Residency training in psychosocial health

Recently, the American Board of Pediatrics (ABP) cited a critical lack of pediatric residency training for behavioral and mental health problems and proposed more education in preventing, recognizing, and managing these conditions.

I very much agree with the call for more pediatric residency training in developmental and behavioral diagnosis and treatment. As the ABP’s article suggests, at least 2 major pediatric residency review commissions have supported this recommendation. I know firsthand the struggles within these commissions as I actively advocated for more training both as a pediatrician and as a representative from the American Academy of Child and Adolescent Psychiatry.

Why more training?

The fact case for more training is strong. Psychosocial issues-development, behavior, psychiatric diagnosis, higher risk of accidents, substance use, suicide-are the most prevalent issues in pediatric practice. While I have personal, deep appreciation for the value of inpatient and intensive care rotations to develop the skills and identity of a pediatrician, residency training is currently out of balance given the needs of the pediatrician and [his or her] future patients.

There has been a modest increase in teaching of psychosocial issues secondary to the rising prevalence of these disorders on inpatient pediatric units, the emergency department, and being seen in outpatient rotations. However, the resources devoted to the psychosocial conditions and teaching continues to be inadequate.

Next: Mental health services in primary care

The shift to population health may provide incentives for change as families with psychiatric disorders are high utilizers of medical services. However, the most crticial first step is for us to step back, look in the mirror, and reconsider a shift in our pediatric training priorities.

3 barriers to residency training

I believe there are 3 reasons why the recommendations for more psychosocial training have had such limited adoption:

1. Economic. Service obligations weigh heavily on residency training. Under fee-for-service reimbursement, inpatient beds, intensive care units, and subspecialties generating high charges (oncology, neurology, GI, and so on) need day-and-night coverage. Hiring hospitalists and intensive care physicians, day and night, is very costly compared with a resident largely paid for through government stipends. Further, psychosocial services and visits are poorly reimbursed and many training programs have a small, poorly paid faculty. Implementing a stronger psychosocial curriculum is costly at a time of declining revenue, although I have to add that even in the boom years of reimbursement growth, programs did not prioritize psychosocial training or access to services.

2. Academic. Many of the key decision makers for residency training requirements are chairs of academic departments who were often hospital-based subspecialists with strong academic credentials, and chosen by other chairs. Primary care faculty and primary care issues are a low priority compared with strengthening specialty fellowships and gaining research funding.

3. Stigma. Psychosocial diagnoses do not carry the excitement of a great medical save such as curing a child's cancer, major heart surgery, or the rescue of a very premature baby. All these are profoundly meaningful and should be a major feature of pediatric training, but not essentially all pediatric training. Preserving the self-esteem of a child with attention-deficit/hyperactivity disorder and seeing [him or her] thrive in school, helping a depressed teenager move away from suicide to recovery, preventing substance abuse, and so on, are worthy of recognition and celebration. Many more teenagers will die from alcohol-related accidents, suicide, homicide, and overdose than from the illnesses residents spend 90% of their time treating. 

Dr Jellinek is professor emeritus of Psychiatry and of Pediatrics, Harvard Medical School, Boston, and chief executive officer, Community Network Lahey Health System, Burlington, Massachusetts. He is also a member of the editorial advisory board of Contemporary Pediatrics.