Competency of Psychiatry Residents in the Treatment of Severe Mental Illness Before and After a Psyc

1
Competency of Psychiatry Residents in the
Treatment of Severe Mental Illness Before and
After a Psychiatric Rehabilitation Community
Rotation
Melinda Randall MD, Mauricio Romero-Gonzalez MD,
Gerardo Gonzalez-Haddad MD, Anne Klee PhD, Paul
Kirwin MD Department of Psychiatry, Yale
University


Results

• Results
• Table 2 Differential Improvement in CAI
  competencies by group
• Cases Controls
• N8
  N15 F p-value
• Goal setting .33 .04
  5.0 .04
• Client preferences .13 .01
  4.8 .04
• Intensive Case M. .19 .00
  3.4 .08
• Holistic Approach .20 .03
  4.1 .05
• Skills .18 -.06
  9.8 .005
• Team Value .10 -.00
  7.7 .01

• Methods
• The cases are Yale PGY-2 psychiatry residents
  attending a three month rotation at the Community
  Reintegration Program (CRP), a psychiatric
  rehabilitation day program at the Errera
  Community Care Center (ECCC) at VA Connecticut.
• We administered the Competency Assessment
  Instrument (CAI) at the beginning and the end of
  their three month rotation.
• The CAI is a self-report survey which measures 15
  provider competencies critical to recovery,
  rehabilitation, and empowerment in people with
  SMI, providing a score (0-1) for each competency
  where 0no competency and 1competent (Chinman
  et al, 2003).
• We compared the CAI scores of the CRP group to
  those second year psychiatry residents who never
  rotated through CRP, and therefore had no formal
  training in psychiatric rehabilitation during the
  second year. This control group completed the
  CAI survey at the beginning and the end of the
  year.

• Background
• Psychiatric Rehabilitation is the field of
  evidence-based interventions with the goal of
  recovery for people with severe mental illness
  (SMI).
• Recovery from SMI refers to the pursuit of a
  meaningful life despite the persistence of
  symptoms of SMI.
• Psychiatric Rehabilitation services include
  Assertive Community Treatment, Supportive
  Employment, Supportive Housing, and Illness
  Management and Recovery based on CBT, Relapse
  prevention, and Motivational techniques.
• There have been no controlled or prospective
  studies of psychiatry residents attitudes,
  skills, or knowledge about SMI or psychiatric
  rehabilitation.
• Minkoff and Stern noted the following paradox
  residents may face when treating people with SMI
  doctors treat illness but symptoms of SMI often
  persist despite treatment. They raise the
  concern that focusing on adaptation and
  rehabilitation, therefore, leads residents to
  feel helpless, hopeless, and ineffective
  (Minkoff, Stern, 1985).
• They recommended providing psychiatry residents
  with experience and supervision to help them
  value rehabilitation and a holistic approach, and
  to evaluate their own feelings about working with
  people with SMI.
• Psychiatry residents are interested in community
  psychiatry, but their career paths are focused on
  urban, hospital-based practice despite economic
  pressures to treat people with SMI in the
  community (Freeland et al, 2000).
• We assessed whether a PGY-2 three month,
  elective rotation in a psychiatric rehabilitation
  center changes their competency levels in
  recovery, psychiatric rehabilitation, and
  evidence-based treatment of SMI.

Response Rate Baseline
91 Completers 56
Cases who completed 73
Controls who completed
47 Table 1 PGY-2 Psychiatry Resident
baseline characteristics
All N43
Cases N11 Controls N32 p
value Age (yrs) 32 34
31 n.s. Female () 61
46 67
n.s. Caucasian () 54 82
46 n.s. Chose to rotate at
intervention site () 21 64
6 .00 Plan a career
working with SMI () 55 55
55 n.s. Competencies mea
n mean
mean (SD) (SD)
(SD) p value Goal
Functioning 0.48 0.52 0.47
n.s. (.20) (.22)
(.19) Stress 0.57 0.53
0.58 n.s. (.24) (.22)
(.19) Client Preferences 0.66
0.66 0.65
n.s. (.10) (.10) (.10)
Intensive Case Management (ICM) 0.24
0.27 0.23 n.s. (.18)
(.18) (.19) Holistic
Approach 0.51 0.52 0.50
n.s. (.16) (.20)
(.15) Family Education 0.42 0.46
0.41 n.s. (.15)
(.14) (.15) Rehabilitation 0.02
0.02 0.02
n.s. (.01) (.01) (.01)
Skills 0.39 0.43 0.37
n.s. (.16) (.13)
(.17) Integration/natural supports 0.38
0.44 0.36
n.s. (.20) (.17)
(.21) Stigma 0.80 0.80
0.80 n.s. (.12) (.06)
(.13) Community Resources 0.58
0.50 0.60 n.s. (.19)
(.20) (.18) Medication
Management 0.51 0.56 0.50
n.s. (.17) (.19)
(.16) Family Involvement 0.59 0.55
0.60 n.s. (.18)
(.14) (.19) Team Value 0.66
0.68 0.66
n.s. (.10) (.07)
(.11) Evidence-based practice 0.65
0.62 0.66 n.s. (.18)
(.19) (.18) Optimism 0.40
0.42 0.39
n.s. (.11) (.12) (.11)




plt.05
CAI Competencies Goal Functioning
Assist clients to get and achieve
goals Stress
Assist clients in coping with stressors Client
Preferences Learn and respect
clients preferences Intensive Case Management
Leave the office to help clients obtain
services Holistic Approach
Elicit life experiences in trusting
atmosphere Family Education
Educate family members about mental
illness Rehabilitation
Practice psychiatric rehabilitation Skills
Create
opportunities for clients to practice
skills Integration/natural supports
Encourage clients to use their own natural
supports Stigma
Work with clients to cope with
stigma Community Resources Refer
clients to local resources to support
recovery Medication Management Teach
symptom and side effect self-monitoring Family
Involvement Involve family and
help them cope Team Value
Provide services as part of a coordinated
team Evidence-based practice Focus on
services that are evidence-based Optimism
Believe clients will
have positive outcomes

• Educational Intervention
• Each resident acts as a CRP coordinator, within
  a multidisciplinary team, with responsibility for
  the holistic care of 4-10 veterans.
• This holistic approach includes pharmacotherapy,
  psychotherapy, and case management, including
  home and workplace visits.
• The resident also facilitates two groups
  cognitive therapy and psychoeducation.
• The resident also participates in formal
  didactics in psychiatric rehabilitation and is
  exposed to other evidence-based services in the
  ECCC the ACT team, supported housing, supported
  employment, and the homeless team.

Abstract Objective Psychiatric Rehabilitation
is a field of evidence-based services with the
goal of recovery for people with severe mental
illness (SMI). Therefore, psychiatry residents
should understand the services and be familiar
with the principles of psychiatric
rehabilitation. We assessed whether a three
month rotation in a psychiatric rehabilitation
center changes the competency level of second
year psychiatry residents in recovery,
psychiatric rehabilitation, and evidence-based
treatment of SMI. Research Design The study is
a prospective, Case-Control comparison using a
validated, self-report Survey Instrument. Methodol
ogy The cases are second year Yale psychiatry
residents attending a three month rotation at the
Community Reintegration Program (CRP), a
psychiatric rehabilitation day program at the
Errera Community Care Center (ECCC) at VA
Connecticut in West Haven. We administered the
Competency Assessment Instrument (CAI) at the
beginning and the end of their three month
rotation in order to assess change in their
competency in psychiatric rehabilitation. The
CAI measures 15 provider competencies critical to
recovery, rehabilitation, and empowerment in
people with SMI, providing a score for each
competency. We compared the CAI scores of the
CRP group to those second year psychiatry
residents who never rotate through CRP, and
therefore have no formal training in psychiatric
rehabilitation. Results A three month
rotation in psychiatric rehabilitation
significantly improved PGY-2 residents
competency in Goal Functioning, Client
Preferences, Holistic Approach, Skills, and Team
Value. Conclusion A brief community psychiatry
rotation in the 2nd year of residency improves
some skills in treating people with severe mental
illness.