The Current and Ideal State of Mental Health Training: Pediatric Program Director Perspectives Cori Green, MD, MS; Elisa Hampton, MD; Mary J. Ward, PhD; Huibo Shao, MS; Susan Bostwick, MD, MBA From the Department of Pediatrics, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY (Drs Green, Hampton, Ward, and Bostwick); and Baptist Memorial Health Care Corporation Department of Quality, Memphis, Tenn (Mr Shao) The authors declare that they have no conflict of interest. Address correspondence to Cori Green, MD, MS, Weill Cornell Medical Center Department of Pediatrics, 525 East 68th St, Room 628B, Box 139, New York, NY 10065 (e-mail: [email protected]). Received for publication September 23, 2013; accepted May 26, 2014.
ABSTRACT OBJECTIVE: To assess pediatric residency program director (PD) perceptions of the current state of mental health (MH) training, their receptivity to curricular changes, and perceptions of their residents’ knowledge and skills in MH care. METHODS: We performed a cross-sectional study utilizing a Web-based survey of pediatric residency PDs to assess program characteristics, learning modalities PDs currently had or would implement, and their knowledge of the new American Academy of Pediatrics’ MH competencies. PDs then ranked their residents’ knowledge and skills for 29 MH competencies. Analyses included descriptive statistics and bivariate and multivariate analyses to assess for associations between variables, particularly MH model of care and perceived competence. RESULTS: Ninety-nine PDs (51%) responded. A total of 87% of PDs reported that MH care was taught as part of another rotation, yet PDs were receptive to curricular changes. Only 45% of PDs were aware of the 2009 American Academy of Pediatrics
WHAT’S NEW Pediatric program directors report mental health (MH) training is not emphasized in residency, leading to deficiencies in resident knowledge and skills, but are receptive to various teaching modalities. Co-location of MH services may enhance resident MH knowledge and skills.
OVER THE PAST 3 decades, serious acute illnesses have become rare and chronic illnesses have become more prevalent.1 In addition, the types of chronic conditions that cause limitations for children have changed.1,2 In the early 1990s, conditions of the respiratory system were the leading cause of limitations for children with chronic conditions.3 Now asthma has fallen to number 6 on this list; the 5 conditions above it are developmental, learning, and behavioral disorders.1,3 Currently, mental health (MH) disorders affect 1 in 5 children, with only approximately half of affected children seeking treatment with a MH specialist and only a minority (25%) receiving services.4–6 In order to begin to address this health care problem in the face of a shortage of MH specialists, primary pediatricians must begin to
competencies, and PDs infrequently rated their residents’ MH skills and knowledge to be above average. Attention-deficit/ hyperactivity disorder (ADHD) was an exception: 64% reported above-average ADHD knowledge in diagnoses and 57% in treatment. There was an association between enhanced MH services in continuity clinics and perceived resident systems-based practice (P < .01) and medical knowledge (P ¼ .04). CONCLUSIONS: PDs acknowledged that MH training is not emphasized, leading to deficiencies in their residents’ knowledge and skills in MH care. The receptivity of PDs suggests the need for targeted dissemination of national guidelines or curriculum. Integrated models of care may be one way to improve resident competencies, but this deserves further study.
KEYWORDS: mental health; pediatric program directors; pediatric residency training
ACADEMIC PEDIATRICS 2014;14:526–532
take more active roles in caring for pediatric MH conditions.5,7 However, practicing pediatricians often state that they are not comfortable in identifying or treating MH concerns in their primary care practice, citing inadequate training as a barrier.8 Pediatric residency programs have evolved as the epidemiology of pediatrics has changed. For instance, the Residency Review Committee for Pediatrics of the Accreditation Council for Graduate Medical Education (ACGME) released guidelines in 1997 requiring residents to spend a minimum of 50% of training in ambulatory settings and 1-month rotations in developmental/behavioral pediatrics and adolescent medicine.9 However, surveys of graduating pediatric residents suggest these rotations alone are still not adequate to assure that pediatricians have the skills to recognize and manage most MH issues in children.8,10–12 In fact, studies of graduates in 1997 and 2011 consistently describe training gaps in pediatric behavioral and MH care with little difference reported between 1997 and 2011.13–15 In order to address these gaps nationally, the American Academy of Pediatrics (AAP) generated a set of MH competencies for pediatricians.16 These competencies were created to better define and distinguish the role a primary pediatrician would take in providing MH
ACADEMIC PEDIATRICS 526 Published by Elsevier Inc. on behalf of the Academic Pediatric Association
Volume 14, Number 5 September–October 2014
ACADEMIC PEDIATRICS
MENTAL HEALTH TRAINING
care and they used the ACGME framework with the goal that these could influence residency training. Nationally, tools and training sessions have been implemented to help practicing pediatricians attain these competencies.17,18 However, few of these national efforts have been implemented in residency training programs. Few residency programs have successfully implemented curricular interventions to better prepare residents to care for children with MH conditions.19–22 In addition, approximately a third of residency programs have begun to adapt models of integrated/collaborative care into residents’ continuity clinic where a MH specialist is available for consultation at the time of identification of a problem.23 Although these isolated curricular efforts are promising, no national guidelines or curricular interventions have been proposed in order to improve and standardize MH training. The first step in making curricular changes is to perform a needs assessment, identifying gaps between the current and ideal approaches to a health care problem.24 Pediatric PDs are key stakeholders in medical education, and curricular and programmatic changes would be impossible without their support. The aim of this study was therefore to survey pediatric PDs to assess current MH training practices, plans and receptivity to changes given the new AAP MH competencies, and their perceptions of resident knowledge and skills in MH care. We hypothesized that despite these new competencies, few programs have addressed them, further propagating training gaps in pediatric MH care. We also sought to assess whether current program characteristics influenced current and future MH training, because this could help inform curriculum development and implementation. More specifically, we wanted to know whether there was any association between current models of MH care and perceived resident knowledge and skills.
METHODS A cross-sectional design was employed using a Webbased survey to assess current MH curriculum practices, receptivity and preferences for curriculum reform, knowledge and influence of AAP MH competencies, and perceptions of current resident knowledge and skills in addressing MH issues. SUBJECTS AND SETTING All 193 PDs who were members of the Association of Pediatric Program Directors (APPD) e-mail list in January 2011 were eligible to participate in the survey. The survey was submitted and approved by the local institutional review board. The survey was then submitted to the APPD’s Research Task Force, where it was peer reviewed and approved for submission through their e-mail list. DATA COLLECTION The APPD e-mailed the survey with an introductory text explaining the survey and consent for the survey to their PD e-mail list. Two reminder e-mails were sent, asking those
527
who had not yet completed the survey to consider participating in the study. SURVEY INSTRUMENT The researchers developed the survey after extensive literature review (Online Supplement). The researchers piloted the survey within the Division of General Academic Pediatrics at the authors’ university and with members of the APPD. The survey included 16 questions within the following domains: 1) program characteristics including continuity clinic model of MH care; 2) MH education modalities (current practices, receptivity to new modalities, and preferences for new modalities); and 3) perceived resident MH competence. The preceding domains included closed-ended questions but a final question not included in the above domains intended to elicit further openended comments. DOMAIN 1: CHARACTERISTICS AND MH MODEL OF CARE Program characteristics collected included program type, size, location, payer mix, and translator needs. Models of care for MH services in continuity clinics were defined from the literature, and participants were asked to choose 1 of 5 models: exclusive referral, traditional care, phone consultation model, enhanced care, and integrated/collaborative care.25 These models are further defined in the Online Supplement. The variable Model of MH Care was transformed to yield a dichotomy between traditional or referral-only models versus models involving presence of a MH professional (enhanced care, phone consultation, and integrated/collaborative care models). We considered the presence of any MH professional an enhanced model. DOMAIN 2: LEARNING MODALITIES The survey assessed how programs currently integrate MH education into training and which educational modalities they would desire and implement (Online Supplement). PDs were asked if they would implement annotated cases, online curriculum, prepared presentations, video lectures, MH rotation, and an integrated experiential learning curriculum. Each modality a PD would implement was given a point, and a summative variable of these modalities was created for analysis, entitled Curricular Index. DOMAIN 3: MH COMPETENCIES PDs were asked about their awareness of the new MH competencies proposed by the AAP in 2009 and whether these would influence curricular changes. Chosen competencies from the AAP’s statement were then listed for PDs to rate their residents’ behavior and knowledge in caring for children with MH concerns. The survey included 9 MH patient care and communication skills and 3 skills involving communication with other professionals. The frequency residents performed patient care/communication and systems-based skills were ranked on a 5-point Likert scale ranging from never to always. The rankings for
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each of the 9 MH patient care and communication skills were added up and combined to create a summative outcome variable entitled Patient Care and Communication Competency (0 ¼ never, 1 ¼ rarely, 2 ¼ sometimes, 3 ¼ often, 4 ¼ always). Three measures that described skills on communication with other professionals were combined to create the summative variable entitled Systems-Based Practice Competency. This variable was created using the same ranking scale described above. Seventeen measures of medical knowledge included 6 MH diagnoses, their treatments, and general behavioral health treatments. These were ranked using a Likert scale ranging from poor to excellent. The rankings for each of 17 measures of knowledge of diagnoses and treatment were combined to create the summative outcome variable entitled Medical Knowledge Competency (0 ¼ poor, 1 ¼ average, 2 ¼ excellent). These composite variables were created for each ACGME competency because they better summarized our individual measures. FREE-TEXT COMMENTS The survey concluded with a text box which allowed for free-text comments. STATISTICAL ANALYSIS We included all surveys with 9 or more questions completed. SPSS for Windows was used for data analyses (IBM, Armonk, NY). Descriptive statistics were derived for program and continuity clinic characteristics, current curricular practices, likelihood to implement new curriculum, knowledge and influence of the 2009 AAP MH competencies, and PD perceptions of current resident MH knowledge and skills. To assess whether specific program demographics influenced current and future MH practices bivariate and multivariate analyses were conducted with the use of Fisher’s exact test, t tests, and logistic regression to look for associations between variables: program demographics as the independent variable and 1) current curricular practices, 2) receptivity to implementing new curricula, and 3) knowledge of MH competencies as the outcome variables. We
also examined associations among 1) program demographics, 2) awareness of MH competencies, and 3) likelihood to implement various curricular activities to the outcome variable, PD perceptions of their residents’ MH competencies. Internal consistency was assessed for each composite variable in order to assess the degree that each MH skill or knowledge item in the variable measured a single construct, or competency. This was done via Cronbach’s alpha. Comments at the end of the survey were reviewed and grouped into preexisting categories (most expanded on already existing answer choices) or separate categories if necessary.
RESULTS DOMAIN 1: CHARACTERISTICS AND MH MODEL OF CARE Data from 99 pediatric PDs (51%) were included for analysis (Table). We were unable to assess characteristics of those who did not respond. However, the proportion of respondents was similar to all programs nationally in terms of size and location. In addition, the proportion of our participants’ MH care model was similar to prior results in the literature.23 More than 70% of programs were in urban locations, and half had a continuity clinic at their main institute. Eleven programs responded having a combination of urban, suburban, and rural locations. Respondents’ clinics served primarily children who were uninsured or eligible for government insurance, although in 10% of clinics, at least half of the patients were covered by commercial insurance. Twenty-eight percent of programs had MH specialists located in clinic, with half of those (14%) endorsing co-location. DOMAIN 2: LEARNING MODALITIES Figure 1 illustrates MH educational modalities and whether PDs currently, plan to, or want to have each modality. By report, 87% of programs taught MH knowledge and skills as part of another rotation, while only 8% (n ¼ 7 programs) required a separate MH rotation. MH was taught most often as an elective or in didactic sessions.
Table. Program Characteristics Characteristic
Variable
Total Respondents (n ¼ 99)
National Data (n ¼ 199)
P
Program size (% by no. of residents)
0–20 21–40 41–60 61–80 >80 Urban Combination Hospital based Off-site Private office Combination Exclusive referral Traditional care Phone consultation model Enhanced care Integrated/collaborative care
12.1% (12) 42.4% (42) 26.3% (26) 10.1% (10) 9.1% (9) 77.8% (77) 11.1% 48.5% 12.1% 1.0% 37.4% 15.4% (14) 54.9% (50) 1.1% (1) 14.3% (13) 14.3% (13)
14.6% (29) 39.7% (79) 22.6% (45) 9.5% (19) 13.6% (27) 84.4% (168)
.83 .77 .72 .96 .72 .17
Program location Continuity clinic sites
Continuity clinic model
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MENTAL HEALTH TRAINING
529
Figure 1. Current and future mental health educational activities reported by pediatric residency directors.
However, PDs were receptive to implementing various MH learning activities. At least 60% of PDs would implement all modalities suggested. The activities endorsed most frequently were MH rotation (80%) and annotated cases (89%). DOMAIN 3: PERCEIVED MH COMPETENCIES Only 45% of PDs were aware of the published AAP MH competencies; 65% of these PDs were planning to make changes. Figures 2 and 3 show PDs’ perception of residents’ patient care and communication and systemsbased competencies. Overall, PDs rarely stated their residents always screen, recognize, and/or manage MH problems. However, there are specific competencies that more than half of PDs report their residents accomplish often or always screen for behavioral issues, recognize and treat MH issues, and collaborate with MH specialists. For the remainder of the skills listed, less than half of PDs reported that their residents frequently used each skill. Figure 4 illustrates 11 of the 17 medical knowledge compe-
tencies included in the variable, primarily treatment knowledge. Knowledge of diagnostic criteria was similar to treatment, except 64% of PDs reported above-average knowledge in diagnosing attention-deficit/hyperactivity disorder (ADHD) and 57% in ADHD treatment. Otherwise, the majority of PDs ranked their resident knowledge of various DSM diagnoses and treatments as average. Knowledge about psychosocial and pharmacological interventions was infrequently ranked as above average at 18.6% and 30.2%, respectively. In multivariate analyses, we found no associations between program characteristics (including MH model of care) and current curricular practices. However, we did find that larger programs had a lower curricular index, meaning they were less likely to implement a combination of learning activities (P < .05). In contrast, programs with exclusive referral as their model for MH care in continuity clinic were more likely to implement multiple curricular activities (P < .05) compared to traditional care models; more specifically, they were more likely to implement a
Figure 2. Program director assessment of how frequently residents perform patient care and communication competency behaviors in providing care for mental health conditions.
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FREE-TEXT COMMENTS Twenty participants left comments at the end of the survey. Seven comments reinforced the need for MH curricular interventions, including a comment on how this was the weakest part on their graduated residents’ pediatric boards. Three comments suggested that access to resources was a barrier to both teaching and caring for pediatric MH issues. Three comments suggested that a barrier to enhance MH education is competing priorities in the setting of reduced work hours.
Figure 3. Program director assessment of how frequently residents perform behaviors to communicate with other professionals in providing care for mental health conditions.
MH rotation (P < .05). There were no further associations between program characteristics and future curricular practices. Of note, PDs of large programs (>80 residents) were 15 times more likely to be aware of the new AAP MH competencies (P < .05) compared to small programs (
ABSTRACT OBJECTIVE: To assess pediatric residency program director (PD) perceptions of the current state of mental health (MH) training, their receptivity to curricular changes, and perceptions of their residents’ knowledge and skills in MH care. METHODS: We performed a cross-sectional study utilizing a Web-based survey of pediatric residency PDs to assess program characteristics, learning modalities PDs currently had or would implement, and their knowledge of the new American Academy of Pediatrics’ MH competencies. PDs then ranked their residents’ knowledge and skills for 29 MH competencies. Analyses included descriptive statistics and bivariate and multivariate analyses to assess for associations between variables, particularly MH model of care and perceived competence. RESULTS: Ninety-nine PDs (51%) responded. A total of 87% of PDs reported that MH care was taught as part of another rotation, yet PDs were receptive to curricular changes. Only 45% of PDs were aware of the 2009 American Academy of Pediatrics
WHAT’S NEW Pediatric program directors report mental health (MH) training is not emphasized in residency, leading to deficiencies in resident knowledge and skills, but are receptive to various teaching modalities. Co-location of MH services may enhance resident MH knowledge and skills.
OVER THE PAST 3 decades, serious acute illnesses have become rare and chronic illnesses have become more prevalent.1 In addition, the types of chronic conditions that cause limitations for children have changed.1,2 In the early 1990s, conditions of the respiratory system were the leading cause of limitations for children with chronic conditions.3 Now asthma has fallen to number 6 on this list; the 5 conditions above it are developmental, learning, and behavioral disorders.1,3 Currently, mental health (MH) disorders affect 1 in 5 children, with only approximately half of affected children seeking treatment with a MH specialist and only a minority (25%) receiving services.4–6 In order to begin to address this health care problem in the face of a shortage of MH specialists, primary pediatricians must begin to
competencies, and PDs infrequently rated their residents’ MH skills and knowledge to be above average. Attention-deficit/ hyperactivity disorder (ADHD) was an exception: 64% reported above-average ADHD knowledge in diagnoses and 57% in treatment. There was an association between enhanced MH services in continuity clinics and perceived resident systems-based practice (P < .01) and medical knowledge (P ¼ .04). CONCLUSIONS: PDs acknowledged that MH training is not emphasized, leading to deficiencies in their residents’ knowledge and skills in MH care. The receptivity of PDs suggests the need for targeted dissemination of national guidelines or curriculum. Integrated models of care may be one way to improve resident competencies, but this deserves further study.
KEYWORDS: mental health; pediatric program directors; pediatric residency training
ACADEMIC PEDIATRICS 2014;14:526–532
take more active roles in caring for pediatric MH conditions.5,7 However, practicing pediatricians often state that they are not comfortable in identifying or treating MH concerns in their primary care practice, citing inadequate training as a barrier.8 Pediatric residency programs have evolved as the epidemiology of pediatrics has changed. For instance, the Residency Review Committee for Pediatrics of the Accreditation Council for Graduate Medical Education (ACGME) released guidelines in 1997 requiring residents to spend a minimum of 50% of training in ambulatory settings and 1-month rotations in developmental/behavioral pediatrics and adolescent medicine.9 However, surveys of graduating pediatric residents suggest these rotations alone are still not adequate to assure that pediatricians have the skills to recognize and manage most MH issues in children.8,10–12 In fact, studies of graduates in 1997 and 2011 consistently describe training gaps in pediatric behavioral and MH care with little difference reported between 1997 and 2011.13–15 In order to address these gaps nationally, the American Academy of Pediatrics (AAP) generated a set of MH competencies for pediatricians.16 These competencies were created to better define and distinguish the role a primary pediatrician would take in providing MH
ACADEMIC PEDIATRICS 526 Published by Elsevier Inc. on behalf of the Academic Pediatric Association
Volume 14, Number 5 September–October 2014
ACADEMIC PEDIATRICS
MENTAL HEALTH TRAINING
care and they used the ACGME framework with the goal that these could influence residency training. Nationally, tools and training sessions have been implemented to help practicing pediatricians attain these competencies.17,18 However, few of these national efforts have been implemented in residency training programs. Few residency programs have successfully implemented curricular interventions to better prepare residents to care for children with MH conditions.19–22 In addition, approximately a third of residency programs have begun to adapt models of integrated/collaborative care into residents’ continuity clinic where a MH specialist is available for consultation at the time of identification of a problem.23 Although these isolated curricular efforts are promising, no national guidelines or curricular interventions have been proposed in order to improve and standardize MH training. The first step in making curricular changes is to perform a needs assessment, identifying gaps between the current and ideal approaches to a health care problem.24 Pediatric PDs are key stakeholders in medical education, and curricular and programmatic changes would be impossible without their support. The aim of this study was therefore to survey pediatric PDs to assess current MH training practices, plans and receptivity to changes given the new AAP MH competencies, and their perceptions of resident knowledge and skills in MH care. We hypothesized that despite these new competencies, few programs have addressed them, further propagating training gaps in pediatric MH care. We also sought to assess whether current program characteristics influenced current and future MH training, because this could help inform curriculum development and implementation. More specifically, we wanted to know whether there was any association between current models of MH care and perceived resident knowledge and skills.
METHODS A cross-sectional design was employed using a Webbased survey to assess current MH curriculum practices, receptivity and preferences for curriculum reform, knowledge and influence of AAP MH competencies, and perceptions of current resident knowledge and skills in addressing MH issues. SUBJECTS AND SETTING All 193 PDs who were members of the Association of Pediatric Program Directors (APPD) e-mail list in January 2011 were eligible to participate in the survey. The survey was submitted and approved by the local institutional review board. The survey was then submitted to the APPD’s Research Task Force, where it was peer reviewed and approved for submission through their e-mail list. DATA COLLECTION The APPD e-mailed the survey with an introductory text explaining the survey and consent for the survey to their PD e-mail list. Two reminder e-mails were sent, asking those
527
who had not yet completed the survey to consider participating in the study. SURVEY INSTRUMENT The researchers developed the survey after extensive literature review (Online Supplement). The researchers piloted the survey within the Division of General Academic Pediatrics at the authors’ university and with members of the APPD. The survey included 16 questions within the following domains: 1) program characteristics including continuity clinic model of MH care; 2) MH education modalities (current practices, receptivity to new modalities, and preferences for new modalities); and 3) perceived resident MH competence. The preceding domains included closed-ended questions but a final question not included in the above domains intended to elicit further openended comments. DOMAIN 1: CHARACTERISTICS AND MH MODEL OF CARE Program characteristics collected included program type, size, location, payer mix, and translator needs. Models of care for MH services in continuity clinics were defined from the literature, and participants were asked to choose 1 of 5 models: exclusive referral, traditional care, phone consultation model, enhanced care, and integrated/collaborative care.25 These models are further defined in the Online Supplement. The variable Model of MH Care was transformed to yield a dichotomy between traditional or referral-only models versus models involving presence of a MH professional (enhanced care, phone consultation, and integrated/collaborative care models). We considered the presence of any MH professional an enhanced model. DOMAIN 2: LEARNING MODALITIES The survey assessed how programs currently integrate MH education into training and which educational modalities they would desire and implement (Online Supplement). PDs were asked if they would implement annotated cases, online curriculum, prepared presentations, video lectures, MH rotation, and an integrated experiential learning curriculum. Each modality a PD would implement was given a point, and a summative variable of these modalities was created for analysis, entitled Curricular Index. DOMAIN 3: MH COMPETENCIES PDs were asked about their awareness of the new MH competencies proposed by the AAP in 2009 and whether these would influence curricular changes. Chosen competencies from the AAP’s statement were then listed for PDs to rate their residents’ behavior and knowledge in caring for children with MH concerns. The survey included 9 MH patient care and communication skills and 3 skills involving communication with other professionals. The frequency residents performed patient care/communication and systems-based skills were ranked on a 5-point Likert scale ranging from never to always. The rankings for
528
GREEN ET AL
ACADEMIC PEDIATRICS
each of the 9 MH patient care and communication skills were added up and combined to create a summative outcome variable entitled Patient Care and Communication Competency (0 ¼ never, 1 ¼ rarely, 2 ¼ sometimes, 3 ¼ often, 4 ¼ always). Three measures that described skills on communication with other professionals were combined to create the summative variable entitled Systems-Based Practice Competency. This variable was created using the same ranking scale described above. Seventeen measures of medical knowledge included 6 MH diagnoses, their treatments, and general behavioral health treatments. These were ranked using a Likert scale ranging from poor to excellent. The rankings for each of 17 measures of knowledge of diagnoses and treatment were combined to create the summative outcome variable entitled Medical Knowledge Competency (0 ¼ poor, 1 ¼ average, 2 ¼ excellent). These composite variables were created for each ACGME competency because they better summarized our individual measures. FREE-TEXT COMMENTS The survey concluded with a text box which allowed for free-text comments. STATISTICAL ANALYSIS We included all surveys with 9 or more questions completed. SPSS for Windows was used for data analyses (IBM, Armonk, NY). Descriptive statistics were derived for program and continuity clinic characteristics, current curricular practices, likelihood to implement new curriculum, knowledge and influence of the 2009 AAP MH competencies, and PD perceptions of current resident MH knowledge and skills. To assess whether specific program demographics influenced current and future MH practices bivariate and multivariate analyses were conducted with the use of Fisher’s exact test, t tests, and logistic regression to look for associations between variables: program demographics as the independent variable and 1) current curricular practices, 2) receptivity to implementing new curricula, and 3) knowledge of MH competencies as the outcome variables. We
also examined associations among 1) program demographics, 2) awareness of MH competencies, and 3) likelihood to implement various curricular activities to the outcome variable, PD perceptions of their residents’ MH competencies. Internal consistency was assessed for each composite variable in order to assess the degree that each MH skill or knowledge item in the variable measured a single construct, or competency. This was done via Cronbach’s alpha. Comments at the end of the survey were reviewed and grouped into preexisting categories (most expanded on already existing answer choices) or separate categories if necessary.
RESULTS DOMAIN 1: CHARACTERISTICS AND MH MODEL OF CARE Data from 99 pediatric PDs (51%) were included for analysis (Table). We were unable to assess characteristics of those who did not respond. However, the proportion of respondents was similar to all programs nationally in terms of size and location. In addition, the proportion of our participants’ MH care model was similar to prior results in the literature.23 More than 70% of programs were in urban locations, and half had a continuity clinic at their main institute. Eleven programs responded having a combination of urban, suburban, and rural locations. Respondents’ clinics served primarily children who were uninsured or eligible for government insurance, although in 10% of clinics, at least half of the patients were covered by commercial insurance. Twenty-eight percent of programs had MH specialists located in clinic, with half of those (14%) endorsing co-location. DOMAIN 2: LEARNING MODALITIES Figure 1 illustrates MH educational modalities and whether PDs currently, plan to, or want to have each modality. By report, 87% of programs taught MH knowledge and skills as part of another rotation, while only 8% (n ¼ 7 programs) required a separate MH rotation. MH was taught most often as an elective or in didactic sessions.
Table. Program Characteristics Characteristic
Variable
Total Respondents (n ¼ 99)
National Data (n ¼ 199)
P
Program size (% by no. of residents)
0–20 21–40 41–60 61–80 >80 Urban Combination Hospital based Off-site Private office Combination Exclusive referral Traditional care Phone consultation model Enhanced care Integrated/collaborative care
12.1% (12) 42.4% (42) 26.3% (26) 10.1% (10) 9.1% (9) 77.8% (77) 11.1% 48.5% 12.1% 1.0% 37.4% 15.4% (14) 54.9% (50) 1.1% (1) 14.3% (13) 14.3% (13)
14.6% (29) 39.7% (79) 22.6% (45) 9.5% (19) 13.6% (27) 84.4% (168)
.83 .77 .72 .96 .72 .17
Program location Continuity clinic sites
Continuity clinic model
ACADEMIC PEDIATRICS
MENTAL HEALTH TRAINING
529
Figure 1. Current and future mental health educational activities reported by pediatric residency directors.
However, PDs were receptive to implementing various MH learning activities. At least 60% of PDs would implement all modalities suggested. The activities endorsed most frequently were MH rotation (80%) and annotated cases (89%). DOMAIN 3: PERCEIVED MH COMPETENCIES Only 45% of PDs were aware of the published AAP MH competencies; 65% of these PDs were planning to make changes. Figures 2 and 3 show PDs’ perception of residents’ patient care and communication and systemsbased competencies. Overall, PDs rarely stated their residents always screen, recognize, and/or manage MH problems. However, there are specific competencies that more than half of PDs report their residents accomplish often or always screen for behavioral issues, recognize and treat MH issues, and collaborate with MH specialists. For the remainder of the skills listed, less than half of PDs reported that their residents frequently used each skill. Figure 4 illustrates 11 of the 17 medical knowledge compe-
tencies included in the variable, primarily treatment knowledge. Knowledge of diagnostic criteria was similar to treatment, except 64% of PDs reported above-average knowledge in diagnosing attention-deficit/hyperactivity disorder (ADHD) and 57% in ADHD treatment. Otherwise, the majority of PDs ranked their resident knowledge of various DSM diagnoses and treatments as average. Knowledge about psychosocial and pharmacological interventions was infrequently ranked as above average at 18.6% and 30.2%, respectively. In multivariate analyses, we found no associations between program characteristics (including MH model of care) and current curricular practices. However, we did find that larger programs had a lower curricular index, meaning they were less likely to implement a combination of learning activities (P < .05). In contrast, programs with exclusive referral as their model for MH care in continuity clinic were more likely to implement multiple curricular activities (P < .05) compared to traditional care models; more specifically, they were more likely to implement a
Figure 2. Program director assessment of how frequently residents perform patient care and communication competency behaviors in providing care for mental health conditions.
530
GREEN ET AL
ACADEMIC PEDIATRICS
FREE-TEXT COMMENTS Twenty participants left comments at the end of the survey. Seven comments reinforced the need for MH curricular interventions, including a comment on how this was the weakest part on their graduated residents’ pediatric boards. Three comments suggested that access to resources was a barrier to both teaching and caring for pediatric MH issues. Three comments suggested that a barrier to enhance MH education is competing priorities in the setting of reduced work hours.
Figure 3. Program director assessment of how frequently residents perform behaviors to communicate with other professionals in providing care for mental health conditions.
MH rotation (P < .05). There were no further associations between program characteristics and future curricular practices. Of note, PDs of large programs (>80 residents) were 15 times more likely to be aware of the new AAP MH competencies (P < .05) compared to small programs (
