The public-sector psychiatrist must be an expert not only in individual
patient care, but in the creation, management, and evaluation of whole systems
So say thought leaders in psychiatric education and public psychiatry
queried for a report on public-sector training that appeared in the February
Yet the same report shows that directors at training programs around the
country— including those that are invested in public-sector
training—consistently downplay the importance of tasks that involve
integration of services across institutions with different missions.
"We really owe it to our patients to try to make sure the educational
system provides our trainees the opportunity to evaluate whole systems of
care, so they will be in a better position to make decisions for our
patients," said Carol Bernstein, M.D., a lead author of the
Psychiatric Services report and the residency training director at
New York University School of Medicine.
But Bernstein said the current emphasis on training in"
competencies" has naturally tended to emphasize competency in
individual care of patients. "When it comes to leading the charge around
health care system development, that requires another set of
competencies," she said.
So adequate training in systems management will require leadership and
initiative from directors who care about public-sector psychiatry. "The
job we have as training directors is so complicated and so determined by
multiple requirements," she said. "Unless you are a well-resourced
program with strong leadership, your program ends up being driven by
Bernstein and colleagues conducted indepth interviews with 10 leaders in
psychiatric education and practice who were knowledgeable and concerned about
public-sector care. Those thought leaders identified 16 tasks
Most of the tasks could be grouped into one of two categories: coordination
across social-service systems (for example, incorporating psychiatric
intervention into psychosocial rehabilitation and interacting with staff of
supportive housing programs to care for patients) and integration across
institutions with different missions (for example, determining whether the
behavioral problems of a prisoner stem from an underlying psychiatric disorder
and providing continuing treatment in nonpsychiatric settings, such as prisons
Directors of all general psychiatry residency programs in the United States
were then surveyed to determine how they rate the importance of these tasks
for delivery of care and how their training program prepares residents to
perform each task. Possible scores ranged from 1 to 10, with higher scores
indicating higher priority. A total of 114 of 150 residency directors (76
percent) responded to the survey.
Slightly more than half of the program directors said their programs placed
above-average emphasis on public-sector care.
Yet tasks entailing integration of services across institutions with
different missions were consistently rated least important, preparation to
perform them was least likely to be required, and, when required, the tasks
were addressed through less-intensive modalities.
But Bernstein and colleagues emphasized the importance of such training to
effective public-sector leadership, citing the fact that there are three times
as many people with mental illness in jails and prisons as in psychiatric
institutions and that 40 percent of people with mental illness have had some
involvement with the criminal justice systems.
"Acknowledging these dynamics, the recent report of the New Freedom
Commission on Mental Health recommended the coordination of a broad array of
services and attention to the interaction of mental health, employment,
housing, and protection from unjust incarceration," Bernstein and
So, how well are training programs preparing psychiatrists for leadership
in the public sector?
"It depends on the structure of the program," Bernstein told
Psychiatric News. "If it has public-sector patients in the
program, the residents will learn something more or less, depending on the
scope of the program. Most programs do have Medicare and Medicaid patients, so
most residents get some exposure.
"But how much they get to look at the entire system and consider ways
to create other systems is a different story," she said.
"A Survey of Psychiatric Residency Directors on Current
Priorities and Preparation for Public Sector Care" is posted at<http://psychservices.psychiatryonline.org/cgi/content/full/57/2/238>.▪