Psychiatric Residency Training, Managed Care, and Contemporary Clinical Practice

Although a few departments have restructured their residency programs to address current practice realities, the modal approach to training in psychiatry can be described as follows. Didactic material related to health care economics and managed care is limited to a handful of lectures scattered throughout the residency experience. Residents receive some early exposure, without much preparation, to the most intrusive aspect of managed care, which is the utilization management of inpatient services. Residents tend to gain minimal experience with the modalities favored by managed care, such as brief treatment, intensive outpatient care, and ambulatory detoxification. Because managed care organizations exclude trainees from their panels, many residents do not have the opportunity to work in outpatient settings where the care is managed and time-sensitive treatment approaches predominate.

Of considerable concern is that residents' supervisors often present only negative views of managed care rather than a balanced discussion of the strengths and weaknesses of both managed care and traditional approaches to treatment. There appear to be few faculty role models who have embraced the changing assumptions about practice patterns and who are demonstrating adaptive and satisfying approaches to working in the current health care environment.

The result is that many residents leave training largely unprepared for the realities and demands of the health care marketplace, encountering what Gabbard (5) has referred to as "the big chill." Citing the gulf between current approaches to training and practice realities, Yager and colleagues (6) have gone so far as to accuse academic psychiatry of "pedagogic malfeasance." Given the complex nature of academic settings, keeping pace with changes in the field has been a daunting challenge for most departments, including our own.

Although training programs seem to have made little accommodation to recent changes in the field, the need to make the clinical aspects of residency education more relevant has not gone unnoticed (7). Many professionals have offered recommendations on residency training (5,6,7,8,9,10,11,12,13,14,15,16,17). To further develop this work, we have integrated their suggestions and combined them with our own experience (18) to outline new directions for residency education in relation to managed care and contemporary clinical practice. This effort is similar to other recent initiatives to define the training objectives, content, and teaching strategies for specific areas of psychiatric residency education such as psychotherapy (19), psychopharmacology (20), community psychiatry (21), consultation-liaison psychiatry (22), and child psychiatry (23).

Over the past decade, some very talented individuals have tackled the issue of what we must do to ensure that residents are provided with the necessary skills to thrive after completing their training. The truly puzzling question is not what academic psychiatry should do but rather why it has taken so few steps in these directions (27). In a series of case studies of academic psychiatry and managed care, Meyer (25) identified only one department that, in his view, had transformed its clinical, training, and research programs broadly and quickly enough to respond adequately to changes in the health care environment.

Numerous causes for the slow process of change have been suggested. On the surface, it appears that many psychiatrists in academic medical centers continue to question the permanence of changes in the field. Perhaps encouraged by the recent backlash against managed care, many hope that the field will revert to traditional assumptions and practices. Alternatively, Sabin (28) has suggested that the absence of a timely response to changes is due to the "moral myopia" of academic psychiatry. He defines this myopia as difficulty in attending to the needs of populations while simultaneously maintaining the traditional and very important emphasis on the needs of individuals.

Monica Oss, the editor of Open Minds, has suggested that many provider organizations change only when forced to do so (personal communication, May 1998), leading to the hypothesis that academic psychiatry and academic psychiatrists may have been somewhat isolated from the contingencies of the marketplace. Although few academic departments have escaped the economic pressures of managed care, many have been somewhat protected by their host universities or medical centers, which have absorbed department operating losses (29). Similarly, the principle of academic freedom and the practice of granting tenure have isolated some faculty members from the need to respond to market changes in a timely fashion.

Another dynamic that has impeded change in some departments is an underlying ambivalence about the clinical mission. Traditionally, clinical care has been one aspect of the tripartite mission of academic psychiatry and of unquestioned value given its ability to generate substantial cross-subsidies for the other missions of teaching and research. Since it can no longer generate such significant subsidies, some departments have an unresolved ambivalence, whether explicit or implicit, about the importance of a continued clinical mission. Particularly in research-oriented departments, this dynamic has lessened faculty motivation to respond to changes in the market and to modify their approaches to clinical care and clinical teaching.

The solutions proposed for moving academic psychiatry forward are complex. Levinson (30), a noted organizational consultant, has suggested that in times of change organizations and the individuals within them must grieve and accept their losses before they can effectively move forward. For most departments, reassessing and reaffirming a commitment to the clinical mission for reasons other than subsidizing research and teaching also seem essential. Recruiting new faculty and retraining selected faculty can reshape and balance perspectives within a department. Introducing contingencies that reward successful clinical endeavors is perhaps the most rapid way in which to change faculty behavior. Lastly, some departments have chosen to accept contracts to manage mental health and substance abuse care (31). This strategy undoubtedly broadens departmental perspectives on clinical care from the individual patient to the population level.

In the end, the question of how change is initiated and accomplished is as elusive for academic organizations as it is for the individuals we treat. Emotions, beliefs, and behaviors collide repeatedly with the changing environment until motivation for individual or organizational change develops. New behaviors then slowly emerge. Highly relevant and applicable to this process for academic psychiatry is the literature on changing individual behavior (32,33,34), physician behavior (35,36), and organizations as a whole (37,38,39).

Although managed care as we know it may die at the hands of legislators and the courts, the practice of psychiatry has been dramatically altered. Academic psychiatry must respond to the changes in the field. On the educational front, it must meet its obligation to prepare residents by providing the knowledge and skills they will require to thrive professionally after completing their training.

Academic organizations are complex systems. Changing one aspect, such as the educational program, will undoubtedly have some unintended or unwanted effects on other aspects of the academic enterprise. Nonetheless, the educational mission carries with it the responsibility to educate residents about current practice patterns and marketplace realities.

The recommendations outlined above suggest directions for increasing the relevance of the psychiatric residency. The next steps involve accelerating the pace with which such ideas are incorporated into department curricula and developing model curricula to further inform efforts to update education programs.

Dr. Hoge is associate professor of psychiatry and director of managed behavioral health care, Dr. Jacobs is professor of psychiatry, and Dr. Belitsky is associate clinical professor of psychiatry and director of residency training in psychiatry at Yale University School of Medicine in New Haven, Connecticut. Dr. Jacobs is also director of the Connecticut Mental Health Center. Send correspondence to Dr. Hoge at Yale University School of Medicine, 25 Park Street, Sixth Floor, New Haven, Connecticut 06519 (e-mail, [email protected]). An earlier version of this paper was presented at the Behavioral Healthcare Delivery System Integration Conference held on January 22, 1999, in Washington, D.C.