The first postresidency fellowship programs dedicated to clinical training in community psychiatry were created in the decade after the 1963 Community Mental Health Centers Act at Harvard, University of California, Los Angeles, Columbia University, and Albert Einstein College of Medicine (1). These and similar one- to two-year programs of the ensuing 40 years have focused on clinical work in community settings, often with management, research, and evaluation experiences. Unfortunately, these programs have rarely survived more than a decade.
The Public Psychiatry Fellowship (PPF) of New York State Psychiatric Institute at Columbia University Medical Center was founded in 1981 and is distinct from Columbia's earlier fellowship. PPF is the oldest, largest, and best known program for training psychiatrists to become public-sector leaders. The institute provides one-third of fellows' salaries and supports four core faculty members, some of whom work part-time. This stable source of funding is the most important factor in the longevity of the program.
Since its creation 27 years ago, PPF has graduated over 200 psychiatrists and, for more than a decade, has trained ten fellows per year. Ongoing (ppf.hs.columbia.edu) and published (2) surveys show that 95% of alumni continue to work in the public sector and that 65% are in leadership roles. Changing the designation of the program from community to public psychiatry shifted the program's conceptualization from the location of the services to the funding and organizational structure of complex mental health systems. This column uses the term "public-community psychiatry."
PPF's faculty has frequently been consulted by other psychiatry departments planning public-community fellowships. The developers of the programs at Emory and Yale consulted PPF's faculty. The other three current programs are at University of Maryland, Case Western, and University of Vermont. These five programs were created in the past decade and train one or two fellows per year.
A recent publication of the Group for the Advancement of Psychiatry's Committee on Mental Health Services (3) used American Psychiatric Association membership data to demonstrate that early- and midcareer psychiatrists work more hours in publicly funded organizational settings than in private practice settings. Consistent with this trend, there has been increased interest in developing fellowships in public-community psychiatry. Pennsylvania recently designated three academic centers of excellence and innovation—University of Pittsburgh, Lake Erie Osteopathic Medical College, and University of Pennsylvania—using a model developed in Ohio (4). Each center is expected to create a public-sector fellowship training program with PPF as a suggested model. The Pittsburgh and Penn programs have begun consulting with PPF's faculty, which is also consulting with five other developing programs: Johns Hopkins University, New York University, University of Toronto, Orange County Behavioral Health Services with University of California, Irvine, and George Washington University with St. Elizabeths Hospital.
PPF's faculty, in consultation with alumni, has developed seven core elements for its one-year program. PPF's longevity and the career paths of its graduates suggest that these core elements represent a best-practices model for fellowship training in public-community psychiatry.
Each of the following core elements describes how PPF executes that element and how it could be implemented in a smaller program.
Element 1: The academic curriculum covers the essential topics in public psychiatry. The academic curriculum consists of 12 modules, each comprising three to six sessions: (a) Structure of Public Psychiatry I: The American Welfare State and Public Mental Health, (b) The Role of the Psychiatrist in Community-Based Services, (c) Recovery and Psychosocial Rehabilitation I: Introduction to Programs for Adults With Severe and Persistent Mental Illness, (d) Internal Program Evaluation, (e) Structure of Public Psychiatry II: The Structure of Public Mental Health Services, 1948—1990, (f) Substance Use Disorders, (g) Fiscal Management, (h) Recovery and Psychosocial Rehabilitation II: Recovery-Oriented Programs, (i) Posttraumatic Stress Disorder, (j) Homelessness and Housing Policy, (k) Current Directions in the Structure of Public Mental Health, and (l) Public Mental Health Advocacy. PPF originally focused on adults with severe and persistent mental illness. Modules c and h retain that focus, whereas the other modules address broader public-sector populations. Topics are chosen for their importance and relevance to fellows' activities at their field-placement sites.
In a smaller program this curriculum could be taught in a once- or twice-weekly supervised tutorial, including guest experts as appropriate. In a two-year program, organizational modules (a, d, e, g, and k) could be presented in the first year, with clinical modules (b, c, f, and h—j) presented in the second year. The second group of fellows could take the clinical units first, allowing both first- and second-year fellows to attend tutorials together.
Element 2: Fellows apply concepts learned in the academic curriculum to their field placements. Fellows prepare and lead five 90-minute presentations and two shorter presentations on the following: their residency training program, using the congruence model (5), a structure that PPF has found useful in describing organizations and analyzing strategies for system change; their field placement, using the congruence model; a system-oriented clinical presentation; a fiscal presentation (45 minutes); an advocacy presentation (30 minutes); an internal program evaluation; and a final presentation on their field placement, using the congruence model.
These presentations, described in more detail in the syllabus section on the PPF Web site (ppf.hs.columbia.edu), reveal to fellows and faculty what fellows are doing at their field-placement sites and provide fellows the opportunity to learn how to run a meeting to create strategies for change. All four core faculty members attend each of the fellows' presentations. Fellows share feedback received in these meetings with their field-placement supervisors to help inform system change.
In a smaller program these presentations could be part of the tutorial mentioned in the first core element.
Element 3: Presentations by guest speakers illustrate topics covered in the academic curriculum. PPF devotes approximately one session per week to a guest speaker. The topics of these sessions are coordinated with the academic curriculum. Fellows visit selected agencies approximately monthly.
In a smaller program fellows could hear presentations by agency heads during visits to selected agencies.
Element 4: Fellows complete a practicum in mental health administration. Six didactic sessions in the PPF present basic concepts in mental health administration. These sessions are interspersed with six case presentations by alumni who are medical directors in public mental health organizations. These presentations address current management problems to which fellows and faculty suggest strategic solutions. In the didactic sessions that follow, fellows discuss and evaluate how the management concepts are being applied in the case presentations.
Throughout the year approximately 25 other alumni, also medical directors in public mental health organizations, describe current management problems and encourage fellows to suggest solutions. Several alumni return later in the year and present follow-ups to the problems analyzed earlier in the year, focusing particularly on the impact of the interventions suggested by fellows. This ongoing contact with alumni extends the concept of "fellowship" beyond the fellowship year. The alumni receive support from fellows and faculty, and current fellows develop an understanding of their predecessors' career paths.
In a smaller program the practicum could be met during the field visits described for element 3, and the didactic component could take place during the supervised tutorial.
Element 5: Field placement in a public mental health organization achieves a comprehensive clinical and management experience. PPF fellows select field-placement agencies where they work three days a week throughout the fellowship year. Agencies are chosen with regard to their willingness to allow fellows to assume leadership roles and their track record of providing positive experiences to previous fellows. Some agencies attract fellows almost every year, whereas others are selected on the basis of fellows' individual interests. Agencies generally provide two-thirds of total salary support, an investment that facilitates fellows' remaining at their agencies at the end of the fellowship year. More than half of fellows elect to do so. Whether or not the fellow remains at the agency, she or he is encouraged to negotiate the role of program medical director (6).
In a smaller program this element could be carried out as above, with recognition that funding for any program will depend on local considerations. An alternative strategy is to use the fellowship to recruit junior faculty, with two possible funding variations. The participating agency could hire the fellow full-time with a half-day of protected class time over two years or 80% time with the training institution securing separate funds to support one day per week of classes for one year.
Element 6: Weekly meetings with a faculty preceptor support individuals in academic and field-placement experiences. Each fellow meets weekly with one of four faculty preceptors to whom he or she has been assigned. The preceptor helps the fellow prepare presentations and discusses the fellow's field-placement experience. These discussions facilitate the integration of the didactic curriculum and the field-placement experience. Toward this goal each of the four preceptors attends all fellows' presentations as well as much of the academic curriculum.
Each fellow has an identified field-placement supervisor to meet with regularly for clinical and administrative supervision. Whenever possible, this supervisor is a former fellow. The faculty preceptor serves as liaison with the fellow's field-placement supervisor.
In a smaller program this element could be carried out as above. The preceptor would be the person conducting the supervised tutorial.
Element 7: Faculty provide mentorship and other ongoing support beyond the fellowship year. Faculty members are aware of the difficulties that public-sector agencies experience in recruiting and retaining psychiatrists. A major factor is the isolation that many public-community psychiatrists experience, especially in community-based agencies lacking the structural academic advantages available in teaching hospitals. Even in academic centers, mentors are not readily available to most public-sector psychiatrists, because senior faculty are more likely to be experts in areas other than public psychiatry. PPF faculty strategically provide active mentorship and ongoing support to alumni, a natural extension of the preceptor's role during the fellowship year (element 6). In addition to inviting presentations by alumni (element 4), faculty members maintain regular contact with alumni through consultations at crucial career junctures, periodic alumni reunions, a Web site that is updated with annual reports of activities of faculty and alumni, and an active Listserv that offers job postings and the opportunity for professional discussions. In a smaller program this element could be carried out as above.
On the first day of the fellowship, fellows are introduced to the ideas of psychiatric rehabilitation and recovery as the most comprehensive conceptual approach to working with people with severe mental illness. Throughout the year they are encouraged to use rehabilitation and recovery-oriented practices and to evaluate their agencies' practices in this light. Fellows are introduced to advocacy and the ongoing use of data as crucial tools for effective public-sector leadership. The basic approach, carried out in both academic and field-placement activities, encourages fellows to learn which strategies are most effective by participating in their creation and implementation, with the belief that students learn best by participating rather than observing. This active strategy is evident throughout the core elements.
Each week fellows attend five 90-minute classes and one hour of precepting by one of the four core faculty members (elements 1—4 and 6). All ten fellows and at least two core faculty members attend every class. Fellows complete anonymous written evaluations of each didactic unit and each presentation by outside speakers. These evaluations are discussed in class, and the faculty indicates what changes in the curriculum will result from the feedback. The group process creates a strong bond among fellows and faculty, a bond that is sustained throughout the fellows' careers (element 7).
Each fellow spends three days each week at a field-placement agency under the supervision of a senior professional at that agency (element 5). The faculty preceptor consults with the field-placement supervisor to ensure that the didactic and field-placement activities are coordinated and optimized and to address any field-placement issues that arise during the course of the year (element 6).
PPF's faculty has presented the core elements to the executive board of the American Association of Community Psychiatrists (AACP), to each of the developing programs with which it is consulting, and to the Yale program that consulted with PPF's faculty during its planning stage. Response has been enthusiastic. All of these programs have indicated that they could use the core elements to inform the development or expansion of their programs. The AACP board has used the core elements as the basis for creating guidelines for the development of future fellowships and possibly as a structure to create criteria for formal recognition of fellowship programs.
New programs are encouraged to start with at least two fellows. If the program can support only one fellow per year, the creation of a two-year program is recommended. By so doing a minimal group process between the first- and second-year fellows could take place starting in the second year. To guarantee the delivery of a reasonably complete curriculum, we recommend that classes be scheduled a minimum of one day per week, allowing time for four 90-minute classes. If class time has to be limited to one half-day per week, a two-year program is again recommended.
By adopting the core elements, fellowship training programs in public-community psychiatry may be sustained through the inception and difficult years of early implementation. The addition of new public-community psychiatry training programs will increase the number of psychiatrists prepared to meet the recruitment and retention needs of public-sector agencies. The PPF faculty hopes that training programs that adopt the core elements will replicate the program's success in producing psychiatrists who devote their careers to leadership positions in the public sector and deliver high-quality care to the patients they serve.