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Original Article

Is Child Psychiatric Service Different When Provided by

Attendings Versus Clinicians-in-Training?

Sharon E. Williams, Ph.D., Jacqueline L. Martin, Ph.D.

Jennifer Dyer-Friedman, Ph.D., Lynne C. Huffman, M.D.

Objective: This study examines the clinical management char-

acteristics of outpatient child and adolescent psychiatric care
provided by attendings and clinicians-in-training in an academic
A cademic training centers offer a unique opportunity
to provide quality services in an environment in-
formed by the most up-to-date advances in patient care.
institution. The authors hypothesized that no significant differ- Patients often seek out academic centers because of this
ences would exist between initial evaluations conducted by at-
belief. Care at such institutions often includes services
tendings and those conducted by clinicians-in-training.
from clinicians-in-training—those who have obtained a
Methods: The amount of information obtained during an initial medical degree and are now receiving advanced training
evaluation and the number and type of services recommended through a residency or fellowship program. Service deliv-
postevaluation were assessed for 429 patients treated in the child ery provided at institutions with training programs is de-
and adolescent psychiatry clinics at Stanford University by at- signed to offer equitable levels of care from attendings and
tending psychiatrists and clinicians-in-training. clinicians-in-training. Despite this, patients often have
mixed opinions about being assigned to clinicians-in-train-
Results: No significant differences were found for the evalua- ing and some request to be seen by attendings only. This
tions conducted by attendings and clinicians-in-training for the may be due in part to patients’ misperceptions regarding
amount of data collected during an evaluation of the number or
clinicians-in-training (1); nonetheless, it adds to the com-
type of recommendations made postevaluation.
plexity of providing care in training institutions. Studies
have addressed this impact of clinicians-in-training in ser-
Conclusion: These findings lend themselves to the conclusion
that attendings and clinicians-in-training offer comparable ser- vice delivery from a variety of perspectives, each of which
vices in the assessment of new patients. Study limitations and is reviewed briefly.
future areas of study are discussed.
Financial Cost
Academic Psychiatry 2008; 32:400–404 Adopting training as a core institutional component car-
ries a financial cost. Research addressing this issue has fo-
cused primarily on the monetary impact of clinicians-in-
training and the utilization of resources in inpatient
settings. Wachter et al. (2) studied a hospital-based train-
ing setting and found no differences in patient mortality
and morbidity and utilization of subspecialty consultation
services when attendings and intern/resident assignment
Received September 27, 2006; revised February 7 and August 14,
2007; accepted October 16, 2007. Dr. Williams is affiliated with Child structures were varied on inpatient medical units. De-
and Adolescent Psychiatry at Stanford University in Palo Alto, Calif.; creases in the length of stay and hospital charges were
Dr. Martin is affiliated with the Judge Baker Children’s Center in
noted when attendings were more involved in care. Rep-
Boston; Dr. Dyer-Friedman is in private practice; Dr. Huffman is
affiliated with General Pediatrics at Stanford University and with licating Wachter’s study, Kearns et al. (3) found differences
The Children’s Health Council. Address correspondence to Sharon in patient length of stay when comparing attending and
E. Williams, Ph.D., Child and Adolescent Psychiatry, Stanford Uni- resident assignment structures. The authors suggested that
versity, 401 Quarry Rd., Stanford, CA 94305-5719; sharonw@
stanford.edu (e-mail). increased faculty experience, involvement in the service,
Copyright 䊚 2008 Academic Psychiatry and use of protocols were factors contributing to these dif-

400 http://ap.psychiatryonline.org Academic Psychiatry, 32:5, September-October 2008


ferences. Hayward et al. (4) found no difference between ferences in a variety of patient care factors do exist be-
attendings and interns/residents with regard to the use of tween more and less experienced clinicians.
hospital resources as measured by relative value units, and The current study was designed to expand what has been
hypothesized that this may be due in part to the team struc- documented regarding clinicians-in-training and their im-
ture used on the wards which provided a check and balance pact on the delivery of care in academic settings by ex-
for standards of practice. Hayward cited the need for anal- amining clinical management as one aspect of quality of
ogous populations in future service provider studies to bet- care for children and adolescents in a psychiatric outpa-
ter assess resource usage. tient setting. The current study differs from previous re-
search. First, studies to date have only examined care in
Patient Satisfaction the adult psychiatric population. This study addresses the
Research assessing patient satisfaction for clinicians-in- provision of mental health services to pediatric popula-
training has yielded mixed findings. Probst et al. (5) as- tions, a complex process involving multiple consumers and
sessed factors influencing satisfaction (i.e., level of train- sources of information and requiring a unique skill set for
ing, wait time, level of attention paid by the provider) and eliciting information that yields accurate diagnoses. Sec-
found no difference between patient satisfaction ratings ond, all of the patients assessed in this study came from
for residents and attendings. However, O’Malley et al. (6) the same clinic in which they experienced the same clinical
found that satisfaction was greater when patients were procedures and the same evaluation structure, thereby
seen jointly by residents and attendings compared to at- eliminating some potential confounding factors noted pre-
tendings only. Yancy et al. (7) assessed patient satisfaction viously (7).
at academic and nonacademic sites and found significantly We expected no significant differences would exist be-
tween the clinical management of patients assigned to at-
greater satisfaction with attendings in the academic set-
tendings and clinicians-in-training. Specifically, we hypoth-
ting, compared to residents in that setting. No significant
esized that no significant differences would exist between
differences were found in the nonacademic sites. They
attendings and clinicians-in-training regarding the amount
speculated that differences in experience and knowledge
of information obtained during initial evaluations, the
between clinicians, difference in patient populations be-
number of postevaluation services recommended, and the
tween settings, and differences in clinic structure each
type of postevaluation services.
might have influenced the satisfaction ratings.
Characteristics of Psychiatric Care
Quality of patient care provided is a broad construct
with multiple definitions and methodologies of measure- Setting
ment. The study of the characteristics of care provided by The Child and Adolescent Psychiatry Outpatient Clinic
attendings and clinicians-in-training in psychiatry has been at Stanford University School of Medicine is an academic
varied with regard to what factors are investigated and setting in the San Francisco Bay Area. Each year, mental
which type of provider is examined. Wise et al. (8) assessed health clinicians in the Outpatient Clinic evaluate and treat
psychiatric residents and community physicians in an in- over 800 new patients who present with diverse diagnoses.
patient setting and found no significant differences in the The outpatient clinic includes four subspecialty clinics:
Anxiety Disorders Clinic, Mood Disorders Clinic, Neuro-
medications ordered for patients or the diagnoses utilized.
psychiatry/Pervasive Developmental Disorders Clinic, and
Other studies, however, have identified differences among
Attention Deficit Hyperactivity Disorder (ADHD)/Disrup-
clinicians with varying degrees of experience. Hansen et al.
tive Behavior Disorders Clinic.
(9) found that psychiatric residents were less likely than
attending researchers to accurately recognize and diagnose Study Participants
specific psychiatric symptoms such as tardive dyskinesia
and drug-induced parkinsonism. Further, Meyerson et al. Attendings and Clinicians-in-Training. The attend-
(10) assessed psychiatry residents and found that, com- ings group in this study was made up of eight psychiatrists.
pared to senior residents, junior residents admitted pa- All attendings had received advanced training in the treat-
tients more often and prescribed outpatient medications ment of children and adolescents and were board-certified.
for depression more often. These studies suggest that dif- Attendings provided evaluations to 65.3% of the patient

Academic Psychiatry, 32:5, September-October 2008 http://ap.psychiatryonline.org 401


study sample (n⳱280). The clinicians-in-training group Measures. Ratings of subjects’ emotional and behav-
was composed of child psychiatry fellows and general psy- ioral problems were assessed using the Child Behavior
chiatry residents who were completing a child rotation. Checklist, 4–18 year-old version Parent Report (12) to pro-
There were 11 fellows; all were in their first or second year vide a standardized description of the patient sample for
of advanced training for the treatment of children and ad- each group. The Child Behavior Checklist is a 118-item
olescents and were assigned to the clinic for 1 year, either measure that generates composite scores for Internalizing
half- or full-time. They provided evaluations to 28.9% of Problems, Externalizing Problems, and Total Problems.
the patient sample (n⳱124). Twelve psychiatry residents Possible T scores range from 50 to 100, with higher scores
were included in the clinicians-in-training group. However, indicating greater symptomatology. Comprehensive reli-
the impact of adult residents on patient care was minimal, ability and validity evidence are available on this widely
as they provided evaluations to only 5.8% (n⳱25) of the used measure (12).
patient sample. The PMHOI Evaluation Record is a clinician-com-
pleted form developed for use in the Stanford Child and
Patients. The patient sample consisted of 429 children Adolescent Psychiatry clinic. This record included infor-
and adolescents who were seen in the four subspecialty mation on the amount and type of clinical data collected
clinics over a 1.5-year period. The mean age of the sample as part of the evaluation (e.g., verbal consultation with
was 10.6 years old (SD⳱4.6). The sample consisted of teacher, reports from previous provider, psychological
65.7% boys (n⳱282) and 33.1% girls (n⳱142). The eth- testing, laboratory tests), the number and type of postev-
nicity of the sample was as follows: 64.8% Caucasian aluation services recommended, and the patient’s current
(n⳱278), 9.3% Asian (n⳱40), 8.6% Hispanic (n⳱37), DSM-IV diagnosis. All attendings and clinicians-in-train-
and 5.4% other ethnic groups (n⳱23). The sample’s pri- ing received a general orientation to the forms prior to the
mary diagnoses were made based on clinical interviews and implementation into the clinic structure.
fell into the following categories: 23.5% mood/depressive
disorders (n⳱101), 19.3% anxiety disorders (n⳱83), Procedures. Evaluations in the clinic consisted of par-
15.4% pervasive developmental disorders (n⳱66), 13.1% ent and child interviews and inspection of parent- and
ADHD (n⳱56), 6.5% disruptive behavior disorders child-completed measures, which were collected before
(n⳱28), 4.7% adjustment disorders (n⳱20), and 11.2% the initial appointment. Additional components could in-
other diagnostic groups (n⳱48). In terms of emotional/ clude record reviews and collateral contacts. Interviews oc-
behavior problem symptom severity, the study sample fell curred during a 2-hour appointment. Attendings and cli-
within the clinically significant range for the Child Behav- nicians-in-training independently completed the PMHOI
ior Checklist Total Problems, mean T score 65.5 Evaluation Record immediately following the initial eval-
(SD⳱10.4). The mean Internalizing Problems T score was uation. Clinicians-in-training reviewed their cases with
63.3 (SD⳱11.1), corresponding to the borderline clinical their supervising attending during regularly scheduled su-
range, and the mean Externalizing Problems T score was pervision, or sooner as warranted. Based on primary DSM-
60.1 (SD⳱12.6), corresponding to the nonclinical range. IV diagnosis, patients were placed into seven diagnostic
The clinic director assigned all patients to service pro- groups: anxiety disorders, mood/depressive disorders, per-
viders. Assignments were based primarily on service pro- vasive developmental disorders, attention deficit disorders,
viders’ scheduled availability. If a patient requested an ap- disruptive behavior disorders, adjustment disorders, and
pointment with an attending, the request was considered other disorders.
but seldom granted, due to limited availability of initial Approval to conduct the current study was received
evaluation slots in attendings’ schedules. from the Stanford University Institutional Review Board
for Medical Human Subjects.
Data Analyses
Data Collection. The study data are derived from a Initial analyses were conducted to compare the patients
larger dataset of the Pediatric Mental Health Outcomes who were assigned to attendings and clinicians-in-training
Initiative (PMHOI) in the Division of Child and Adoles- groups. Independent samples t tests or Mann-Whitney
cent Psychiatry (11). The use of these data was consistent tests were computed for patient age, family education
with human subject approval. level, family income, and Child Behavior Checklist scores.

402 http://ap.psychiatryonline.org Academic Psychiatry, 32:5, September-October 2008


Chi-square analyses were computed for patient ethnicity larly, analysis of variance indicated that there were no dif-
and diagnosis. Hypotheses were tested using analysis of ferences in the number of postevaluation services recom-
variance (ANOVA) to examine whether the amount of mended by attendings and clinicians-in-training.
data collected during an evaluation and the number and Service providers in the two groups also did not differ
type of postevaluation services differed depending on the in the frequency with which they recommended further
type of service provider. The effect of patient age, patient evaluation, psychotherapy, medication management, edu-
gender, patient diagnosis, and all two-way interactions cational services, further evaluation, or other therapies
were controlled for in each ANOVA. Initial models in- (such as behavioral services provided in the home).
cluded all simple effects and their two-way interactions.
When interactions were nonsignificant, they were removed Discussion
and only simple effects were reported. For all analyses, an
alpha of 0.05 was used as the threshold of statistical sig- Overall, this study revealed no significant differences be-
nificance. tween the evaluations conducted by attendings and clini-
cians-in-training regarding the components of the evalua-
Results tion and postevaluation services. Specifically, there were
no differences between the groups for the amount of data
Chi-square analyses indicated that there were no signifi- collected or the number and type of recommendations
cant differences in patient assignment found between the made postevaluation.
attendings and clinicians-in-training groups for patient The lack of differences between attendings and clini-
ethnicity. Mann-Whitney analysis indicated that patients cians-in-training supports the hypothesis that evaluations
assigned to both groups also had comparable levels of fam- conducted by clinicians-in-training at teaching institutions
ily education and family income. Similarly, independent are analogous to those conducted by attendings. Several
sample t test analyses indicated no significant differences aspects of the clinical service examined in this study are
for Child Behavior Checklist Total, Internalizing, or Ex- likely to have contributed to these findings. They are dis-
ternalizing Problems scores of patients assigned to attend- cussed below.
ings and clinicians-in-training. However, patient diagnosis, First, the role of supervision plays a key role in both the
age, and sex differed by group. Chi-square analyses indi- methodology of these types of studies and the subsequent
cated that male patients (v2⳱4.5, p⬍0.05) were more findings. In this study, as in other studies addressing at-
likely to be assigned to the attendings. Mann-Whitney non- tendings and clinicians-in-training, there exists interplay
parametric analysis indicated that compared to patients as- between attendings and clinicians-in-training. In a training
signed to the clinicians-in-training group, younger patients model, cases seen by clinicians-in-training are supervised
were assigned to the attending group (attendings’ patient by attendings, who influence the management and out-
mean age⳱10.3 years; trainees’ patient mean age⳱11.1 come of each case, thereby creating a potential confound
years; Z⳱ⳮ2.5, p⬍0.01). Patients’ primary diagnosis also in the data and subsequent findings. However, in the cur-
differed between attendings and clinicians-in-training rent study, clinicians-in-training submitted the PMHOI
(v2⳱21.1, p⬍0.01). Attendings were more likely to be as- Evaluation Record form prior to review with an attending,
signed patients with anxiety disorders, pervasive develop- thereby significantly minimizing the impact of direct su-
mental disorders/developmental delay, disruptive behav- pervision on the findings of the study. Nonetheless, it is
ior, and mood/depressive disorders. There was no likely that regularly scheduled supervision impacted the
difference in assignment for ADHD, adjustment disorders, overall knowledge base of clinicians-in-training and posi-
or other disorders. Given that patient assignment differed tively influenced their ability to make decisions analogous
for attending versus clinician-in-training groups, the effect to those made by attendings. A thorough assessment of
of patient age, gender, diagnostic group, and their two-way the type of supervision provided and the information im-
interactions were controlled for in all subsequent analyses. parted is needed to fully examine the impact of supervision
Analysis of variance indicated that service providers in on the evaluations provided by clinicians-in-training.
the attendings and clinicians-in-training groups collected Second, the use of the PMHOI Evaluation Record form
the same amount of data (e.g., verbal consultation with may have positively influenced the outcome of the treat-
teacher, reports from previous provider, psychological ment delivered. By completing the form, attendings and
testing, laboratory tests) during patient evaluations. Simi- clinicians-in-training reviewed a list of potential sources

Academic Psychiatry, 32:5, September-October 2008 http://ap.psychiatryonline.org 403


for clinical data and potential services for recommenda- uations from attendings and clinicians-in-training in an
tion. This process allowed all clinicians, both attendings academic setting.
and clinicians-in-training, to systematically review possible References
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404 http://ap.psychiatryonline.org Academic Psychiatry, 32:5, September-October 2008