Training the Psychiatrist of the Future

The essential importance of the doctor-patient relationship and the need for trainees to develop their rapport-building, history-taking, and collaboration skills will be ever more important in the future collaborative and technology-driven health care environment. The psychiatrist of the future will likely have less regular face-to-face contact with patients (like our colleagues in other medical specialties), making the ability to develop an effective therapeutic alliance for assessment and treatment even more important. We will have to do more with less.

Training programs will need to focus intensively on these skills and help trainees adapt the essential elements to new settings—for example, communicating with patients while accessing electronic medical records, telepsychiatry, and other forms of telephonic or Internet-based contact with patients and other clinicians, and team-based care such as Assertive Community Treatment.

Psychiatry encompasses a broad range of illnesses and a particularly broad range of treatments. We practice in a variety of care levels and provide treatment in the form of psychopharmacology, neuromodulation, psychotherapy, and other psychosocial treatments, including individual, family, and group. Our work has a broader social context, not infrequently involving the legal and educational systems and the social safety net. There will always be a diversity of treatments and approaches in our field, and maintaining the psychiatrist’s familiarity with the full range of treatments is a challenge for training programs. The tension between the need to provide generalists to take care of many and subspecialists to advance knowledge and provide expertise on specific problems will continue and increase. We will need to support both general and subspecialty training as psychiatric medicine continues to diversify.

Training programs will need to balance training psychiatrists who will practice in traditional roles, such as general psychiatry outpatient provider, with fellowship training for subspecialty experts, as well as potential new roles like clinical neuroscientist and behavioral health specialist integrated with primary care practice.

The momentum for patient-centered care, the medical home, and integration of behavioral health with primary care creates a new role for psychiatrists. Many are doing this now, but the roles are evolving as the systems are changing. We do know that this role, which will expand in the coming years, involves increased knowledge and comfort with primary care medicine, understanding of chronic illness and how people adapt, a population-based approach, as well as strong skills in interpersonal communication and collaboration and knowledge about systems of care.

A number of centers have an established track record of training their medical students and residents in such knowledge, skills, and attitudes. The rest will need to find the best rotation venues, didactics, faculty mentoring, and other training opportunities to make this happen.

The neuroscience explosion and its application in psychiatry have led to advances in our field that are not always captured in residency training. Many outstanding training programs do not have adequate access to neuroscience faculty members with sufficient time to teach and mentor. Recent discussions about the role of DSM-5 and the Research Domain Criteria being developed by the National Institute of Mental Health have helped bring awareness to the exciting developments in this area.

The ACGME Psychiatry Milestones, set for implementation in July 2014, include an ambitious set of developmental expectations for residents in this area.

There is clearly an appetite for learning about neuroscience and an increasing requirement for providing it. This will become increasingly important as the gap between neuroscience knowledge and psychiatric practice closes.

A nationally developed, shared, and disseminated set of resources to support improved neuroscience education would help to meet these goals. The American Association of Directors of Psychiatric Residency Training’s Neuroscience Education Initiative is taking on this challenge and is supported by our APA Council on Medical Education and Lifelong Learning. Grant funding may be required to achieve this goal.

The increased awareness that errors reside in systems and that outcomes are determined by processes as much as individuals provides an extraordinary opportunity to improve care. But this will only occur if we learn how to effectively and efficiently study our systems and change them appropriately. Quality improvement has traditionally been an afterthought in medical school and residency training, regarded as a necessary but “back office” function. However, the transformation of the health care system has catalyzed greater attention to this area, and regulatory requirements from the ACGME, at the institutional and program levels, buttress the need to make it a more central aspect of training. In order for this to happen, however, progress in metrics and measures of care quality and outcomes will be required.

Training programs need to enliven and invigorate this aspect of the curriculum and help trainees be part of genuine efforts at self-study and quality improvement. Programs that already have made robust commitments to quality improvement report both improved system functioning and great enthusiasm from trainees.

The psychiatrists of the future will certainly need to know how to connect with and relate to others, and they will also need experience in the breadth of assessments and treatments our field will have to offer. To prepare them for the next 40 to 50 years, our junior colleagues will also need training in integration with primary care practice, application of clinical neuroscience, and an appreciation for systems of care and quality improvement. As the health care system changes, so must our training programs to effectively prepare the next generations of psychiatrists for the future. ■