Practice eligible route for certification in geriatric psychiatry: why some Canadian psychiatrists are disinterested in writing the RCPSC subspeciality examination?

Geriatric psychiatry was officially recognized as a subspecialty by the Royal College of Physicians and Surgeons of Canada (RCPSC) in 2009, with the first RCPSC exam written in 2013 (Andrew and Shea, 2010). The unique mental health needs of Canadians’ seniors requires geriatric psychiatrists trained to address them (Herrmann, 2004), but current rates of recruitment in informal fellowship programs have been inadequate (Bragg et al., 2012). One hope of subspeciality recognition was to increase recruitment in Canada, but there have been some challenges in accrediting psychiatrists already caring for older adults. Many currently practicing geriatric psychiatrists have elected to take the Royal College examination, with >120 graduates in the first year, 2013, but others have been more ambivalent. In this letter, we perform a preliminary exploration of the prevalence and correlates of disinterest in completing the RCPSC geriatric psychiatry examination.

We conducted a survey of the current priorities of Canadian geriatric psychiatrists. Members of the Canadian Academy for Geriatric Psychiatry (CAGP) board distributed paper copies of the survey to geriatric psychiatrists in their region, including CAGP non-members, and an online survey was sent to all CAGP members. Respondents were informed that the results of this survey would be available online as a report from the CAGP. Formal ethics approval was not obtained as the survey fell under the category of quality improvement and program evaluation of the CAGP.

The main outcome was intention toward writing the RCPSC psychiatry exams. Participants had to choose one of the three following options: “I have written the RCPSC examination”, “I am planning to do the RCPSC examination,” or “I am not planning to do the RCPSC exam in geriatric psychiatry”. The latter category comprised “disinterest” in the examination.

We examined whether a number of variables correlated with disinterest in writing the RCPSC examination: duration (years) of post-residency clinical experience, gender, working in an academic center, or currently supervising trainees, whether 80% or more of the clinical practice is devoted to geriatric patients, geographic location (province), being a CAGP member, or being a researcher. Bivariate associations between potential correlates and disinterest writing the exam were assessed using χ² and Mann–Whitney U tests, as appropriate.

A total of 109 geriatric psychiatrists responded to the survey (53% response rate). The survey had been sent to 205 geriatric psychiatrists using two sequential mechanisms: (1) each of the 12 CAGP board members representing a variety of Canadian provinces were asked to contact 10–15 geriatric psychiatrists in their region and (2) surveys were sent twice to the membership using the CAGP emailing list. Although geographic distribution was pretty representative of the membership, we cannot be sure about age, sex, and current CAGP membership status (particularly in the ones who were offered the paper survey by a board member but then refused). In large part, respondents had >10 years of post-residency experience (63.5%), were female (57%), were current CAGP members (88%), and worked at academic centers (>85%). Most respondents practiced in Ontario (43.5%) and Quebec (26%) provinces. Although there were approximately 225 CAGP members at the time of the survey, the number, and demographics of all potential Canadian geriatric psychiatrists is unknown as there is no registry of all psychiatrists with primarily geriatric practice.

The survey found that 70.4 % wrote or were planning to write the exams, while 29.6 % were “disinterested” in going through the formal examination. Of the factors examined, only one was associated with disinterest in writing the exams: more years of post-residency practice (U = 479.5, p < 0.001). Specifically, 83.8% (28/62) of those with up to 20 years experience either wrote the exam or were interested in writing it, compared with none of those with 31 or more years of experience. Those with 21–30 years of experience were more mixed. There was also a trend towards an association of disinterest with being non-academic or not currently supervising trainees (χ² = 3.60, p = 0.058): please see Table S1 published as supplementary material online attached to the electronic version of this paper at http://journals.cambridge.org/ipg.

It is possible that 70.4% is an over-estimate of those who wrote or planned to write the examination, as it was difficult to collect data in many non-CAGP members, and those members who did not respond may have been less likely to be interested in the examination.

The relative disinterest of more experienced psychiatrists could potentially be explained by greater job security or closer proximity to retirement. They may also have higher levels of anxiety about being evaluated after significant time without having written exams.

Geriatric psychiatrists who were non-academic or not currently supervising trainees showed a trend toward low interest. One could speculate that those psychiatrists receive less peer-pressure from colleagues to complete those exams, do not need extra credentials to be recognized by their institution, or that academic psychiatrists feel pressure to complete the examination in order to supervise trainees.

In order to secure geriatric psychiatry as a subspecialty and promote high-quality specialized late-life mental healthcare nation- and world-wide, original ways to encourage psychiatrists to become board certified need to be found, particularly in those with >10 years post-residency experience and those providing care outside of the academia. Given that more than 32 countries have a recognized geriatric psychiatry subspecialty (Camus et al., 2003), other nations may also struggle with providing incentives for geriatric psychiatrists to pursue board certification, particularly for more senior clinicians in non-academic positions. Countries have had different approaches to subspecialty accreditation. In the USA, practicing psychiatrists at the time of the subspeciality's creation (1989) were “grandfathered in”, without needing an accredited fellowship, but needed to take their exam in order to be formally recognized as geriatric psychiatrists. Similarly in the Netherlands, since 2011 psychiatrists need to re-register every 5 years by accumulating continuing medical education credits, in order to be formally recognized as a geriatric psychiatrist and to be able to see patients in government-funded clinics/hospitals. Creative ideas in this area ultimately have potential for international impact on the capacity of psychiatrists to care for the elderly.

Description of authors’ roles

V. Laliberté co-designed the statistical analysis plan, performed analyses, and wrote the paper. M. Rapoport and K. Rhaberu provided constructive feedback on the survey and statistical analysis plan, and critically reviewed all drafts of the manuscript. S. Rej designed and implemented the survey and co-supervised V. Laliberté in data analysis and manuscript preparation.