The Effects of Sequence of Clinical Experience During Psychiatry Residency Allan Tasman, M.D.
This article provides a preliminary report on theeducational impact ofscheduling inpatient rotations either before or after an outpatient year. The inpatient psychiatry evaluations ofagroup ofPGY-3 residents who had their inpatient training rotation after a psychodynamically focused outpatient PGY-2 were compared with those of agroup of PGY-2 residents who had their initial psychiatry training at thesame inpatient service with thesame supervisors during thesame academic year. The PGY-3 residents had more difficulty in acquiring inpatient diagnostic skills, in understanding therange ofinpatient psychopathology, in understanding therange oftherapeutic interactions, andin developmentofprofessional psychiatric identity than PGY-2 residents on thesame rotation. The implications of these preliminary findings for educational planning andfuture research are discussed.
has been standard practice in residency of all specialties that early cliniIcaltprograms placements most often involve inpatient rotations. A 1986survey of psychiatry residency programs (l) indicates that most of the responding programs follow this pattern of training, with only about 10%of responding programs having a PGY-2 outpatient rotation as the first clinical psychiatry training experience before an initial inpatient psychiatry rotation in PGY-3. Although this survey showed that this pattern is the accepted standard of practice, there is little literature to support whether it is the optimal sequence of training. In fact, there is little in the recent literature to support any particular sequence Dr. Tasman is professor and chairman, Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine. Address correspondence to Dr. Tasman, Dept. of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY40292. Copyright © 1991 Academic Psychiatry.
;
of training. A MEDLINEsearch from 1987to the present revealed no articles on this topic in the psychiatric literature. There were some articles in the 19605 and early 19705 on the experience and stress of the first year of psychiatry residency (2-8), but none of these articles includes assessment of differences in learning in an inpatient vs. outpatient first clinical experience. Although this subject is not reported in the literature, psychiatry educators continue to discuss the optimal sequence of training. One .side argues that the apprenticeship model used in inpatient work has been an effective way to rapidly immerse residents in a situation that helps them to develop a broad range of diagnostic skills and an armamentarium of therapeutic interventions. Furthermore, because of the significant amount of supervision and contact with other mental health professionals that is often available in inpatient units, an inpatient rotation at the beginning of training has \ ~ lIl
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: \ c., \ I \ "
been argued to be more protective of the resident. Those who argue that an outpatient experience should come first often cite the literature regarding the stresses of the first year of training and its relationship to the inpatient psychiatry rotation. This position holds that the sense of mastery that is gained in working in a less supervised setting with psychiatric patients whose illnesses are less severe and, therefore, theoretically easier to treat enhances the residents' sense of competency and professional self-esteem. In addition, some argue that the "outpatient first" approach strengthens the ability to teach psychopathology from a developmental approach. In the absence of data, this argument seems to have no solution. Those supporting each side often base their position on impressions gained from academic experience in training programs that have used one or the other of these models to teach residents. Obviously, the apparent strengths of either approach are clearer to faculty who have a particular investment in a certain model of training. This article reports preliminary findings of the educational impact of sequence of training based on the experience at the University of Connecticut (UConn) Psychiatric Residency Program. The training program was originally developed with the aim of training residents from a developmental perspective. For over 10 years, the curriculum provided PGY-2 residents with outpatient experience in both adult psychiatry and child and adolescent psychiatry that was primarily based on a psychodynamic approach; PGY-3 was devoted to inpatient work. In the 19805, because of a variety of factors, the sequence was changed so that the inpatient year preceded the outpatient year. This change presented an opportunity to assess different aspects of resident performance in those who had either an outpatient or inpatient experience immediately following internship in the same program.
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METHODS In the year in which ueonn's sequence of training was changed, 12 residents (6 PGY-3 residents who had devoted PGY-2 to outpatient work, and 6 PGY-2 residents in their first clinical rotation following medical internship) spent the year on the inpatient service. Evaluations of the inpatient experiences of PGY-3 and PGY-2 resident groups were performed by the same group of supervisors using the same evaluation criteria during the same academic year. This provided an equivalence of clinical experience and supervision for both PGY resident groups. Residents received written evaluations every 3 months during their inpatient year, which provided an opportunity to assess changes in clinical skills (e.g., ability to perform a diagnostic evaluation, ability to develop a treatment plan), knowledge (e.g., appropriate therapeutic interventions matched to psychopathology), and attitudes (e.g., ability to work with staff, sense of professional identity). In addition, each evaluation form provided an opportunity for supervisors to provide narrative comments.
RESULTS Both scaled ratings and narrative comments were reviewed. Because of the extremely small sample size, no statistical analysis could be done and therefore conclusions cannot be drawn about specific factors involving the educational impact of the sequence for any single resident. The scaled ratings revealed no statistically significant differences between the PGY-3 and PGY-2 groups, but a review of the narrative comments of the supervisors suggests that when the two groups were compared, the sequence of training had an impact on resident performance in the areas of diagnostic skills, comprehension of the range of inpatient psychopathology, comprehension of the range of therapeutic interventions, and development of professional psychiatry identity. AI-
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though these data are preliminary, there is so little in the literature regarding the effect of sequencing of residents' experience on their performance that a descriptive presentation of the findings from the UConn program study is warranted. Diagnostic Skills PGY-3 residents who had spent a year doing outpatient work before their inpatient rotation seemed to have more difficulty in understanding the broad range of diagnostic criteria for psychiatric illnesses, especially for Axis I disorders. These residents were more likely to underestimate the significance of symptoms and tended to interpret illness more in line with Axis II disorders. Although there clearly was improvement by the end of the year, PGY-3 residents continued to have more diagnostic difficulties than PGY-2 residents whose initial clinical rotation in psychiatry was the inpatient rotation. Understanding the
Spectrum of Psychopathology PGY-3 residents' diagnostic problems affected the way they formulated psychopathology in their patients. Patients with major psychotic or mood disorders were often seen as having less severe pathology. When approaching psychopathology from a dynamic perspective, PGY-3 residents had more difficulty appreciating the biological and social/interpersonal aspects of psychopathology than their PGY-2 colleagues who had their inpatient training first. As with the findings in diagnostic skills, PGY-3 residents showed consistent improvement as the year progressed but still had more difficulties in this area at year's end. Understanding the Range of Therapeutic Interventions Even though the outpatient rotation included work with some severely ill indi-
viduals whose primary treatment involved medication, PGY-3 residents seemed more hesitant in the use of psychotropic medications than PGY-2 residents. PGY-3 residents also were more likely to have difficulty making rapid, directive interventions than PGY-2 residents. Supervisors noted that for PGY-3 residents on a short-term inpatient unit, providing more directive and structured interventions seemed to be at odds with the nondirective approach they had learned during the previous outpatient year. Professional Identity Development As expected, those residents who were in the inpatient rotation during PGY-2 experienced many of the psychological stresses that have been identified in the literature concerning the first year of training. Surprisingly, however, residents in the PGY-3 group also seemed to have many of the same problems in professional identity formation even though this was their second full year of psychiatry training. Several PGY-3 residents seemed to have even more difficulty with these issues than PGY-2 residents in the inpatient rotation. This was interpreted by the supervisors as the result of a professional identity formation that had solidified during the year of training in the outpatient department, but which now needed to be extensively reworked during the subsequent inpatient rotation. DISCUSSION The significance and interpretability of this preliminary report are limited because the sample is small and comes from a single program. It was decided to change the UConn program's training sequence and put the inpatient rotation in PGY-2. The supervisors were aware of this institutional training decision and were therefore not blind to the year of training of their residents. Our preliminary findings suggest, however, that the effects of training sequence require
further investigation. Although PGY-3 residents had seminars in diagnosis and psychopathology during PGY-2,it appears that the initial imprinting that occurred during the outpatient PGY-2 colored their inpatient experience. The ability of PGY-3 residents to perform in a rapid, directive, focused way on a short-term inpatient setting was limited compared with PGY-2 residents with less clinical experience. Another area worthy of further investigation is the nature of the outpatient experience. In the UConn program, the outpatient experience was weighted toward a psychodynamic approach; it is not known whether residents trained in an outpatient setting that emphasizes psychopharmacologic, cognitive, or behavioral approaches would have had the same difficulties with inpatient work as did the PGY-3 residents described in this report. It is also important to note that this report only investigated the performance of residents on an inpatient ser-
vice who had done outpatient psychotherapy first. We have no similar evaluation of the outpatient setting. It is possible that residents who began outpatient work in PGY-2 would have been shown to be better in psychotherapy than residents with an outpatient PGY-3. Further research that explores the conventional wisdom that places inpatient experience earlier in training than outpatient psychiatry rotations is needed to see if the educational benefits outweigh the impact of the psychosocial stress reported during early inpatient experiences. The lack of databased reports in the literature regarding the effects of sequence of service experiences on training indicates that there is much work to be done. Such research is necessary to provide objective data to assist training directors and academic faculty in the construction of training sequences that optimize the educational process and the formation of professional identity.
References 1. Tasman A, Kay]: Setting the stage: residency training in 1986, in Training Psychiatrists for the 90s: Issues and Recommendations,edited by Nadelson ee, Robinowitz CB. Washington, DC, American Psychiatric Press,1987,pp 49-54 2. Uston Eli: Residency training in adult inpatient psychiatry, in Teaching Psychiatry and Behavioral Science, edited by Yager ]. New York, Grune &: Stratton, 1982, pp 25>-271 3. Lazare A, Eisenberg L: Psychiatric residency training: an outpatient first year program. Seminars in Psychiatry 1970;2:201-210
4. Halleck5L, Woods5M:Emotionalproblems of psychiatricresidents. Psychiatry 1962;25:339-346 5. Ungerleider]T: That most difficult year. Am] Psychiatry 1965; 122:542-545 6. Merklin L ]r, Uttle RB: Beginning psychiatry syndrome. Am] Psychiatry 1967;124:193-197 7. Worby CM: The first-year psychiatric resident and the professional identity crisis. Mental Hygiene 1970;54:374-377 8. Pasnau RO, Bayley 5]: Personallty changes in the first year of psychiatric residency training. Am ] Psychiatry1971; 128:79-84
This article provides a preliminary report on theeducational impact ofscheduling inpatient rotations either before or after an outpatient year. The inpatient psychiatry evaluations ofagroup ofPGY-3 residents who had their inpatient training rotation after a psychodynamically focused outpatient PGY-2 were compared with those of agroup of PGY-2 residents who had their initial psychiatry training at thesame inpatient service with thesame supervisors during thesame academic year. The PGY-3 residents had more difficulty in acquiring inpatient diagnostic skills, in understanding therange ofinpatient psychopathology, in understanding therange oftherapeutic interactions, andin developmentofprofessional psychiatric identity than PGY-2 residents on thesame rotation. The implications of these preliminary findings for educational planning andfuture research are discussed.
has been standard practice in residency of all specialties that early cliniIcaltprograms placements most often involve inpatient rotations. A 1986survey of psychiatry residency programs (l) indicates that most of the responding programs follow this pattern of training, with only about 10%of responding programs having a PGY-2 outpatient rotation as the first clinical psychiatry training experience before an initial inpatient psychiatry rotation in PGY-3. Although this survey showed that this pattern is the accepted standard of practice, there is little literature to support whether it is the optimal sequence of training. In fact, there is little in the recent literature to support any particular sequence Dr. Tasman is professor and chairman, Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine. Address correspondence to Dr. Tasman, Dept. of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY40292. Copyright © 1991 Academic Psychiatry.
;
of training. A MEDLINEsearch from 1987to the present revealed no articles on this topic in the psychiatric literature. There were some articles in the 19605 and early 19705 on the experience and stress of the first year of psychiatry residency (2-8), but none of these articles includes assessment of differences in learning in an inpatient vs. outpatient first clinical experience. Although this subject is not reported in the literature, psychiatry educators continue to discuss the optimal sequence of training. One .side argues that the apprenticeship model used in inpatient work has been an effective way to rapidly immerse residents in a situation that helps them to develop a broad range of diagnostic skills and an armamentarium of therapeutic interventions. Furthermore, because of the significant amount of supervision and contact with other mental health professionals that is often available in inpatient units, an inpatient rotation at the beginning of training has \ ~ lIl
\ 11 I; ' '\ l \1111 1< ,. \ \ 1,\1 1 1< 1''''1
: \ c., \ I \ "
been argued to be more protective of the resident. Those who argue that an outpatient experience should come first often cite the literature regarding the stresses of the first year of training and its relationship to the inpatient psychiatry rotation. This position holds that the sense of mastery that is gained in working in a less supervised setting with psychiatric patients whose illnesses are less severe and, therefore, theoretically easier to treat enhances the residents' sense of competency and professional self-esteem. In addition, some argue that the "outpatient first" approach strengthens the ability to teach psychopathology from a developmental approach. In the absence of data, this argument seems to have no solution. Those supporting each side often base their position on impressions gained from academic experience in training programs that have used one or the other of these models to teach residents. Obviously, the apparent strengths of either approach are clearer to faculty who have a particular investment in a certain model of training. This article reports preliminary findings of the educational impact of sequence of training based on the experience at the University of Connecticut (UConn) Psychiatric Residency Program. The training program was originally developed with the aim of training residents from a developmental perspective. For over 10 years, the curriculum provided PGY-2 residents with outpatient experience in both adult psychiatry and child and adolescent psychiatry that was primarily based on a psychodynamic approach; PGY-3 was devoted to inpatient work. In the 19805, because of a variety of factors, the sequence was changed so that the inpatient year preceded the outpatient year. This change presented an opportunity to assess different aspects of resident performance in those who had either an outpatient or inpatient experience immediately following internship in the same program.
\
I
) ,
••
(
t ) ...
)
(
I I J \ ! l~ \
METHODS In the year in which ueonn's sequence of training was changed, 12 residents (6 PGY-3 residents who had devoted PGY-2 to outpatient work, and 6 PGY-2 residents in their first clinical rotation following medical internship) spent the year on the inpatient service. Evaluations of the inpatient experiences of PGY-3 and PGY-2 resident groups were performed by the same group of supervisors using the same evaluation criteria during the same academic year. This provided an equivalence of clinical experience and supervision for both PGY resident groups. Residents received written evaluations every 3 months during their inpatient year, which provided an opportunity to assess changes in clinical skills (e.g., ability to perform a diagnostic evaluation, ability to develop a treatment plan), knowledge (e.g., appropriate therapeutic interventions matched to psychopathology), and attitudes (e.g., ability to work with staff, sense of professional identity). In addition, each evaluation form provided an opportunity for supervisors to provide narrative comments.
RESULTS Both scaled ratings and narrative comments were reviewed. Because of the extremely small sample size, no statistical analysis could be done and therefore conclusions cannot be drawn about specific factors involving the educational impact of the sequence for any single resident. The scaled ratings revealed no statistically significant differences between the PGY-3 and PGY-2 groups, but a review of the narrative comments of the supervisors suggests that when the two groups were compared, the sequence of training had an impact on resident performance in the areas of diagnostic skills, comprehension of the range of inpatient psychopathology, comprehension of the range of therapeutic interventions, and development of professional psychiatry identity. AI-
-,1
1, 1, J '\.l i I
Ii ( I I'\.I( \1 I \ 1'1
«n
'\. l i
though these data are preliminary, there is so little in the literature regarding the effect of sequencing of residents' experience on their performance that a descriptive presentation of the findings from the UConn program study is warranted. Diagnostic Skills PGY-3 residents who had spent a year doing outpatient work before their inpatient rotation seemed to have more difficulty in understanding the broad range of diagnostic criteria for psychiatric illnesses, especially for Axis I disorders. These residents were more likely to underestimate the significance of symptoms and tended to interpret illness more in line with Axis II disorders. Although there clearly was improvement by the end of the year, PGY-3 residents continued to have more diagnostic difficulties than PGY-2 residents whose initial clinical rotation in psychiatry was the inpatient rotation. Understanding the
Spectrum of Psychopathology PGY-3 residents' diagnostic problems affected the way they formulated psychopathology in their patients. Patients with major psychotic or mood disorders were often seen as having less severe pathology. When approaching psychopathology from a dynamic perspective, PGY-3 residents had more difficulty appreciating the biological and social/interpersonal aspects of psychopathology than their PGY-2 colleagues who had their inpatient training first. As with the findings in diagnostic skills, PGY-3 residents showed consistent improvement as the year progressed but still had more difficulties in this area at year's end. Understanding the Range of Therapeutic Interventions Even though the outpatient rotation included work with some severely ill indi-
viduals whose primary treatment involved medication, PGY-3 residents seemed more hesitant in the use of psychotropic medications than PGY-2 residents. PGY-3 residents also were more likely to have difficulty making rapid, directive interventions than PGY-2 residents. Supervisors noted that for PGY-3 residents on a short-term inpatient unit, providing more directive and structured interventions seemed to be at odds with the nondirective approach they had learned during the previous outpatient year. Professional Identity Development As expected, those residents who were in the inpatient rotation during PGY-2 experienced many of the psychological stresses that have been identified in the literature concerning the first year of training. Surprisingly, however, residents in the PGY-3 group also seemed to have many of the same problems in professional identity formation even though this was their second full year of psychiatry training. Several PGY-3 residents seemed to have even more difficulty with these issues than PGY-2 residents in the inpatient rotation. This was interpreted by the supervisors as the result of a professional identity formation that had solidified during the year of training in the outpatient department, but which now needed to be extensively reworked during the subsequent inpatient rotation. DISCUSSION The significance and interpretability of this preliminary report are limited because the sample is small and comes from a single program. It was decided to change the UConn program's training sequence and put the inpatient rotation in PGY-2. The supervisors were aware of this institutional training decision and were therefore not blind to the year of training of their residents. Our preliminary findings suggest, however, that the effects of training sequence require
further investigation. Although PGY-3 residents had seminars in diagnosis and psychopathology during PGY-2,it appears that the initial imprinting that occurred during the outpatient PGY-2 colored their inpatient experience. The ability of PGY-3 residents to perform in a rapid, directive, focused way on a short-term inpatient setting was limited compared with PGY-2 residents with less clinical experience. Another area worthy of further investigation is the nature of the outpatient experience. In the UConn program, the outpatient experience was weighted toward a psychodynamic approach; it is not known whether residents trained in an outpatient setting that emphasizes psychopharmacologic, cognitive, or behavioral approaches would have had the same difficulties with inpatient work as did the PGY-3 residents described in this report. It is also important to note that this report only investigated the performance of residents on an inpatient ser-
vice who had done outpatient psychotherapy first. We have no similar evaluation of the outpatient setting. It is possible that residents who began outpatient work in PGY-2 would have been shown to be better in psychotherapy than residents with an outpatient PGY-3. Further research that explores the conventional wisdom that places inpatient experience earlier in training than outpatient psychiatry rotations is needed to see if the educational benefits outweigh the impact of the psychosocial stress reported during early inpatient experiences. The lack of databased reports in the literature regarding the effects of sequence of service experiences on training indicates that there is much work to be done. Such research is necessary to provide objective data to assist training directors and academic faculty in the construction of training sequences that optimize the educational process and the formation of professional identity.
References 1. Tasman A, Kay]: Setting the stage: residency training in 1986, in Training Psychiatrists for the 90s: Issues and Recommendations,edited by Nadelson ee, Robinowitz CB. Washington, DC, American Psychiatric Press,1987,pp 49-54 2. Uston Eli: Residency training in adult inpatient psychiatry, in Teaching Psychiatry and Behavioral Science, edited by Yager ]. New York, Grune &: Stratton, 1982, pp 25>-271 3. Lazare A, Eisenberg L: Psychiatric residency training: an outpatient first year program. Seminars in Psychiatry 1970;2:201-210
4. Halleck5L, Woods5M:Emotionalproblems of psychiatricresidents. Psychiatry 1962;25:339-346 5. Ungerleider]T: That most difficult year. Am] Psychiatry 1965; 122:542-545 6. Merklin L ]r, Uttle RB: Beginning psychiatry syndrome. Am] Psychiatry 1967;124:193-197 7. Worby CM: The first-year psychiatric resident and the professional identity crisis. Mental Hygiene 1970;54:374-377 8. Pasnau RO, Bayley 5]: Personallty changes in the first year of psychiatric residency training. Am ] Psychiatry1971; 128:79-84
