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Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
The Current and Ideal State of Mental Health Training: Pediatric Resident Perspectives a
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Elisa Hampton , Joshua E. Richardson , Susan Bostwick , Mary J. Ward & Cori Green
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Department of General Academic Pediatrics, Weill Cornell Medical College, New York, New York, USA b
Weill Cornell Medical Library, Weill Cornell Medical College, New York, New York, USA Published online: 20 Apr 2015.
Click for updates To cite this article: Elisa Hampton, Joshua E. Richardson, Susan Bostwick, Mary J. Ward & Cori Green (2015) The Current and Ideal State of Mental Health Training: Pediatric Resident Perspectives, Teaching and Learning in Medicine: An International Journal, 27:2, 147-154, DOI: 10.1080/10401334.2015.1011653 To link to this article: http://dx.doi.org/10.1080/10401334.2015.1011653
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Teaching and Learning in Medicine, 27(2), 147–154 Copyright Ó 2015, Taylor & Francis Group, LLC ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2015.1011653
The Current and Ideal State of Mental Health Training: Pediatric Resident Perspectives Elisa Hampton Department of General Academic Pediatrics, Weill Cornell Medical College, New York, New York, USA
Joshua E. Richardson Weill Cornell Medical Library, Weill Cornell Medical College, New York, New York, USA
Susan Bostwick, Mary J. Ward, and Cori Green
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Department of General Academic Pediatrics, Weill Cornell Medical College, New York, New York, USA
Phenomenon: Mental health (MH) problems are prevalent in the pediatric population, and in a setting of limited resources, pediatricians need to provide MH care in the primary medical home yet are uncomfortable doing so citing a lack of training during residency as one barrier. Approach: The purpose of this study is to describe pediatric residents’ experiences and perspectives on the current and ideal states of MH training and ideas for curriculum development to bridge this gap. A qualitative study using focus groups of pediatric residents from an urban academic medical center was performed. Audio recordings were transcribed and analyzed using a grounded theory approach. Findings: Twenty-six residents participated in three focus groups, which is when thematic saturation was achieved. The team generated five major themes: capabilities, comfort, organizational capacity, coping, and education. Residents expressed uncertainty at every step of an MH visit. Internal barriers identified included low levels of comfort and negative emotional responses. External barriers included a lack of MH resources and mentorship in MH care, or an inadequate organizational capacity. These internal and external barriers resulted in a lack of perceived capability in handling MH issues. In response, residents reported inadequate coping strategies, such as ignoring MH concerns. To build knowledge and skills, residents prefer educational modalities including didactics, experiential learning through collaborations with MH specialists, and tools built into patient care flow. Insights: Pediatric residency programs need to evolve in order to improve resident training in MH care. The skills and knowledge requested by residents parallel the American Academy of Pediatrics statement on MH competencies. Models of collaborative care provide similar modalities of learning requested by residents. These national efforts have not been operationalized in training programs yet may be useful for curriculum development and dissemination to enhance trainees’ MH knowledge and skills to provide optimal MH care for children. Keywords
mental health, pediatric residency training, resident education, and behavioral health
Correspondence may be sent to Elisa Hampton, Weill Cornell Medical College, 525 E. 68th Street, Box 139, New York, NY 10065, USA. E-mail: [email protected]
INTRODUCTION Mental health (MH) diagnoses were first described as “the new morbidity” in pediatrics almost 40 years ago1,2 and are now becoming even more prevalent.3 Today one in eight American children between 8 and 15 years of age meets Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnostic criteria.4 Chronic MH conditions have surpassed chronic physical health conditions as the most common disabilities in children3,5 and have lifelong impacts on quality of life.5,6 However, pediatric MH issues remain under recognized and undertreated.7 Furthermore, access to subspecialty MH care is limited by a shortage of MH professionals, a situation that will not improve in the foreseeable future.8 Although practicing pediatricians recognize the need to assume additional responsibility for MH care, they cite inadequate training, confidence, and support as barriers to the underrecognition and treatment of pediatric MH concerns.9,10 Improving MH care and access to services is a high priority of the American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry, who have jointly issued a statement that MH care should be integrated into the primary pediatric medical home.11,12 Furthermore, an AAP policy statement specifies MH competencies pediatricians should achieve by the year 2020.13 Although these national statements and competencies are ideal standards to strive for, they do not specifically address how residency programs should evolve to train future pediatricians to uphold these standards. Improving developmental and behavioral (DBP) training in primary care has been discussed since the 1980s14,15 and resulted in the Accreditation Council for Graduate Medical Education (ACGME) requiring a 1-month rotation in DBP in the 1990s.16 Today the ACGME more specifically requires resident training in MH surveillance, screening, recognition, and counseling of developmental and behavioral abnormalities during DBP rotations.17 Despite these requirements, graduating pediatric residents and pediatric program directors report that residents’ training and skills in MH care are
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suboptimal.18,19 In addition, practicing pediatricians report variability in comfort in recognition and treatment of behavioral health problems.20 A few residency programs have successfully responded with increased rigor in their MH training,21–24 but to our knowledge these educational interventions were designed without the benefit of formal needs assessments. As a first step in curriculum development, this pilot study provided a needs assessment of targeted learners,25 pediatric residents, to inform mental health training in pediatric residency programs. The objective of this study was to describe pediatric residents’ experiences and perspectives on the current state of MH training, the ideal state in MH training, and ideas for curriculum development in order to bridge this gap.
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METHODS Overview Researchers conducted focus groups of pediatric residents. Focus groups are multiperson interviews intended to foster dialogue between subjects, which can generate information beyond what could otherwise be gathered by one-on-one interviews.26 The Institutional Review Board of Weill Cornell Medical College approved this study. This project was carried out by a multidisciplinary team of researchers: a pediatric attending involved nationally with medical education and MH efforts (CG), a pediatric resident with training in focus group moderating (EH), a biomedical informatics researcher with qualitative expertise (JR), a child psychologist (MW), and an executive vice chair of pediatric education (SB). Using a multidisciplinary team broadens the scope of perspectives to data analysis thereby improving rigor and trustworthiness of results.27 The research team developed a focus group guide comprised of open-ended questions and prompts geared toward assessing the current state of residents’ MH training: (a) experiences, knowledge, skills, and attitudes; (b) the ideal state of training; and (c) educational strategies to reach this ideal. This approach is in line with Kern’s model of curriculum development that relies on needs assessments to identify the differences between current and ideal approaches for given healthcare problems.25 Questions were pilot tested and iteratively refined based on feedback from one focus group of general pediatric attendings (see Table 1).
Settings and Subjects The setting was an academic urban teaching hospital that trains 60 residents. The residency curriculum included 3 weeks of DBP and adolescent rotations required by the ACGME. Residents staffed weekly continuity clinics at one of three urban pediatric clinics that primarily served children who qualify for government-based insurance. Forty residents
TABLE 1 Focus group questions What do you think of when I say mental health? Think about a patient you have seen in clinic with a mental health issue. How comfortable were you as a pediatrician in providing care for this patient’s mental health issue? What are the positive aspects of caring for a patient with mental health issues? What are the frustrations of caring for patients with mental health issues? What do you think the role of the pediatrician should be in addressing mental health issues? Ideally, how would you like to learn about addressing mental health issues within a primary care setting? How has your residency experience so far differed from this ideal experience? What advice would you give to a program director that is creating an improved curriculum in mental health issues?
conducted their continuity clinics at the hospital in the main academic center, and 20 residents worked at two affiliated community clinics. Each of these clinic sites followed a relatively traditional model of MH care with social workers available on site, but otherwise residents referred the majority of patients with MH complaints to MH specialists. The resident coinvestigator (EH) enrolled a convenience sample of pediatric residents by issuing a call for participation via e-mail. Food was offered as an incentive to participation.
Data Collection The resident coinvestigator moderated each focus group. She was purposefully chosen to be the focus group moderator because as a peer to the resident subjects, the research team felt she could best establish rapport with the residents to gain insider perspectives. All focus groups were audio-recorded in addition to having a note-taker present. The moderator asked respondents the same interview guide questions in the same sequence, supplemented by inductive probing on key responses. As focus groups were conducted, the researcher made a conscious effort to summarize participants’ answers and gain confirmation that her summaries were accurate. The research team iteratively conducted focus groups and analyzed focus group data until achieving thematic saturation (the point at which no new ideas are uncovered).26,28 Thematic saturation was determined after two investigators (EH and CG) completed initial analyses and mutually agreed.
Data Analysis A professional transcriptionist transcribed focus group audiotapes. Transcripts were deidentified by the resident
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coinvestigator to assure that other coinvestigators were blind to the identities of participating residents. Finally, with the aid of notes taken during the focus groups, the resident coinvestigator attributed statements to resident labels (“Resident A,” “Resident B,” etc.) and created a key for the other researchers that linked level of training to resident labels. Focus group transcripts were analyzed by using common coding techniques for qualitative data employing grounded theory method. Grounded theory is a qualitative method for inductively generating results in the form of “themes” based on primary data from interviews, observations, or both.26,28 Themes emerge from the primary data after researchers assign labels to primary data (“codes”), define those codes, and then explicate the relationships between those codes (“axial coding”). Three coinvestigators (EH, JR, CG) independently read the transcripts and attributed self-defined codes to words and phrases in the text. Codes and their definitions were stored and organized in NVivo version 10 (QSR International; Doncaster, Australia) qualitative research software. The investigators routinely met to compare codes, develop code definitions, and delineate the relationships between those codes while maintaining an audit trail of codes. Through these structured teambased dialogues, the research team grouped codes into subthemes and then developed five overarching themes pertaining to the research question. Two coinvestigators who were not involved in the coding process (SB, MW) reviewed the themes and provided comments and criticisms. The researchers took multiple steps to establish rigor in the process thus assuring the trustworthiness of the results: convening a multidisciplinary research team, clarifying and summarizing participant responses throughout focus groups, and vetting findings with investigators not involved in coding.
RESULTS Twenty-six residents participated in one of three 1-hour focus groups between October 2010 and January 2011, including six Year 1 residents, twelve Year 2 residents, and eight Year 3 residents. The research team organized participants’ described needs into five overarching themes: Capability – the degree of knowledge and skills required to care for patients with MH concerns. Comfort – factors internal to the resident, including emotional responses and perceptions of MH care. Organizational Capacity – factors beyond a resident’s direct control but intrinsic to the organization in which they practice. Coping – actions reported when presented with patients and families with MH issues. Education – content and means for acclimating pediatric residents to MH.
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These themes are described next, with further examples of key quotations in Table 2. As the researchers reviewed the focus group transcripts, they observed that residents’ opinions did not notably differ by their levels of training. Resident year of training is also included in Table 2.
Theme 1: Capability One of the most prominent themes expressed by residents throughout each focus group was uncertainty regarding knowledge and skills pertaining to MH care. In particular, residents felt their MH knowledge was lacking in comparison to their knowledge about physical health complaints. For example, a resident remarked, “The medical stuff . . . we can . . . handle. But the psych issues and . . . all of the home/life issues . . . I don’t even know where to begin.” When asked about the definition of MH, none of the 26 focus group residents were familiar with the AAP’s definition of MH. One resident stated, “I never realized that [the] AAP’s definition included . . . neurodevelopment and behavioral” concerns. Beyond the definition of MH, residents expressed uncertainty at every step of a patient encounter required by the ACGME: surveillance, screening, recognition, and counseling of behavioral and developmental abnormalities. On the topic of eliciting behavioral or emotional concerns, one resident asked, “What questions are we supposed to ask for different age groups? . . . I feel like I’m lacking [knowledge].” Once a concern was recognized, residents were unsure of next steps: “I was so used to people saying no, that when I had a patient say yes I didn’t really know what to say . . . besides . . . ‘Do you want to talk to someone?’” This suggests residents lack both the communication skills and knowledge to appropriately handle an MH encounter. In addition, residents questioned how to make an MH diagnosis since “there’s no blood test . . . no . . . objective data” to “pinpoint a diagnosis.” In terms of management residents reported uncertainty, not “really know [ing] . . . what exactly the best resources [are],” and feeling unprepared to “partner with the parents” when discussing and implementing a management plan. While discussions on psychostimulant medications were common, residents expressed unfamiliarity with prescribing such medications including one who stated, “All I remember is the scary stuff. The black box warning.”
Theme 2: Comfort Throughout the focus groups, residents predominantly expressed discomfort with the provision of MH care. More specifically, they expressed internal feelings such as dislike, limited control, powerlessness, and the stigma associated with MH diagnoses. A few residents described MH as “gross” or “scary.” As one resident stated, “I don’t feel comfortable because I have no interest in that pathology.” Another resident stated, “We don’t enjoy [psychiatry]. Just like I don’t like
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“. . . If [a patient] says, ‘I am feeling depressed.’ It’s like, well what do you do next?” “I think I also just don’t know the drugs as well. I don’t know a lot of the side effects as well and I don’t know how to use them, how to titrate them up.” “I sometimes don’t know what’s normal behavior. And what a parent will describe as [a child’s behavior] being . . . unbearable . . . might sound actually normal to me; and age appropriate, developmentally appropriate. But if it’s causing that family so much distress, I don’t know what to say.” “I’m pretty comfortable and I think the attendings there seem pretty comfortable in just referring people to emergency rooms but . . . short of that, I don’t . . . know what to do.” The resident reported, “. . . a sense of despair maybe because I rarely see any of these patients getting better.” “Psych is the one thing I feel like I refer to over and over and over and over and nothing ever happens.” “. . . We look to our preceptors for guidance . . . and they clearly are not comfortable with it [MH].” “We’re always on a time crunch and. . .any time you start going into looking at [a] psychiatric history, it’s a very time consuming process. So I tend to prioritize those issues further down and that’s a problem.” “It seems like in general, getting patients follow-up, especially in the outpatient setting [is difficult]. I always just call the social worker and then I have no clue what happens after that. I’m left out of the process.” “I feel like we’re always deciding, ‘OK. That’s probably a behavioral thing. It’s not an acute.’ [. . .] so we’ll [address] it the next time.” “I had a patient with bipolar and Asperger’s, and he actually sees . . . a psychiatrist who manages all his psychiatric medication and sees a counselor who does whatever counseling and psychological stuff that they do. And I really don’t feel comfortable at all treating him. I just make sure that he is not suicidal, homicidal, or his behavior is out of control, and at that point I would probably refer him to a psychiatrist.” “I think that would be really helpful, to actually see [MH care] in progress. Kind of shadow and just take it in.” “It’d be . . . the best learning environment to just sort of see, even how those professionals couch these topics, in . . . the right language.” “I really just think it’s an exposure thing. Unless we saw a lot more of it . . . I wouldn’t be comfortable.”
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3 3 2 3
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Resident Year of Training
Quote
Note: MH D mental health.
Education
Coping
Organizational Capacity
Comfort
Capability
Theme
TABLE 2 Appendix of quotations
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taking trips to the adult side.” Resident comments also suggested they are more comfortable with treating physical illness than MH conditions. As one resident stated, “I’d be more comfortable titrating warfarin than Strattera.” Another resident stated, “I think that . . . it’s much more difficult to say to a parent, “‘Your daughter is borderline,’ than it is to say, . . . ‘Your daughter has meningitis.’” While residents did feel comfortable referring patients with acute MH issues such as suicidal ideation to the Emergency Department, they felt “helpless” and powerless if they were that resident evaluating the patient in the Emergency Department. Other residents described MH issues as “un-gratifying” and that “nothing ever happens” after referrals are made. Residents also brought up the topic of stigma about MH diagnoses: their own biases, their preceptors’ responses, and their perceptions of patients’ and families’ opinions. One resident explained, “[MH disease is] a huge burden . . . to diagnose . . . a 15-year-old child as being bipolar. . . . It’s hugely stigmatized in our society.”
monitoring for side effects. If new MH concerns came up during a visit, another resident suggested their job was to “identify [MH problems] and . . . triage . . . [or] send them to the ER.” However for patients that did not need emergent care, residents reportedly referred to MH specialists and would “just sort of cross [their] fingers and hope that [patients] follow up with the list of numbers that they’re given.” These comments suggest that residents coped by reducing their scope of medical practice by triaging and referring MH care rather than accepting more responsibility. However, residents did state that given the “shocking dearth of child psychiatrists,” pediatricians needed to continue to be “a jack of all trades” and assume responsibility for MH care. Others suggested that even if they subspecialize, “mental health is a major issue” when thinking about medication compliance and managing chronic conditions. One resident astutely stated, “No matter what we do medically, if someone commits suicide, all of our medical expertise is for nothing. So clearly it’s [mental health] very important.”
Theme 3: Organizational Capacity Residents expressed frustrations with the organizational structure in which they saw patients: a continuity clinic and the academic center. Time limitations and continuity of care were specifically mentioned as barriers within their clinic. For example, one participant commented, “There have been several instances where I’ve really wanted to . . . delve into [MH] questions with [patients] . . . but there’s just no time.” They believed MH issues require “incredibly personal conversation [s]” requiring continuity of care, which is at times difficult to achieve in continuity clinic. Organizational barriers to providing MH care included limited resources and support within their continuity clinic, the academic center, and their patients’ communities. Residents again distinguished MH from physical healthcare when caring for a child with a chronic medical condition because other subspecialists were easily accessible. In contrast, when caring for patients with psychiatric problems, residents stated they felt like they were “in the trenches with no backup.” Residents referred to the MH resources that do exist as a “separate jurisdiction,” a “nebulous” place, like “the abyss.” In addition, residents noted that “[their] comfort level often reflects [their] attendings’ comfort levels” and that perhaps MH training needs to “start . . . higher up [with general pediatricians] and then it will trickle down to [residents].”
Theme 5: Education The residents identified training needs throughout the focus groups suggesting educational content, modalities, and tools to help move the current state of MH training to the ideal state. Content areas included depression, attention deficit and hyperactivity disorder, anxiety, autism, and distinguishing abnormal from normal behavior. One resident wanted to know how to determine when a child has “crossed the line from being . . . [a] rambunctious four-year-old to being [one] on his way to . . . social malfunction.” Residents often discussed improving their communication skills. As one resident stated, “Aside from knowing . . . the pros and cons . . . [of medication] side effects . . . knowing the right way to . . . pitch [that medication] . . . would be . . . invaluable.” Residents desired more knowledge with what MH resources exist, how to appropriately allocate them, the processes for making referrals, and the strategies for comanaging patients with specialists. To obtain this knowledge, residents requested a combination of scheduled didactic sessions given by MH specialists and opportunities for experiential learning including, “shadowing along with a psychiatrist,” and actively starting to manage MH care in their own clinic. One resident suggested they would get “the most bang for our buck with . . . our own [continuity clinic] and gen[eral] ped[iatric] attendings start to manage things like that more and teach it to us. . . . That certainly is the most effective way that we learn.” To successfully manage their own patients’ MH care, residents felt they needed more knowledgeable and experienced preceptors to model this care. As one resident stated, “[How to care for patients is] one of those things you . . .learn by example.” Residents suggested that improved training of their preceptors and establishing relationships with MH specialists could offer the support needed for MH training implementation.
Theme 4: Coping Residents expressed suboptimal coping mechanisms including ignoring MH issues when they arose during a patient visit. In addition, various residents described a tendency to “gloss over” any psychostimulants on patients’ medication lists, or “assumed” someone else was checking drug levels and
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Many of the positive experiences with MH that residents reported occurred during their DBP and adolescent rotations. In particular, they highlighted the experiential learning, which occurred during these rotations: “We actually see what’s going on and how they evaluate kids for such things [developmental delay].” Residents suggested that MH training should be integrated in all years of training and those high-yield rotations such as DBP and adolescent medicine should come earlier in their training. Although a few residents suggested an online curriculum could be helpful, the majority of residents rejected this idea. However, residents believed that technology could be used educationally, especially electronic health records (EHR). One resident commented that “if [MH is] supposed to be part of . . . well-child visit . . . then maybe it [should] be a part of [the EHR].” Pocket guides, algorithms, and accessible handouts were also tools that residents suggested could facilitate their ability to care for patients in their own clinic.
DISCUSSION As the prevalence of MH concerns has increased,5 recommendations regarding the scope of practice of pediatricians have also changed.12 However, resident comments within the themes identified in this study suggest that residents feel more capable, comfortable, and supported when caring for children with physical conditions as opposed to MH conditions. This research is one of only a few studies that address MH training for pediatric residents by assessing targeted learners. Our findings offer new insights into MH education by highlighting residents’ perceptions of how current training fails to address internal and external needs and suboptimally implements MH goals and guidelines into actionable training. The results demonstrate that residents face internal barriers in capabilities and comfort surrounding MH, and that effective coping with MH care will rely on educational strategies and organizational capacity that supports resident MH knowledge and skills. Despite ACGME requirements in MH training and AAP competencies that define these skills in detail,13,17 residents self-identified deficiencies in MH knowledge, patient care skills, communication and interpersonal skills, and systemsbased practice. Residents emphasized a lack of communication skills, which is consistent with prior study that demonstrated 60% of residents’ responses to parental psychosocial concerns were suboptimal; 17% of residents ignored psychosocial concerns; and 43% asked follow-up questions but did not provide information, reassurance, or guidance.29 In addition, national efforts to help pediatricians widen their scope of practice and overcome organizational barriers have led to the development of various collaborative care models that include colocation of MH services and telepsychiatry.30–32 These models of care have been shown to increase provider confidence and improve recognition of pediatric MH conditions. Adapting these models into training
programs can utilize concepts of pedagogy to enhance experiential learning experiences and provide the mentorship residents desire. Approximately one third of pediatric programs surveyed by Bunik employ one of these collaborative models, either via a true colocation model or with access to MH specialists in the office on a later date.33 Initial study of these models during training suggest residents have improved skills in systems-based practice and perceived greater access to services. However, further study is needed to further understand how different models of integrated care impact resident learning. Results suggested that targeted interventions to “train the trainers” are needed so that preceptors can model optimal MH care. Residents pointed out that general pediatrics faculty need improved MH education so that the knowledge can “trickle down” to residents. The need for faculty development for practicing pediatricians’ both in community and academic settings has been well established.10,34 National efforts such as toolkits, training sessions, and statements have been made to help integrate MH care into the primary medical home.12,13,35,36 However, these efforts have not targeted faculty in training programs at this point. Residents self-identified MH content and skills that already exist nationally as competencies pediatricians should achieve.13 To build knowledge and skills, residents prefer educational modalities that include didactics, experiential learning, and tools built into their patient care flow. The role of technology in improving MH care and resident education was discussed in focus groups and prior study found that resident confidence increased after viewing evidence-based interactive video vignettes on MH encounters during a DBP rotation.23 Although use of videos was not discussed by residents in this study, most residents rejected an online curriculum. This is particularly interesting, as online curricula are becoming more commonplace to meet the needs of changing hours and work restrictions implemented in residency programs. However, limited study about the impact of e-learning in medical education shows efficient knowledge gain, retention has not been studied, and there is report that trainees do not see online learning as a replacement to other modalities of learning.37 Results of this study support the use of prompts within the EHR during patient visits to empower residents during a visit. There are several limitations of this study. One limitation is that focus groups were conducted within one residency program and so results are not generalizable (as is the case for any qualitative study). Rather, these qualitative findings are “transferrable” given sufficient context of the original setting so that the reader can judge applicability to his or her own setting.35 Furthermore, national data of graduating residents and practicing pediatricians corroborate many of our attitudinal and competence statements and thereby lending further trustworthiness of the results.9,14,18 A second limitation is that focus group data are vulnerable to responder bias, if residents who are particularly
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attuned to MH issues were overrepresented among participants. However, we note that negative reactions to MH issues were openly voiced among participants, suggesting that a variety of opinions were represented. Also, bias in extracting themes was addressed by gathering a multidisciplinary team that included pediatricians, a nonclinician with qualitative research expertise, and a pediatric psychiatrist. Inclusion of only 26 subjects is a limitation, although the three focus groups provided sufficient data for thematic saturation, which is the goal in qualitative research. Finally, we did not collect potentially important quantitative data that could have helped to differentiate residents’ comments by year of training or whether DBP or adolescent medicine rotations had been completed. This is particularly important, as one prior study does suggest quality and length of DBP rotation impacts perceived competence.18 Despite these limitations, this study builds on prior literature supporting the need for curriculum reform and MH standards in primary care training programs.14 Our study is unique in that it provides a first step in assessing the needs of targeted learners, pediatric residents. Next steps should include further qualitative and quantitative studies at residency programs of all sizes and geographic locations. In addition, more specific analyses on the impact of DBP rotations and different models of integrated MH care on learner and patient outcomes are needed. Quality improvement efforts may be another way to improve MH care in certain programs. This study suggests that dissemination and implementation strategies for national training guidelines and curricula may be needed to improve MH training throughout the country.
CONCLUSION With the increasing burden of MH issues and their longterm impacts on children and families comes a responsibility for pediatricians to improve the quality of pediatric and adolescent MH care in the United States. Results from this study add to the growing body of research supporting the need for improved MH training in pediatric residency programs. Programs must address both internal and external barriers that prevent pediatric residents from providing optimal MH care. Content and learning modalities that residents request exist nationally, with the AAP MH competencies, toolkits, and published models of integrated care. However, recommendations are needed on way to best operationalize these national efforts into training programs. These national resources can help inform curricular content and modalities that will enhance resident capabilities and comfort in providing MH care instead of utilizing inadequate coping strategies. In addition, models of integrated MH care provide experiential learning opportunities and enhance programs’ organizational capacity to supporting residents and preceptors to build their knowledge and skills in providing optimal MH care for children.
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FUNDING Support was provided by the Association of Pediatric Program Directors Special Projects Grant (Principal Investigators: Drs. Susan Bostwick and Cori Green).
REFERENCES 1. Wise PH. The rebirth of pediatrics. Pediatrics 2009;123:413–6. 2. Dreyer BP. Mental health and child developmental problems: The “notso-new morbidity”. Academic Pediatrics 2009;9:206–8. 3. Halfon N, Houtrow A, Larson K, Newacheck PW. The changing landscape of disability in childhood. Future Child 2012;22:13–42. 4. Merikangas KR, He JP, Brody D, Fisher PW, Bourdon K, Koretz DS. Prevalence and treatment of mental disorders among US children in the 2001-2004 NHANES. Pediatrics 2010;125:75–81. 5. Slomski A. Chronic mental health issues in children now loom larger than physical problems. Journal of the American Medical Association 2012;308:223–5. 6. Delaney L, Smith JP. Childhood health: Trends and consequences over the life course. Future Child 2012;22:43–63. 7. Rhodes A, Sciberras E, Oberklaid F, South M, Davies S, Efron D. Unmet developmental, behavioral, and psychosocial needs in children attending pediatric outpatient clinics. Journal of Developmental and Behaviorial Pediatrics 2012;33:469–78. 8. Thomas CR, Holzer CE. The continuing shortage of child and adolescent psychiatrists. Journal for the American Acadamy of Child and Adolescent Psychiatry. 2006;45:1023–31. 9. Olson AL, Kelleher KJ, Kemper KJ, Zuckerman BS, Hammond CS, Dietrich AJ. Primary care pediatricians’ roles and perceived responsibilities in the identification and management of depression in children and adolescents. Ambulatory Pediatrics 2001;1:91–8. 10. Stein RE, Horwitz SM, Storfer-Isser A, Heneghan A, Olson L, Hoagwood KE. Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP periodic survey. Ambulatory Pediatrics 2008;8:11–7. 11. Martini R, Hilt R, Marx L, Chenven M, Naylor M, Saret B, et al. Best principles for integration of child psychiatry into the pediatric health home. 2012. Available at: www.aacap.org/ galleries/ defaultfile/ best_principles_for_integration_of_child_psychiatry_into_the_pe diatric_health_home_2012.pdf. 12. American Academy of Child and Adolescent Psychiatry Committee on Health Care Access and Economics Task Force on Mental Health. Improving mental health services in primary care: Reducing administrative and financial barriers to access and collaboration. Pediatrics 2009;123;4:1248–51. 13. American Academy of Child And Adolescent Psychiatry Committee on Health Care Access and Economics Task Force on Mental Health. Policy statement—–The future of pediatrics: mental health competencies for pediatric primary care. Pediatrics 2009;124:410–21. 14. Burns BJ, Scott JE, Burke JD, Kessler LG. Mental health training of primary care residents: A review of recent literature: 1974-1981. Annals of General Hopsital Psychiatry 1983;5:157–69. 15. Dworkin PH, Shonkoff JP, Leviton A, Levine MD. Training in developmental pediatrics. How practitioners perceive the gap. American Journal of Diseases of Children 1979;133:709–12. 16. Johnson RL, Charney E, Cheng TL, Kittredge D, Nazarian L, Chesney RW, et al. Final report of the FOPE II Education of the Pediatrician Workgroup. Pediatrics 2000;106:1175–98. 17. Education ACGM. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ 2013-PR-FAQ-PIF/320_pediatrics_07012013.pdf. Accessed January 6, 2015. 18. Horwitz SM, Caspary G, Storfer-Isser A, Singh M, Fremont W, Golzari M, et al. Is developmental and behavioral pediatrics training related to
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E. HAMPTON ET AL. perceived responsibility for treating mental health problems? Academic Pediatrics 2010;10:252–9. Leigh H, Stewart D, Mallios R. Mental health and psychiatry training in primary care residency programs. Part I. Who teaches, where, when and how satisfied? Annals of General Hopsital Psychiatry 2006;28:189–94. Williams J, Klinepeter K, Palmes G, Pulley A, Foy JM. Diagnosis and treatment of behavioral health disorders in pediatric practice. Pediatrics 2004;114:601–6. Kutner L, Olson CK, Schlozman S, Goldstein M, Warner D, Beresin EV. Training pediatric residents and pediatricians about adolescent mental health problems: A proof-of-concept pilot for a proposed national curriculum. Acadademic Psychiatry 2008;32:429–37. Lewy C, Sells CW, Gilhooly J, McKelvey R. Adolescent depression: Evaluating pediatric residents’ knowledge, confidence, and interpersonal skills using standardized patients. Acadademic Psychiatry 2009;33:389–93. Bauer NS, Sullivan PD, Hus AM, Downs SM. Promoting mental health competency in residency training. Patient Educucation Counseling 2011;85:e260–4. Williams J, Klinepeter K, Palmes G, Foy JM. Use of an electronic record audit to enhance mental health training for pediatric residents. Teaching and Learning in Medicine. 2007;19:357–61. Kern D, Thomas P, Hughes M. Curriculum development for medical education: A six-step approach. 2nd ed. Baltimore, MD: Johns Hopkins University Press, 2009. Shank G. Qualitative research: A personal skills approach. 2nd ed. Cranbury, NJ: Pearson, 2006. Patton M. Qualitative research and evaluation methods. 3rd ed. Thousand Oaks, CA: Sage, 2002.
28. Hanson JL, Balmer DF, Giardino AP. Qualitative research methods for medical educators. Acadademic Pedatrics 2011;11:375–86. 29. Sharp L, Pantell RH, Murphy LO, Lewis CC. Psychosocial problems during child health supervision visits: Eliciting, then what? Pediatrics 1992;89;4 Pt 1:619–23. 30. Sarvet B, Gold J, Bostic JQ, Masek BJ, Prince JB, Jeffers-Terry M, et al. Improving access to mental health care for children: The Massachusetts Child Psychiatry Access Project. Pediatrics 2010;126:1191–200. 31. Briggs RD, Racine AD, Chinitz S. Preventive pediatric mental health care: A co-location model. Infant Mental Health Journal 2007;28:481– 95. 32. Kelleher KJ, Stevens J. Evolution of child mental health services in primary care. Academic Pediatrics 2009;9:7–14. 33. Bunik M, Talmi A, Stafford B, Beaty B, Kempe A, Dhepyasuwan N, et al. Integrating mental health services in primary care continuity clinics: A national CORNET study. Academic Pediatrics 2013;13:551–7. 34. Horwitz SM, Kelleher KJ, Stein RE, Storfer-Isser A, Youngstrom EA, Park ER, et al. Barriers to the identification and management of psychosocial issues in children and maternal depression. Pediatrics 2007;119: e208–18. 35. American Academy of Pediatrics. Addressing mental health care in primary care: A clinician’s toolkit. http://www.aap.org/pcorss/demos/mht. htm. 36. Laraque D, Adams R, Steinbaum D, Zuckerbrot R, Schonfeld D, Jensen PS, et al. Reported physician skills in the management of children’s mental health problems following an educational intervention. Academic Pediatrics 2009;9:164–71. 37. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-learning in medical education. Academic Medicine 2006;81:207–12.
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
The Current and Ideal State of Mental Health Training: Pediatric Resident Perspectives a
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Elisa Hampton , Joshua E. Richardson , Susan Bostwick , Mary J. Ward & Cori Green
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Department of General Academic Pediatrics, Weill Cornell Medical College, New York, New York, USA b
Weill Cornell Medical Library, Weill Cornell Medical College, New York, New York, USA Published online: 20 Apr 2015.
Click for updates To cite this article: Elisa Hampton, Joshua E. Richardson, Susan Bostwick, Mary J. Ward & Cori Green (2015) The Current and Ideal State of Mental Health Training: Pediatric Resident Perspectives, Teaching and Learning in Medicine: An International Journal, 27:2, 147-154, DOI: 10.1080/10401334.2015.1011653 To link to this article: http://dx.doi.org/10.1080/10401334.2015.1011653
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Teaching and Learning in Medicine, 27(2), 147–154 Copyright Ó 2015, Taylor & Francis Group, LLC ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2015.1011653
The Current and Ideal State of Mental Health Training: Pediatric Resident Perspectives Elisa Hampton Department of General Academic Pediatrics, Weill Cornell Medical College, New York, New York, USA
Joshua E. Richardson Weill Cornell Medical Library, Weill Cornell Medical College, New York, New York, USA
Susan Bostwick, Mary J. Ward, and Cori Green
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Department of General Academic Pediatrics, Weill Cornell Medical College, New York, New York, USA
Phenomenon: Mental health (MH) problems are prevalent in the pediatric population, and in a setting of limited resources, pediatricians need to provide MH care in the primary medical home yet are uncomfortable doing so citing a lack of training during residency as one barrier. Approach: The purpose of this study is to describe pediatric residents’ experiences and perspectives on the current and ideal states of MH training and ideas for curriculum development to bridge this gap. A qualitative study using focus groups of pediatric residents from an urban academic medical center was performed. Audio recordings were transcribed and analyzed using a grounded theory approach. Findings: Twenty-six residents participated in three focus groups, which is when thematic saturation was achieved. The team generated five major themes: capabilities, comfort, organizational capacity, coping, and education. Residents expressed uncertainty at every step of an MH visit. Internal barriers identified included low levels of comfort and negative emotional responses. External barriers included a lack of MH resources and mentorship in MH care, or an inadequate organizational capacity. These internal and external barriers resulted in a lack of perceived capability in handling MH issues. In response, residents reported inadequate coping strategies, such as ignoring MH concerns. To build knowledge and skills, residents prefer educational modalities including didactics, experiential learning through collaborations with MH specialists, and tools built into patient care flow. Insights: Pediatric residency programs need to evolve in order to improve resident training in MH care. The skills and knowledge requested by residents parallel the American Academy of Pediatrics statement on MH competencies. Models of collaborative care provide similar modalities of learning requested by residents. These national efforts have not been operationalized in training programs yet may be useful for curriculum development and dissemination to enhance trainees’ MH knowledge and skills to provide optimal MH care for children. Keywords
mental health, pediatric residency training, resident education, and behavioral health
Correspondence may be sent to Elisa Hampton, Weill Cornell Medical College, 525 E. 68th Street, Box 139, New York, NY 10065, USA. E-mail: [email protected]
INTRODUCTION Mental health (MH) diagnoses were first described as “the new morbidity” in pediatrics almost 40 years ago1,2 and are now becoming even more prevalent.3 Today one in eight American children between 8 and 15 years of age meets Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnostic criteria.4 Chronic MH conditions have surpassed chronic physical health conditions as the most common disabilities in children3,5 and have lifelong impacts on quality of life.5,6 However, pediatric MH issues remain under recognized and undertreated.7 Furthermore, access to subspecialty MH care is limited by a shortage of MH professionals, a situation that will not improve in the foreseeable future.8 Although practicing pediatricians recognize the need to assume additional responsibility for MH care, they cite inadequate training, confidence, and support as barriers to the underrecognition and treatment of pediatric MH concerns.9,10 Improving MH care and access to services is a high priority of the American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry, who have jointly issued a statement that MH care should be integrated into the primary pediatric medical home.11,12 Furthermore, an AAP policy statement specifies MH competencies pediatricians should achieve by the year 2020.13 Although these national statements and competencies are ideal standards to strive for, they do not specifically address how residency programs should evolve to train future pediatricians to uphold these standards. Improving developmental and behavioral (DBP) training in primary care has been discussed since the 1980s14,15 and resulted in the Accreditation Council for Graduate Medical Education (ACGME) requiring a 1-month rotation in DBP in the 1990s.16 Today the ACGME more specifically requires resident training in MH surveillance, screening, recognition, and counseling of developmental and behavioral abnormalities during DBP rotations.17 Despite these requirements, graduating pediatric residents and pediatric program directors report that residents’ training and skills in MH care are
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suboptimal.18,19 In addition, practicing pediatricians report variability in comfort in recognition and treatment of behavioral health problems.20 A few residency programs have successfully responded with increased rigor in their MH training,21–24 but to our knowledge these educational interventions were designed without the benefit of formal needs assessments. As a first step in curriculum development, this pilot study provided a needs assessment of targeted learners,25 pediatric residents, to inform mental health training in pediatric residency programs. The objective of this study was to describe pediatric residents’ experiences and perspectives on the current state of MH training, the ideal state in MH training, and ideas for curriculum development in order to bridge this gap.
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METHODS Overview Researchers conducted focus groups of pediatric residents. Focus groups are multiperson interviews intended to foster dialogue between subjects, which can generate information beyond what could otherwise be gathered by one-on-one interviews.26 The Institutional Review Board of Weill Cornell Medical College approved this study. This project was carried out by a multidisciplinary team of researchers: a pediatric attending involved nationally with medical education and MH efforts (CG), a pediatric resident with training in focus group moderating (EH), a biomedical informatics researcher with qualitative expertise (JR), a child psychologist (MW), and an executive vice chair of pediatric education (SB). Using a multidisciplinary team broadens the scope of perspectives to data analysis thereby improving rigor and trustworthiness of results.27 The research team developed a focus group guide comprised of open-ended questions and prompts geared toward assessing the current state of residents’ MH training: (a) experiences, knowledge, skills, and attitudes; (b) the ideal state of training; and (c) educational strategies to reach this ideal. This approach is in line with Kern’s model of curriculum development that relies on needs assessments to identify the differences between current and ideal approaches for given healthcare problems.25 Questions were pilot tested and iteratively refined based on feedback from one focus group of general pediatric attendings (see Table 1).
Settings and Subjects The setting was an academic urban teaching hospital that trains 60 residents. The residency curriculum included 3 weeks of DBP and adolescent rotations required by the ACGME. Residents staffed weekly continuity clinics at one of three urban pediatric clinics that primarily served children who qualify for government-based insurance. Forty residents
TABLE 1 Focus group questions What do you think of when I say mental health? Think about a patient you have seen in clinic with a mental health issue. How comfortable were you as a pediatrician in providing care for this patient’s mental health issue? What are the positive aspects of caring for a patient with mental health issues? What are the frustrations of caring for patients with mental health issues? What do you think the role of the pediatrician should be in addressing mental health issues? Ideally, how would you like to learn about addressing mental health issues within a primary care setting? How has your residency experience so far differed from this ideal experience? What advice would you give to a program director that is creating an improved curriculum in mental health issues?
conducted their continuity clinics at the hospital in the main academic center, and 20 residents worked at two affiliated community clinics. Each of these clinic sites followed a relatively traditional model of MH care with social workers available on site, but otherwise residents referred the majority of patients with MH complaints to MH specialists. The resident coinvestigator (EH) enrolled a convenience sample of pediatric residents by issuing a call for participation via e-mail. Food was offered as an incentive to participation.
Data Collection The resident coinvestigator moderated each focus group. She was purposefully chosen to be the focus group moderator because as a peer to the resident subjects, the research team felt she could best establish rapport with the residents to gain insider perspectives. All focus groups were audio-recorded in addition to having a note-taker present. The moderator asked respondents the same interview guide questions in the same sequence, supplemented by inductive probing on key responses. As focus groups were conducted, the researcher made a conscious effort to summarize participants’ answers and gain confirmation that her summaries were accurate. The research team iteratively conducted focus groups and analyzed focus group data until achieving thematic saturation (the point at which no new ideas are uncovered).26,28 Thematic saturation was determined after two investigators (EH and CG) completed initial analyses and mutually agreed.
Data Analysis A professional transcriptionist transcribed focus group audiotapes. Transcripts were deidentified by the resident
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coinvestigator to assure that other coinvestigators were blind to the identities of participating residents. Finally, with the aid of notes taken during the focus groups, the resident coinvestigator attributed statements to resident labels (“Resident A,” “Resident B,” etc.) and created a key for the other researchers that linked level of training to resident labels. Focus group transcripts were analyzed by using common coding techniques for qualitative data employing grounded theory method. Grounded theory is a qualitative method for inductively generating results in the form of “themes” based on primary data from interviews, observations, or both.26,28 Themes emerge from the primary data after researchers assign labels to primary data (“codes”), define those codes, and then explicate the relationships between those codes (“axial coding”). Three coinvestigators (EH, JR, CG) independently read the transcripts and attributed self-defined codes to words and phrases in the text. Codes and their definitions were stored and organized in NVivo version 10 (QSR International; Doncaster, Australia) qualitative research software. The investigators routinely met to compare codes, develop code definitions, and delineate the relationships between those codes while maintaining an audit trail of codes. Through these structured teambased dialogues, the research team grouped codes into subthemes and then developed five overarching themes pertaining to the research question. Two coinvestigators who were not involved in the coding process (SB, MW) reviewed the themes and provided comments and criticisms. The researchers took multiple steps to establish rigor in the process thus assuring the trustworthiness of the results: convening a multidisciplinary research team, clarifying and summarizing participant responses throughout focus groups, and vetting findings with investigators not involved in coding.
RESULTS Twenty-six residents participated in one of three 1-hour focus groups between October 2010 and January 2011, including six Year 1 residents, twelve Year 2 residents, and eight Year 3 residents. The research team organized participants’ described needs into five overarching themes: Capability – the degree of knowledge and skills required to care for patients with MH concerns. Comfort – factors internal to the resident, including emotional responses and perceptions of MH care. Organizational Capacity – factors beyond a resident’s direct control but intrinsic to the organization in which they practice. Coping – actions reported when presented with patients and families with MH issues. Education – content and means for acclimating pediatric residents to MH.
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These themes are described next, with further examples of key quotations in Table 2. As the researchers reviewed the focus group transcripts, they observed that residents’ opinions did not notably differ by their levels of training. Resident year of training is also included in Table 2.
Theme 1: Capability One of the most prominent themes expressed by residents throughout each focus group was uncertainty regarding knowledge and skills pertaining to MH care. In particular, residents felt their MH knowledge was lacking in comparison to their knowledge about physical health complaints. For example, a resident remarked, “The medical stuff . . . we can . . . handle. But the psych issues and . . . all of the home/life issues . . . I don’t even know where to begin.” When asked about the definition of MH, none of the 26 focus group residents were familiar with the AAP’s definition of MH. One resident stated, “I never realized that [the] AAP’s definition included . . . neurodevelopment and behavioral” concerns. Beyond the definition of MH, residents expressed uncertainty at every step of a patient encounter required by the ACGME: surveillance, screening, recognition, and counseling of behavioral and developmental abnormalities. On the topic of eliciting behavioral or emotional concerns, one resident asked, “What questions are we supposed to ask for different age groups? . . . I feel like I’m lacking [knowledge].” Once a concern was recognized, residents were unsure of next steps: “I was so used to people saying no, that when I had a patient say yes I didn’t really know what to say . . . besides . . . ‘Do you want to talk to someone?’” This suggests residents lack both the communication skills and knowledge to appropriately handle an MH encounter. In addition, residents questioned how to make an MH diagnosis since “there’s no blood test . . . no . . . objective data” to “pinpoint a diagnosis.” In terms of management residents reported uncertainty, not “really know [ing] . . . what exactly the best resources [are],” and feeling unprepared to “partner with the parents” when discussing and implementing a management plan. While discussions on psychostimulant medications were common, residents expressed unfamiliarity with prescribing such medications including one who stated, “All I remember is the scary stuff. The black box warning.”
Theme 2: Comfort Throughout the focus groups, residents predominantly expressed discomfort with the provision of MH care. More specifically, they expressed internal feelings such as dislike, limited control, powerlessness, and the stigma associated with MH diagnoses. A few residents described MH as “gross” or “scary.” As one resident stated, “I don’t feel comfortable because I have no interest in that pathology.” Another resident stated, “We don’t enjoy [psychiatry]. Just like I don’t like
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“. . . If [a patient] says, ‘I am feeling depressed.’ It’s like, well what do you do next?” “I think I also just don’t know the drugs as well. I don’t know a lot of the side effects as well and I don’t know how to use them, how to titrate them up.” “I sometimes don’t know what’s normal behavior. And what a parent will describe as [a child’s behavior] being . . . unbearable . . . might sound actually normal to me; and age appropriate, developmentally appropriate. But if it’s causing that family so much distress, I don’t know what to say.” “I’m pretty comfortable and I think the attendings there seem pretty comfortable in just referring people to emergency rooms but . . . short of that, I don’t . . . know what to do.” The resident reported, “. . . a sense of despair maybe because I rarely see any of these patients getting better.” “Psych is the one thing I feel like I refer to over and over and over and over and nothing ever happens.” “. . . We look to our preceptors for guidance . . . and they clearly are not comfortable with it [MH].” “We’re always on a time crunch and. . .any time you start going into looking at [a] psychiatric history, it’s a very time consuming process. So I tend to prioritize those issues further down and that’s a problem.” “It seems like in general, getting patients follow-up, especially in the outpatient setting [is difficult]. I always just call the social worker and then I have no clue what happens after that. I’m left out of the process.” “I feel like we’re always deciding, ‘OK. That’s probably a behavioral thing. It’s not an acute.’ [. . .] so we’ll [address] it the next time.” “I had a patient with bipolar and Asperger’s, and he actually sees . . . a psychiatrist who manages all his psychiatric medication and sees a counselor who does whatever counseling and psychological stuff that they do. And I really don’t feel comfortable at all treating him. I just make sure that he is not suicidal, homicidal, or his behavior is out of control, and at that point I would probably refer him to a psychiatrist.” “I think that would be really helpful, to actually see [MH care] in progress. Kind of shadow and just take it in.” “It’d be . . . the best learning environment to just sort of see, even how those professionals couch these topics, in . . . the right language.” “I really just think it’s an exposure thing. Unless we saw a lot more of it . . . I wouldn’t be comfortable.”
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3 3 2 3
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2
Resident Year of Training
Quote
Note: MH D mental health.
Education
Coping
Organizational Capacity
Comfort
Capability
Theme
TABLE 2 Appendix of quotations
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taking trips to the adult side.” Resident comments also suggested they are more comfortable with treating physical illness than MH conditions. As one resident stated, “I’d be more comfortable titrating warfarin than Strattera.” Another resident stated, “I think that . . . it’s much more difficult to say to a parent, “‘Your daughter is borderline,’ than it is to say, . . . ‘Your daughter has meningitis.’” While residents did feel comfortable referring patients with acute MH issues such as suicidal ideation to the Emergency Department, they felt “helpless” and powerless if they were that resident evaluating the patient in the Emergency Department. Other residents described MH issues as “un-gratifying” and that “nothing ever happens” after referrals are made. Residents also brought up the topic of stigma about MH diagnoses: their own biases, their preceptors’ responses, and their perceptions of patients’ and families’ opinions. One resident explained, “[MH disease is] a huge burden . . . to diagnose . . . a 15-year-old child as being bipolar. . . . It’s hugely stigmatized in our society.”
monitoring for side effects. If new MH concerns came up during a visit, another resident suggested their job was to “identify [MH problems] and . . . triage . . . [or] send them to the ER.” However for patients that did not need emergent care, residents reportedly referred to MH specialists and would “just sort of cross [their] fingers and hope that [patients] follow up with the list of numbers that they’re given.” These comments suggest that residents coped by reducing their scope of medical practice by triaging and referring MH care rather than accepting more responsibility. However, residents did state that given the “shocking dearth of child psychiatrists,” pediatricians needed to continue to be “a jack of all trades” and assume responsibility for MH care. Others suggested that even if they subspecialize, “mental health is a major issue” when thinking about medication compliance and managing chronic conditions. One resident astutely stated, “No matter what we do medically, if someone commits suicide, all of our medical expertise is for nothing. So clearly it’s [mental health] very important.”
Theme 3: Organizational Capacity Residents expressed frustrations with the organizational structure in which they saw patients: a continuity clinic and the academic center. Time limitations and continuity of care were specifically mentioned as barriers within their clinic. For example, one participant commented, “There have been several instances where I’ve really wanted to . . . delve into [MH] questions with [patients] . . . but there’s just no time.” They believed MH issues require “incredibly personal conversation [s]” requiring continuity of care, which is at times difficult to achieve in continuity clinic. Organizational barriers to providing MH care included limited resources and support within their continuity clinic, the academic center, and their patients’ communities. Residents again distinguished MH from physical healthcare when caring for a child with a chronic medical condition because other subspecialists were easily accessible. In contrast, when caring for patients with psychiatric problems, residents stated they felt like they were “in the trenches with no backup.” Residents referred to the MH resources that do exist as a “separate jurisdiction,” a “nebulous” place, like “the abyss.” In addition, residents noted that “[their] comfort level often reflects [their] attendings’ comfort levels” and that perhaps MH training needs to “start . . . higher up [with general pediatricians] and then it will trickle down to [residents].”
Theme 5: Education The residents identified training needs throughout the focus groups suggesting educational content, modalities, and tools to help move the current state of MH training to the ideal state. Content areas included depression, attention deficit and hyperactivity disorder, anxiety, autism, and distinguishing abnormal from normal behavior. One resident wanted to know how to determine when a child has “crossed the line from being . . . [a] rambunctious four-year-old to being [one] on his way to . . . social malfunction.” Residents often discussed improving their communication skills. As one resident stated, “Aside from knowing . . . the pros and cons . . . [of medication] side effects . . . knowing the right way to . . . pitch [that medication] . . . would be . . . invaluable.” Residents desired more knowledge with what MH resources exist, how to appropriately allocate them, the processes for making referrals, and the strategies for comanaging patients with specialists. To obtain this knowledge, residents requested a combination of scheduled didactic sessions given by MH specialists and opportunities for experiential learning including, “shadowing along with a psychiatrist,” and actively starting to manage MH care in their own clinic. One resident suggested they would get “the most bang for our buck with . . . our own [continuity clinic] and gen[eral] ped[iatric] attendings start to manage things like that more and teach it to us. . . . That certainly is the most effective way that we learn.” To successfully manage their own patients’ MH care, residents felt they needed more knowledgeable and experienced preceptors to model this care. As one resident stated, “[How to care for patients is] one of those things you . . .learn by example.” Residents suggested that improved training of their preceptors and establishing relationships with MH specialists could offer the support needed for MH training implementation.
Theme 4: Coping Residents expressed suboptimal coping mechanisms including ignoring MH issues when they arose during a patient visit. In addition, various residents described a tendency to “gloss over” any psychostimulants on patients’ medication lists, or “assumed” someone else was checking drug levels and
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Many of the positive experiences with MH that residents reported occurred during their DBP and adolescent rotations. In particular, they highlighted the experiential learning, which occurred during these rotations: “We actually see what’s going on and how they evaluate kids for such things [developmental delay].” Residents suggested that MH training should be integrated in all years of training and those high-yield rotations such as DBP and adolescent medicine should come earlier in their training. Although a few residents suggested an online curriculum could be helpful, the majority of residents rejected this idea. However, residents believed that technology could be used educationally, especially electronic health records (EHR). One resident commented that “if [MH is] supposed to be part of . . . well-child visit . . . then maybe it [should] be a part of [the EHR].” Pocket guides, algorithms, and accessible handouts were also tools that residents suggested could facilitate their ability to care for patients in their own clinic.
DISCUSSION As the prevalence of MH concerns has increased,5 recommendations regarding the scope of practice of pediatricians have also changed.12 However, resident comments within the themes identified in this study suggest that residents feel more capable, comfortable, and supported when caring for children with physical conditions as opposed to MH conditions. This research is one of only a few studies that address MH training for pediatric residents by assessing targeted learners. Our findings offer new insights into MH education by highlighting residents’ perceptions of how current training fails to address internal and external needs and suboptimally implements MH goals and guidelines into actionable training. The results demonstrate that residents face internal barriers in capabilities and comfort surrounding MH, and that effective coping with MH care will rely on educational strategies and organizational capacity that supports resident MH knowledge and skills. Despite ACGME requirements in MH training and AAP competencies that define these skills in detail,13,17 residents self-identified deficiencies in MH knowledge, patient care skills, communication and interpersonal skills, and systemsbased practice. Residents emphasized a lack of communication skills, which is consistent with prior study that demonstrated 60% of residents’ responses to parental psychosocial concerns were suboptimal; 17% of residents ignored psychosocial concerns; and 43% asked follow-up questions but did not provide information, reassurance, or guidance.29 In addition, national efforts to help pediatricians widen their scope of practice and overcome organizational barriers have led to the development of various collaborative care models that include colocation of MH services and telepsychiatry.30–32 These models of care have been shown to increase provider confidence and improve recognition of pediatric MH conditions. Adapting these models into training
programs can utilize concepts of pedagogy to enhance experiential learning experiences and provide the mentorship residents desire. Approximately one third of pediatric programs surveyed by Bunik employ one of these collaborative models, either via a true colocation model or with access to MH specialists in the office on a later date.33 Initial study of these models during training suggest residents have improved skills in systems-based practice and perceived greater access to services. However, further study is needed to further understand how different models of integrated care impact resident learning. Results suggested that targeted interventions to “train the trainers” are needed so that preceptors can model optimal MH care. Residents pointed out that general pediatrics faculty need improved MH education so that the knowledge can “trickle down” to residents. The need for faculty development for practicing pediatricians’ both in community and academic settings has been well established.10,34 National efforts such as toolkits, training sessions, and statements have been made to help integrate MH care into the primary medical home.12,13,35,36 However, these efforts have not targeted faculty in training programs at this point. Residents self-identified MH content and skills that already exist nationally as competencies pediatricians should achieve.13 To build knowledge and skills, residents prefer educational modalities that include didactics, experiential learning, and tools built into their patient care flow. The role of technology in improving MH care and resident education was discussed in focus groups and prior study found that resident confidence increased after viewing evidence-based interactive video vignettes on MH encounters during a DBP rotation.23 Although use of videos was not discussed by residents in this study, most residents rejected an online curriculum. This is particularly interesting, as online curricula are becoming more commonplace to meet the needs of changing hours and work restrictions implemented in residency programs. However, limited study about the impact of e-learning in medical education shows efficient knowledge gain, retention has not been studied, and there is report that trainees do not see online learning as a replacement to other modalities of learning.37 Results of this study support the use of prompts within the EHR during patient visits to empower residents during a visit. There are several limitations of this study. One limitation is that focus groups were conducted within one residency program and so results are not generalizable (as is the case for any qualitative study). Rather, these qualitative findings are “transferrable” given sufficient context of the original setting so that the reader can judge applicability to his or her own setting.35 Furthermore, national data of graduating residents and practicing pediatricians corroborate many of our attitudinal and competence statements and thereby lending further trustworthiness of the results.9,14,18 A second limitation is that focus group data are vulnerable to responder bias, if residents who are particularly
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PEDIATRIC RESIDENT MENTAL HEALTH TRAINING
attuned to MH issues were overrepresented among participants. However, we note that negative reactions to MH issues were openly voiced among participants, suggesting that a variety of opinions were represented. Also, bias in extracting themes was addressed by gathering a multidisciplinary team that included pediatricians, a nonclinician with qualitative research expertise, and a pediatric psychiatrist. Inclusion of only 26 subjects is a limitation, although the three focus groups provided sufficient data for thematic saturation, which is the goal in qualitative research. Finally, we did not collect potentially important quantitative data that could have helped to differentiate residents’ comments by year of training or whether DBP or adolescent medicine rotations had been completed. This is particularly important, as one prior study does suggest quality and length of DBP rotation impacts perceived competence.18 Despite these limitations, this study builds on prior literature supporting the need for curriculum reform and MH standards in primary care training programs.14 Our study is unique in that it provides a first step in assessing the needs of targeted learners, pediatric residents. Next steps should include further qualitative and quantitative studies at residency programs of all sizes and geographic locations. In addition, more specific analyses on the impact of DBP rotations and different models of integrated MH care on learner and patient outcomes are needed. Quality improvement efforts may be another way to improve MH care in certain programs. This study suggests that dissemination and implementation strategies for national training guidelines and curricula may be needed to improve MH training throughout the country.
CONCLUSION With the increasing burden of MH issues and their longterm impacts on children and families comes a responsibility for pediatricians to improve the quality of pediatric and adolescent MH care in the United States. Results from this study add to the growing body of research supporting the need for improved MH training in pediatric residency programs. Programs must address both internal and external barriers that prevent pediatric residents from providing optimal MH care. Content and learning modalities that residents request exist nationally, with the AAP MH competencies, toolkits, and published models of integrated care. However, recommendations are needed on way to best operationalize these national efforts into training programs. These national resources can help inform curricular content and modalities that will enhance resident capabilities and comfort in providing MH care instead of utilizing inadequate coping strategies. In addition, models of integrated MH care provide experiential learning opportunities and enhance programs’ organizational capacity to supporting residents and preceptors to build their knowledge and skills in providing optimal MH care for children.
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FUNDING Support was provided by the Association of Pediatric Program Directors Special Projects Grant (Principal Investigators: Drs. Susan Bostwick and Cori Green).
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