A Survey of Child and Adolescent Psychiatry Residents: Perceptions of the Ideal Training Program BERT DECH , M .D . , HOWARD ABIKOFF, PH.D.,
AND
HAROLD S. KOPLEWICZ, M.D.
Abstract. A survey instrument was developed to examine several issues relevant to training in child and adolescent psychiatry. Forty percent of the residents representing 56% of the training programs in the United States completed the questionnaires. A descriptive profile of the typical training experiences of c?ild and adolesce~t psychiatry residents is presented , as is a report of their satisfaction with each component of their ~rogram and their expectations of an ideal training program. In general, satisfaction with :esiden.c~ training. expenence~ wa~ f~und to be highly related to the amount of emphasis reportedly placed on the vanous training expencnces. The implications of the findings for training directors are discussed. J . Am. Acad. Child Adolesc. Psychiatry , 1990,29,6:946-949. Key Words: survey, training , child and adolescent psychiatry, residents. There has been a growing concern over the reduction in the number of psychiatrists who choose to train in child and adolescent psychiatry (Weissman and Bashook, 1986). With fewer medical school graduates entering general psychiatry residency programs , the "pool" of potential child and adolescent psychiatry trainees has diminished (Friedman, 1982; Brunstetter, 1984). The Graduate Medical Education Advisory Committee (GMENAC) estimated a shortage of 4,900 child psychiatrists by 1990 (GMENAC, 1980). To improve the training and recruitment process as well as to increase the attractiveness of child and adolescent psychiatry as a subspecialty, it would seem beneficial to examine child and adolescent psychiatry residents ' perceptions and attitudes regarding their training programs. The collection of such a data base could provide psychiatry educators, in general, and training directors, more specifically , with useful information regarding areas in which to focus and invest their training efforts . The authors are unaware of any systematic surveys that have been carried out to examine child and adolescent psychiatry residents' evaluations of their training experiences. With this in mind, a survey instrument was developed that assessed a number of issues relevant to training in child and adolescent psychiatry. This paper focuses on an examination of child psychiatry residents' descriptions of their residency program, their satisfa ction with various aspects of their residency , and their perceptions as to what constitutes an ideal training program. Accepted June 28, 1990. Dr . Dech is Attending Psychiatrist, Consultation-Liaison Service, Dr. Abikoff is Director of Research, and Dr . Koplewicz is Chief . Division of Child and Adolescent Psychiatry, Schneider Children's Hospital of Long Island Jewish Medical Center. Dr. Abikoff is also Associate Professor of Psychiatry, Albert Einstein College of Medicine. The authors thank Arianne Schneck, M .D., Daniel Grosz, M.D ., Peter Szeibel, M.D ., and Sandra Turner, M .D., f or their input and assistance in this project. Reprint requests to Dr. Dech, 7th Floor Tammen Hall, The Children's Hospital, 1056 East 19th Avenue, Denver, Colorado 802181088. 0890-8567/90/2906-0946$02.00/0© 1990by the American Academy of Child and Adolescent Psychiatry .
Method
Survey instrument and pro cedures . The survey questionnaire had seven sections: (l )demographic information, (2) factors influencing the respondent' s choice of child psychiatry, (3) service demands of the residency, (4) future career plans, (5) descript ion of the residency program, (6) satisfaction with variou s aspects of the program, and (7) perceptions as to what constitutes an ideal tr~ining progra?1' The findings from the final three survey sections, along WIth demographic data, are presented. The last three surve y sections consisted of the same 21 items representing different aspects of child and adolescent psychiatry residency training (e .g., inpatient experience, research, family therapy , liaison and consultation, etc . See Table 2 for a complete listing of the items). The respondents were required to provide three ratings for each of the 21 items using a 5-point rating scale, (l = none, 2 = little , 3 = moderate, 4 = much , and 5 = very much). The first rating, "Description," asked the residents to indicate how much emphasis is given to each item in their residency program. "Satisfaction," the second rating, asked how satisfied the residents are with each aspect of their training program. The third rating, " Ideal," instructed the residents to indicate how much emphasis would be given to each aspect if they were in charge of designing their ideal training program. The questionnaires were mailed to the training directors of 114 child and adole scent psychiatry residency programs in the United State s and Puerto Rico. A packet cover letter instructed the directors to distribute the questionnaires to all first- and second-year child and adolescent psychiatry residents. A letter accompanying each questionnaire asked the residents to complete the questionnaires anonymously and to return them to their training directors , who were instructed to mail all completed surveys back to the authors in an enclosed self-addressed envelope. Results
Study sample. Six hundred and ninety questionnaires were mailed in early March of 1987, corresponding to the maximum number of child and adolescent psychiatry residency
946
A SURVEY OF RESIDENTS TABLE
1. Questionnaire Response Rates for Programs
and Individuals
Programs surveyed Program response rate Questionnaires sent (available residency positions) Estimated positions filleda Questionnaires returneda b
Overall
Programs with :5 6 Positions
Programs with > 6 Positions
114
84
30
64 (56%)
44 (52%)
20 (66%)
690
397
293
552
318
234
223 (40%)
114 (36%)
109 (46%)
Estimates based on 80% of available positions actually filled. Return rate based on number of estimated positions filled.
positions available as indicated in the 1985-86 Directory of Residents Training Programs (American Medical Association). The programs' available training slots ranged from three to 22 positions. A total of 223 questionnaires were returned from 64 (56%) of the residency programs. Responses ranged from one to 18 completed questionnaires returned per program. Table 1 describes response rates for programs and individuals. It was estimated that the overall return rate represented approximately 40% of the child psychiatry residency positions filled in the country. This estimate is based on the assumption that no more than 80% of the available child and adolescent psychiatry residency positions are filled, even in the best years (Brunstetter, 1984) (corroborated by the American Academy of Child and Adolescent Psychiatry statistics for 1985, personal communication, July 1987). The mean age of the sample was 33 years (range = 26 to 50 years). One hundred twenty-five (56%) of the respondents were male, 98 (44%) female. The sample's racial distribution was 82% Caucasian, 7% Asian, 5% Hispanic, and 2% black (racial information was missing for 4% of the respondents). Eighteen percent of the residents were foreign medical school graduates.
Residents' Ratings Table 2 presents the mean "Descriptive," "Satisfaction," and "Ideal" ratings for each of the 21 items. For each of the rating domains, analyses were carried out to establish which, if any, of the mean ratings were statistically different from each other. To this end, 95% confidence intervals (Cl) were calculated for each item mean (available upon request from the authors). Items were considered statistically indistinguishable if their CIs overlapped, while lack of CI overlap between items suggested that raters had made a significantly meaningful distinction. Actual program ratings. Several distinct item clusters were found. The training cluster with the significantly highest emphasis ratings was inpatient experience, outpatient experience, and diagnostic assessment. Child development was emphasized significantly more than the other aspects l.Am.Acad. Child Adolesc.Psychiatry, 29:6, November 1990
of training, though less than the top cluster. A cluster of statistically indistinguishable items received significantly less emphasis than the other aspects of training. This cluster consisted of pediatric neurology, cognitive therapy, group therapy, and the use of a one-way mirror and audiovisual equipment in supervision. Satisfaction ratings. The item cluster that the residents were significantly most satisfied with was inpatient and outpatient experience, diagnostic assessment, and child development. In contrast, they reported the least satisfaction with cognitive therapy, pediatric neurology, group therapy, and school consultation. As can be seen, satisfaction appears to parallel the amount of emphasis placed on the items in training. Accordingly, analyses were carried out to determine whether the residents' satisfaction with their training experiences was related to how much emphasis was placed on those experiences in their residency program. The possibility was also considered that satisfaction with training was also a function of the degree to which the emphasis in training matched the residents' ideal program (described below). Correlations were determined to examine this possibility. The Spearman rank order correlation between the satisfaction and actual emphasis ratings indicated a very high degree of association (p = 0.96, p < 0.001). In addition, a Spearman p of 0.73 (p < 0.001) between the residents' satisfaction ratings and the difference score between their actual and ideal ratings indicated that satisfaction with training was also related to how closely the actual training program matched the residents' ideal program. Ideal program ratings. The item cluster that the residents would like to see emphasized significantly more than other aspects of training is child development, diagnostic assessment, and outpatient experience. In contrast, they would place significantly less emphasis on research, cognitive therapy, and community psychiatry in their ideal program. The high correlation between the residents' actual and ideal emphasis ratings (p = 0.84, p < 0.001) indicates significant agreement regarding the relative emphasis given to actual and ideal training experiences. However, inspection of the mean ratings suggests that the residents would prefer more intensive training experiences. This can be seen by the fact that for all aspects of training, their ideal emphasis ratings were consistently higher than their actual ratings, with the exception of inpatient experience (Table 2). Therapy experience ratings. Six therapeutic approaches (items 9 to 14) were evaluated by the residents. On all three types of ratings, no satistically significant distinctions were made between psychopharmacology, analytically oriented psychotherapy, and family therapy. Additionally, the residents' ratings of emphasis, satisfaction, and preference for these three therapeutic modalities were significantly higher than the corresponding ratings they gave to behavior therapy, cognitive therapy, and group therapy. Discussion
In discussing the results of this survey, there are certain limitations that must be kept in mind. The data in this paper represent the opinions of only 40% of trainees. It is possible 947
DECH ET AL. TABLE
2. Residents' Rating of Their Training Experience Description
Experience Inpatient experience Outpatient experience Liaison/consultation School consultation Research Diagnostic assessment Child development Psychoeducational evaluation Psychopharmacology Analytically oriented psychotherapy Behavior therapy Cognitive therapy Family therapy Group therapy Academic courses Community psychiatry Pediatric neurology Use of one-way mirror or audiovisual equipment in supervision Observation of interview by senior staff Elective
Satisfaction
Ideal
X
SD
X
SD
X
SD
3.99 3.79 3.17 2.36 2.45 3.90 3.61 2.71 3.28 3.27 2.60 2.08 3.23 2.29 3.47 2.48 2.08
0.92 0.98 0.85 1.03 1.18 0.92 1.00 0.94 0.96 1.22 1.00 0.92 1.01 1.02 1.08 1.18 1.01
3.58 3.62 2.92 2.61 2.72 3.69 3.52 2.91 3.20 3.25 2.72 2.31 3.12 2.55 3.32 2.67 2.42
1.09 1.02 1.03 1.22 1.19 0.97 1.04 0.97 0.99 1.18 1.02 1.00 1.14 1.22 1.05 1.21 1.22
3.78 4.21 3.51 3.20 2.97 4.22 4.34 3.34 3.91 3.69 3.31 3.04 3.90 3.25 3.95 3.09 3.26
0.78 0.74 0.83 0.83 0.88 0.78 0.73 0.83 0.77 0.99 0.83 0.84 0.81 0.93 0.88 0.90 0.09
2.42 2.42 2.56
1.19 1.15 1.23
2.73 2.71 2.79
1.31 1.21 1.35
3.48 3.64 3.61
1.01 1.03 0.99
Note: Each rating was done on a 1 to 5 scale, with 1 = none; 2 = little; 3 = moderate; 4 = much; 5 = very much.
that the better, more organized programs are more likely to have a training director who encouraged trainees to respond, or that satisfied residents are more likely to take the time to respond than disgruntled ones. However, having anticipated this potential response bias, every effort was made to offer anonymity to both the programs and trainees. This message was conveyed in cover letters to potential respond-
provide potentially useful information regarding those aspects of training that can be improved. Among the clinical! academic experiences surveyed, pediatric neurology shows the greatest difference between the ideal and the actual programs. This discrepancy appears to represent both a lack in training (pediatric neurology is emphasized least of all the training experiences) and perhaps a perceived need by the
ents and to program directors in order to minimize any
residents for greater medical knowledge and the ability to
concerns that might arise about exposing training inadequacies. The residents' satisfaction with various aspects of their actual training programs ranged from little to high moderate. On average, they report moderate satisfaction (X = 2.98) with their residency experiences. The correlational findings suggest that the degree of satisfaction is strongly related to the emphasis given to the clinical and educational experiences in the residency programs. Therefore, it seems reasonable to conjecture that the least satisfactory training experiences (cognitive therapy, pediatric neurology, group therapy, and school consultation) could be improved for the residents if the training program provided them with more exposure to these experiences. Additional support for this notion comes from two other related findings. First, the residents' satisfaction with their training was shown to be related in large part to the similarity between their actual and ideal residency programs. Second, in the residents' ideal program, all of the surveyed training experiences except inpatient experience would receive greater emphasis than is currently provided in their actual training. (The mean emphasis rating for the actual residency programs is 2.92 versus 3.59 for the residents' ideal program.) Comparisons of the actual and ideal residency programs
make more sophisticated medical differential diagnoses. Relative to their other clinical treatment experiences, the residents would like to see substantially more emphasis placed on cognitive therapy and group therapy. Although this desired increase speaks to an interest in becoming more familiar with various therapeutic approaches, the higher ratings given to psychopharmacology, analytically oriented psychotherapy, and family therapy suggest that the residents prefer training in the more traditional, as well as biologically oriented, treatment modalities. However, the findings support the notion that the classical supervision model of listening to a trainee present progress notes of a previous session or simply describing what occurred in the therapy may be inadequate for an ideal program. Specifically, the ratings indicate that supervision that uses one-way mirrors and audiovisual equipment as well as direct observations of interviews done by senior faculty seems to be underemphasized in most programs, and an increased emphasis in these training procedures is especially preferred by the residents. Inspection of the ratings given by the residents to their research experience is also informative. Although their ideal residency program would provide a moderate emphasis on research, the residents would nevertheless prefer less em-
948
l.Am.Acad. Child Adolesc.Psychiatry, 29:6, November 1990
A SURVEY OF RESIDENTS
phasis on research than any other training component. Moreover, among the training experiences surveyed, one of the smallest increases between actual and preferred emphasis is allotted by the residents to research. Given the relatively minor emphasis reportedly placed on research in the actual residency programs, it appears that if the field of child and adolescent psychiatry is intent on producing psychiatrists who are clinician/scientists , then training directors will have to devise ways in which to offer increased research exposure during the residency training. The ideal program that the residents would create suggests a mix of clinical and academic training. Outpatient experiences, diagnostic assessments, child development, psychopharmacology, family therapy, and academic courses are the most important components that would be emphasized. In fact, no aspect of training seems insignificant to the residents surveyed; as noted previously, they would prefer that an increased emphasis be given to all aspects of their residency training. It needs to be kept in mind that, although the survey findings may be helpful to directors of training programs , there are additional factors that play a role in structuring a residency program. Besides trainee perceptions and satisfaction, faculty interest and expertise , available funding and patient population , as well as hospital and community needs are important factors that may also influence the content of a training program . To the extent that program directors take into account the data from this survey with regard to program development ,
l .Am.Acad. Child Adolesc, Psy chiatry, 29:6, November 1990
the survey data suggest that child and adolescent psychiatry training programs are doing a fair job across the nation , as attested by the residents' moderate satisfaction ratings of their training experiences. However, in response to a request for essentially more of everything , the dilemma for training directors is to manage to keep everything and add even more into a 2-year program. The solution to this dilemma is not readily apparent. Possible strategies to consider include expanding child and adolescent psychiatry training programs to 3 years. Unfortunately, this is likely to make child and adolescent psychiatry trainee recruitment even more difficult. An alternative possibility is for training directors to encourage residents to enter a super subspecialty residency in order to obtain additional training in research, consultation-liaison, forensics, psychopharmacology, addictionology, or a variety of other options.
References Brunstelter, R. (1984), Recruitment issues in child psychiatry . Psychiatric Education, 8:3-15 . Friedman, S. B. (1982), If you had three wishes-fantasies related to child psychiatry training. Am. J. Dis. Child, 136:942-944. Graduate Medical Education National Advisory Committee ( 1980, September 30), Summary report ofthe Graduate Medical Education National Advisory Committee. Report to the Secretary, Department of Health and Human Services, Vol. I, Washington, DC: NSDHHS. Weissman, S. H. & Bashook, P. G. (1986), A view of the prospective child psychiatrist. Am . J . Psychiatry, 143:722-727.
949
AND
HAROLD S. KOPLEWICZ, M.D.
Abstract. A survey instrument was developed to examine several issues relevant to training in child and adolescent psychiatry. Forty percent of the residents representing 56% of the training programs in the United States completed the questionnaires. A descriptive profile of the typical training experiences of c?ild and adolesce~t psychiatry residents is presented , as is a report of their satisfaction with each component of their ~rogram and their expectations of an ideal training program. In general, satisfaction with :esiden.c~ training. expenence~ wa~ f~und to be highly related to the amount of emphasis reportedly placed on the vanous training expencnces. The implications of the findings for training directors are discussed. J . Am. Acad. Child Adolesc. Psychiatry , 1990,29,6:946-949. Key Words: survey, training , child and adolescent psychiatry, residents. There has been a growing concern over the reduction in the number of psychiatrists who choose to train in child and adolescent psychiatry (Weissman and Bashook, 1986). With fewer medical school graduates entering general psychiatry residency programs , the "pool" of potential child and adolescent psychiatry trainees has diminished (Friedman, 1982; Brunstetter, 1984). The Graduate Medical Education Advisory Committee (GMENAC) estimated a shortage of 4,900 child psychiatrists by 1990 (GMENAC, 1980). To improve the training and recruitment process as well as to increase the attractiveness of child and adolescent psychiatry as a subspecialty, it would seem beneficial to examine child and adolescent psychiatry residents ' perceptions and attitudes regarding their training programs. The collection of such a data base could provide psychiatry educators, in general, and training directors, more specifically , with useful information regarding areas in which to focus and invest their training efforts . The authors are unaware of any systematic surveys that have been carried out to examine child and adolescent psychiatry residents' evaluations of their training experiences. With this in mind, a survey instrument was developed that assessed a number of issues relevant to training in child and adolescent psychiatry. This paper focuses on an examination of child psychiatry residents' descriptions of their residency program, their satisfa ction with various aspects of their residency , and their perceptions as to what constitutes an ideal training program. Accepted June 28, 1990. Dr . Dech is Attending Psychiatrist, Consultation-Liaison Service, Dr. Abikoff is Director of Research, and Dr . Koplewicz is Chief . Division of Child and Adolescent Psychiatry, Schneider Children's Hospital of Long Island Jewish Medical Center. Dr. Abikoff is also Associate Professor of Psychiatry, Albert Einstein College of Medicine. The authors thank Arianne Schneck, M .D., Daniel Grosz, M.D ., Peter Szeibel, M.D ., and Sandra Turner, M .D., f or their input and assistance in this project. Reprint requests to Dr. Dech, 7th Floor Tammen Hall, The Children's Hospital, 1056 East 19th Avenue, Denver, Colorado 802181088. 0890-8567/90/2906-0946$02.00/0© 1990by the American Academy of Child and Adolescent Psychiatry .
Method
Survey instrument and pro cedures . The survey questionnaire had seven sections: (l )demographic information, (2) factors influencing the respondent' s choice of child psychiatry, (3) service demands of the residency, (4) future career plans, (5) descript ion of the residency program, (6) satisfaction with variou s aspects of the program, and (7) perceptions as to what constitutes an ideal tr~ining progra?1' The findings from the final three survey sections, along WIth demographic data, are presented. The last three surve y sections consisted of the same 21 items representing different aspects of child and adolescent psychiatry residency training (e .g., inpatient experience, research, family therapy , liaison and consultation, etc . See Table 2 for a complete listing of the items). The respondents were required to provide three ratings for each of the 21 items using a 5-point rating scale, (l = none, 2 = little , 3 = moderate, 4 = much , and 5 = very much). The first rating, "Description," asked the residents to indicate how much emphasis is given to each item in their residency program. "Satisfaction," the second rating, asked how satisfied the residents are with each aspect of their training program. The third rating, " Ideal," instructed the residents to indicate how much emphasis would be given to each aspect if they were in charge of designing their ideal training program. The questionnaires were mailed to the training directors of 114 child and adole scent psychiatry residency programs in the United State s and Puerto Rico. A packet cover letter instructed the directors to distribute the questionnaires to all first- and second-year child and adolescent psychiatry residents. A letter accompanying each questionnaire asked the residents to complete the questionnaires anonymously and to return them to their training directors , who were instructed to mail all completed surveys back to the authors in an enclosed self-addressed envelope. Results
Study sample. Six hundred and ninety questionnaires were mailed in early March of 1987, corresponding to the maximum number of child and adolescent psychiatry residency
946
A SURVEY OF RESIDENTS TABLE
1. Questionnaire Response Rates for Programs
and Individuals
Programs surveyed Program response rate Questionnaires sent (available residency positions) Estimated positions filleda Questionnaires returneda b
Overall
Programs with :5 6 Positions
Programs with > 6 Positions
114
84
30
64 (56%)
44 (52%)
20 (66%)
690
397
293
552
318
234
223 (40%)
114 (36%)
109 (46%)
Estimates based on 80% of available positions actually filled. Return rate based on number of estimated positions filled.
positions available as indicated in the 1985-86 Directory of Residents Training Programs (American Medical Association). The programs' available training slots ranged from three to 22 positions. A total of 223 questionnaires were returned from 64 (56%) of the residency programs. Responses ranged from one to 18 completed questionnaires returned per program. Table 1 describes response rates for programs and individuals. It was estimated that the overall return rate represented approximately 40% of the child psychiatry residency positions filled in the country. This estimate is based on the assumption that no more than 80% of the available child and adolescent psychiatry residency positions are filled, even in the best years (Brunstetter, 1984) (corroborated by the American Academy of Child and Adolescent Psychiatry statistics for 1985, personal communication, July 1987). The mean age of the sample was 33 years (range = 26 to 50 years). One hundred twenty-five (56%) of the respondents were male, 98 (44%) female. The sample's racial distribution was 82% Caucasian, 7% Asian, 5% Hispanic, and 2% black (racial information was missing for 4% of the respondents). Eighteen percent of the residents were foreign medical school graduates.
Residents' Ratings Table 2 presents the mean "Descriptive," "Satisfaction," and "Ideal" ratings for each of the 21 items. For each of the rating domains, analyses were carried out to establish which, if any, of the mean ratings were statistically different from each other. To this end, 95% confidence intervals (Cl) were calculated for each item mean (available upon request from the authors). Items were considered statistically indistinguishable if their CIs overlapped, while lack of CI overlap between items suggested that raters had made a significantly meaningful distinction. Actual program ratings. Several distinct item clusters were found. The training cluster with the significantly highest emphasis ratings was inpatient experience, outpatient experience, and diagnostic assessment. Child development was emphasized significantly more than the other aspects l.Am.Acad. Child Adolesc.Psychiatry, 29:6, November 1990
of training, though less than the top cluster. A cluster of statistically indistinguishable items received significantly less emphasis than the other aspects of training. This cluster consisted of pediatric neurology, cognitive therapy, group therapy, and the use of a one-way mirror and audiovisual equipment in supervision. Satisfaction ratings. The item cluster that the residents were significantly most satisfied with was inpatient and outpatient experience, diagnostic assessment, and child development. In contrast, they reported the least satisfaction with cognitive therapy, pediatric neurology, group therapy, and school consultation. As can be seen, satisfaction appears to parallel the amount of emphasis placed on the items in training. Accordingly, analyses were carried out to determine whether the residents' satisfaction with their training experiences was related to how much emphasis was placed on those experiences in their residency program. The possibility was also considered that satisfaction with training was also a function of the degree to which the emphasis in training matched the residents' ideal program (described below). Correlations were determined to examine this possibility. The Spearman rank order correlation between the satisfaction and actual emphasis ratings indicated a very high degree of association (p = 0.96, p < 0.001). In addition, a Spearman p of 0.73 (p < 0.001) between the residents' satisfaction ratings and the difference score between their actual and ideal ratings indicated that satisfaction with training was also related to how closely the actual training program matched the residents' ideal program. Ideal program ratings. The item cluster that the residents would like to see emphasized significantly more than other aspects of training is child development, diagnostic assessment, and outpatient experience. In contrast, they would place significantly less emphasis on research, cognitive therapy, and community psychiatry in their ideal program. The high correlation between the residents' actual and ideal emphasis ratings (p = 0.84, p < 0.001) indicates significant agreement regarding the relative emphasis given to actual and ideal training experiences. However, inspection of the mean ratings suggests that the residents would prefer more intensive training experiences. This can be seen by the fact that for all aspects of training, their ideal emphasis ratings were consistently higher than their actual ratings, with the exception of inpatient experience (Table 2). Therapy experience ratings. Six therapeutic approaches (items 9 to 14) were evaluated by the residents. On all three types of ratings, no satistically significant distinctions were made between psychopharmacology, analytically oriented psychotherapy, and family therapy. Additionally, the residents' ratings of emphasis, satisfaction, and preference for these three therapeutic modalities were significantly higher than the corresponding ratings they gave to behavior therapy, cognitive therapy, and group therapy. Discussion
In discussing the results of this survey, there are certain limitations that must be kept in mind. The data in this paper represent the opinions of only 40% of trainees. It is possible 947
DECH ET AL. TABLE
2. Residents' Rating of Their Training Experience Description
Experience Inpatient experience Outpatient experience Liaison/consultation School consultation Research Diagnostic assessment Child development Psychoeducational evaluation Psychopharmacology Analytically oriented psychotherapy Behavior therapy Cognitive therapy Family therapy Group therapy Academic courses Community psychiatry Pediatric neurology Use of one-way mirror or audiovisual equipment in supervision Observation of interview by senior staff Elective
Satisfaction
Ideal
X
SD
X
SD
X
SD
3.99 3.79 3.17 2.36 2.45 3.90 3.61 2.71 3.28 3.27 2.60 2.08 3.23 2.29 3.47 2.48 2.08
0.92 0.98 0.85 1.03 1.18 0.92 1.00 0.94 0.96 1.22 1.00 0.92 1.01 1.02 1.08 1.18 1.01
3.58 3.62 2.92 2.61 2.72 3.69 3.52 2.91 3.20 3.25 2.72 2.31 3.12 2.55 3.32 2.67 2.42
1.09 1.02 1.03 1.22 1.19 0.97 1.04 0.97 0.99 1.18 1.02 1.00 1.14 1.22 1.05 1.21 1.22
3.78 4.21 3.51 3.20 2.97 4.22 4.34 3.34 3.91 3.69 3.31 3.04 3.90 3.25 3.95 3.09 3.26
0.78 0.74 0.83 0.83 0.88 0.78 0.73 0.83 0.77 0.99 0.83 0.84 0.81 0.93 0.88 0.90 0.09
2.42 2.42 2.56
1.19 1.15 1.23
2.73 2.71 2.79
1.31 1.21 1.35
3.48 3.64 3.61
1.01 1.03 0.99
Note: Each rating was done on a 1 to 5 scale, with 1 = none; 2 = little; 3 = moderate; 4 = much; 5 = very much.
that the better, more organized programs are more likely to have a training director who encouraged trainees to respond, or that satisfied residents are more likely to take the time to respond than disgruntled ones. However, having anticipated this potential response bias, every effort was made to offer anonymity to both the programs and trainees. This message was conveyed in cover letters to potential respond-
provide potentially useful information regarding those aspects of training that can be improved. Among the clinical! academic experiences surveyed, pediatric neurology shows the greatest difference between the ideal and the actual programs. This discrepancy appears to represent both a lack in training (pediatric neurology is emphasized least of all the training experiences) and perhaps a perceived need by the
ents and to program directors in order to minimize any
residents for greater medical knowledge and the ability to
concerns that might arise about exposing training inadequacies. The residents' satisfaction with various aspects of their actual training programs ranged from little to high moderate. On average, they report moderate satisfaction (X = 2.98) with their residency experiences. The correlational findings suggest that the degree of satisfaction is strongly related to the emphasis given to the clinical and educational experiences in the residency programs. Therefore, it seems reasonable to conjecture that the least satisfactory training experiences (cognitive therapy, pediatric neurology, group therapy, and school consultation) could be improved for the residents if the training program provided them with more exposure to these experiences. Additional support for this notion comes from two other related findings. First, the residents' satisfaction with their training was shown to be related in large part to the similarity between their actual and ideal residency programs. Second, in the residents' ideal program, all of the surveyed training experiences except inpatient experience would receive greater emphasis than is currently provided in their actual training. (The mean emphasis rating for the actual residency programs is 2.92 versus 3.59 for the residents' ideal program.) Comparisons of the actual and ideal residency programs
make more sophisticated medical differential diagnoses. Relative to their other clinical treatment experiences, the residents would like to see substantially more emphasis placed on cognitive therapy and group therapy. Although this desired increase speaks to an interest in becoming more familiar with various therapeutic approaches, the higher ratings given to psychopharmacology, analytically oriented psychotherapy, and family therapy suggest that the residents prefer training in the more traditional, as well as biologically oriented, treatment modalities. However, the findings support the notion that the classical supervision model of listening to a trainee present progress notes of a previous session or simply describing what occurred in the therapy may be inadequate for an ideal program. Specifically, the ratings indicate that supervision that uses one-way mirrors and audiovisual equipment as well as direct observations of interviews done by senior faculty seems to be underemphasized in most programs, and an increased emphasis in these training procedures is especially preferred by the residents. Inspection of the ratings given by the residents to their research experience is also informative. Although their ideal residency program would provide a moderate emphasis on research, the residents would nevertheless prefer less em-
948
l.Am.Acad. Child Adolesc.Psychiatry, 29:6, November 1990
A SURVEY OF RESIDENTS
phasis on research than any other training component. Moreover, among the training experiences surveyed, one of the smallest increases between actual and preferred emphasis is allotted by the residents to research. Given the relatively minor emphasis reportedly placed on research in the actual residency programs, it appears that if the field of child and adolescent psychiatry is intent on producing psychiatrists who are clinician/scientists , then training directors will have to devise ways in which to offer increased research exposure during the residency training. The ideal program that the residents would create suggests a mix of clinical and academic training. Outpatient experiences, diagnostic assessments, child development, psychopharmacology, family therapy, and academic courses are the most important components that would be emphasized. In fact, no aspect of training seems insignificant to the residents surveyed; as noted previously, they would prefer that an increased emphasis be given to all aspects of their residency training. It needs to be kept in mind that, although the survey findings may be helpful to directors of training programs , there are additional factors that play a role in structuring a residency program. Besides trainee perceptions and satisfaction, faculty interest and expertise , available funding and patient population , as well as hospital and community needs are important factors that may also influence the content of a training program . To the extent that program directors take into account the data from this survey with regard to program development ,
l .Am.Acad. Child Adolesc, Psy chiatry, 29:6, November 1990
the survey data suggest that child and adolescent psychiatry training programs are doing a fair job across the nation , as attested by the residents' moderate satisfaction ratings of their training experiences. However, in response to a request for essentially more of everything , the dilemma for training directors is to manage to keep everything and add even more into a 2-year program. The solution to this dilemma is not readily apparent. Possible strategies to consider include expanding child and adolescent psychiatry training programs to 3 years. Unfortunately, this is likely to make child and adolescent psychiatry trainee recruitment even more difficult. An alternative possibility is for training directors to encourage residents to enter a super subspecialty residency in order to obtain additional training in research, consultation-liaison, forensics, psychopharmacology, addictionology, or a variety of other options.
References Brunstelter, R. (1984), Recruitment issues in child psychiatry . Psychiatric Education, 8:3-15 . Friedman, S. B. (1982), If you had three wishes-fantasies related to child psychiatry training. Am. J. Dis. Child, 136:942-944. Graduate Medical Education National Advisory Committee ( 1980, September 30), Summary report ofthe Graduate Medical Education National Advisory Committee. Report to the Secretary, Department of Health and Human Services, Vol. I, Washington, DC: NSDHHS. Weissman, S. H. & Bashook, P. G. (1986), A view of the prospective child psychiatrist. Am . J . Psychiatry, 143:722-727.
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