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Certification of the Child Psychiatrist
Certification of the Child Psychiatrist What Is Special about the Specialist?
John F. McDermott, Jr., M.D .
Since the 1920s, medical specialties in the United States have developed their own "Boards" with dual fun ctions: maintaining standards of train ing through accreditation of programs and measuring the competence of individuals practicing that specialty through certification examinations. In 1959 the American Board of Psychiatry and Neurology, Inc. established its first and onl y official subspecialty, Child Psychiatry, with the Committee on Certification in Child Psychiatry (hereafter referred to as "the Board") placed in charge of accreditation of training programs and certification of child psychiatrists who had completed their training in these approved programs. Presumably this dual function should be a re ciprocal one which connects training and certification in a fluid and changing, rather than a static relationship. The Board should function not only to define and measure the essentials of core training. It should also encourage the further development of the training experience and the evaluation of it to keep pace with the changing nature of the field caused by the knowledge explosion. In other words, the certification process (and in the future , recertification) should complement the training experience by systematically measuring in candidates from approved programs the basic knowledge, skills, and attitudes considered essen tial for the competent child psychiatrist practitioner. GENERAL PROBLEMS OF EXAMINATION AND ACCREDITATION
In recent years, there has been increasing cr iticism within the psychiatric profession itself about the ways in which the Board fun cDr. M cDermott is Chairman of the Committee on Certification in Child Psychiatry, Am erican B oard of Psychiatry and Neu rology, Inc. H e is also Professor and Chairman , Department of Psychiatry, University of Ha waii, School of Medicine, 367 5 K ilauea Avenue, Hon olulu , Ha waii 96816.
196
Certification of the Child Psychiatrist
197
tions are carried out (Taylor and Torrey, 1972; Morgenstern, 1970; Holden, 1969). Frequently, suggestions are made for changes in the training sequence established by the Board (Cohen and Henderson, 1973; McGuire, 1969; Pokorny and Frazier, 1966). Some have commented on the limited nature of professional competence that the Board examination samples and have noted that at best these examinations measure predominantly the candidates' ability to recall fragments of information solicited by the examiner (McGuire, 1969; Pokorny and Frazier, 1966). Furthermore, it has been observed that the information or task chosen for examination is likely to be arbitrary and frequently varies from candidate to candidate. Candidates who have taken the examination note this potential weakness in the Board's capacity to measure the elusive quality of clinical competence. They have complained that the examination depends upon accident in the candidate-examiner assignments, implying that an examiner's particular bias (or that of the Board itself) reflects an invalid and unreliable test of competence in the subspecialty of child psychiatry. Such criticisms are particularly paradoxical in an era of educational planning and evaluation in which objectives of training and evaluation of results are becoming more and more systematic. Training requirements and standards are also criticized as oldfashioned and static, not reflecting the rapid changes in the field since the 1950s. Training directors complain that impressionistic and arbitrary reports about their programs reflect the Board's uncertainty about common basic guidelines for training, and that the accreditation process itself is a loosely performed function, largely determined by site visitors who are not even psychiatrists, let alone child psychiatrists. It is significant that the certification examination is not even attempted by the majority of qualified child psychiatrists finishing accredited training programs. While there are 750 child psychiatrist training positions each year, fewer than 1,000 child psychiatrists have been certified over the past 15 years, with less than 100 candidates taking the examination each year. Furthermore, the failure rate in the examination itself approaches 50 percent (although many candidates "condition" only one part of the total examination), shockingly high for a subspecialty in which all the candidates have previously been certified in general psychiatry in order to be eligible for child psychiatry examination. It would appear that child psychiatrists by the hundreds are content to practice without their subspecialty boards. If they are content because they consider themselves "Board eligible," they are in error, since eligi-
198
John F. M cDermott, J r.
bility occurs only after the candidates' credentials have been reviewed and approved. Why, from a practical standpoint, do child psychiatrists avoid certification in their own subspecialty? Part of the reason, of course, is that psychiatry as a specialty lends itself to independent outpatient work not requiring hospital staff privileges. Thus, Board certification seems less necessary or important than in other medical specialties, such as internal medicine or surgery, or their subspecialties. Furthermore, salar ied psychiatric po sitions are primarily related to certification in general psychiatry, with requirements for certification in child psychiatr y relativel y less frequent. Child psychiatrists who have already been certified in general psychiatry and are "tired " of being examined may thus find less reason to go on, unless they have a special motivating factor , such as a career in academic medicine for which sufficient advantage would be gained by obtaining Board certification in child psychiatry. Finally, surprisingly large numbers of the training directors of our child psychiatry program s throughout the country are not Board-certified. It is difficult to imagine that they provide motivating models for their trainees to point toward certification, even though almost all training directors indicate that they "encourage" Board certification in their programs. While over three fourths of training directors indicate formal evaluation programs for residents during the course of their training, less than one sixth of the directors report any kind of examination related to certification procedure, such as "mini-Board s." Again, there seems to be a very uneven and disconnected rel ationship between training and certification in child psychiatry, rather than a reciprocal mirroring. The current rapidly changing national scene preceding passage of a national health insurance program finds larger and larger numbers of psychiatrists who have or would have previously avoided the certification process now preparing for and taking the examination in general psychiatry. The reasons are obvious: the level of third-party payments will increasingly be determined by special competence as measured by Board certification in a specialty or subspecialty. Recent developments, such as in institutional "quality of service" requirements by third-party pa yors, will probably also increase the demand for Board-certified child ps ychiatrists by residential treatment cen ter s and psychiatric inpatient programs. The Joint Commission on Accreditation of Hospitals' inclusion of specific child psychiatric standards is perhaps the most important example to date.
Certification of the Child Psychiatrist
199
THE SPECIFIC ISSUES IN THE Low ApPLICATION AND HIGH EXAMINATION FAILURE RATE
The responsibility for the low ap plication and high failure rate for the examination must be shared by the Board itself and the training program directors throughout the country. The Board ha s been faulted for not clearly articulating just what it is examining, i.e., what constitutes the specific components of competency in child psychiatry which are being measured, how they are being measured, what sou rce materials are used for the oral and written examination, etc. In particular, the validity and reliability of the examination are questioned. For instance, if the Board determines what it wishes to measure, to what extent is the examination actually measuring those competencies and that knowledge? How accurate are the measurements and judgments which are made, i.e. , will two or more examiners observing the same examination independently arrive at the same, or closely similar, grades? Some critics question whether grades would be modified to a significant degree if the candidate were seen with a different patient or were asked to respond to a second set of questions purported to sample the same area , but different from those to which he responded in the first examination. Finall y, the efficiency and effectiveness of the examination in general have been brought under question: to what extent are professional resources being used to obtain the maximum amount of relevant and reliable information about the candidate with the least redundancy or overlap? Is time wasted on testing aspects of competence which are trivial or irrelevant to satisfactory professional performance? Are some issues emphasized disproportionately to their importance in clinical practice? The answers to these questions lie in the assessment of what constitutes clinical practice, how the training is to be oriented toward specific competence in this profile of clinical practice, and how an examination is to be built to measure the prime requisites for such a model of good clinical practice in a systematic fashion . So far, the Board and the training directors themselves have lacked consensus as to a common "core" training experience. There is such wide variation among programs that it is clearly impossible for the Board to design an examination through which all or most of th e candidates from these programs can pass successfully. Indeed, when the Board has specified to some extent its examination content, i.e ., three separate clinical examinations, one on the preschool child , one on the school-age child, and one on the
200
john F. McDermott,jr.
adolescent, the experience is startling. Little attention seems to be paid to the arrangement of thi s di vision and weighting. Candidates show very uneven abilities in these three age groups, perhaps weakest in the preschool child, followed by the adolescent. Indeed, preliminary results from the nationwide study conducted by the Board in 1974-75 bear this out. About half the patient population in training programs throughout the country is of school age, less than one sixth preschool , and the balance, adolescent. There are certain programs in which virtually all of the patients come from a single age group, and there are other programs with no patients in one of the three age groups, and only a scattering in the second . In many programs, the vast majority of patients come from a single age group. The enormous variation in the amount and distribution of didactic instruction now appears to constitute another significant variable. For example, one program reports 500 didactic hours of childhood ps ychopathology; another reports none. One reports over 500 hours on consultation skills, while five programs report no didactic instruction in this area. The same wide vari ation is observed with respect to the amount of instruction on various forms of therapy, with very small amounts of time generally devoted to psychopharmacology, behavior therapy, and crisis intervention. These wide variations are not explained by differences in primary objectives stated by the program director, or by the needs of the trainees. The most likely explanation appears to be that they arise as unplanned consequences of variations in staffing patterns which develop accidentally over time or in response to the special interests of leaders in the field and the clinical demands on the setting itself. In future years, it will be po ssible for programs to be informed regarding the performance of their graduates so that they can note high- and low-pass rates which ma y reflect patterns of strength or weakness in certain areas measured by the Board examination. TOWARD A SOLUTION
The Examination Committee ha s recognized that there are significant and real problems. Since 1970 , the Committee has obtained ongoing consultation from the Center for Education Development at the University of Illinois College of Medicine.' Since then, the examination process itself has been observed systematically and I Christin e McGuire, Associate Dire ctor fo r Research, became the consultant a nd director of the research project on certification and tr aining which is now being spo nso red by the Board .
Certification
of the Child Psychiatrist
201
analyzed for validity and reliability, and modifications have been made as a result of these yearly assessments. For example, reliability studies were helpful in the development of a written form for two of the original six oral examinations: History and Literature, and Growth and Development. The three clinical examinations (preschool, school-age, and adolescent child) have gradually become more standardized and uniform , presenting behavioral objectives to be measured, and providing a reduction of unintended overlap, improvements in examiner techniques , greater uniformity from examiner to examiner through preexamination training sessions, and the use of more relevant types of case materials presented in more nearly standard form. The examiners in the Interprofessional and Community Relations sequence are developing a set of simulated consultation situations in which the candidates' ability to function as consultants can be tested more readily. Most importantly, the Board decided to embark on a long-range study of certification itself in order to discover the essential components of competence in the practice of child psychiatry and the most valid and reliable techniques of assessing these. A major objective is to obtain information which can be passed along to training directors to help them increase the efficiency and effectiveness of their programs." Phase I of the study had as its objective the determination of the essential components of competence in child psychiatry. A national survey was conducted, placing primary reliance on questionnaires to: (a) directors of all training programs in child psychiatry; (b) all Fellows in training in child psychiatry; (c) a sizable sample of practitioners in child psychiatry, both certified and noncertified; and (d) a sample of the "consumers" of child ps ychiatric consultation services (pediatricians and juvenile court judges). The data from these in-depth questionnaires are now being coded for anal ysis. Already, some preliminary indicators of discrepancies between actual practice and training can be identified. For example, child psychiatrist practitioners indicate they are most often asked in consulting with courts to become involved in custody determinations. However, the survey of training programs shows an insignificant amount of emphasis on this skill development. The Development of a Profile of Competence in Child Psychiatry
Perhaps the most crucial part of the questionnaire to child psychiatrist practitioners throughout the country was the critical incident report. Modeled after the well-known Orthopaedic Training 2 This project is made possible by the generous support of the Gr ant Foundation, the Ittleson Family Foundation , and the Maurice Falk Medical Fund.
202
John F. McDermott, Jr.
Study, this study sampled clinical experiences which are considered particularly effective, and those which are particularly ineffective, by the practitioners themselves in their everyday work. Classified and categorized, these bits of memorable clinical data form the skeleton of a profile of competence from which may emerge the description of a competent child psychiatrist practitioner, to be developed, then measured. Some examples of these skills and abilities in a very general and broad sense are: information gathering, diagnostic acumen , therapeutic planning, therapeutic ability, skill in relating to patient, skill in relating to parents, crisis management, continuing care and aftercare , ability to relate to other professionals, skills in teaching, research, and administration, and professional responsibility. The Future
Phase II of the research project (1974-75) is being devoted to exploring the implications of the data, modifying the examination further, and developing this profile of competence further. Phase III of the project (1975-76) will provide for a major conference on child psychiatry training. It is hoped that program directors throughout the country will be able to meet and consider the re sults and implications, to link improvements in the examination with residency training itself. It is likely that revision of criteria for approved residency training programs will emerge from this joint consideration. CONCLUSION
Perhaps the most important consideration in binding (a) the process of training in child psychiatry with (b) the practice of the specialty, and (c) the measurement of competence via a certification and continuing certification process is the design which this "package" will take, the identification of its parts, and their most appropriate delegation. Specifically, it is likely that certain aspects of competence in child psychiatry should be measured during the training experience itself; e.g., treatment skills as well as attitudes to ward patients and families are best assessed over a longitudinal period. This evaluation could consist of Part I of the certification process (local). Part II might then consist of a written examination (regional) , during or following the training experience in which essential "knowled ge and information" are measured. Part II would test for generally agreed-upon , important basic knowledge and new information in the field which were gained during the training
Certification of the Child Psychiatrist
203
process itself. Part III (national) of the certification process could then consist of a smaller and less dramatic Board Certification examination, a live assessment of clinical judgment and interviewing skills. Part IV might consist of an ongoing recertification process based on continuing self and group education, the continued process of upgrading knowledge and skills (requiring a system for identification of significant new developments in the field). It is through the relationship of these four hypothetical parts of a possible future certification process that training could be related to actual practice and to consumer needs. It is toward this goal we all look, to make the specialty of child psychiatry a more meaningful contribution relevant to the health needs of our nation and its children. REFERENCES COHEN, R. L . & HENDERSON, P. B. (1973), Experiences in the alteration of sequence in child psychiatric training. This Journal, 12:441-460. HOLDEN, W. D. (1969), The evolutionary functions of American medical specialty boards.]. Med. Educ., 44:819-824. MCGUIRE, C. (1969), Evaluation of certification examination. Presented at the 13th annual scientific assembly of the College of Family Physicians of Canada. MORGENSTERN, A. L. (1970 ), A criticism of psychiatry's board examinations. Amer. J. Psychiat., 127:33-40. POKORNY, A. D. & FRAZIER, S. H., JR., (1966), An evaluation of oral examinations.]. Med. Educ., 41:28-40. TAYLOR, R. L. & TORREY, E. F. (1972), The pseudo-regulation of American psychiatry. Amer. ]. Psychiat., 129:658--662.
John F. McDermott, Jr., M.D .
Since the 1920s, medical specialties in the United States have developed their own "Boards" with dual fun ctions: maintaining standards of train ing through accreditation of programs and measuring the competence of individuals practicing that specialty through certification examinations. In 1959 the American Board of Psychiatry and Neurology, Inc. established its first and onl y official subspecialty, Child Psychiatry, with the Committee on Certification in Child Psychiatry (hereafter referred to as "the Board") placed in charge of accreditation of training programs and certification of child psychiatrists who had completed their training in these approved programs. Presumably this dual function should be a re ciprocal one which connects training and certification in a fluid and changing, rather than a static relationship. The Board should function not only to define and measure the essentials of core training. It should also encourage the further development of the training experience and the evaluation of it to keep pace with the changing nature of the field caused by the knowledge explosion. In other words, the certification process (and in the future , recertification) should complement the training experience by systematically measuring in candidates from approved programs the basic knowledge, skills, and attitudes considered essen tial for the competent child psychiatrist practitioner. GENERAL PROBLEMS OF EXAMINATION AND ACCREDITATION
In recent years, there has been increasing cr iticism within the psychiatric profession itself about the ways in which the Board fun cDr. M cDermott is Chairman of the Committee on Certification in Child Psychiatry, Am erican B oard of Psychiatry and Neu rology, Inc. H e is also Professor and Chairman , Department of Psychiatry, University of Ha waii, School of Medicine, 367 5 K ilauea Avenue, Hon olulu , Ha waii 96816.
196
Certification of the Child Psychiatrist
197
tions are carried out (Taylor and Torrey, 1972; Morgenstern, 1970; Holden, 1969). Frequently, suggestions are made for changes in the training sequence established by the Board (Cohen and Henderson, 1973; McGuire, 1969; Pokorny and Frazier, 1966). Some have commented on the limited nature of professional competence that the Board examination samples and have noted that at best these examinations measure predominantly the candidates' ability to recall fragments of information solicited by the examiner (McGuire, 1969; Pokorny and Frazier, 1966). Furthermore, it has been observed that the information or task chosen for examination is likely to be arbitrary and frequently varies from candidate to candidate. Candidates who have taken the examination note this potential weakness in the Board's capacity to measure the elusive quality of clinical competence. They have complained that the examination depends upon accident in the candidate-examiner assignments, implying that an examiner's particular bias (or that of the Board itself) reflects an invalid and unreliable test of competence in the subspecialty of child psychiatry. Such criticisms are particularly paradoxical in an era of educational planning and evaluation in which objectives of training and evaluation of results are becoming more and more systematic. Training requirements and standards are also criticized as oldfashioned and static, not reflecting the rapid changes in the field since the 1950s. Training directors complain that impressionistic and arbitrary reports about their programs reflect the Board's uncertainty about common basic guidelines for training, and that the accreditation process itself is a loosely performed function, largely determined by site visitors who are not even psychiatrists, let alone child psychiatrists. It is significant that the certification examination is not even attempted by the majority of qualified child psychiatrists finishing accredited training programs. While there are 750 child psychiatrist training positions each year, fewer than 1,000 child psychiatrists have been certified over the past 15 years, with less than 100 candidates taking the examination each year. Furthermore, the failure rate in the examination itself approaches 50 percent (although many candidates "condition" only one part of the total examination), shockingly high for a subspecialty in which all the candidates have previously been certified in general psychiatry in order to be eligible for child psychiatry examination. It would appear that child psychiatrists by the hundreds are content to practice without their subspecialty boards. If they are content because they consider themselves "Board eligible," they are in error, since eligi-
198
John F. M cDermott, J r.
bility occurs only after the candidates' credentials have been reviewed and approved. Why, from a practical standpoint, do child psychiatrists avoid certification in their own subspecialty? Part of the reason, of course, is that psychiatry as a specialty lends itself to independent outpatient work not requiring hospital staff privileges. Thus, Board certification seems less necessary or important than in other medical specialties, such as internal medicine or surgery, or their subspecialties. Furthermore, salar ied psychiatric po sitions are primarily related to certification in general psychiatry, with requirements for certification in child psychiatr y relativel y less frequent. Child psychiatrists who have already been certified in general psychiatry and are "tired " of being examined may thus find less reason to go on, unless they have a special motivating factor , such as a career in academic medicine for which sufficient advantage would be gained by obtaining Board certification in child psychiatry. Finally, surprisingly large numbers of the training directors of our child psychiatry program s throughout the country are not Board-certified. It is difficult to imagine that they provide motivating models for their trainees to point toward certification, even though almost all training directors indicate that they "encourage" Board certification in their programs. While over three fourths of training directors indicate formal evaluation programs for residents during the course of their training, less than one sixth of the directors report any kind of examination related to certification procedure, such as "mini-Board s." Again, there seems to be a very uneven and disconnected rel ationship between training and certification in child psychiatry, rather than a reciprocal mirroring. The current rapidly changing national scene preceding passage of a national health insurance program finds larger and larger numbers of psychiatrists who have or would have previously avoided the certification process now preparing for and taking the examination in general psychiatry. The reasons are obvious: the level of third-party payments will increasingly be determined by special competence as measured by Board certification in a specialty or subspecialty. Recent developments, such as in institutional "quality of service" requirements by third-party pa yors, will probably also increase the demand for Board-certified child ps ychiatrists by residential treatment cen ter s and psychiatric inpatient programs. The Joint Commission on Accreditation of Hospitals' inclusion of specific child psychiatric standards is perhaps the most important example to date.
Certification of the Child Psychiatrist
199
THE SPECIFIC ISSUES IN THE Low ApPLICATION AND HIGH EXAMINATION FAILURE RATE
The responsibility for the low ap plication and high failure rate for the examination must be shared by the Board itself and the training program directors throughout the country. The Board ha s been faulted for not clearly articulating just what it is examining, i.e., what constitutes the specific components of competency in child psychiatry which are being measured, how they are being measured, what sou rce materials are used for the oral and written examination, etc. In particular, the validity and reliability of the examination are questioned. For instance, if the Board determines what it wishes to measure, to what extent is the examination actually measuring those competencies and that knowledge? How accurate are the measurements and judgments which are made, i.e. , will two or more examiners observing the same examination independently arrive at the same, or closely similar, grades? Some critics question whether grades would be modified to a significant degree if the candidate were seen with a different patient or were asked to respond to a second set of questions purported to sample the same area , but different from those to which he responded in the first examination. Finall y, the efficiency and effectiveness of the examination in general have been brought under question: to what extent are professional resources being used to obtain the maximum amount of relevant and reliable information about the candidate with the least redundancy or overlap? Is time wasted on testing aspects of competence which are trivial or irrelevant to satisfactory professional performance? Are some issues emphasized disproportionately to their importance in clinical practice? The answers to these questions lie in the assessment of what constitutes clinical practice, how the training is to be oriented toward specific competence in this profile of clinical practice, and how an examination is to be built to measure the prime requisites for such a model of good clinical practice in a systematic fashion . So far, the Board and the training directors themselves have lacked consensus as to a common "core" training experience. There is such wide variation among programs that it is clearly impossible for the Board to design an examination through which all or most of th e candidates from these programs can pass successfully. Indeed, when the Board has specified to some extent its examination content, i.e ., three separate clinical examinations, one on the preschool child , one on the school-age child, and one on the
200
john F. McDermott,jr.
adolescent, the experience is startling. Little attention seems to be paid to the arrangement of thi s di vision and weighting. Candidates show very uneven abilities in these three age groups, perhaps weakest in the preschool child, followed by the adolescent. Indeed, preliminary results from the nationwide study conducted by the Board in 1974-75 bear this out. About half the patient population in training programs throughout the country is of school age, less than one sixth preschool , and the balance, adolescent. There are certain programs in which virtually all of the patients come from a single age group, and there are other programs with no patients in one of the three age groups, and only a scattering in the second . In many programs, the vast majority of patients come from a single age group. The enormous variation in the amount and distribution of didactic instruction now appears to constitute another significant variable. For example, one program reports 500 didactic hours of childhood ps ychopathology; another reports none. One reports over 500 hours on consultation skills, while five programs report no didactic instruction in this area. The same wide vari ation is observed with respect to the amount of instruction on various forms of therapy, with very small amounts of time generally devoted to psychopharmacology, behavior therapy, and crisis intervention. These wide variations are not explained by differences in primary objectives stated by the program director, or by the needs of the trainees. The most likely explanation appears to be that they arise as unplanned consequences of variations in staffing patterns which develop accidentally over time or in response to the special interests of leaders in the field and the clinical demands on the setting itself. In future years, it will be po ssible for programs to be informed regarding the performance of their graduates so that they can note high- and low-pass rates which ma y reflect patterns of strength or weakness in certain areas measured by the Board examination. TOWARD A SOLUTION
The Examination Committee ha s recognized that there are significant and real problems. Since 1970 , the Committee has obtained ongoing consultation from the Center for Education Development at the University of Illinois College of Medicine.' Since then, the examination process itself has been observed systematically and I Christin e McGuire, Associate Dire ctor fo r Research, became the consultant a nd director of the research project on certification and tr aining which is now being spo nso red by the Board .
Certification
of the Child Psychiatrist
201
analyzed for validity and reliability, and modifications have been made as a result of these yearly assessments. For example, reliability studies were helpful in the development of a written form for two of the original six oral examinations: History and Literature, and Growth and Development. The three clinical examinations (preschool, school-age, and adolescent child) have gradually become more standardized and uniform , presenting behavioral objectives to be measured, and providing a reduction of unintended overlap, improvements in examiner techniques , greater uniformity from examiner to examiner through preexamination training sessions, and the use of more relevant types of case materials presented in more nearly standard form. The examiners in the Interprofessional and Community Relations sequence are developing a set of simulated consultation situations in which the candidates' ability to function as consultants can be tested more readily. Most importantly, the Board decided to embark on a long-range study of certification itself in order to discover the essential components of competence in the practice of child psychiatry and the most valid and reliable techniques of assessing these. A major objective is to obtain information which can be passed along to training directors to help them increase the efficiency and effectiveness of their programs." Phase I of the study had as its objective the determination of the essential components of competence in child psychiatry. A national survey was conducted, placing primary reliance on questionnaires to: (a) directors of all training programs in child psychiatry; (b) all Fellows in training in child psychiatry; (c) a sizable sample of practitioners in child psychiatry, both certified and noncertified; and (d) a sample of the "consumers" of child ps ychiatric consultation services (pediatricians and juvenile court judges). The data from these in-depth questionnaires are now being coded for anal ysis. Already, some preliminary indicators of discrepancies between actual practice and training can be identified. For example, child psychiatrist practitioners indicate they are most often asked in consulting with courts to become involved in custody determinations. However, the survey of training programs shows an insignificant amount of emphasis on this skill development. The Development of a Profile of Competence in Child Psychiatry
Perhaps the most crucial part of the questionnaire to child psychiatrist practitioners throughout the country was the critical incident report. Modeled after the well-known Orthopaedic Training 2 This project is made possible by the generous support of the Gr ant Foundation, the Ittleson Family Foundation , and the Maurice Falk Medical Fund.
202
John F. McDermott, Jr.
Study, this study sampled clinical experiences which are considered particularly effective, and those which are particularly ineffective, by the practitioners themselves in their everyday work. Classified and categorized, these bits of memorable clinical data form the skeleton of a profile of competence from which may emerge the description of a competent child psychiatrist practitioner, to be developed, then measured. Some examples of these skills and abilities in a very general and broad sense are: information gathering, diagnostic acumen , therapeutic planning, therapeutic ability, skill in relating to patient, skill in relating to parents, crisis management, continuing care and aftercare , ability to relate to other professionals, skills in teaching, research, and administration, and professional responsibility. The Future
Phase II of the research project (1974-75) is being devoted to exploring the implications of the data, modifying the examination further, and developing this profile of competence further. Phase III of the project (1975-76) will provide for a major conference on child psychiatry training. It is hoped that program directors throughout the country will be able to meet and consider the re sults and implications, to link improvements in the examination with residency training itself. It is likely that revision of criteria for approved residency training programs will emerge from this joint consideration. CONCLUSION
Perhaps the most important consideration in binding (a) the process of training in child psychiatry with (b) the practice of the specialty, and (c) the measurement of competence via a certification and continuing certification process is the design which this "package" will take, the identification of its parts, and their most appropriate delegation. Specifically, it is likely that certain aspects of competence in child psychiatry should be measured during the training experience itself; e.g., treatment skills as well as attitudes to ward patients and families are best assessed over a longitudinal period. This evaluation could consist of Part I of the certification process (local). Part II might then consist of a written examination (regional) , during or following the training experience in which essential "knowled ge and information" are measured. Part II would test for generally agreed-upon , important basic knowledge and new information in the field which were gained during the training
Certification of the Child Psychiatrist
203
process itself. Part III (national) of the certification process could then consist of a smaller and less dramatic Board Certification examination, a live assessment of clinical judgment and interviewing skills. Part IV might consist of an ongoing recertification process based on continuing self and group education, the continued process of upgrading knowledge and skills (requiring a system for identification of significant new developments in the field). It is through the relationship of these four hypothetical parts of a possible future certification process that training could be related to actual practice and to consumer needs. It is toward this goal we all look, to make the specialty of child psychiatry a more meaningful contribution relevant to the health needs of our nation and its children. REFERENCES COHEN, R. L . & HENDERSON, P. B. (1973), Experiences in the alteration of sequence in child psychiatric training. This Journal, 12:441-460. HOLDEN, W. D. (1969), The evolutionary functions of American medical specialty boards.]. Med. Educ., 44:819-824. MCGUIRE, C. (1969), Evaluation of certification examination. Presented at the 13th annual scientific assembly of the College of Family Physicians of Canada. MORGENSTERN, A. L. (1970 ), A criticism of psychiatry's board examinations. Amer. J. Psychiat., 127:33-40. POKORNY, A. D. & FRAZIER, S. H., JR., (1966), An evaluation of oral examinations.]. Med. Educ., 41:28-40. TAYLOR, R. L. & TORREY, E. F. (1972), The pseudo-regulation of American psychiatry. Amer. ]. Psychiat., 129:658--662.