Systems-Based Practice and Practice-Based Learning for the General Psychiatrist: Old Competencies, New Emphasis

Since the development and propagation of the six-competency framework, there has been a lack of understanding among both residents and teaching faculty of what systems-based practice (SBP) and practice-based learning and improvement (PBLI) entail [1–3]. In our anecdotal experience, these have been viewed as “soft” competencies, acquired incidentally as part of rigorous clinical training. This reflects cumbersome titles whose meanings are not intuitive to many physicians, few established teaching methods in either competency, and a lack of metrics for many of the corresponding program requirements. However, even as those metrics and training practices have emerged in other medical and surgical disciplines, psychiatry has been slow to adopt and disseminate them [4, 5]. As the Psychiatry Milestone Project began, multiple converging trends compelled our Working Group to pay particular attention to PBLI and SBP and to establish Milestones that will more closely align psychiatry with other specialties. First, the nature of medical practice is changing in ways that will impact psychiatry. New physicians in all specialties are increasingly choosing employment in large groups/ systems [6], and in these environments, they will be expected to join formal quality improvement (QI) processes. As large practices transform into Accountable Care Organizations (ACOs) under the Patient Protection and Affordable Care Act, that trend is expected to accelerate [4]. Psychiatry and allied behavioral specialties have outstanding potential for controlling costs and improving outcomes if we can appropriately prepare our trainees for that work [7–9]. Impending reforms in health care financing have also spurred interest in integrated and collaborative care as a specific practice model [10–12]. These modes of practice will demand skills that, in our experience, only a handful of departments currently teach well [13]. Atop this, the continuing presence of suicide reduction as a National Patient Safety Goal [14] highlights the need for psychiatry and psychiatric training to join the work started by our general medical colleagues. Second, an emphasis on quality and safety is woven throughout the Accreditation Council for Graduate Medical Education (ACGME)’s Next Accreditation System (NAS). The Psychiatry Milestone Project itself is an attempt to implement QI philosophies through continuous outcomes tracking in medical education [15]. Within NAS, the Clinical Learning Environment Review (CLER) replaces institutional site visits and specifically assesses “opportunities for residents to report errors, unsafe conditions, and near misses” and “how sponsoring institutions engage residents in the use of data to improve systems of care, reduce health care disparities and improve patient outcomes” [16]. Our experiences as CLER “alpha test” sites showed that ACGME site visitors are seeking evidence of resident engagement in systems-level improvement throughout the institution and that no department or service line will be exempted. Third, PBLI is increasingly important to board certification and licensure. The American Board of Psychiatry and Neurology (ABPN)Maintenance of Certification (MOC) process requires annual self-assessment, lifelong learning, and documented practice modification based on patient/peer feedback [17]. With certification potentially tied to Maintenance of Licensure (MOL) in the coming years [18], new graduates must be prepared for a career of rigorous self-assessment and improvement. J. Hunt Alpert Medical School at Brown University, Providence, RI, USA