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Original Article
464 http://ap.psychiatryonline.org Academic Psychiatry, 29:5, November-December 2005
Administrative Restructuring of a Residency Training
Program for Improved Efficiency and Output
Louis T. van Zyl, M.B., Ch.B., M.Med.Psych., Susan J. Finch, M.D., C.M.
Paul R. Davidson, Ph.D., Julio Arboleda-Florez, M.D., Ph.D.
Received September 20, 2004; revised June 17, 2005; accepted July
12, 2005. Dr. van Zyl is Past Director of Postgraduate Education,
Chair, Division of Consultation-Liaison Psychiatry, Queen’s Univer-
sity, Kingston, Ontario, Canada. Dr. Finch is Director of Postgradu-
ate Education, Director of Emergency Psychiatry, Queen’s Univer-
sity, Kingston, Ontario, Canada. Dr. Davidson is Co-Director of the
Anxiety Disorders Program, Department of Psychiatry, Queen’s Uni-
versity, Kingston, Ontario, Canada. Dr. Arboleda-Florez is Professor
and Head, Department of Psychiatry, Queen’s University, Kingston,
Ontario, Canada. Address correspondence to Dr. van Zyl, Division
of Consultation-Liaison Psychiatry, Connell-4, Suite 2-489, Kingston
General Hospital, 76 Stuart St., Kingston, ON, K7L 2V7, Canada;
vanzyl@post.queensu.ca (E-mail). Copyright 䊚 2005 Academic Psy-
chiatry.
Objectives: Canadian residency training programs (RTP) have
a program director (PD) and a residency program committee
(RPC) overseeing program administration. Limited guidance is
available about the ideal administrative structure of an RTP. This
article describes administrative load in Canadian RTPs, presents
a novel approach to delegating core administrative tasks within
the RTP, and provides initial impressions of positive outcomes
following implementation of this new system.
Method: All PDs of Canadian psychiatry RTPs were surveyed
with respect to their program administrative structure, involve-
ment of their training committees, and the percentage of work
done by the PD compared to the rest of the RPC. At Queen’s
University, program domains were created representing well-
defined areas within the RTP, each being assigned a program
domain manager.
Results: RPCs were mainly consultative, averaging 14 members.
The average PD: RPC workload ratio was 80:20. Three programs
allowed for 50% of the program director’s time to be dedicated
to serving that position, with an average time dedication of 37%.
Conclusion: The position of PD in psychiatry requires an av-
erage of 37% of the program director’s time, while carrying an
estimated 82% of the administrative workload. The program do-
main manager administration system implemented at Queen’s
University enabled the PD to be simultaneously up to date with
all major areas of the program while experiencing a substantial
decrease in the administrative workload, achieved through in-
creased work contribution of the RPC. This system encourages
closer involvement of RPC members in decision making and
development of their program domains, allowing the PD more
time for developing, implementing and overseeing innovations
across the RTP spectrum. Furthermore, it has led to a PD: RPC
workload shift from a ratio of 90:10 to one of about 60:40. Es-
sentially, this resulted in a more efficient and adaptable RPC
and RTP.
Academic Psychiatry 2005; 29:464–470
T
he Royal College of Physicians and Surgeons of Can-
ada is the body that sets standards and guidelines for
all residency training programs (RTP) throughout the
country. The Royal College also reviews each program reg-
ularly, to ensure that it meets all requirements for full ac-
creditation.
Standard B.1 of their document entitled “General Stan-
dards Applicable to All Residency Programs” addresses
the administrative structuring of a residency program (6).
It identifies the need for, and broadly outlines the respon-
sibilities of, a program director (PD) and a supportive res-
idency program committee (RPC). While the program di-
rector devises, constructs, and implements systems for
effective management of the overall residency training
program, the RPC is expected to analyze specific issues
and provide carefully considered recommendations (4).
Currently, however, it happens that most of the work falls
to the program director.
The functioning of a flexible and innovative RPC, ca-
pable of providing leadership in education and setting
standards of performance for residents and faculty, is a
challenge for any clinical academic department. Depart-
ments of psychiatry are particularly strained in this regard
VAN ZYL ET AL.
Academic Psychiatry, 29:5, November-December 2005 http://ap.psychiatryonline.org 465
because of the varied streams existing within the specialty,
the multiple agencies that intersect in mental health, and
the explosion of knowledge accrued from research on psy-
chotherapies, neurosciences, neuroimaging, genetics, epi-
demiology, pharmacotherapies and the new psychosocial
and rehabilitative interventions. In addition, the changing
structures of the mental health system impose a change of
venues for training as well as new skill-sets such as research
and statistics to be taught. As psychiatrists move farther
afield from the hospital setting and venture into multidis-
ciplinary community-based mental health agencies and te-
lepsychiatry, the teaching of administrative psychiatry,
ethics and deontological precepts has to be reinforced and
expanded.
High demands made of the RTP could easily swamp the
PD and cause difficulties for him/her in meeting other
clinical and academic expectations and advancement pos-
sibilities. Potential “job exhaustion” may lead the PD to
make a career move due to a lack of work satisfaction (1).
There is considerable variability in the term of appoint-
ment of program directors across Canada. Among cur-
rently serving directors the average length of time in the
position is 3.3 years (SD⳱2.5 range⳱less than 1 to 10
years). The average total length of tenure for previous di-
rectors is 4.8 years (SD⳱2.5 range ⳱ 1 to 10 years) (van
Zyl, unpublished). Given that PDs are responsible for all
aspects of the residents’ curriculum (development, imple-
mentation, and evaluation), training and clinical compe-
tence (7), PD overload and resignation could significantly
affect the residents and the RTP.
The PD position is thus in danger of being rendered
ineffectual with a high turnover rate; consequently, the vi-
sion and evolution of the RTP are also at risk as incoming
PDs are continually adjusting to the position. Establishing
a more even spread of duties among the members of the
RPC merits serious consideration as it may provide the PD
with a better sense of control and lessen the possibility of
burnout (5).
Assessment of Administrative Workload of
Canadian Psychiatry Residency Programs
At Queen’s University, the traditional workload carried
by the PD was being questioned. A recent assessment of
the Queen’s program’s administrative structure identified
inefficient processes coupled with dramatic workload im-
balances. The PD was expected to run the program, make
adjustments, and develop and implement changes virtually
alone but required the agreement of a large RPC on any
decisions. It was felt that too little time was available to
the PD to adequately meet all the demands of the position,
and that although a large number of persons were involved
in the residency program administration in the form of the
RPC, the latter body contributed little to the overall ad-
ministrative work associated with the RTP. The ratio of
administrative input by the PD versus the RPC was esti-
mated to be 90:10.
In response to this situation, an innovative administra-
tive structure was developed. Concurrently, for purposes
of comparison, psychiatry residency training program di-
rectors at the other 15 Canadian medical schools were
surveyed with respect to their program administrative
structure and executive involvement of their training
committees (Table 3). PDs from the various schools were
also asked to estimate the percentage of work that was
done by the director and by the rest of the RPC (Table
1). Completed surveys were received from all 15 pro-
grams. Programs were grouped according to the number
of residents in the program: 5 small programs (fewer than
25 residents), 6 medium-sized programs (26 to 40 resi-
dents) and 4 large programs (more than 40 residents).
Findings indicate that the size of the RPC does not ap-
pear to be related to size of the program (Table 1). How-
ever, some relationship was found between the number of
standing subcommittees and the size of the program.
Twelve of the 15 programs reported having at least one
standing subcommittee (range ⳱ 1 to 10), with smaller
programs reporting fewer (average ⳱ 1.5) than medium-
sized (average ⳱ 4.0) or large (average ⳱ 6.3) programs.
All programs reported specific work roles for some mem-
bers of the committee, but these varied between programs.
Small programs had an average of 1.8 work roles, medium-
sized programs 2.0 roles, and large programs had an av-
erage of 3.5 roles assigned per RPC. The overall average
was 2.3. These roles included managing the review of ro-
tation evaluation forms; psychotherapy; individual pro-
gram/site matters; curriculum development; developing
training objectives; funding resident activities; research;
core program management; safety/security; Canadian res-
idency matching service; PGY-1; and continuing profes-
sional development.
The role of the RPC was consistent across the sample.
Thirteen of the 15 directors reported that their RPC was
mainly consulting in nature and the average estimate of
the percentage of the committee’s work done by the di-
rector was 82% (range⳱67% to 90%).
IMPROVED EFFICIENCY AND OUTPUT
466 http://ap.psychiatryonline.org Academic Psychiatry, 29:5, November-December 2005
TABLE 1. Survey Summary of Administrative Aspects of Canadian Psychiatric Residency Training Programs
Program
Survey Question
Small Programs
(⬍25 residents)
(*Queen’s excluded)
5 programs
Medium Programs
(26 to 40 residents)
6 programs
Large Programs
(⬎40 residents)
4 programs
Summary
(*All but Queen’s)
PD assisted by a co-
director? N 5/5 N 4/6 N 4/4 N 13/15
Secretarial support (% of
full time)? 49 73 84 69
% of PD’s work time
dedicated to program? 35 38 38 37
If this is not sufficient,
what would be ideal? 50 45 50 48
# Residents in Program? 18 31 69 37
# Members on RPC? 11 12 23 14
# Residents on RPC? 4 4 6 4
Are there RPC standing
committees? Y 3/5 Y 5/6 Y 4/4 Y 12/15
How many standing
committees? 1 3.8 6 4
Is the RPC role mainly
consulting? Y 4/5 Y 5/6 Y 4/4 Y 13/15
Substantial workload
carried by RPC
Members? N 5/5 N 4/6 Y 4/4 Y 6/15
% Workload carried by
PD(s)? 86 80 83 82
Specific roles assigned
per RPC? 1.8 2.0 3.5 2.3
Legend: PD⳱Program Director; N⳱No; Y⳱Yes; # ⳱Number; M⳱Monthly; RPC⳱Residency Program Committee
* Data in this table exclude Queen’s University as it has already instituted the described system.
Administrative Restructuring:
The New Approach
In an effort to more equitably distribute administrative
workload, the entire administrative system of the Queen’s
University psychiatry RTP was restructured to operate un-
der decentralized management. The primary intent of the
new configuration was to transform the residency program
committee from a large advisory body into that of a smaller
work-sharing entity.
Decentralization entailed the identification of specific
program domains, representing each area within the train-
ing program, and the appointment of individual program
domain managers (PDMs) responsible for managing those
specific domains. The PDMs were to report directly to the
PD who would not be involved in the direct administration
of these program domains.
Program Domains
Eight specific program domains were created at
Queen’s, based on local program requirements
1. Program Accreditation, Resident Career
Issues and Rotations
This position involves preparing for all accreditation
surveys mandated by the Royal College of Physicians and
Surgeons of Canada, or any reviews instructed by either
the university or the Royal College. Another standing re-
sponsibility is to meet annually with each resident in order
to discuss career and rotation issues and organize rotation
placements for the following year.
2. Curriculum Development, Implementation,
and Review
Identifies and appoints members of a curriculum com-
mittee to actively assist him/her with regularly reviewing
the curriculum, adjusting it to emerging needs, and moni-
toring its implementation.
3. CaRMS (Canadian Resident Matching Service)
Arranges all aspects and associated processes of the Ca-
nadian Residency Matching Service.
VAN ZYL ET AL.
Academic Psychiatry, 29:5, November-December 2005 http://ap.psychiatryonline.org 467
4. International Medical Graduate
Programs (IMGP)
Monitors constant changes to existing rules and regula-
tions within the various IMGPs to make informed decisions
about appropriate applicants. Also organizes interviewers,
supervisors and evaluators in the recruiting process.
5. Mentorship
Identifies and coordinates potential members of faculty
as mentors for residents within the RTP and monitors the
overall ongoing process.
6. Program Promotion and Liaison
Promotes the RTP locally and across the country (to fill
all available residency training positions).
7. Research in Education
Identifies, initiates and leads resident research in the
field of resident education. Residents and members of fac-
ulty are recruited to assist in the research and coauthor
relevant papers. The aim is to facilitate increased resident
research productivity (3).
8. Fellowship Programs
Traditionally, all administration involved in the recruit-
ment, selection, and appointment of fellows was exclu-
sively managed by the specific division of the psychiatry
department offering the fellowship. However, the need
was identified to centralise organization under one admin-
istration, and accordingly, this position was created. The
PDM of Fellowship Programs is responsible for verifying
credentials; liaising with the College of Physicians and Sur-
geons of Ontario regarding licensing issues; calling for let-
ters of reference; setting up an on-site interview with the
applicant and relevant division members; and liaising with
the office of the dean of postgraduate medical education.
Integrating Residency Training Program Domains
and the Residency Program Committee
In order to meet RPC membership guidelines of the
Royal College, the following initiatives were taken:
1. The PD serves as Chair, heading the administrative
structure and linking all the PDMs and their domains. Ad-
ditionally, he or she is the main administrative link be-
tween the Royal College of Physicians and Surgeons of
Canada, the College of Physicians and Surgeons of On-
tario (the provincial licensing authority), and the post-
graduate dean at the university. While fairly autonomous,
the PD reports to the head of the department.
2. No members of faculty other than the PDMs are in-
vited onto the residency program committee. PDMs ad-
ditionally represent either the training facility in which
they work or the academic division of the department of
psychiatry to which they belong, or both. The representa-
tive of an academic division of the department of psychi-
atry, in effect, represents all teaching programs within that
division.
3. Corresponding members are appointed in the situa-
tion where a given division or teaching site is not repre-
sented by an existing core member (Figure 1).
4. Although corresponding members are nonvoting
members and do not attend regular RPC meetings, they
receive all meeting agendas and minutes and are invited
to respond to those documents.
5. The resident representatives on the RPC are the chief
resident, the deputy chief resident and the junior Coordi-
nators of Psychiatric Education (COPE) representative.
All the resident representatives are peer-elected and form
part of the core membership.
The new system within the Queen’s University psychi-
atry program was phased in over a period of 1 year; flexible
adjustment to new needs has been paramount.
Since inception, one program domain has already been
suspended, and two new ones instated (Table 2). Due to
governmental initiatives, the extraordinary expansion of
medical school and residency training positions has been
called for, and in response to these pressures, two new
program domains have been created: Family Medicine Li-
aison and Psychiatry Outreach. The former domain pri-
marily requires the reviewing and adjusting of family med-
icine resident education in psychiatry; the latter entails
developing community rotations in psychiatry. Program
Promotion and Liaison was suspended as our success at
filling our residency positions has improved.
With this new system, the opportunity has been created
for the PD to oversee important initiatives without being
directly involved in organizing the details, for example, de-
velopment of new rotations in community sites.
To make it possible for the PD to rapidly implement
adjustments to the program without expense to core pro-
gram functions, the new nature of the PD position has
ameliorated the historically disruptive event of PD swit-
chover. In contrast to the old system, administrative pro-
cessing delays due to the learning phase of the newcomer
have been minimized; a recent switchover—despite occur-
ring in the midst of the resident placement interviews and
shortly after a Royal College program accreditation sur-
vey—attested to this.
IMPROVED EFFICIENCY AND OUTPUT
468 http://ap.psychiatryonline.org Academic Psychiatry, 29:5, November-December 2005
FIGURE 1. The Residency Training Program
Resident Representatives
Corresponding
membership
Core
membership
Residency
Program
Committee
Corresponding membership
Core membership
Teaching Centers
Kingston General Hospital
Hotel Dieu Hospital
Providence Continuing Care Center
Residency Training
Program Domains
Program accreditation, resident
career issues, and rotations
Curriculum development,
implementation, and
maintenance
CaRMS (Canadian Resident
Matching Service)
International medical graduate
programs
Mentorship
Program promotion and liaison
Education research
Fellowship programs
Departmental Programs
Adult Psychiatry
Adult treatment and rehabilitation
psychiatry
Child and adolescent psychiatry
Consultation--liaison psychiatry
Psychiatry of developmental
disabilities
Forensic psychiatry
Geriatric psychiatry
Psychopharmacology
Psychotherapy
Continuing professional
development
Residency training program domain managers administer well-circumscribed administrative aspects of the residency training program, while
simultaneously constituting the core membership of the residency program committee. These individuals also represent one of the participating
institutions and/or a major component/program of the residency training program. A corresponding membership of the residency program committee
is activated when core members do not represent one of the teaching institutions or one of the major programs.
Since implementation of the new system, PDMs have
shown keen interest in their particular areas of responsi-
bility. Regular communication between PDMs and the PD,
and among PDMs themselves, has emerged as an inter-
esting phenomenon that has led to a degree of cohesive-
ness not previously present between members of the RPC.
This, in turn, has created the opportunity for improved
decision making and problem resolution by allowing the
PD open and rapid communication lines with the various
PDMs who are simultaneously also members of the RPC.
While more weighty issues continue to be managed by the
entire RPC, many decisions are now effectively and more
efficiently dealt with by a small committee made up of the
PD and the associated PDM. All discussions are minuted,
and resulting decisions are reported at the following
monthly meeting of the full committee. The net effect has
been the streamlining and improved flow of administrative
work associated with the RTP.
Another noticeable improvement has been the increase
in the voluntary time commitment from all the PDMs. Pre-
vious members of the RPC were essentially expected to at-
tend and advise at committee meetings and were found to
be reluctant to offer any additional time if the need arose.
The reluctance, thought to be based on the issue of unex-
pected and sporadic requests for time, seemed to vanish
upon implementation of the new system, suggesting that ac-
ceptance of the position of PDM implies a requirement for
increased time commitment and flexibility around it.
Time input associated with each program domain varies;
for example, while the CaRMS program domain requires
VAN ZYL ET AL.
Academic Psychiatry, 29:5, November-December 2005 http://ap.psychiatryonline.org 469
TABLE 2. Program Domains: Initial and Current
Program Domain Central Aspect of Domain
Present at Initiation
of New System Current Domain Status
Program Accreditation, Resident
Career Issues and Rotations
Maintain Accreditation standards ⻬ Active
Curriculum Development,
Implementation, and Review
Ensure review and adjust
curriculum
⻬ Active
CaRMS (Canadian Residency
Matching Service)
Recruitment of Residents ⻬ Active
International Medical Graduate
Programs
Facilitation of international
applications
⻬ Active
Mentorship Oversight of mentorship program ⻬ Active
Program Promotion and Liaison Promotion of program locally
and nationally
⻬ Temporarily suspended
Education Research Coordination of resident research ⻬ Active
Fellowships Administration of fellowships ⻬ Active
Family Medicine Liaison Review and adjust family
medicine resident education in
Psychiatry
✗ Active [New]
Psychiatry Outreach Development of community
rotations
✗ Active [New]
6 months of intense work, other program domains—such
as mentorship—require yearlong PDM involvement at
much lower intensity.
Discussion
Having competent PDMs provides the program director
with a better sense of control and lessens the possibility of
burnout (3, 5).
The overall time commitment of the PD may be, but is
not necessarily, reduced. Thirteen of the 16 program di-
rectors in our survey noted that their time commitment
was less than the recommended amount of about 0.5 full
time equivalent (FTE), the average being 0.37 FTE (2)
(Table 1). Following introduction of the new system at
Queen’s University, the time commitment remained es-
sentially unchanged, though an estimated shift in workload
ratio of PD to RPC from 90:10 to about 60:40 was appar-
ent. This shift allowed the PD to spend more time on de-
velopment and implementation of initiatives rather than
on excessive detail work and crisis management.
A potential pitfall is that a shift in time commitment may
require increased compensation for RPC members spend-
ing more time on RTP responsibilities. At Queen’s this is
not an issue, as we have a unique funding agreement that
allows for flexibility of academic time. However, other pro-
grams may face this as a problem if specific remuneration
exists for administrative and education commitments.
To circumvent the risk of a program domain becoming
too independent and taking on an errant course, the PD
should ensure that frequent communication occurs with all
PDMs. Another associated risk is that a PDM responsible
for one of the more taxing program domains might
promptly resign due to overwork. To prevent this situation,
part of the PDM’s role is to strike and Chair a subcom-
mittee to help spread workload.
In this study we were not able to pursue specific reasons
for program directors leaving their positions prior to com-
pleting their term of office and whether this related to job
exhaustion. For this reason we needed to make certain
assumptions in this regard as described in the paper. This
lack of information constitutes a limitation of the current
study and opens an area for further research. Another lim-
itation lies in the way program directors were asked to
estimate the ratio of PD to RPC workload. Factors to be
considered in this estimate were not specified to the PDs,
and accordingly it is likely that this resulted in some vari-
ability in the method of estimation between sites.
Conclusions
The position of program director in psychiatry is a de-
manding one that requires 25% to 55% (average 37%) of
the program director’s time, carrying an estimated 67% to
90% (average 82%) of the administrative workload. The
program domain manager administration system imple-
mented at Queen’s University enabled the program direc-
tor to be simultaneously up to date with all major areas of
the program while experiencing a substantial decrease in
the administrative workload, achieved through increased
work contribution of the RPC. This system encourages
IMPROVED EFFICIENCY AND OUTPUT
470 http://ap.psychiatryonline.org Academic Psychiatry, 29:5, November-December 2005
TABLE 3. Questionnaire Completed By All Canadian Departments of Psychiatry
A. Program Director
1. Are you assisted by a Co-Director (CoPD)? Yes No
If yes, please indicate the PD: CoPD workload distribution. PD : CoPD
(e.g., 50:50)
2. Do you have secretarial support? Yes No
If yes, how much? Full-time Half-time
Other (Specify):
3. Approximately what proportion (%) of your total work time is dedicated to fulfilling duties
associated with your position as Program Director?
%
4. Do you regard this amount of time as being sufficient? Yes No
If no, how much of your total work time do you feel that you should ideally dedicate to
effectively administrate your Program?
%
5. How many psychiatry residents are currently enrolled in your psychiatry residency program? #:
B. Program Director and RPC
1. How many persons serve on your RPC? #:
2. How many residents serve on your RPC? #:
3. Is the chief resident a member? Yes No
4. How frequently does the RPC meet? Monthly Quarterly
Other: (Specify)
5. Does your RPC have standing subcommittees? Yes No
If yes, how many? #:
6. Does your RPC function primarily as a consulting body, assisting you in decision making? Yes No
7. Do members of the RPC assume a substantial portion of the overall workload associated
with the administration of the Program?
Yes No
If yes, please indicate:
a. How much of the overall administrative workload do you estimate is carried by the
members of the RPC in relation to the program director (PD:RPC, e.g. 50:50)? This should
not include the time spent at the RPC meetings.
PD : RPC
(e.g., 50:50)
b. Are any RPC members assigned specific work roles that they routinely attend to? Yes No
If yes, please provide examples:
#⳱number
RPC members to be closely involved in decision making
and development of their own program domains and al-
lows the program director more time for developing, im-
plementing and overseeing innovations across the entire
spectrum of the RTP. Essentially, this results in a more
efficient and adaptable RPC and RTP.
The authors thank all the directors of postgraduate education of
the departments of psychiatry in Canada who participated in this
survey.
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