Educational Resource Column

Transforming Residency Training:A Case Study

Erica Shoemaker, M.D., M.P.H., Caroly Pataki, M.D.Michele Pato, M.D., Carlos Pato, M.D., Ph.D.

This column presents a case study of how the Univer-sity of Southern California (USC) Department of Psy-

chiatry and Behavioral Sciences set out to improve itsgeneral-psychiatry and child-and-adolescent psychiatryresidency training programs. This change happened in thecontext of a decade of massive expansion at USC, USC’spurchase of University and Norris Hospitals, and the LosAngeles County (LAC) � USC Medical Center buildingof a $1.1-billion replacement hospital.

Starting in 2005, USC set a major strategic goal totransform the department of psychiatry into a leading neu-roscience and genomics unit. A new Chair and AssociateChair were recruited with university-funded resources toachieve this goal. This new leadership explicitly chose torebuild the department as a whole, however, focusing onbuilding the education programs in tandem with biomed-ical research. One of the first areas of attention was facultyrecruitment. In 2006, we had 35 full-time faculty members,and, as of this writing, we have 47. This has been achieved byrecruiting 20 new faculty members, 6 of whom are primarilyresearchers and 14 of whom are primarily clinical educators(8 existing faculty members have left the department). Thisexpansion of the department faculty required a significantinvestment by the department.

In 2006, new leadership was chosen for our trainingprograms; the director of the adult program had been onfaculty for a number of years, and the director of thechild-and-adolescent program was hired from outside.Both directors were aware of the opportunity posed by aninflux of new resources (facilities, funds, and faculty).

Both were also aware that their programs would undergoAccreditation Council for Graduate Medical Education(ACGME) review in the 2008–2009 academic year. Thedirectors and the department chose to regard this time ofexpansion and tumult as a “golden moment” to reviewwhat had consistently worked well and what could beimproved in our residency programs. As a department, wefocused on four areas of training: mission, resident recruit-ment, didactics and scholarly work by residents, and clin-ical training experiences.

Defining Our MissionBeresin (1) has written that the “values and ideals” that

underlie a residency program set the content and tone ofthe entire program. It is also true that the source of fundingof a program highly influences the training mission. In ourcase, the USC training programs are primarily funded by LosAngeles County and the LAC�USC Medical Center. In bothprograms, most clinical rotations are on the Medical Centerinpatient units and clinics, and attending physicians are pri-marily psychiatrists who dedicate their careers to the publicsector. One of the most important values of our trainingprograms has always been that underserved populations areentitled to accessible and high-quality psychiatric care. In linewith this philosophy, over the last 30 years, our residencyprograms have consistently produced graduates who areskilled and dedicated community psychiatrists and who havebecome leaders in public-sector psychiatry. Along with arenewed scholarly focus in the faculty of our department,however, we wanted to expand our mission to include train-ing graduates who saw scholarly activity and lifelong learn-ing as part of that dedication to patient care for underservedpopulations.

Interestingly, both programs defined their mission notjust to change the internal content of those programs, butto better communicate with applicants what we weresearching for in potential residents and what we felt our

Received December 23, 2009; revised January 28, 2010; accepted Febru-ary 17, 2010. The authors are affiliated with the Department of Psychiatryand Behavioral Sciences at the University of Southern California KeckSchool of Medicine, in Los Angeles. Address correspondence to EricaZoe Shoemaker, University of Southern California, Psychiatry and theBehavioral Sciences, 2250 Alcazar St, Suite 2200, Los Angeles 90403;erica.shoemaker@usc.edu (e-mail).

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programs offered. The leadership of the residency pro-grams developed the following mission statement: TheUSC residency training mission is to produce graduateswho provide compassionate, quality mental health care forpersons of all ages and ethnic groups; have the capacity toteach and understand research; possess skills necessaryfor lifelong learning; and abide by the highest ethical andprofessional standards.

RecruitmentSome of the first changes we made were changes in

recruitment. Our programs have always recruited residentswith a commitment to public service, strong interpersonaland clinical skills, and leadership ability. With the expan-sion of our department, we wanted to attract residents whowould mirror (and enhance) the changes in our depart-ment. We strived for our new process to reflect both res-idency programs as being organized and well planned; tohighlight the idea that all members of the department,including residents, engage in scholarly work; and toshowcase the premise that faculty and residents are activeparticipants in the residency program and the recruitmentprocess. Previous studies (2) note that a well-organized“recruitment day” allows faculty to demonstrate commit-ment to the recruitment process and showcase the highesteem in which they hold applicants, and that applicantsvalue this experience highly. In the past, both programsinterviewed applicants on multiple days per week over therecruitment season. Faculty did most of the interviews,and one or two residents met with an applicant for lunch.Clinical demands would sometimes force interviewers tocancel appointments, resulting in last-minute changes toschedules and less-prepared interviewers. We felt that weneeded a new recruitment process that would better reflectour commitment to attracting competitive applicants.

Our training programs now hold approximately 5 re-cruitment days with several applicants at a time (up to 25per day for the general program and 5 per day for the childand adolescent program). This allows faculty and residentsto commit to recruitment for specific days in advance, sothat they can clear their schedules and be reliably engagedand prepared during interviews. Given that multiple stud-ies have shown that current resident satisfaction is one ofthe most important factors by which applicants evaluate aprogram (2, 3), we wanted to showcase resident involve-ment in the training programs and the high esteem inwhich the department holds residents (4). Residents, aswell as funded research faculty, now serve as formal in-terviewers and valued members of the selection commit-

tees. Residents and faculty attend an orientation/discussiongroup regarding the recruitment process to discuss theprogram and its goals and to review information abouthow to effectively interview applicants. Sacks (2) writesthat applicants are often disappointed when they do not getto meet the Chair. In line with this observation, the gen-eral-psychiatry program added a “meet and greet” with theChair, the program director, and the Associate Chair forEducation. All child-psychiatry residency candidates meetwith both the training director and the division chair. In-terviews for both programs take place in the psychiatryadministrative offices, the halls of which are lined withresearch posters by residents and faculty.

The improved organization of the recruitment process,along with the major transformation of the department, hashad an immediate effect. Both the general-psychiatry res-idency program and the child-and-adolescent residencyprogram have filled in the match in the past 2 years.Increase in fit has progressed in the program’s preferencesand candidates’ choices, leading to matched trainees withmore competitive academic credentials and a higher per-centage of trainees who are graduates of U.S. medicalschools.

DidacticsBoth program directors undertook reviews of their lec-

ture and seminar schedules (comparing them withACGME requirements), resulting in the addition of severalhours of didactics for each program. Both programs alsoreviewed and optimized the order in which topics werepresented. In particular, didactics were ordered so thatthey started with surveys of psychopathology and treat-ment (using textbooks and review articles as readings) andthen proceeded to more in-depth discussions of treatmentand evidence-based medicine (using the current peer-re-viewed literature as readings). Topics deemed essential tosafe psychiatric practice by residents, such as managementof acute agitation/aggression and medico-legal require-ments for involuntary psychiatric holds, were scheduled atthe beginning of the first academic year. There was also aneffort to emphasize subjects in didactics that coincidedwith residents’ order of clinical rotations, so that residents’clinical experience and didactic knowledge reinforcedeach other. For example, the introduction of a lectureseries on structured diagnostic interviews was added inPostgraduate Year 2 of the psychiatry residency. Lastly,both programs increased the percentage of seminars thatrequire active resident participation and preparation, espe-cially in the later stages of training.

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As important as attending to the content and format ofdidactics was, ensuring that residents attended the lectureswas equally important; 70% attendance is required byACGME. Both programs took steps to monitor attendanceand protect didactic time. First, we emphasized with fac-ulty and staff that didactic attendance was optimal fortraining and is an ACGME requirement. We also began torigorously monitor attendance and counsel/discipline res-idents with poor attendance, which helped change residentpriorities. Second, we ensured that residents had clinicalcoverage during didactics so that they would not be dis-turbed (e.g., paged or called back to the ward/clinic) dur-ing didactics. Lastly, we moved the didactic sessions outof the hospital to an education center at the department’sadministrative offices.

Scholarly ActivityBoth programs have had a long tradition of residents’

giving annual Grand Rounds presentations, usually con-sisting of a case presentation followed by a short literaturereview. Over the past 4 years, both programs have movedto require that all senior residents complete a researchproject/poster and present it to their resident and facultycolleagues. At an annual poster day, faculty members re-view the residents’ posters. (Faculty are also encouragedto display their research posters from the past year on theposter day.) The top three posters are given awards, and allresidents are encouraged to submit their posters as YoungInvestigators Posters to APA for the next year. Also, re-searchers in the department began actively recruiting res-idents to work with them on funded research, particularlyin psychiatric genomics. If possible, residents receive sup-port to attend meetings where they have been invited topresent their work.

In his 1997 nationwide survey of graduating child-and-adolescent psychiatry residents, Yudowsky (7) found thatmost residents value highly the opportunity to participate inresearch during their training. Although most residents fromour programs will not go on to full-time academic careers,active involvement in scholarship cements residents’ identityas clinician-scholars, which is essential for graduating resi-dents who have a commitment to lifelong learning (8).

Clinical TrainingSurveys of graduates and residents of other programs

have consistently pointed to clinical training as the mostimportant part of their residency programs (7, 9). Themajority of clinical rotations for both residencies are at theLAC�USC Medical Center. This site provides outstand-

ing training opportunities for residents to master treatingpatients from the public sector—patients who are medi-cally indigent or insured by Medicaid, patients with severeand acute psychiatric illnesses, and patients from lowersocioeconomic groups. Likewise, our graduates have longbeen skilled at the systems tasks required of psychiatristsworking with this population—particularly, coordinatingwith other public agencies (Social Security, juvenile jus-tice, child welfare) to provide these patients the best care.Because so many of our patients and their families do notspeak English, our residents were highly competent inusing treatment modalities such as medication manage-ment and brief supportive interventions that could be ad-ministered effectively through interpreters. We believethat the clinical rotations at the LAC�USC Medical Cen-ter will remain a major strength of our programs.

General-Psychiatry ProgramEarly in this transformation process, the department

sponsored a voluntary external review of the general-psy-chiatry residency program. One of the main points offeedback from this review was to find ways to protectresidents from the sometimes overwhelming service de-mands of the County Medical Center, for example, byscaling back the number of patients that residents wererequired to see by designating non-teaching services oninpatient units and in the emergency department, whichallowed residents to treat their patients on teaching ser-vices with greater attention to detail. The external reviewalso focused on the need to increase the diversity of thepatient population. The training director addressed thisconcern by developing a geriatrics rotation at the VeteransAdministration (adding diversity by age) and increasingthe residents’ experiences at the private university healthsystem (adding diversity of socioeconomic status). AtLAC�USC Medical Center, the County hospital pays foran overwhelming share of the residents’ salary, benefits,and attending supervision. (The LAC�USC Medical Cen-ter sees primarily patients with Medicaid or with no in-surance. The Medical Center sees a fairly small percentageof patients with Medicare. As such, the Medical Centerreceives very little in indirect or direct medical educationsupport from the federal government.) The LAC�USCInstitutional GME requires a strong educational justifica-tion for residents’ rotating outside the Medical Center.Adding these rotations was no easy feat. However, fromthe strengths of the external review and the ACGME re-quirement that residents train with a diverse patient pop-

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ulation, the training director was able to put these newrotations in place.

Child-and-Adolescent Psychiatry ProgramAs the general-psychiatry program underwent external

review, the child-and-adolescent psychiatry residency pro-gram underwent an internal Institutional GME review.This review pointed out a concern with second year resi-dents’ outpatient experience being interrupted by emer-gency department service and elective time. (ACGMErequires that residents treat some outpatients for 12 con-tinuous months.) The best solution was to rearrange theorder of rotations so that all inpatient and emergencypsychiatry rotations happened in the first year and alloutpatient rotations happened in the second, freeing up thesecond year for 12 continuous months of outpatient clinicwork. The elective experience, which had been a 1-monthblock, was changed to a 10%-time longitudinal experi-ence. As one would expect, this transition was awkward anddifficult for residents and faculty, resulting in some clinicalservices being understaffed and some being overstaffed tem-porarily. It was only because of the backing of the InternalReview Committee and the ACGME requirement for conti-nuity that the program director was able to make this change.

The child-psychiatry program director also wanted touse the momentum from the department’s scholarly activ-ity to integrate evidence-based practices into the residencyprogram. The new chief of the division and a secondfaculty member obtained a Substance Abuse MentalHealth Services Agency (SAMHSA) grant to develop aLevel III subspecialty trauma treatment outpatient pro-gram within our child outpatient psychiatric clinic. Resi-dents in this clinic learned to use specialized screeninginstruments to detect exposure to trauma. This clinic alsobecame the vehicle for residents to learn and practicetrauma-focused cognitive-behavioral therapy. Residentsexperienced firsthand how the establishment of this clinicresulted in more targeted treatments for their patients, andthey also worked alongside a research psychologist usingstructured instruments. The Trauma Treatment Clinic hasproved a fruitful union of research and clinical training.

ChallengesIt would be disingenuous to state that all changes in the

training programs went smoothly. For example, a majorinitiative was taken on by the department to create anurgent-care center, a walk-in clinic staffed by psychia-trists, masters-level social workers, and a substance-abuse

treatment liaison. We intended for this center to provide amissing level of care and a new opportunity for trainingresidents in a broader spectrum. The urgent-care centerwould serve adults as well as children and adolescents.The attempt to establish this service took over one-and-a-half years of negotiations with funders, the University, andthe Medical Center. We believed that this center wouldprovide improved quality of care and would serve as anexcellent training site. However, to avoid promising a newprogram that we might not be able to deliver, we waited tobring in our residents until we thought we were assuredfunding for the program. When we did finally bring resi-dents on service at the center, the rotation was perceived asan unwanted increase in clinical work. The fact that theopen communication between administration and residentswas established late in the planning process strengthenedthe perception that this was being forced on the trainees ina top-down manner. Ironically, as the residents organizedto oppose this new rotation, they were instrumental inidentifying clinical issues that had not been adequatelyaddressed in the planning phase. Ultimately, we aban-doned the new service, not because of the residents’ op-position but because open communication revealed thatthis level of service needed to be performed outside of theMedical Center structure.

The leadership of the department and both training pro-grams have a philosophical commitment to open commu-nication and transparency. Experience such as ours withthe urgent-care center taught us all that this philosophicalorientation needed to be backed up with daily action. Toensure “bottom-up” input, both training directors addedformal and informal meetings with residents and, espe-cially, cultivated their participation in residency educa-tional policy committees. Both directors discovered thatincluding residents and faculty in the process of revisingresidency program policies and rotation/didactic goals andobjectives went a long way toward maintaining a sense offairness and agency among residents. At the departmentallevel, the Chair chose to reveal to faculty that, during the 4years described here, about 10% of new investment wentdirectly to the new training program; 30% went to the re-search program; and 60% was dedicated to faculty salarysupport in the form of higher compensation and new facultypositions, thus counteracting the impression that the majorityof new investment was focused on building research. Thistransparency, at both the residency program and departmentlevel, reaped important benefits in resident and faculty mo-rale.

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Conclusion and Future DirectionsOver the last 4 years, our residency training programs

were presented with enhanced university resources, cou-pled with pressure to transform. We chose to harness theseforces to upgrade our programs in four areas: mission,resident recruitment, didactics and resident scholarly ac-tivity, and clinical training. We discovered that it was es-sential for leadership to maintain transparency and open com-munication with residents and faculty. Only throughmaintaining “bottom-up” input were we able to implementthese substantive changes. The process of implementationhas meant reshaping our institutional culture, and changing aculture is a slow process. We strive for a culture that holdsthat education, clinical care, and research do not compete forresources in a zero-sum game, but that all aspects of ourdepartment enhance the others. Leadership, faculty, and res-idents must be committed to all aspects of the department inorder for it to become a leading academic department.

To confirm that these changes have been valuable, wewill monitor in-training exam scores, board scores, facultyevaluation of resident performance, number of residentsparticipating in conferences or publishing, and residentand faculty evaluations of our overall program. We alsoplan to add an alumni survey. It is worth emphasizing thatthe “nuts-and-bolts” programmatic changes have broughtdividends in “soft” factors such as cooperation betweenresidents and faculty and improved resident morale. Thesemilieu factors have been helpful with recruitment andresident and faculty satisfaction during training.

The authors of this article gratefully acknowledge the extensive inputof Isabel T. Lagomasino in preparing and revising this column.

At the time of submission, the authors reported no competinginterests.

References

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3. Santos AL, Saunders B, Robert J: Choosing a psychiatricresidency. Am J Psychiatry 1988; 145:775–776

4. Ellencweig N, Weizman A, Fischel T: Factors determiningsatisfaction in psychiatry training in Israel. Acad Psychiatry2009; 33:169–173

5. Haupt D, Farber N, Volkman E, et al: Psychiatry/medicine: acomparison of factors in resident role satisfaction. J PsychiatrEduc 1987; 11:78–86

6. Simmonds AC, Robbins JM, Brinker MR, et al: Factorsimportant to students in selecting a residency program. AcadMed 1990; 65:640–643

7. Yudowsky R, Elliott R, Schwartz A: Two perspectives on theindicators of quality in psychiatry residencies: program di-rectors’ and residents’. Acad Med 2002; 77:57–64

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9. Stubbe DE: Preparation for practice: child-and-adolescentpsychiatry graduates’ assessment of training experiences.J Am Acad Child and Adolesc Psychiatry 2002; 41:131–139

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