Acad Psychiatry DOI 10.1007/s40596-014-0248-y
COLUMN: "DOWN TO EARTH" ACADEMIC SKILLS
Mentorship for Residents in Psychiatry: a Competency-based Medical Education Perspective with Career Counseling Tools Jordan Cohen & Aliya Kassam
Received: 11 June 2014 / Accepted: 22 October 2014 # Academic Psychiatry 2014
The purpose of this article is to provide some practical ideas to help program directors develop, navigate, and execute the process of establishing a mentorship program during psychiatry residency. An evaluation of this mentorship program with respect to mentee and mentor satisfaction is beyond the scope of this article. The comments are intended to provide guidance, but are not meant to be a rigid recipe. The program was developed by a psychiatry postgraduate residency program director (Dr. Jordan Cohen) in collaboration with an ad hoc resident committee on mentoring. While there is no formal evaluation of resident performance during the mentorship program, the program is competency based in that the mentor provides formative evaluation to ensure the resident achieves competence in addressing patient expectations, is held socially responsible, and pursues professional development areas that are key to career growth ensuring readiness for practice. This mentoring process is reflective, and thus, the resident learns from this process which involves nonjudgmental/supportive feedback from the mentor.
Competency-based Medical Education (CBME) and Mentorship The Royal College of Physicians and Surgeons of Canada (RCPSC) CanMEDS roles framework is used as the basis for developing medical curricula and measurement tools to assess resident physicians (RPs) throughout their training programs [1]. This framework situates the medical expert role centrally, which integrates six other non-medical expert roles (communicator, collaborator, manager, health advocate, J. Cohen : A. Kassam (*) University of Calgary, Calgary, AB, Canada e-mail: [email protected]
scholar, and professional) to provide an encompassing definition of physician competence. The CanMEDS framework outlines the abilities required by physicians oriented to optimal health and healthcare outcomes. The CanMEDS roles are designed to answer “What do physicians need to be able to do for effective practice and career growth?” Postgraduate medical educators must use CanMEDS roles as the basis for developing medical curricula and assessment tools for physician competency. Program directors must use CanMEDS as standards for accreditation of residency programs. The CanMEDS roles reflect a system of education and evaluation leading to optimal outcomes for patients and society. Since the last revision in 2005 [1], the Royal College of Physicians and Surgeons of Canada (RCPSC) has championed the need for developing and integrating a competency-based medical education (CBME) approach across the continuum of learning, from training to practice in 2009 [2, 3]. To reach this goal, the current CanMEDS framework is undergoing revisions by creating milestones and new content within the existing CanMEDS roles described above, which will be incorporated with a CBME approach. Mentorship is an excellent method to develop a trainee’s skills in the non-medical expert CanMEDS roles. Adopting a competency-based medical education approach will 1. Address patient expectations for high-quality and safe care in a new era of public accountability; 2. Improve residents’ readiness for practice once they complete training programs; 3. Equip specialists to demonstrate maintenance of competence and performance over time, throughout their careers; 4. Equip physicians to keep up with constantly evolving medical research, technologies, and procedures;
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5. Advise physicians when to adopt these changes in their practice; and leverage the opportunity to join many other countries as they move toward competency-based medical education, including the USA, Australia, and the Netherlands. Under the RCPSC’s new CBME model which is due for implementation in 2015 [3], completion of specific competencies will allow for clear targets for learning and assessment. A resident will not be able to complete the program, or write the College’s certification exams, until all milestones have been reached. Given the adoption of the CBME model, appropriate mentorship tools with that have been evaluated will be needed in postgraduate medical education (PGME). In the USA, the Accreditation Council for Graduate Medical Education (ACGME) promotes both research and mentorship in addition to core competencies [4–7]. A strong emphasis has been put on redefining the role of mentoring to develop stronger mentor-mentee relationships during residency [6]. While the importance of mentoring may be collectively accepted, it is not consistently available in medical education [8]. Research has shown that 50 % of medical students are mentored, and in some fields, less than 20 % of faculty and residents [8]. This is concerning given that mentorship allows for a confidential, professional, and supportive relationship by an experienced colleague, able and willing to share his or her knowledge and experience to a mentee to develop and thrive.
Development of the Formalized Competency-based Mentorship Program Psychiatry residents need mentorship to sustain personal and professional growth and also as a source of support during residency. Mentorship for residents in psychiatry touches on elements of supervision, career-counseling, and psychotherapy that are active ingredients to a successful mentorship relationship [9–11]. Mentoring has the joint aspiration of promoting resident wellness and supporting the development of professionalism, while addressing the personal and professional challenges of providing psychiatric care [11]. Several studies have shown a need for mentorship for residents in psychiatry. In a study conducted in the USA that surveyed 229 chief residents found 49 % reported that they did not have a career development mentor and 39 % reported that they did not feel adequately mentored [11]. Chief psychiatry residents with mentors report feeling better prepared to practice after residency compared with those lacking mentors [11]. In the past, residency program directors have relied on an informal network of faculty mentors to provide guidance for
residents. An ad hoc psychiatry resident committee on mentoring from a pilot of a formalized mentoring program in 2013 at the University of Calgary revealed the need for a prescriptive curriculum spanning each year of residency to guide the mentor and trainee in the relationship and ensure that there is a focus on career development which is also supported by the evidence that most residents want more career counseling during training and supports for challenges they may incur during training [12]. Taking this into consideration, the formalized mentorship program discussed here (developed by JC) includes a CBME program with career counseling tools that are used to help guide the resident through their program (see Fig. 1). These career counseling tools are used in the form of pocket cards to ensure they are practical and easily accessible for residents.
Objectives of the Formalized Competency-based Mentorship Program The main objective of the formalized competency-based mentorship program is that the mentoring will support residents during training thereby leading to more confident residents skilled at career planning. The secondary aim for the program is to create an additional method of support that will ensure our residents feel strongly supported by the psychiatry training program. The program addresses challenging topics of professionalism, including ethics with trainees with the intent to foster a more professionally developed trainee by graduation. The mentorship meetings are expected to occur a minimum of four meetings per year and provide an opportunity for the residents to reflect and have a sounding board for their development during training. As a result, the program maintains an appropriate status in postgraduate medical education, recognizing the mentors as teachers in a unique relationship in which they too will learn from the mentee. Caveats for the mentorship program include being nonevaluative (but can provide formative feedback), safe and confidential (but can help connect with physician health support services, program director, and other local physicians), not including psychotherapy (but they are meant to be selfreflective), promoting friendship (while still respecting the boundary of trainer/trainee), and calling for a mutual responsibility in the relationship (however, at first, the mentor should extend the invitations to meet to avoid the mentee feeling uncomfortable). There is a notion of safety in having a mentor to discuss clinical and ethical situations that occur during training with a preceptor who is not formally evaluating them, but rather serves as the role of an experienced confidante who will hopefully show their own humility and share their challenges during training too.
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Fig. 1 Model of CBME formalized mentorship program
Implementing the Competency-based Mentorship Program How does the concept of mentoring fit into today’s postgraduate curriculum for psychiatry? The training of tomorrow’s psychiatrists involves multiple components with engagement from several disciplines, various clinicians, topics, and geographical sites. Mentorship needs to be adequately defined and that the qualities of a good mentor must be taken into consideration before developing a mentorship program [9]. In terms of the quality of a mentoring relationship, female and minority residents and female and minority faculty may be more likely to agree that gender and ethnicity are important to the mentoring relationship. Furthermore, this affects the sustainability of a mentoring relationship which needs to be supported by faculty development, training for residents such as workshops and the residents and provision of faculty incentives such as
formal evaluations, protected time, and awards. The creation of an environment for interactions outside of the hospital is necessary. Residents and faculty agree that mentoring should be a vital component in today’s residency curricula in psychiatry [9, 13]. A mentoring relationship may vary along a spectrum from informal/short term to formal/long term in which faculty members with relevant experience, knowledge, skills, and/or wisdom offer advice, information, guidance, support, or opportunity to another faculty member or student for that individual’s professional (and personal) development [10]. Qualities of a good mentor include supportiveness, generosity with time, accessibility, an emphasis on building relationships, and promotion of professional growth [11, 14]. Impediments to good mentoring include perceived lack of time, task-oriented mentors (applying for grants, locating funding), lack of prerequisite mentoring skills, and lack of perceived benefit from the relationship [15].
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While there are other types of mentoring relationships, the dyadic or one-to-one model has dominated the mentoring pursuit with residents and is the basis for the competency based mentorship program described here. Faculty members are paired with residents according to mutual interests to engage in a productive relationship that is rewarding for both participants [16]. There are attempts to match the residents with mentors based on personality (e.g. extroverted vs. introverted) or lifestyle similarities (e.g. both with young families), although there is no set formula. What then follows is a contractual mentorship agreement. As part of the contract, both mentors and mentees must complete a mentorship survey (Appendix 1 and 2). The contract thus sets a precedence of regularly scheduled formal meetings, clarification of confidentiality and limits, a mutual definition of the relationship, a creation of expectations for each party, goal establishment, and the development of meaningful and realistic challenges for mentees. Mentors are paid for their participation as a mentor to recognize mentorship as an important academic contribution to training. The mentorship program begins with first-year residents and continues throughout the 5 years of residency. The minimum expectation is that the mentor meets with their mentees four times per year of residency. There is funding for 6 meetings per year and mentors are paid in advance for 4 sessions. In their third year, residents may be transferred to a new mentor, but are given the opportunity to stay with their original mentor, if they wish. The timeline for first-year residents outlines the sessions to be discussed in the first year across 4 meetings. In each meeting, overarching relevance of the specific discussion topics to the CanMEDS roles and their relevance in setting milestones for competence in psychiatry are discussed. Discussions of non-medical expert CanMEDS roles are nurtured in a nonevaluative environment. For example, the health advocacy role can be discussed for issues dealing with the stigma and discrimination of psychiatric patients; the professional role for aspects around resident wellness as well as ethics; the communicator role aspects of sharing clinical teaching approaches and communicating with patients, their families, and allied healthcare team members; the manager role aspects such as time management career planning, training for billing, and practice transition; and the scholar role aspects such as sharing research topics and teaching techniques when supervising junior trainees such as medical students. Other topics that are discussed throughout the mentorship program across the 5 years of residency include elective opportunities, career directions, fellowship opportunities, conferences, bursaries, awards, the culture of future practice and addresses issues such as autonomy, team support, payment systems, location, flexibility to schedules, expectations, and responsibilities.
Themes for junior residents encompass career possibilities, teaching others, recognizing struggles in themselves, and sharing clinical practice experiences whereas themes for senior residents encompass plotting out a career path and transitioning into practice. The “Why I Love What I Do” (WILD card) pocket card (Fig. 2) is a career counseling tool that is based on awareness of the pursuit of meaningful work [17]. This was developed by JC and is based on the academic context and conceptual model for understanding meaningful work and alignment that can be taught in mentorship programs [18]. The WILD card allows the resident to identify a personal vision for their work taking into account their strengths, values, and interests that evolve through their residency and serves as a reminder for residents to reflect on their own progress and share with faculty members. Verbal abuse and bullying which manifest as threats, humiliation, excessive criticism, exclusion, or denial of access to learning and career opportunities, undue additions to work requirements, and shifting of responsibilities without appropriate notice are all examples of psychological harassment to which residents in psychiatry may be exposed. These are behaviors that may not be defined easily nor validated which begs the need for a safe environment to voice such concerns and relevant information on the mistreatment in psychiatry training [19]. The inability to address these concerns may result in work dissatisfaction and even burnout in the training environment. Burnout is defined as a syndrome composed of emotional exhaustion, cynicism, and inefficacy, which occurs in response to chronic emotional and interpersonal work-related stressors [20]. The reported risk factors for burnout include excessive work hours [21, 22], stressful work environment [22, 23], poor support system [24], and fatigue [25]. Other factors associated with burnout include pessimism, being a perfectionist, lack of control, poor relationship with colleagues, lack of time, difficult patients, excessive paperwork, regret over chosen career, and lack of recognition [22]. The teaching card on supporting trainees with poor behaviors and challenges regarding professionalism (not shown) was developed by JC in his work with the RCPSC physician health guide and to help teach CanMEDS roles to residents using a scenario related to professionalism which they could use in everyday practice [26, 27]. The teaching card uses a scenario about residents incurring challenges during training and the complex overlap with multiple domains of stress. This tool is intended to build an approach to apply the CanMEDS framework and the questions that a resident could be asked if they are experiencing difficulties in the program. As a whole, this formalized competency-based mentorship program provides career counseling within the context of the CanMEDs roles framework with an overarching theme of professionalism. Professionalism in postgraduate medical education is often a part of a hidden curriculum [28]; however,
Acad Psychiatry QUESTIONS TO ASK *
Strengths: − What personal strengths have you discovered about yourself and what medical specialties would support these skills? − What surprised you most about your strengths? − Consider pursuing two other career areas that would benefit from your strengths. How would these areas support your values and interests? Interests: − What are you passionate about in medicine? − How were your passions connected to your current field of choice and what other careers did you consider based upon those ideas? − What surprised you most about one of your passions? − Was there ever a conflict between your passions and strengths and how did you deal with this issue? Values: − What do you truly value in life? (e.g. 1. work-life balance, 2. autonomy, 3. financial compensation, 4. personal growth, 5. recognition, 6. flexibility, 7. family, 8. travel, etc.) − What is the most rewarding/challenging issue about the culture of your field? (This can be asked directly of mentors, but can also be used to reflect on whether you still find the same values important in a specific area of medicine) − Have you had any surprises about changes in your values over the last year? − Are there other career possibilities you should consider based upon changing values? − Are there any conflicts between your values and your current career of interest?
Career Counselling: Identify a Personal Vision
THE WILD CARD
USING THE WILD CARD WILD = “This is Why I Love What I Do!” −
This career counselling tool was developed by Dr. Jordan Cohen, based on the work of Dr. Susan Lieff.
−
It can be used by any teaching faculty or with a specific focus by the program director (e.g. fireside chat).
−
Scalable to 5 minutes, 1 hour, or 2-3 hours (workshop).
−
Can be updated throughout training.
−
Trainees can reflect on their own progress and share with faculty mentors.
* Created by Dr. Jordan Cohen based upon the RCPSC Train the Trainee workshop: Physician Health
MEANINGFUL WORK Strengths: What are you particular good at within the work setting (e.g. interpersonal traits, making complex issues more simple)? What roles do you excel in? (e.g. Medical Expert, Communicator, Collaborator, Health Advocate, Scholar, Manager or Professional) (CanMEDS
See Reference 3)
Interests: What are you passionate about in medicine? Imagine the key elements of medical practice that will most satisfy you. Values: What do you want out of your career in medicine (e.g. work-life balance, autonomy, justice, other personal values)? What is the culture of medicine you are trying to establish your career in? This may involve the University, Faculty of Medicine, academic departments, and a variety of clinical settings.
Lieff 2009
CONTEXTUAL ALIGNMENT What are the opportunities and how do they fit with what you want in your future career?
REFERENCES 1.
2. 3.
Lieff S. The missing link in academic career planning and development: pursuit of meaningful and aligned work. Acad. Med. 2009;84:1383-1388 Frank JR., ed. 2005. The 2005 Physician Competency Framework. Ottawa: The Royal College The Royal College Train the Trainer: Physician Health. April 26, 2010. Ottawa, Ontario, Canada
Fig. 2 Why I Love What I Do (WILD card) pocket card
What are the needs of the setting you wish to enter (e.g. time commitment, call-hours, expected clinical duties, expected nonclinical duties, opportunities for advancement, university requirements, department requirements, clinical population needs, etc.)?
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through this program and its tools, safe discussions can occur that will build trainees’ approaches to their own personal professionalism and in how to model and teach others in the future. Areas such as knowledge related to emotional intelligence and insight surpass medical expertise in that its acquisition involves experiences different from those provided in textbooks and training. Factors such as the physician’s personality and communication with patients are just as important as what they know. The use of the career counseling tools in a competency-based mentoring program is useful since mentoring relationships can help cultivate such insight around professionalism by working to consistently improve awareness of it [29]. Professional and personal boundaries are also important aspects of resident training within psychiatry that can be fostered through mentoring relationships. The importance of nurturing relationships in medicine and especially psychiatry cannot be understated. Additionally, seeking work-life balance, preventing burnout while advancing a career can be achieved by recognition that psychiatrists are also obligated to their personal lives and that achieving a reasonable management of these physician health issues promotes insight and compassion [29]. Professional and patient boundaries concern issues surrounding privacy, confidentiality, language, and behaviors when “off duty.” Professional obligations require psychiatrists to serve the interests of patients above themselves. Derogatory language about a patient or colleague that may reflect an ignorance, prejudice, or discrimination on the basis of gender, race, religion, socioeconomic status, or sexuality are unprofessional. Mentoring relationships help solidify such obligations but may also provide a safe venue for residents to express concerns. Mentors can act as role models who portray professionalism beyond the work environment and how one should conduct themselves in public settings [29]. Self-reflection is an integral aspect of the formal competency-based mentorship program described here and relates to a core competency of professionalism that serves many important attributes in clinical practice. Self-reflection allows for the identification of feelings of frustration that can threaten clinical practice when identification is important for providing the highest quality of patient care. Self-reflection can help address the stigma attached to people with mental illness toward patients labeled as psychiatrically ill which may result from a lack of knowledge and negative attitudes and behavior. Selfreflection can be cultivated in a mentoring relationship to help residents to learn from experience and increase emotional intelligence around patients. This may ultimately foster compassion toward patients with mental illness [29].
Evaluating a Formalized Competency-based Mentorship Program Given the nature of mentorship, the nuances within a mentoring relationship, and the need to understand the effectiveness of a mentoring program, further research is warranted to determine the experiences of both the mentee and mentor while participating in this or any mentorship program. For quality assurance purposes, mentorship programs must also undergo evaluation not only to determine whether they are effective in meeting the mentee’s needs but also to understand the phenomenon of the mentee and mentor in engaging in the mentorship relationship as part of a formal mentorship program. While surveys are useful, they do not allow for the exploration of the experiences of mentorship. Psychiatry as a residency is interwoven with issues around professionalism when dealing with vulnerable patients such as those with mental illness. Qualitative research would lend itself as a powerful tool in understanding the complexity of psychiatry residency, the role of mentorship, professionalism, and the interplay of other competencies as outlined by the CanMEDS roles. A rigorous evaluation of this mentorship program is the next logical step with survey data analysis and focus groups. It is hoped that new information will emerge from its evaluation which could lead to the generation of other hypotheses as well as further development of mentoring within the program. We also hope to discover the key features that are needed for a proper mentoring relationship as well as barriers and facilitators to a formalized mentorship relationship. Those responsible for faculty development could provide training sessions for possible mentors engaging in a mentorship program. Ultimately, if residents find that by engaging in such a formalized mentorship that uses a CBME framework as well as career counseling tools improves their experience as a resident then the program may be useful in enhancing residency. If this program is deemed effective, it could be disseminated among all medical specialties at the postgraduate medical education level, tailoring competence objectives for formative evaluation during each year of residency.
Disclosure This work was supported by in-kind support from the department of psychiatry. On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Frank J. The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. Ottawa: Royal College of Physicians and Surgeons of Canada; 2005. 2. Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32:638–45.
Acad Psychiatry 3. Royal College of Physicians and Surgeons of Canada: CanMEDS 2015: the next evolution of the CanMEDS framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2013. 4. Fahy BN, Todd SR, Paukert JL, Johnson ML, Bass BL. How accurate is the Accreditation Council for Graduate Medical Education (ACGME) resident survey? Comparison between ACGME and inhouse GME survey. J Surg Educ. 2010;67:387–92. 5. Rose SH, Long TR. Accreditation Council for Graduate Medical Education (ACGME) annual anesthesiology residency and fellowship program review: a “report card” model for continuous improvement. BMC Med Educ. 2010;10:13. 6. Guerrero LR, Baillie S, Wimmers P, Parker N. Educational experiences residents perceive as most helpful for the acquisition of the ACGME competencies. J Grad Med Educ. 2012;4:176–83. 7. Miller N, MacNew H, Nester J, Wiggins JB, Shealy C, Senkowski C. Jump starting a quality and performance improvement initiative to meet the updated ACGME guidelines. J Surg Educ. 2013;70:758–68. 8. Sambunjak D, Straus SE, Marusic A. Mentoring in academic medicine: a systematic review. [Review] [56 refs]. JAMA. 2006;296:1103–15. 9. Williams LL, Levine JB, Malhotra S, Holtzheimer P. The goodenough mentoring relationship. Acad Psychiatry. 2004;28:111–5. 10. Berk RA, Berg J, Mortimer R, Walton-Moss B, Yeo TP. Measuring the effectiveness of faculty mentoring relationships. [Review] [58 refs]. Acad Med. 2005;80:66–71. 11. Lis LD, Wood WC, Petkova E, Shatkin J. Mentoring in psychiatric residency programs: a survey of chief residents. Acad Psychiatry. 2009;33:307–12. 12. Cohen JS, Patten S. Well-being in residency training: a survey examining resident physician satisfaction both within and outside of residency training and mental health in Alberta. BMC Med Educ. 2005;5:21. 13. Rodenhauser P, Rudisill JR, Dvorak R. Skills for mentors and protégés applicable to psychiatry. Acad Psychiatry. 2000;24:14–27. 14. Sockalingam S, Stergiopoulos V, Maggi J. Residents’ perceived physician-manager educational needs: a national survey of psychiatry residents. Can J Psychiatr Rev Can Psychiatr. 2008;53:745–52. 15. Tor PC, Goh LG, Ang YG, Lim L, Winslow RM, Ng BY, et al. Qualities of a psychiatric mentor: a quantitative Singaporean survey. Acad Psychiatry. 2011;35:407–10.
16. Straus S, Sackett D. Mentorship in academic medicine. 1st ed. Oxford: Wiley; 2013. 17. Lieff SJ. Perspective: the missing link in academic career planning and development: pursuit of meaningful and aligned work. Acad Med. 2009;84:1383–8. 18. Cohen J. Developing teaching tool for “The physician lifecycle”; CanMEDS train the trainer: physician health. Ottawa: Royal College of Physicians and Surgeons of Canada; 2011. 19. Coverdale JH, Balon R, Roberts LW. Mistreatment of trainees: verbal abuse and other bullying behaviors. Acad Psychiatry. 2009;33: 269–73. 20. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397–422. 21. Gopal R, Glasheen JJ, Miyoshi TJ, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005;165:2595–600. 22. Eckleberry-Hunt J, Lick D, Boura J, Hunt R, Balasubramaniam M, Mulhem E, et al. An exploratory study of resident burnout and wellness. Acad Med. 2009;84:269–77. 23. West CP, Shanafelt TD. Physician well-being and professionalism. Minn Med. 2007;90:44–6. 24. Lemkau JP, Purdy RR, Rafferty JP, Rudisill JR. Correlates of burnout among family practice residents. J Med Educ. 1988;63:682–91. 25. Ripp J, Babyatsky M, Fallar R, Bazari H, Bellini L, Kapadia C, et al. The incidence and predictors of job burnout in first-year internal medicine residents: a five-institution study. Acad Med. 2011;86: 1304–10. 26. Cohen J, Kirkham J, Yang H. How to deal with poor trainee behaviour: a 3 dimensional perspective; Canadian Medical Association’s 2nd Conference on Physician Health. Toronto: Canadian Medical Association; 2011. 27. Puddester D, Flynn L, Cohen J. CanMEDS physician health guide: a practical handbook for physician health and well-being. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2009. 28. O’Sullivan H, van Mook MW, Fewtrell R, Wass V. Integrating professionalism into the curriculum: AMEE Guide No. 61. Med Teach. 2012;34:e64–77. 29. Coverdale JH, Balon R, Roberts LW. Cultivating the professional virtues in medical training and practice. Acad Psychiatry. 2011;35: 155–9.
COLUMN: "DOWN TO EARTH" ACADEMIC SKILLS
Mentorship for Residents in Psychiatry: a Competency-based Medical Education Perspective with Career Counseling Tools Jordan Cohen & Aliya Kassam
Received: 11 June 2014 / Accepted: 22 October 2014 # Academic Psychiatry 2014
The purpose of this article is to provide some practical ideas to help program directors develop, navigate, and execute the process of establishing a mentorship program during psychiatry residency. An evaluation of this mentorship program with respect to mentee and mentor satisfaction is beyond the scope of this article. The comments are intended to provide guidance, but are not meant to be a rigid recipe. The program was developed by a psychiatry postgraduate residency program director (Dr. Jordan Cohen) in collaboration with an ad hoc resident committee on mentoring. While there is no formal evaluation of resident performance during the mentorship program, the program is competency based in that the mentor provides formative evaluation to ensure the resident achieves competence in addressing patient expectations, is held socially responsible, and pursues professional development areas that are key to career growth ensuring readiness for practice. This mentoring process is reflective, and thus, the resident learns from this process which involves nonjudgmental/supportive feedback from the mentor.
Competency-based Medical Education (CBME) and Mentorship The Royal College of Physicians and Surgeons of Canada (RCPSC) CanMEDS roles framework is used as the basis for developing medical curricula and measurement tools to assess resident physicians (RPs) throughout their training programs [1]. This framework situates the medical expert role centrally, which integrates six other non-medical expert roles (communicator, collaborator, manager, health advocate, J. Cohen : A. Kassam (*) University of Calgary, Calgary, AB, Canada e-mail: [email protected]
scholar, and professional) to provide an encompassing definition of physician competence. The CanMEDS framework outlines the abilities required by physicians oriented to optimal health and healthcare outcomes. The CanMEDS roles are designed to answer “What do physicians need to be able to do for effective practice and career growth?” Postgraduate medical educators must use CanMEDS roles as the basis for developing medical curricula and assessment tools for physician competency. Program directors must use CanMEDS as standards for accreditation of residency programs. The CanMEDS roles reflect a system of education and evaluation leading to optimal outcomes for patients and society. Since the last revision in 2005 [1], the Royal College of Physicians and Surgeons of Canada (RCPSC) has championed the need for developing and integrating a competency-based medical education (CBME) approach across the continuum of learning, from training to practice in 2009 [2, 3]. To reach this goal, the current CanMEDS framework is undergoing revisions by creating milestones and new content within the existing CanMEDS roles described above, which will be incorporated with a CBME approach. Mentorship is an excellent method to develop a trainee’s skills in the non-medical expert CanMEDS roles. Adopting a competency-based medical education approach will 1. Address patient expectations for high-quality and safe care in a new era of public accountability; 2. Improve residents’ readiness for practice once they complete training programs; 3. Equip specialists to demonstrate maintenance of competence and performance over time, throughout their careers; 4. Equip physicians to keep up with constantly evolving medical research, technologies, and procedures;
Acad Psychiatry
5. Advise physicians when to adopt these changes in their practice; and leverage the opportunity to join many other countries as they move toward competency-based medical education, including the USA, Australia, and the Netherlands. Under the RCPSC’s new CBME model which is due for implementation in 2015 [3], completion of specific competencies will allow for clear targets for learning and assessment. A resident will not be able to complete the program, or write the College’s certification exams, until all milestones have been reached. Given the adoption of the CBME model, appropriate mentorship tools with that have been evaluated will be needed in postgraduate medical education (PGME). In the USA, the Accreditation Council for Graduate Medical Education (ACGME) promotes both research and mentorship in addition to core competencies [4–7]. A strong emphasis has been put on redefining the role of mentoring to develop stronger mentor-mentee relationships during residency [6]. While the importance of mentoring may be collectively accepted, it is not consistently available in medical education [8]. Research has shown that 50 % of medical students are mentored, and in some fields, less than 20 % of faculty and residents [8]. This is concerning given that mentorship allows for a confidential, professional, and supportive relationship by an experienced colleague, able and willing to share his or her knowledge and experience to a mentee to develop and thrive.
Development of the Formalized Competency-based Mentorship Program Psychiatry residents need mentorship to sustain personal and professional growth and also as a source of support during residency. Mentorship for residents in psychiatry touches on elements of supervision, career-counseling, and psychotherapy that are active ingredients to a successful mentorship relationship [9–11]. Mentoring has the joint aspiration of promoting resident wellness and supporting the development of professionalism, while addressing the personal and professional challenges of providing psychiatric care [11]. Several studies have shown a need for mentorship for residents in psychiatry. In a study conducted in the USA that surveyed 229 chief residents found 49 % reported that they did not have a career development mentor and 39 % reported that they did not feel adequately mentored [11]. Chief psychiatry residents with mentors report feeling better prepared to practice after residency compared with those lacking mentors [11]. In the past, residency program directors have relied on an informal network of faculty mentors to provide guidance for
residents. An ad hoc psychiatry resident committee on mentoring from a pilot of a formalized mentoring program in 2013 at the University of Calgary revealed the need for a prescriptive curriculum spanning each year of residency to guide the mentor and trainee in the relationship and ensure that there is a focus on career development which is also supported by the evidence that most residents want more career counseling during training and supports for challenges they may incur during training [12]. Taking this into consideration, the formalized mentorship program discussed here (developed by JC) includes a CBME program with career counseling tools that are used to help guide the resident through their program (see Fig. 1). These career counseling tools are used in the form of pocket cards to ensure they are practical and easily accessible for residents.
Objectives of the Formalized Competency-based Mentorship Program The main objective of the formalized competency-based mentorship program is that the mentoring will support residents during training thereby leading to more confident residents skilled at career planning. The secondary aim for the program is to create an additional method of support that will ensure our residents feel strongly supported by the psychiatry training program. The program addresses challenging topics of professionalism, including ethics with trainees with the intent to foster a more professionally developed trainee by graduation. The mentorship meetings are expected to occur a minimum of four meetings per year and provide an opportunity for the residents to reflect and have a sounding board for their development during training. As a result, the program maintains an appropriate status in postgraduate medical education, recognizing the mentors as teachers in a unique relationship in which they too will learn from the mentee. Caveats for the mentorship program include being nonevaluative (but can provide formative feedback), safe and confidential (but can help connect with physician health support services, program director, and other local physicians), not including psychotherapy (but they are meant to be selfreflective), promoting friendship (while still respecting the boundary of trainer/trainee), and calling for a mutual responsibility in the relationship (however, at first, the mentor should extend the invitations to meet to avoid the mentee feeling uncomfortable). There is a notion of safety in having a mentor to discuss clinical and ethical situations that occur during training with a preceptor who is not formally evaluating them, but rather serves as the role of an experienced confidante who will hopefully show their own humility and share their challenges during training too.
Acad Psychiatry
Fig. 1 Model of CBME formalized mentorship program
Implementing the Competency-based Mentorship Program How does the concept of mentoring fit into today’s postgraduate curriculum for psychiatry? The training of tomorrow’s psychiatrists involves multiple components with engagement from several disciplines, various clinicians, topics, and geographical sites. Mentorship needs to be adequately defined and that the qualities of a good mentor must be taken into consideration before developing a mentorship program [9]. In terms of the quality of a mentoring relationship, female and minority residents and female and minority faculty may be more likely to agree that gender and ethnicity are important to the mentoring relationship. Furthermore, this affects the sustainability of a mentoring relationship which needs to be supported by faculty development, training for residents such as workshops and the residents and provision of faculty incentives such as
formal evaluations, protected time, and awards. The creation of an environment for interactions outside of the hospital is necessary. Residents and faculty agree that mentoring should be a vital component in today’s residency curricula in psychiatry [9, 13]. A mentoring relationship may vary along a spectrum from informal/short term to formal/long term in which faculty members with relevant experience, knowledge, skills, and/or wisdom offer advice, information, guidance, support, or opportunity to another faculty member or student for that individual’s professional (and personal) development [10]. Qualities of a good mentor include supportiveness, generosity with time, accessibility, an emphasis on building relationships, and promotion of professional growth [11, 14]. Impediments to good mentoring include perceived lack of time, task-oriented mentors (applying for grants, locating funding), lack of prerequisite mentoring skills, and lack of perceived benefit from the relationship [15].
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While there are other types of mentoring relationships, the dyadic or one-to-one model has dominated the mentoring pursuit with residents and is the basis for the competency based mentorship program described here. Faculty members are paired with residents according to mutual interests to engage in a productive relationship that is rewarding for both participants [16]. There are attempts to match the residents with mentors based on personality (e.g. extroverted vs. introverted) or lifestyle similarities (e.g. both with young families), although there is no set formula. What then follows is a contractual mentorship agreement. As part of the contract, both mentors and mentees must complete a mentorship survey (Appendix 1 and 2). The contract thus sets a precedence of regularly scheduled formal meetings, clarification of confidentiality and limits, a mutual definition of the relationship, a creation of expectations for each party, goal establishment, and the development of meaningful and realistic challenges for mentees. Mentors are paid for their participation as a mentor to recognize mentorship as an important academic contribution to training. The mentorship program begins with first-year residents and continues throughout the 5 years of residency. The minimum expectation is that the mentor meets with their mentees four times per year of residency. There is funding for 6 meetings per year and mentors are paid in advance for 4 sessions. In their third year, residents may be transferred to a new mentor, but are given the opportunity to stay with their original mentor, if they wish. The timeline for first-year residents outlines the sessions to be discussed in the first year across 4 meetings. In each meeting, overarching relevance of the specific discussion topics to the CanMEDS roles and their relevance in setting milestones for competence in psychiatry are discussed. Discussions of non-medical expert CanMEDS roles are nurtured in a nonevaluative environment. For example, the health advocacy role can be discussed for issues dealing with the stigma and discrimination of psychiatric patients; the professional role for aspects around resident wellness as well as ethics; the communicator role aspects of sharing clinical teaching approaches and communicating with patients, their families, and allied healthcare team members; the manager role aspects such as time management career planning, training for billing, and practice transition; and the scholar role aspects such as sharing research topics and teaching techniques when supervising junior trainees such as medical students. Other topics that are discussed throughout the mentorship program across the 5 years of residency include elective opportunities, career directions, fellowship opportunities, conferences, bursaries, awards, the culture of future practice and addresses issues such as autonomy, team support, payment systems, location, flexibility to schedules, expectations, and responsibilities.
Themes for junior residents encompass career possibilities, teaching others, recognizing struggles in themselves, and sharing clinical practice experiences whereas themes for senior residents encompass plotting out a career path and transitioning into practice. The “Why I Love What I Do” (WILD card) pocket card (Fig. 2) is a career counseling tool that is based on awareness of the pursuit of meaningful work [17]. This was developed by JC and is based on the academic context and conceptual model for understanding meaningful work and alignment that can be taught in mentorship programs [18]. The WILD card allows the resident to identify a personal vision for their work taking into account their strengths, values, and interests that evolve through their residency and serves as a reminder for residents to reflect on their own progress and share with faculty members. Verbal abuse and bullying which manifest as threats, humiliation, excessive criticism, exclusion, or denial of access to learning and career opportunities, undue additions to work requirements, and shifting of responsibilities without appropriate notice are all examples of psychological harassment to which residents in psychiatry may be exposed. These are behaviors that may not be defined easily nor validated which begs the need for a safe environment to voice such concerns and relevant information on the mistreatment in psychiatry training [19]. The inability to address these concerns may result in work dissatisfaction and even burnout in the training environment. Burnout is defined as a syndrome composed of emotional exhaustion, cynicism, and inefficacy, which occurs in response to chronic emotional and interpersonal work-related stressors [20]. The reported risk factors for burnout include excessive work hours [21, 22], stressful work environment [22, 23], poor support system [24], and fatigue [25]. Other factors associated with burnout include pessimism, being a perfectionist, lack of control, poor relationship with colleagues, lack of time, difficult patients, excessive paperwork, regret over chosen career, and lack of recognition [22]. The teaching card on supporting trainees with poor behaviors and challenges regarding professionalism (not shown) was developed by JC in his work with the RCPSC physician health guide and to help teach CanMEDS roles to residents using a scenario related to professionalism which they could use in everyday practice [26, 27]. The teaching card uses a scenario about residents incurring challenges during training and the complex overlap with multiple domains of stress. This tool is intended to build an approach to apply the CanMEDS framework and the questions that a resident could be asked if they are experiencing difficulties in the program. As a whole, this formalized competency-based mentorship program provides career counseling within the context of the CanMEDs roles framework with an overarching theme of professionalism. Professionalism in postgraduate medical education is often a part of a hidden curriculum [28]; however,
Acad Psychiatry QUESTIONS TO ASK *
Strengths: − What personal strengths have you discovered about yourself and what medical specialties would support these skills? − What surprised you most about your strengths? − Consider pursuing two other career areas that would benefit from your strengths. How would these areas support your values and interests? Interests: − What are you passionate about in medicine? − How were your passions connected to your current field of choice and what other careers did you consider based upon those ideas? − What surprised you most about one of your passions? − Was there ever a conflict between your passions and strengths and how did you deal with this issue? Values: − What do you truly value in life? (e.g. 1. work-life balance, 2. autonomy, 3. financial compensation, 4. personal growth, 5. recognition, 6. flexibility, 7. family, 8. travel, etc.) − What is the most rewarding/challenging issue about the culture of your field? (This can be asked directly of mentors, but can also be used to reflect on whether you still find the same values important in a specific area of medicine) − Have you had any surprises about changes in your values over the last year? − Are there other career possibilities you should consider based upon changing values? − Are there any conflicts between your values and your current career of interest?
Career Counselling: Identify a Personal Vision
THE WILD CARD
USING THE WILD CARD WILD = “This is Why I Love What I Do!” −
This career counselling tool was developed by Dr. Jordan Cohen, based on the work of Dr. Susan Lieff.
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It can be used by any teaching faculty or with a specific focus by the program director (e.g. fireside chat).
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Scalable to 5 minutes, 1 hour, or 2-3 hours (workshop).
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Can be updated throughout training.
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Trainees can reflect on their own progress and share with faculty mentors.
* Created by Dr. Jordan Cohen based upon the RCPSC Train the Trainee workshop: Physician Health
MEANINGFUL WORK Strengths: What are you particular good at within the work setting (e.g. interpersonal traits, making complex issues more simple)? What roles do you excel in? (e.g. Medical Expert, Communicator, Collaborator, Health Advocate, Scholar, Manager or Professional) (CanMEDS
See Reference 3)
Interests: What are you passionate about in medicine? Imagine the key elements of medical practice that will most satisfy you. Values: What do you want out of your career in medicine (e.g. work-life balance, autonomy, justice, other personal values)? What is the culture of medicine you are trying to establish your career in? This may involve the University, Faculty of Medicine, academic departments, and a variety of clinical settings.
Lieff 2009
CONTEXTUAL ALIGNMENT What are the opportunities and how do they fit with what you want in your future career?
REFERENCES 1.
2. 3.
Lieff S. The missing link in academic career planning and development: pursuit of meaningful and aligned work. Acad. Med. 2009;84:1383-1388 Frank JR., ed. 2005. The 2005 Physician Competency Framework. Ottawa: The Royal College The Royal College Train the Trainer: Physician Health. April 26, 2010. Ottawa, Ontario, Canada
Fig. 2 Why I Love What I Do (WILD card) pocket card
What are the needs of the setting you wish to enter (e.g. time commitment, call-hours, expected clinical duties, expected nonclinical duties, opportunities for advancement, university requirements, department requirements, clinical population needs, etc.)?
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through this program and its tools, safe discussions can occur that will build trainees’ approaches to their own personal professionalism and in how to model and teach others in the future. Areas such as knowledge related to emotional intelligence and insight surpass medical expertise in that its acquisition involves experiences different from those provided in textbooks and training. Factors such as the physician’s personality and communication with patients are just as important as what they know. The use of the career counseling tools in a competency-based mentoring program is useful since mentoring relationships can help cultivate such insight around professionalism by working to consistently improve awareness of it [29]. Professional and personal boundaries are also important aspects of resident training within psychiatry that can be fostered through mentoring relationships. The importance of nurturing relationships in medicine and especially psychiatry cannot be understated. Additionally, seeking work-life balance, preventing burnout while advancing a career can be achieved by recognition that psychiatrists are also obligated to their personal lives and that achieving a reasonable management of these physician health issues promotes insight and compassion [29]. Professional and patient boundaries concern issues surrounding privacy, confidentiality, language, and behaviors when “off duty.” Professional obligations require psychiatrists to serve the interests of patients above themselves. Derogatory language about a patient or colleague that may reflect an ignorance, prejudice, or discrimination on the basis of gender, race, religion, socioeconomic status, or sexuality are unprofessional. Mentoring relationships help solidify such obligations but may also provide a safe venue for residents to express concerns. Mentors can act as role models who portray professionalism beyond the work environment and how one should conduct themselves in public settings [29]. Self-reflection is an integral aspect of the formal competency-based mentorship program described here and relates to a core competency of professionalism that serves many important attributes in clinical practice. Self-reflection allows for the identification of feelings of frustration that can threaten clinical practice when identification is important for providing the highest quality of patient care. Self-reflection can help address the stigma attached to people with mental illness toward patients labeled as psychiatrically ill which may result from a lack of knowledge and negative attitudes and behavior. Selfreflection can be cultivated in a mentoring relationship to help residents to learn from experience and increase emotional intelligence around patients. This may ultimately foster compassion toward patients with mental illness [29].
Evaluating a Formalized Competency-based Mentorship Program Given the nature of mentorship, the nuances within a mentoring relationship, and the need to understand the effectiveness of a mentoring program, further research is warranted to determine the experiences of both the mentee and mentor while participating in this or any mentorship program. For quality assurance purposes, mentorship programs must also undergo evaluation not only to determine whether they are effective in meeting the mentee’s needs but also to understand the phenomenon of the mentee and mentor in engaging in the mentorship relationship as part of a formal mentorship program. While surveys are useful, they do not allow for the exploration of the experiences of mentorship. Psychiatry as a residency is interwoven with issues around professionalism when dealing with vulnerable patients such as those with mental illness. Qualitative research would lend itself as a powerful tool in understanding the complexity of psychiatry residency, the role of mentorship, professionalism, and the interplay of other competencies as outlined by the CanMEDS roles. A rigorous evaluation of this mentorship program is the next logical step with survey data analysis and focus groups. It is hoped that new information will emerge from its evaluation which could lead to the generation of other hypotheses as well as further development of mentoring within the program. We also hope to discover the key features that are needed for a proper mentoring relationship as well as barriers and facilitators to a formalized mentorship relationship. Those responsible for faculty development could provide training sessions for possible mentors engaging in a mentorship program. Ultimately, if residents find that by engaging in such a formalized mentorship that uses a CBME framework as well as career counseling tools improves their experience as a resident then the program may be useful in enhancing residency. If this program is deemed effective, it could be disseminated among all medical specialties at the postgraduate medical education level, tailoring competence objectives for formative evaluation during each year of residency.
Disclosure This work was supported by in-kind support from the department of psychiatry. On behalf of all authors, the corresponding author states that there is no conflict of interest.
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