Programs Fail to Teach Coordination of Services

The public-sector psychiatrist must be an expert not only in individual patient care, but in the creation, management, and evaluation of whole systems of care.

So say thought leaders in psychiatric education and public psychiatry queried for a report on public-sector training that appeared in the February Psychiatric Services.

Yet the same report shows that directors at training programs around the country— including those that are invested in public-sector training—consistently downplay the importance of tasks that involve integration of services across institutions with different missions.

“We really owe it to our patients to try to make sure the educational system provides our trainees the opportunity to evaluate whole systems of care, so they will be in a better position to make decisions for our patients,” said Carol Bernstein, M.D., a lead author of the Psychiatric Services report and the residency training director at New York University School of Medicine.

But Bernstein said the current emphasis on training in“ competencies” has naturally tended to emphasize competency in individual care of patients. “When it comes to leading the charge around health care system development, that requires another set of competencies,” she said.

So adequate training in systems management will require leadership and initiative from directors who care about public-sector psychiatry. “The job we have as training directors is so complicated and so determined by multiple requirements,” she said. “Unless you are a well-resourced program with strong leadership, your program ends up being driven by regulatory agencies.”

Bernstein and colleagues conducted indepth interviews with 10 leaders in psychiatric education and practice who were knowledgeable and concerned about public-sector care. Those thought leaders identified 16 tasks (see box).

Most of the tasks could be grouped into one of two categories: coordination across social-service systems (for example, incorporating psychiatric intervention into psychosocial rehabilitation and interacting with staff of supportive housing programs to care for patients) and integration across institutions with different missions (for example, determining whether the behavioral problems of a prisoner stem from an underlying psychiatric disorder and providing continuing treatment in nonpsychiatric settings, such as prisons or shelters).

Directors of all general psychiatry residency programs in the United States were then surveyed to determine how they rate the importance of these tasks for delivery of care and how their training program prepares residents to perform each task. Possible scores ranged from 1 to 10, with higher scores indicating higher priority. A total of 114 of 150 residency directors (76 percent) responded to the survey.

Slightly more than half of the program directors said their programs placed above-average emphasis on public-sector care.

Yet tasks entailing integration of services across institutions with different missions were consistently rated least important, preparation to perform them was least likely to be required, and, when required, the tasks were addressed through less-intensive modalities.

But Bernstein and colleagues emphasized the importance of such training to effective public-sector leadership, citing the fact that there are three times as many people with mental illness in jails and prisons as in psychiatric institutions and that 40 percent of people with mental illness have had some involvement with the criminal justice systems.

“Acknowledging these dynamics, the recent report of the New Freedom Commission on Mental Health recommended the coordination of a broad array of services and attention to the interaction of mental health, employment, housing, and protection from unjust incarceration,” Bernstein and colleagues wrote.

So, how well are training programs preparing psychiatrists for leadership in the public sector?

“It depends on the structure of the program,” Bernstein told Psychiatric News. “If it has public-sector patients in the program, the residents will learn something more or less, depending on the scope of the program. Most programs do have Medicare and Medicaid patients, so most residents get some exposure.

“But how much they get to look at the entire system and consider ways to create other systems is a different story,” she said.

“A Survey of Psychiatric Residency Directors on Current Priorities and Preparation for Public Sector Care” is posted at<http://psychservices.psychiatryonline.org/cgi/content/full/57/2/238>.▪