Acad Psychiatry (2014) 38:253–254 DOI 10.1007/s40596-014-0096-9

IN DEPTH ARTICLE: COMMENTARY

Introduction and Commentary on the Psychiatry Milestones Christopher R. Thomas

Received: 17 December 2013 / Accepted: 6 March 2014 / Published online: 25 March 2014 # Academic Psychiatry 2014

Abstract Objective The Psychiatry Milestones are a major change in the accreditation of residency training and evaluation of residents and programs. This introduction provides an overview of the papers in this issue describing the Psychiatry Milestones and a commentary on the process of their development. Methods The author describes the challenges and experiences in creating the Psychiatry Milestones as a member of the Working Group and Advisory Group. Results While there were many potential obstacles in development, the Psychiatry Milestones were created due to the efforts of all those involved. Conclusion The inclusive and participatory process was successful and serves as a model for the implementation and further development of the Psychiatry Milestones. Keywords Milestone . Competency . Accreditation “…if I were asked to name the most needed of all reforms in the spirit of education, I should say: Cease conceiving of education as mere preparation for later life, and make it the full meaning of the present life.” John Dewey [1]. This issue of Academic Psychiatry contains articles providing a detailed description of the Psychiatry Milestones and their implications for residency training in our field as we transition to the next accreditation system. There is an overview article that describes the major features of the Psychiatry Milestones and their development, papers that focus on the six Core Competencies, articles focusing on Milestones for

C. R. Thomas (*) University of Texas Medical Branch at Galveston, Galveston, TX, USA e-mail: [email protected]

outpatient care, neuroscience, patient safety and quality improvement, and a paper providing residents’ perspective on the Milestones. The authors are all members of the Psychiatry Milestones Working Group, with one exception (Dr. Heather Schultz is the current resident member of the Psychiatry Review Committee). These articles provide a valuable resource as our training programs move forward in implementing the Psychiatry Milestones. Perhaps as important in understanding the Psychiatry Milestones as the details of their development, is a description of the experience of the entire process. This article presents that perspective from the beginning through their completion. As the Chair of the Psychiatry Review Committee, I knew that the ACGME had mandated that all specialties develop Milestones as the next phase in implementing the Core Competencies, but I had no idea as to how that could be accomplished. In addition, there was a deadline of only 2 years in which to do this. The challenge of describing the essential knowledge, skill, and attributes of a competent psychiatrist and the discrete steps in achieving that goal from the start of residency to completion was overwhelming. It became incomprehensible to think that such a set of Milestones would be generally agreed on by a professional community, let alone its program directors. Furthermore, we were instructed to have a maximum of 35 sub-competencies under the six Core Competencies in classifying the Milestones. I initially thought back to my own training and all the experiences and encounters with patients, their families, supervisors, and colleagues, both planned and unplanned, that had shaped me into the psychiatrist I have become. My learning and development did not end with residency, so how was it determined that I was ready to graduate? I also thought about all the residents I have worked with first as a supervisor and then a program director over the past 30 years and what took part in their learning and growth. What is essential and necessary and what is optional? What is a mere

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reflection of current thinking and what is timeless? Even if one can decide the answer to these questions, how is knowledge divided up and organized in an understandable fashion with valid stages of development? As I discussed these concerns with colleagues, I learned I was not alone in my apprehension about what we confronted. The first step in this journey was the creation of the Milestone Working Group and the Milestone Advisory Group, each composed of leaders in psychiatric education. The Working Group was charged with creating the Psychiatry Milestones and the Advisory Group to provide review guidance. All of these individuals have reached their positions of authority with strong views about psychiatry and residency training. To paraphrase the old joke “if you put two psychiatrists in a room, you’ll get at least three opinions.” This task demanded that we have as broad and diverse a view of professional thinking as possible but that increased the challenge in reaching common ground on all topics. My fears of having to break up heated arguments and failing to reach agreement on issues were unjustified. Members of the Working Group expressed strong opinions, but opposing views always received fair hearing and consensus was reached. The debates were civil and usually forged a stronger position that brought together all sides on the issue being discussed. The Advisory Group provided useful questions in clarifying the intent of the Milestones and perspective on the overall project. Members of the Working and Advisory Groups clearly recognized the importance of the task at hand and the responsibility owed to our colleagues and residents. In addition, we were not working without guidance or precedent. The Core Competencies for Psychiatric Education [2] and Core Competencies for Psychiatric Practice [3] established general objectives following the ACGME six Core Competencies. The content outlines for the ABPN exams served as a guide in organizing the Milestones. We also had the benefit from the experience of the other specialties that preceded us in developing Milestones. Another major concern was achieving involvement and participation from the community. This reform of specialty accreditation did not originate within programs or professional societies. The Core Competencies were created to address public expectations that professional training be based on demonstrated ability. The Milestones followed to establish outcome-based assessment of training. This coincided with the implementation of the Duty Hour Requirements in response to public demands. Added to the increasing pressures on program directors to deal with the clinical demands on faculty members and growing administrative burden, any change could easily be perceived as another imposition taking away time away from teaching residents. I recalled the concerns and questions raised when the Clinical Skills Verification Exams were introduced in training by the ABPN, which are also a competency assessment measure. In light of these

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concerns, the Milestone Working Group decided that the process had to be as transparent and inclusive as possible to assure stakeholder involvement and participation. A series of surveys, presentations, and workshops were planned to assure that those involved in residency training would be aware and have a chance to question and comment on the Milestones. I was pleased that the response was not one of outright rejection, but an open and thoughtful attitude. Many changes to the Milestones came from individual and group comments and questions. A good example of the contribution made by training programs was the intensive pilot of the Milestones. The Working Group had hoped to have ten to fifteen programs participate, but nineteen participated in the alpha test. Recognizing that many of the pilot programs might be at the annual meeting, the American Association of Directors of Psychiatric Residency Training Executive Council quickly arranged a special session for the Working Group and the pilot program directors and coordinators. I asked three times during the discussion if the Milestones were impractical or impossible and not one objection was raised. Instead, thoughtful suggestions on how to make the process feasible and tips from their experience were given in response. When asked if there were unnecessary Milestones, the pilot participants answered that they identified areas that needed better attention in their programs. The Milestones are not perfect and this is only the starting point in their further development. They can only be improved through their use and review to refine the goals of residency training and improve our assessments. Several years of data collection will be needed to identify issues and make revisions. We reached this stage through the hard work and dedication of all those involved. It has been a rare opportunity and privilege to be part of this process and to work with leaders in psychiatric education. Based on what has been accomplished, I have every confidence that the Psychiatry Milestones can fulfill the promise of improving residency training. Disclosures The corresponding author states that there is no conflict of interest.

References 1. The collected works of John Dewey, 1882–1953, ed. by Jo Ann Boydston (Carbondale and Edwardsville: Southern Illinois University Press, 1967–1991). 2. Andrews LB, Burruss JW. Core Competencies for psychiatric education: defining, teaching, and assessing resident competence. Washington, DC: American Psychiatric Publishing, Inc.; 2004. 3. Schreiber S, Kramer T, Adamowski S, editors. Core Competencies for psychiatric practice: what clinicians need to know. Washington, DC: American Psychiatric Publishing, Inc.; 2003.

Introduction and commentary on the psychiatry milestones.

The Psychiatry Milestones are a major change in the accreditation of residency training and evaluation of residents and programs. This introduction pr...
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