COLUMN: EDUCATIONAL RESOURCE

The Evolution of Public Psychiatry Fellowships

Jeanne L. Steiner & Marisa A. Giggie & Steve Koh &

Christina Mangurian & Jules M. Ranz

Received: 27 January 2014 /Accepted: 12 May 2014# Academic Psychiatry 2014

AbstractObjective The growth of Public Psychiatry Fellowships(PPFs) has reached a new developmental stage, providing awide array of academic partnerships and educational oppor-tunities in psychiatric leadership and administration. The au-thors examine the evolution of these programs and illustratethree distinct models.Methods Data from yearly surveys and discussions with PPFdirectors were used to identify key similarities and areas ofdivergence as the programs have evolved.Results The first period of program expansion took place8–10 years ago when new programs were modeled on theColumbia PPF, and key elements of that program and theAmerican Association of Community Psychiatrists (AACP)guidelines were incorporated broadly. Examples of multi-ple source (Columbia), single source (Yale and UCSF),and grant-funded programs (Alabama and UCSD) arepresented.Conclusions A review of the current status of PPFs reveals adiversity of structures and strategies for success, which can be

attributed to the range of their funding sources. The advan-tages and potential disadvantages of those models are outlinedwith respect to the educational experience and opportunitiesfor growth and sustainability.

Key words Public psychiatry . Fellowships . Academicpartnerships

Public Psychiatry Fellowships (PPFs) provide advanced train-ing to psychiatrists who are interested in engaging in clinicalcare, teaching, and program/policy development and evalua-tion within the public sector. They are based on diversesettings, including urban, rural, hospital, and community lo-cations, but share a vision and commitment to promotingrecovery oriented care to the most vulnerable individualswithin the system of care.

Among current PPFs, the first program was establishedat the New York State Psychiatric Institute and ColumbiaUniversity in 1981 [1]. A burst of growth of similarfellowships began approximately 8 years ago. Programdirectors in academic institutions across the country struc-tured the fellowships in somewhat different ways, but theinitial emphasis was to develop programs that werealigned with the Columbia program. In the past few years,there have been 14–15 active PPFs at any given time, andDr. Jules Ranz created a network of PPF program direc-tors who share data about multiple parameters of theirprograms including details about the source and allocationof their resources.

Methods

Fellowship directors complete yearly surveys that pose spe-cific questions about the level of adherence to the core

J. L. Steiner (*)Yale University School of Medicine and The Connecticut MentalHealth Center, New Haven, CT, USAe-mail: jeanne.steiner@yale.edu

M. A. GiggieUniversity of Alabama School of Medicine,Tuscaloosa, AL, USA

S. KohUniversity of California, San Diego, CA, USA

C. MangurianUniversity of California, San Francisco, CA, USA

J. M. RanzColumbia University College of Physicians and Surgeons and TheNew York State Psychiatric Institute, New York, NY, USA

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elements for PPFs published by Columbia faculty [2] andguidelines from the American Association of CommunityPsychiatrists (AACP) [3]. The results are reviewed anddiscussed at the meetings of the fellowship directors. Addi-tional analysis of survey results plus a review of programupdates have been held via electronic communication.

Results

The yearly reviews, held in an open format, have encourageda certain degree of comparability between programs. Bysharing the data and discussing the results publicly, twooutcomes were achieved: (1) we gained a sense of sharedidentity, since all programs had common goals of educatingand preparing early career psychiatrists to work in the publicsector and to enhance the recruitment and retention of psy-chiatric leaders in this arena; and (2) we developed an under-standing and appreciation of the differences in the structuresof the programs.

Some of the diversity can be attributed to obvious factorssuch as geography, i.e., urban versus rural location of the hostacademic center. However, the most significant differencesappear to be related to the funding mechanisms for the fel-lowships and how each local system of care is organized. Thespecific source and stability of the funding stream are likelythe most salient features that influence the structure of eachfellowship and its clinical and administrative placements. Inaddition to Columbia, four examples of evolving fundingarrangements are programs affiliated with Yale University,the University of California San Francisco (UCSF), the Uni-versity of Alabama, and the University of California SanDiego (UCSD) (see Table 1). The five PPFs highlighted in

this article were chosen after discussion within the listserv ofall PPF directors in the USA. They are prototypic cases of thethree models of funding outlined in the article.

Multiple Funding Sources and Sites—the Columbia Model

The Columbia PPF receives one third of its funding from theState Mental Health Authority—the New York State Office ofMental Health—and two thirds from community agencieswhere the fellows make a significant contribution to clinicalservice needs [4]. One advantage of the Columbia PPF ar-rangement is that the fellows become very familiar with theirsites and are often offered opportunities for employment at thecompletion of the fellowship. Another significant advantage isthe large number of public agencies in the New York Cityarea, which means a large base of funding and multipleopportunities for expansion. A potential disadvantage is thelack of direct oversight or control by the fellowship directorover the quality of the experience at those sites.

Single Funding Source – Yale and UCSF

The Yale PPF is an example of a program that is fundedthrough a single source, which in this case is the State MentalHealth Authority, the Connecticut Department of MentalHealth and Addiction Services (DMHAS). The program wasbuilt into an existing relationship between DMHAS and YaleUniversity to manage and provide professional services for anacademic community mental health center. The state pays theuniversity through a “staffing contract” to hire Yale physi-cians, psychologists, and senior administrators. A single costcenter within this contract funds positions for residents andattending psychiatrists.

Table 1 Funding Models for PPFs

Fellowship Funding type Clinical placements

Columbia University Multiple sources: Agencies throughout New York Cityone third New York State and two thirdscommunity agencies

Yale University Single source: Rotation through inpatient services at State hospitalor outpatient programs at Connecticut MentalHealth Center in New Haven—all supported byConnecticut Department of Mental Health andAddiction Services

State of Connecticut Dept. of Mental Health andAddiction Services

University of California,San Francisco

Single source: Year long placement at one of theCBHS-affiliated clinicsSan Francisco County Behavioral Health Services (CBHS)

University of Alabama Grant funded: Rural community mental health center withmobile and telemedicine servicesBristol Meyers Squibb, transitioned to community mental

health center/veterans administration funds

University of California, San Diego Grant funded: Longitudinal sites [2–3 days/week] for entire year,and rotational [1–2 days/week for 4–6 weeks]County of San Diego

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When the Yale PPF was developed in 2007 and expandedin 2012, DMHAS provided additional funds to the staffingcontract, which covers the fellows’ clinical and academiccommitments. The fellows’ commitment for 50 % clinicaltime is spent within ambulatory services at the ConnecticutMental Health Center (CMHC), an urban CMHC run jointlyby the state and Yale, or on inpatient services at ConnecticutValley Hospital, a 900 bed state facility. The fellows’ other50 % effort is devoted to academic activities such as seminars,Department of Psychiatry Grand Rounds, and scholarship.This structure provides flexibility for fellows to be exposedto a variety of treatment settings in the state’s system of carewithin their weekly schedules (e.g., outpatient Hispanic Clin-ic, ACT team, forensic, and general inpatient units) and op-portunities to modify their schedule during the course of theyear according to their specific interests. One advantage ofthis arrangement is that the fellowship leaders also hold directadministrative responsibility for management of the clinicalservices where the fellows are placed, e.g., the fellowshipdirector is also the Medical Director of the CMHC. An “ap-prenticeship” model is provided, whereby the fellows partic-ipate in hospital and statewide administrative meetings alongwith the program directors. A disadvantage of this program isthe reliance on a single source of funding, which is subject tostate budgetary constraints. The risk of funding cuts is miti-gated, however, by the successful recruitment of graduates ofthe fellowship into positions within the state mental healthsystem.

The UCSF PPF is another example of a program that isprimarily funded through a single source. The San FranciscoCounty Behavioral Health Services (CBHS) uses a portion ofallocated Mental Health Services Act (MHSA) funds to sup-port the fellowship infrastructure (faculty and administration),and fellows are placed in CBHS-affiliated clinics. As thefellowship has gained recognition in San Francisco, localnonprofit community mental health clinics have approachedUCSF to provide funding to support individual fellows at theirsites as well. Regardless of the funding source, all fellows aretechnically UCSF academic employees and are all paidthrough the university. Similar to Columbia’s PPF, all fellowsare placed at a single site throughout the academic year. Thisprovides the main advantage of becoming very familiar withsites. The disadvantage, particularly with non-CBHS clinics,has been the expected growing pains that come with newplacements. In these situations, the fellowship director focuseson ensuring weekly individualized clinical mentorship at thenew sites from strong supervisors and using the “growingpains” as learning experiences for the fellows during fellow-ship supervision time.

The UCSF single-site model is critical given the evolutionof this particular fellowship to incorporate a rigorous mentalhealth services research component [5]. Fellows are expected

to implement a mental health services research project ad-dressing a specific systemic issue at the clinic during the year.CBHS provides funding to support a part-time research fac-ulty mentor, a half-time research assistant, and travel to dis-seminate findings at academic meetings. These projects aredesigned and carried out with clinical leadership at the sites toensure relevance to CBHS priorities. These projects are pre-sented at academic meetings and/or published in peer-reviewjournals. The evolution of the UCSF PPF to embrace researchin the public sector is a reflection of both the institution—UCSF being a leader in both public health and biomedicalresearch—and also both fellowship directors who are NIMH-funded health services research investigators. The UCSF PPFintentionally trains fellows to value mental health servicesresearch and develop skills, and a network of connections toeffectively collaborate with academic partners to conductresearch in the public sector.

Grant Funded Programs—Alabama and UCSD

The University of Alabama PPF was developed in collabora-tion with a parallel Behavioral Medicine Fellowship in Pri-mary Care. Both fellowships started in 2009 and were initiallyfunded by a larger Bristol Meyers Squibb (BMS) grant fo-cused on increasing mental health services to the rural Ala-bama “Black Belt” region, one of the poorest areas in theUSA. The grant funded 3 years of the fellowship in which thefellows spent the majority of their clinical time in a ruralcommunity mental health center (CMHC) incorporating theextensive use of telepsychiatry to provide services to remoterural areas. In 2013, BMS seed money ran out. However, thepositive experience of the fellows at the rural CMHC con-vinced the CMHC board to continue funding the fellowship.Currently, the CMHC funds four fifth of the fellowship whilethe Veterans Administration funds one fifth with a focus onrural outreach via mobile clinics and telemedicine. The overallphilosophy of the fellowship is to train psychiatrists to becomeleaders in public psychiatry with focus on rural underservedareas and collaboration with primary care colleagues. So far,the fellowship program has produced two public psychiatryand two family physician graduates. One of the psychiatrygraduates is involved in rural public psychiatry while the otherseeks to expand training. The two family physician graduatesare practicing primary care in rural areas and utilizing theirpsychiatry training extensively as the main providers of psy-chiatric care in underserved populations.

The current funding and organizational structure of theAlabama PPF offer several advantages. First, psychiatry fel-lows are offered the opportunity to collaborate with primarycare physicians in an innovative approach to integratingpsychiatric services with primary care through shared train-ing. Second, fellows provide valuable clinical services to

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underserved rural areas of Alabama using telemedicine.Third, fellows are required to conduct research based on aperceived need related to quality improvement in psychiatricservices focused on rural areas. A disadvantage is the lack ofon-site supervision in remote rural sites, which has beenaddressed by weekly face to face supervision with the pro-gram director and use of telemedicine equipment for imme-diate supervision when necessary. Currently, the program isattempting to expand rural sites and obtain funding fromother CMHCs that have on-site supervision available.

The UCSD PPF was developed as a contract between theCounty of San Diego and UCSD. The initial discussionsstarted in 2010 and the contract terms started in 2011. UCSDgraduated its inaugural class in 2013. The funding is 100 %allocated from the County’s MHSA Work, Education andTraining (WET) program. This is a time limited fundingsource, likely to be phased out in 2016 to 2017. During theduration of the contract, all direct and indirect costs associatedwith the PPF are covered by the WET funding. It is expectedthat UCSD aggressively seek outside funding to sustain theprogram after the contract termination. This arrangementposes a unique situation for UCSD PPF. On one hand, thecontract’s Statement of Work mandates certain deliverablesand the program reports to the County’s Contracting Officer’sTechnical Representative. This is in addition to the reportingto the UCSD Department of Psychiatry and to the Countyleadership. Meanwhile, the program must establish and nur-ture relationship with community partners to gradually replacethe WET funding with outside resources.

The shared vision of the PPF between the County of SanDiego and UCSD is to “train the next generation ofCommunity/Public Psychiatry Clinicians and Leaders.” Tothis end, the program takes a lifespan approach to mentalhealth in the public sector, emphasizes leadership and man-agerial skills, and requires health services related projects.The fellows are placed in both longitudinal (approximately2–3 days a week for the entire year) and rotational (approx-imately 1–2 days a week for 4–6 weeks) sites to exposethem to as many learning environments as possible. Thelongitudinal sites are then ideally suited for quality improve-ment projects while a rotational site is opportunity for small-er individual research project. The didactics are hosted byUCSD but the invited educators are a mix of UCSD facultyand community mental health directors, executives, andclinicians. Under the terms of the contract, UCSD PPFworks with UCSD medical school and general psychiatryresidency programs. The PPF directors have taken on rolesto provide community psychiatry perspective to the medicalschool 2–4 years training and now lead the communitypsychiatry didactics track within the general residency. Thefellows are expected to mentor medical students and generalresidents during their third year clerkships and post-graduateyear, 2 and 3 years, respectively.

Discussion

The establishment of a network of Public Psychiatry Fellow-ship Directors and the distribution of yearly surveys within thisgroup provide an effective mechanism to share information,including strategies for success. In the first phase of programexpansion, the PPFs developed a common vision and set ofgoals according to the Columbia and AACP guidelines. Thiswas an important developmental stage in order to insure con-sistency and quality across disparate institutions and systems ofcare. At this current juncture, however, when approximately 15PPFs are in existence, we have come to value their diversity asthey strive for sustainability in creative and distinct ways.

A basic educational principle emphasized within each ofthe PPF’s didactic and experiential components is that theorganization of clinical and recovery services within anysystem of care is dependent to a great extent on sources offunding and how they are administered. In the same vein, thePPF’s themselves have developed in association with eachother across the country, but their identities and future successare dependent on the financial and workforce developmentrelationships they have established within their own local,state, and academic homes.

Implications for Academic Leaders

& Public Psychiatry Fellowships provide educational opportunities forpsychiatrists who are interested in developing leadership skills andadministrative experience.

& Public Psychiatry Fellowships have been established in 14–16academic Departments of Psychiatry and serve as an example ofinnovative academic/state partnerships.

& Formation of a network of fellowship directors has proved to be aneffective mechanism to share data about strategies for developmentand enhancing quality of the programs.

& Three models of public funding—single source, multiple source, andgrants—are examined with respect to potential advantages anddisadvantages for educational experience and sustainability.

Disclosure Support for Dr. Steiner is provided by the ConnecticutDepartment of Mental Health and Addiction Services. Dr. Mangurian issupported by an NIH/National Institute of Mental Health Career Devel-opment Award (1K23MH093689).

References

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2. Ranz JM, Deakins SM, LeMelle SM, Rosenheck SD, Kellermann SL.Core elements of a public psychiatry fellowship. Psychiatr Serv.2008;59:718–20.

3. American Association of Community Psychiatrists: Guidelines forDeveloping and Evaluating Public and Community PsychiatryTraining Fellowships. http://www.communitypsychiatry.org/publications/clinical_and_administrative_tools_guidelines/fellowship.aspx, 2008

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4. Le Melle SL, Mangurian C, Ali OM, Giggie MA, Hadley T,Lewis M, et al. Public psychiatry fellowships: a developingNetwork of Public-Academic Collaborations. Psychiatr Serv.2012;63:851–4.

5. Mangurian C, Shumway M, Dilley J. Mental Health Services ResearchTraining for the Next Generation of Leaders in the Public Health Sector:A Case Study of the UCSF/SFGH Public Psychiatry Fellowship.Academic Psychiatry, published online February 26, 2014.

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