Downloaded from http://journals.lww.com/ectjournal by BhDMf5ePHKbH4TTImqenVIu1/FN/J4kONM1k0BmfC5ULIb7s5jKCb6FutlEGTMjtrT6PabGjJko= on 10/12/2020 Competency by Design for Electroconvulsive Therapy in Psychiatry Postgraduate Training Face and Content Validation Study Samim A. Al-Qadhi, MD, MEd, FAAP, FRCPC,* Taran Chawla,MD,† Jamie A. Seabrook, PhD,‡§ Craig Campbell, MD, FRCPC, FSCAME,|| and Amer M. Burhan, MBChB, MScCH, FRCPC¶# Introduction: Psychiatry is in the process of shifting curricula in post- graduate training to a competency-by-design approach. One core aspect of postgraduate psychiatry training is the knowledge and practice of elec- troconvulsive therapy (ECT). The aim of this study was to develop and val- idate the corresponding set of competencies that need to be developed during postgraduate training in psychiatry. Methods: This study involves the proposal of a set of competencies by an ECT curriculum committee from the University Department of Psychiatry, based on the competency-by-design principles, followed by a modified Delphi process, to reach expert consensus on the proposed, modified, and added competencies. Results: Six ECT experts meeting the preset criteria were recruited to the study from 6 academic centers across Canada and participated in the 2 Delphi rounds. Thirty-one competencies were proposed in the first round. Twenty-three proceeded to the second round by meeting 80% agreement on a score of ≥4 using a 5-point Likert scale. Three competencies required rewording based on qualitative feedback; accordingly, 10 new competen- cies were suggested. Thirty-five competencies were rated by experts and reached the threshold of agreement and rating. Cronbach α increased from 0.89 after the first round to 0.95 after the second iteration. Discussion: Consensus was generated on 35 competencies that need to be achieved during postgraduate training in psychiatry. These competen- cies can serve as the basis for developing ECT curricula in postgraduate psychiatry training. The method used is feasible and can be adopted for the development of other competencies and curricula in psychiatry and other medical fields. Key Words: electroconvulsive therapy, competency, psychiatry postgraduate training (J ECT 2020;36: 18–24) E lectroconvulsive therapy (ECT) is a safe and effective proce- dure for treating severe psychiatric disorders. 1,2 Competency to practice ECT is a prerequisite for professional certification in psychiatry by most credentialing bodies, including The Royal Col- lege of Physicians and Surgeons of Canada (RCPSC). 3 Electrocon- vulsive therapy training and practice have been challenged by significant variability in competency among graduating psychia- trists. This variability likely stems from several sources, including negative perceptions of ECT in the media 4 and a history of inappro- priate use, 5,6 which likely contributed to continued negative attitudes among public and health care providers toward this treatment. 7–10 Nonetheless, evidence suggests that attitudes of health care profes- sionals toward ECT can change with enhanced education. 11–13 The psychiatric residency curriculum lacks a mandatory and structured curriculum specific for ECT. Most senior psychiatric residents do not feel comfortable administering ECT, and an inad- equate preparation to competently administer ECT is reported by 60% of senior residents in the United States. 14 In Canada, only 175 of 1273 hospitals surveyed across the country practiced ECT. 15 In addition, 107 of 175 centers practicing ECT responded to a survey regarding ECT teaching. Sixty percent of respondents did not have a formal ECT teaching program for psychiatry trainees, and there was significant variability in teaching methods and training requirements among these centers. The authors raised concerns regarding lack of standardization of ECT training in Canada and limited opportunity for psychiatry residents to prac- tice ECT without direct supervision while in training. 15 The RCPSC has developed the competency-by-design initia- tive with the goal of shifting medical training into competency- based medical education, with time as a resource rather than a metric in acquiring competency. In this initiative, training in post- graduate programs (residency training) requires a hybridization between time-based postgraduate education (PGE) training and competency-based medical education. 16 Incorporating competency-by-design in medical education is challenging and requires clarification on the similarities and differ- ences between the concepts and principles of competency-based medical education versus time-based medical education, and the physician competency framework developed by RCPSC back in 2005 referred to as CanMEDS. CanMEDS roles have governed specialty medical education curricula in Canada for decades. This clarification required outlining the process by which a hybrid model between competency-based medical education, time-based medical education, and CanMEDS roles is developed. 17 Previous research in procedurally oriented medical specialty education illus- trates how a time-based medical education curriculum can be shaped by the interrelation among theoretical and practical fac- tors. 18 Hybridizing competency-based medical education and time-based medical education to create the competency-by-design framework provides a potential approach to address ECT training challenges. It integrates curricular, pedagogical, and societal needs on explicit competencies to organize the residency curriculum and provide a framework for assessment. From the *Centre for Education Research and Innovation, Health Science Addition, Western University, London; †Psychiatry Resident, Northern Ontario School of Medicine, Thunder Bay; ‡Department of Epidemiology and Biostatistics, Western University, London; §Lawson Health Research Institute, London; ||Competency- based Continuing Professional Development, Office of Specialty Education, The Royal College of Physicians and Surgeons of Canada, Ottawa; ¶Western University, London; and #Therapeutic Brain Stimulation Program, Parkwood Institute–Mental Health Care Building, London, Ontario, Canada. Received for publication May 13, 2019; accepted October 14, 2019. Reprints: Amer M. Burhan, MBChB, MScCH, FRCPC, Parkwood Institute– Mental Health Care Building, 550 Wellington Rd, London, Ontario, Canada N6C 0A7 (e‐mail: amer.burhan@sjhc.london.on.ca). The authors have no conflicts of interest. Dr Amer Burhan discloses that he was paid consultancy fees by Johnson & Johnson Company, CRC Research Inc, and Atheneum Partners. He is peer funded by the Canadian Institutes for Health Research, National Institutes of Health, Brain Canada, Centre for Aging + Brain Health Innovation, St Joseph's Health Care London, Lawson Health Research Institute, and Schulich School of Medicine for various projects unrelated to this work. Other authors do not have any disclosures. Ethics approval: This study was given exemption by Western University Research Ethics Board. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000646 ORIGINAL STUDY 18 www.ectjournal.com Journal of ECT • Volume 36, Number 1, March 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.