Early developments in Canadian geriatric psychiatry education

The need for expertise in the treatment of mental health in older age is clearly not a new phenomenon. More than 32 countries worldwide have achieved full recognition of geriatric psychiatry as a subspecialty of psychiatry, including the U.S.A., Australia, and many European countries (Camus et al., Reference Camus2003). In Canada, more than two decades have been devoted to the pursuit of psychiatry subspecialty designation from the Royal College of Physicians and Surgeons of Canada (RCPSC). The RCPSC oversees the standards of training programs, examinations, and credentialing for all Canadian medical specialists. Canadian family physicians have a separate body responsible for training standards and credentialing, the College of Family Physicians of Canada (CFPC). When the RCPSC was established in 1929 only two specialties – Medicine and Surgery – existed. Psychiatry was first recognized as a specialty in 1944. As of 2008, over 60 disciplines have been officially recognized, including geriatric medicine (approved in 1977).

In the absence of subspecialty recognition by the RCPSC, Canadian psychiatrists with an interest in geriatric patients grouped together in provincial psychogeriatric societies and associations, some of which had a multidisciplinary focus. La Société de psychogériatrie du Québec, the field's first organized specialty society, was founded in 1978. In the same year, the Canadian Psychiatric Association (CPA) formed a Section for those with interest in geriatric psychiatry. Later, many sought recognition and affiliation through membership in national academies, which developed standards for membership based on minimum amounts of training or practical experience working as geriatric psychiatrists. The first of these was the Canadian Academy of Child and Adolescent Psychiatry (CACAP), followed by the Canadian Academy of Geriatric Psychiatry (CAGP) and the Canadian Academy of Psychiatry and the Law (CAPL). In 1991, the CPA began discussions with the RCPSC to lay groundwork for the recognition of the first psychiatric subspecialties. As a result of concerns regarding potential fragmentation of the parent specialty, psychiatry, in 1994 the council of academies was established to provide the groups of geriatric psychiatry, child and adolescent psychiatry, and forensic psychiatry a unified voice within the governance structure of the CPA. The subsequent founding of the Canadian Academy of Psychosomatic Medicine (CAPM) brought the Council of Academies to its current complement of four member groups.

The Canadian Academy of Geriatric Psychiatry (CAGP) was formed in 1993 and developed into a national voice for education, advocacy, research and service delivery for the mentally ill elderly. It has grown to include approximately 200 currently practicing members. Members of the CAGP have contributed internationally, including Joel Sadavoy as the past president of the International Psychogeriatrics Association (IPA), Bruce Pollack as the past president of the American Association for Geriatric Psychiatry (AAGP), and Susan Lieff as primary author of the Geriatric Psychiatry Core Competencies content document for the United States Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Psychiatry and Neurology (ABPN) (Lieff et al., Reference Lieff, Kirwin and Colenda2005). Within Canada, members have been influential in advocacy, with Marie-France Rivard chairing the Seniors Mental Health Advisory Committee of the Mental Health Commission of Canada since 2007, and David Conn and Ken LeClair serving as founding Co-chairs of the Canadian Coalition for Seniors Mental Health (CCSMH).

In his article entitled “Progress in geriatric psychiatry in Canada”, Martin Cole (Reference Cole1999) outlined the advances in education, clinical services, infrastructure, and research activity that led to the conclusion that geriatric psychiatry in Canada had reached a level of sophistication where subspecialty status was both warranted as well as necessary for further development. LeClair and Sadavoy (Reference LeClair and Sadavoy1998) published a scholarly discussion of geriatric psychiatry's credentials as compared with RCPSC criteria for development of a subspecialty. They too reached the same conclusion. However, subspecialty designation did not follow quickly after the publication of these articles. Many factors contributed to this delay, but the development of geriatric psychiatry clinical services, educational programs, advocacy initiatives, and research in Canada proceeded.

Specific to education, numerous programs have been developed, both nationally and locally, to support professionals, community members and caregivers in caring for older adults with mental health needs. Over the past decade, more formal educational outcomes were established for trainees in general psychiatry, who would inevitably see geriatric patients when in practice. Ultimately, these educational developments provided the foundation on which a subspecialty curriculum could be developed and approved by the RCPSC.

Initial steps: education of primary care physicians and other primary care mental health professionals

Just as clinical presentations range from mild and common to the most severe and rare, clinical services in psychiatry have been described as a continuum. Each level requires appropriate educational interventions to support service delivery adequately. The tiered model described by Draper and colleagues (Draper et al., Reference Draper, Brodaty and Low2006) moves from public education sessions in a preventive role for the general population and those with risk factors in the bottom two tiers, through the education of primary care physicians and other primary caregivers in management of mild mental disorders (tier 3), the education of general psychiatrists to manage moderate mental disorders (tier 4) and finally to the highest tiers of complex moderate, severe and extreme mental disorders requiring the expertise of geriatric psychiatrists and specialized multidisciplinary teams and care settings.

Many of the most significant educational initiatives of the CAGP have focused on those providing primary care for elderly patients. The health care system in Canada is a publically funded system, dedicated to universal access, with primary care/family physicians serving as the “gatekeepers” to consultant specialty and subspecialty physicians. The need for educational initiatives around geriatric mental health issues in primary care, including prevention and early detection strategies, was readily recognized. Psychiatrists with a particular interest in geriatric care embraced activities of education and capacity enhancement. Through these initiatives, geriatric psychiatrists have built a strong network of support for their primary care colleagues in meeting the bulk of older adults’ mental health care needs across a broad range of settings, including residential settings in both the community and long-term care.

Some examples of those educational initiatives that have achieved national scope include:

• • The Canadian Coalition for Seniors’ Mental Health (CCSMH). This multidisciplinary group was conceived of as a millennium project by the CAGP and now includes more than 950 individuals and 90 national and provincial organizations. It promotes the mental health needs of older adults through advocacy, education, research, and best practices and by fostering connections and collaboration between interested groups. The CCSMH orchestrated the writing of the first set of evidence-based national guidelines for four key areas of seniors’ mental health care: depression (CCSMH, 2006a), assessment and treatment of mental health issues in long term care (CCSMH, 2006b), suicide risk assessment and prevention (CCSMH, 2006c), and delirium (CCSMH, 2006d).

• • Canadian Collaborative Mental Health Initiative (CCMHI). A consortium of 12 national organizations, including those representing families and caregivers, who have come together to support collaborative initiatives across organizations and sectors in order to promote access to quality mental health care for all Canadians. CAGP members have been involved in developing the series of collaborative toolkits (Kates, et al., Reference Kates, Ackerman, Crustolo and Mach2006), including one aimed at establishing collaborative initiatives for seniors between mental health services and primary care.

• • PIECES Education program. This program was originally conceived as a means to enhance capacity of long-term care facility staff as resources to meet the care needs of individuals with increasingly complex physical and cognitive concerns and associated behavioral issues. PIECES has expanded to become a system-wide approach to education for a variety of regulated health professionals, including modules for those who work with older patients in acute hospital care, the emergency room, retirement homes, family practice, and in community settings, and front-line caregivers (PIECES Consult Group, Reference Hamilton, Harris, Le Clair and Collins2008). The program is now utilized in six Canadian provinces or territories.

Education of Canadian general psychiatrists in geriatric content

Although many initiatives were under way for education in primary care settings by 2000, geriatric psychiatry retained a relatively low-profile in Canadian psychiatry residency programs. The Royal College's formal training requirements for general psychiatry had not changed substantively in many years. In order to qualify as a psychiatrist, it was suggested that residents obtain some supervised experience, not necessarily in a dedicated clinical rotation, sufficient to assure competence in geriatric psychiatry. While some exposure to geriatric patients was mandatory, no specific standards for rotation length, content, supervision or definitions of competence were established. In practice, many programs had limited numbers of supervising geriatric psychiatrists available, and utilized rotations of three months’ duration, or in some cases blended geriatric experiences with other training experiences such as consultation-liaison rotations. Typically, these rotations occurred in the senior residency years. In contrast, all residents completed a mandatory six-month rotation in child psychiatry during their junior residency years. Despite these limitations, geriatric psychiatry educators crafted educational objectives and wrote scholarly papers on recruitment and training issues, all in support of further developing the base of expertise in geriatric psychiatry among general psychiatrists (Herrmann et al., Reference Herrmann, Shulman and Silver1992; Thorpe et al., Reference Thorpe, LeClair, Donnelly and MacBeath1993)

Interestingly, although the RCPSC had not yet granted formal recognition of geriatric psychiatry, many medical schools in Canada proceeded to develop divisions of geriatric psychiatry within academic departments of psychiatry. Geriatric psychiatry educators flourished in this academic system, providing ever increasing geriatric psychiatry training sites for general psychiatry residency programs.

The issue of generalist education has played a prominent role in the attempts of the psychiatric subspecialists to gain recognition by the RCPSC. After applications to gain official recognition for psychiatry subspecialities were declined in 1996 and 2000, the RCPSC advised the CPA to develop a consensus within psychiatry regarding the core competencies required for a general psychiatrist to practice psychiatry effectively “across the lifespan”, thereby clarifying the distinction between the skills and practice of a general psychiatrist with older patients, and those of a subspecialist in geriatric psychiatry. General psychiatrists were thus recognized as having a distinct role to play in providing care for those with disorders more complicated than can generally be managed in primary care settings, but room was also left for the unique set of skills and competencies that is required to care for those problems at the most complex and severe end of the continuum.

In pursuit of establishing agreed-upon competencies for the generalist, a symposium on postgraduate education, sponsored by CPA, was held in 2001. A group of educational leaders and stakeholders, including the CAGP Education Co-Chairs, was convened to participate in the National Strategy on Postgraduate Education (NSPGE) Working Group.

This group used a web-based, modified Delphi approach to survey Canadian psychiatrists, seeking their opinions as to the essential skills required to practice general psychiatry effectively. The group ultimately arrived at a consensus regarding accepted competencies of a general psychiatrist, agreed upon by psychiatrists, resident representatives, academies of subspecialists and the CPA. The RCPSC also agreed to accept the new competencies as developed by psychiatry, such that these competencies have now become the standard expectations for all Canadian psychiatry training programs (RCPSC, 2007a; 2007b).

General psychiatry training in Canada remains a five-year program, post MD. The first postgraduate year (PGY) is designed to consolidate basic clinical skills. PGY2 through PGY5 involve core psychiatry training in adult, child, geriatric, severe and persistent mental illness, consultation-liaison psychiatry, psychotherapy and addictions with increasing levels of responsibility in the senior years.

Important features that differentiate the new general psychiatry training requirements from the previous model are as follows:

1. 1. Life span approach: Years 2 and 3 of training concentrate on the development of fundamental psychiatric knowledge and skills in order for trainees ultimately to provide psychiatric care across the lifespan. As such, geriatric psychiatry is included at an earlier, more foundational level of general training, rather than as a specialized senior rotation.

2. 2. Mandatory core training in geriatric psychiatry: The new training requirements specify that a total of six months’ training within the second and third postgraduate training years must be dedicated to geriatric psychiatry, in a variety of clinical settings. Inpatient units, day hospitals, ambulatory care clinics, outreach teams to community and long-term care homes, and shared care practices are examples of potential teaching settings, although each one of these is not necessarily available at every university offering a residency in psychiatry The six months can be offered in one continuous block or two three-month blocks, and the specific details of this training can be adapted to local circumstances.

3. 3. Competencies in psychiatry are embedded entirely within the CanMEDS Framework: In response to societal needs, the RCPSC developed a set of competencies that a member of the public might expect from every physician. At the centre is that of medical expert, but the range of competencies also includes those required to be an effective communicator, collaborator, manager, health advocate, scholar and professional (Frank, et al., Reference Frank2005). This framework guides every RCPSC-accredited specialty program, and is increasingly being utilized in family medicine and undergraduate medical education.

   Geriatric psychiatry rotations are based on objectives of training for each of the CanMEDS competencies. For example, the emphases on working in a multidisciplinary approach, and within shared care models, will serve to develop collaborator competency and particular skills required of an effective communicator. There are many opportunities to learn and demonstrate health advocacy at the level of the individual as well as at the level of the health care system when working with the vulnerable, and frequently overlooked, geriatric population. The opportunity to utilize educational skills to enhance the capacity of other care providers to deal effectively with geriatric patients is an important element of developing a resident's overall competency as a scholar in psychiatry. Complex ethical issues, inherent in geriatric care, broaden trainees’ experience in applying competencies of the Professional role.

These changes apply to general psychiatry residents who began postgraduate training in July 2009 or later. Thus, the first cohort of residents is only now entering PGY2 and experiencing the new, mandatory core training. It is anticipated that Canadian training programs, which vary in size from fewer than 20 total residents to more than 100, will require support as they continue to adapt their local training resources to fit the new guidelines. In order to facilitate this transition, the CPA has published a book that provides practical advice for specific areas of training, including geriatric psychiatry (Shea and Andrew, Reference Shea, Andrew, Leverette, Hnatko and Persad2009), and on topics such as aligning evaluation practices with the new training objectives.

In this way, a new cohort of graduate psychiatrists will each have a core set of skills with which to approach the geriatric patient. These skills will have been acquired in an integrated fashion with patients from across the lifespan, rather than as an isolated “geriatric” experience late in the residency, when many other interests may have already developed. This represents a very significant change in the amount of training that all Canadian psychiatrists will have received with older patients, and may result in general psychiatrists being more willing and comfortable to tackle geriatric patients in their practices (Lieff, et al., Reference Lieff, Andrew and Tiberius2004). These psychiatrists will be equipped to deal with those patient scenarios that are more involved than would usually be handled in the primary care setting, and that require psychiatric expertise. Yet, even with six months’ training, these well-trained generalists may not feel confident to handle the most complex, multifaceted patients in the continuum, which require the particular blend of integrated medical and psychiatric knowledge and skills that is unique to the dedicated geriatric psychiatrist.

Geriatric psychiatry as a subspecialty in Canada

Until this point, training in geriatric psychiatry has taken place primarily during the residency training years in psychiatry. A minority of residents completed senior elective experiences in geriatric psychiatry to further their skills. Approximately six to eight each year nationwide went on to complete further formal “fellowship” training. A 1994 set of learning objectives for fellowship training was developed by the CAGP, but the final curriculum and standards for such training have always been determined by the university in which training has occurred. This resulted in significant variability. Training typically focused on enhancing clinical skills, and ranged from 6 to 12 months of post-residency training. These training positions have been funded on an ad hoc basis, generally utilizing highly individual combinations of university funds and fee-for-service billings by the trainee. The goal was to expand the number of psychiatrists who had interest and expertise in working with seniors. A few trainees each year combined added clinical experience with formal training in research or education, sometimes completing fellowships and masters degrees concurrently over two to three years post-primary certification in psychiatry.

With baby boomers approaching the age of 65, there can be no doubt about the growing need for high quality mental health care for older adults. This educated group of consumers increasingly demands a more standardized approach to credentialing the physician they will turn to as their “geriatric psychiatrist”. The designation of “Seniors Mental Health” as one of three priority areas for the Mental Health Commission of Canada, chaired by senator Michael Kirby, also attests to this need. Subspecialization has been recognized as a way to move toward better meeting this growing need. As stated by the World Health Organization (WHO) in its position paper on psychiatry and the elderly, “The emergence of the specialty of psychiatry of the elderly has helped to raise the status of this vulnerable group and has also fostered research which offers hope for better treatment and outlook” (WHO, 1996).

Canadian patients stand to benefit by increased development of geriatric psychiatry as a subspecialty. In the coming years, subspecialists will be required to manage the more unusual and multifaceted presentations with which generalists are inexperienced. This subspecialty group will also be required to provide leadership in service and policy development, advocacy, and advancing the research agenda for the expanding cohort of seniors with mental health needs (LeClair and Sadavoy, Reference LeClair and Sadavoy1998). For these reasons, many in Canada strongly agree with Nathan Herrmann's editorial “Geriatric psychiatry: a subspecialty whose time has come” (Herrmann, Reference Herrmann2004).

In September 2007, with the core competencies for general psychiatry adopted and embedded in psychiatry training programs, four psychiatry groups submitted coordinated applications for subspecialty recognition. These included submissions from CAGP, CAPL, CACAP, and the more recently established, first-time applicant, the Canadian Academy of Psychosomatic Medicine (CAPM). In November 2007, the CAPL and CACAP applications received Part I approval, the CAPM application was declined, and the CAGP was required to submit a clarification. The RCPSC requested more information on the definition of geriatric psychiatry and more evidence of a discrete body of knowledge and societal need for subspecialty recognition.

At the March 2008 meeting of the Royal College Committee on Specialties (COS), the CAGP clarification was reviewed, and geriatric psychiatry was approved to proceed also with Part II. The three Part II applications were approved by COS in April 2009, and by RCPSC Council in September 2009.

Key features of the proposed subspecialty curriculum and training plans

1. 1. Duration of training. The proposed model for subspecialty training is that candidates for RCPSC Certification in Geriatric Psychiatry will undertake a total of two years’ training. Of this, up to one year's credit for training completed while the candidate is a resident in psychiatry is possible. This system will allow most residents, with some advanced planning, to complete the required training time within one year after their psychiatry training, while not excluding those “late bloomers” or practicing general psychiatrists who wish to undertake a subspecialty program, and who may not have completed appropriate rotations while in training.

2. 2. Breadth of experience. Subspecialty training will reflect the breadth of unique skills required to practice geriatric psychiatry. Required rotations in subspecialty training include dedicated clinical rotations with geriatric psychiatry patients, across a variety of settings, for a total of at least one year of the training. Research and educational skills may be developed longitudinally, or incorporated into specific rotations. Enhanced competency in areas integral to the practice of geriatric psychiatry, such as knowledge of chronic medical conditions and physical illnesses of late life, and skills at working with family and caregivers, may be developed through experience in various selective rotations.

3. 3. Training is both time and competency based. The objectives of training and evaluations for the new subspecialty are structured to complement the paradigm shift toward competency-based education (Carraccio et al., Reference Carraccio, Wolfsthal, Englander, Ferentz and Martin2002) that is underway within Canadian specialty training. In addition to simply completing a designated number of months’ training time, evidence of attaining a level of competency appropriate to the residents’ level of training will be sought during the final evaluations of both in-training rotations and during the RCPSC formal examinations completed at the conclusion of training. While this emphasis may seem intuitively obvious, evolving to a competency-based training system has been challenging in many specialties and jurisdictions (Carraccio et al., Reference Carraccio, Wolfsthal, Englander, Ferentz and Martin2002).

The framework outlined in Figure 1 was originally developed to guide the assessment of competency for psychiatry training. Levels of competency for subspecialists have been defined relative to those for generalists and aligned with the existing framework. While general psychiatrists are expected to have working knowledge or proficiency level competency for geriatric problems, subspecialists with additional training will be expected to attain advanced levels of competency for the common issues of geriatric practice. While expert competency may be developed in some specific areas, it is expected that this level will be developed via the wisdom and experience that comes from practicing in the field.

Figure 1.

Levels of competency in Canadian psychiatry training (RCPSC, 2007a).

Work is presently underway to refine and finalize documents to guide the standards for accreditation of training, and to develop an appropriate assessment process both for future trainees, as well as for those currently practicing geriatric psychiatry and who wish to obtain a subspecialty designation without undertaking further formal training.

Implications of subspecialization

At this point subspecialization is in its infancy. Admission of the first cohort of subspecialty trainees is anticipated within the next two to three years, thus the implications of this change have not yet been realized. Geriatric psychiatry trainees are now to be considered as residents, rather than post-residency fellows. It is unclear how these new residency positions will be funded. The parent specialty of psychiatry is confident that officially recognizing subspecialties meets a societal need and will not fragment psychiatry. However, concerns exist that provincial budgetary constraints will cause funding for the new subspecialty training positions to be redirected from established training positions in other specialties.

Accreditation by the RCPSC also carries the onus of significantly more administrative responsibilities associated with training, at both national and local levels, than did the previous model of informal fellowships. This responsibility has the potential to tax the existing geriatric psychiatry manpower. It is also unclear as to whether those with an official subspecialist designation will be eligible for differential payments in the fee-for-service system. Because individual provinces within Canada are responsible for separate health care budgets in most cases, there exists the potential for discrepancies within the country with respect to remuneration tied to subspecialty status and funding of training positions.

Conflict of interest

None.

Description of authors' roles

Both authors were members of the NSPGE Working Group and shared the writing of the 2007 application for subspecialty recognition. They co-chair the Education Committee of the CAGP. Both shared in the literature review and writing of this paper.