12 September 2015. Sunderji N, Zaretsky A. Shared care education: results of a national survey. Meeting of the Coordinators of Psychiatric Education (COPE). 2011.
