Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via HighWire Citing Articles via Google Scholar Articles by Silberman, E. K. Search for Related Content PubMed Citation Articles by Silberman, E. K. Primary Care

Should We Train Psychiatrists as Primary Care Providers?

Received July 22, 1998; revised September 18, 1998; accepted October 7, 1998. From the Department of Psychiatry and Human Behavior, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA. Address reprint requests to Dr. Silberman, Department of Psychiatry, Jefferson Medical College, Thomas Jefferson University, 1020 Sansom St., Suite 1652G, Thompson Building, Philadelphia, PA 19107-5004.

ABSTRACT

The author discusses the proposition that psychiatrists would be appropriate primary physicians for specific types of patients. The author reviews the arguments for and against psychiatrists as primary care providers, proposes questions that must be addressed in training for such a role, and describes current models of primary care education and practice for psychiatrists. The author believes that primary care may be an appropriate career track within psychiatry and suggests that the development of family medicine may provide useful guidance in incorporating primary care functions into psychiatry.

Key Words: Primary Care • Perspective

Whether it is desirable or practical for psychiatrists to provide primary care has long been a matter of controversy. The majority opinion within the general medical community has been that the medical needs of patients with mental disorders are best served by nonpsychiatric physicians.^1,2 Psychiatrists themselves often see primary care as beyond the scope of their training, interest, or continuing education.³ Even those who view medical care as part of psychiatric practice are often reluctant to perform functions such as physical examinations, fearing that they would disrupt the therapeutic relationship.⁴ Others maintain that psychiatry is essentially a consulting specialty rather than one that should provide longitudinal care.⁵

An alternative (although probably minority) view has been that the task of psychiatrists, by its nature, includes evaluation and treatment of routine medical problems.⁶ Fink and Oken suggest that the psychiatrist, by providing a point of first contact for assessment, longitudinal follow-up, coordination of care, and availability as an advisor and confidante, fulfills many of the defining criteria of a primary caregiver.⁷ Bloom has proposed that both "primary care physician" and "primary care specialist" roles might be appropriate for some psychiatrists.⁸ As a primary care physician, the psychiatrist would treat the full range of primary care patients in addition to patients with psychiatric disorders. In the primary care specialist role, the psychiatrist would perform first-line assessment and treatment of common medical problems in selected psychiatric patients, such as the elderly and those with severe, chronic psychiatric illnesses.^9–11

How might it benefit patients to receive primary care from their psychiatrists? It is well established that psychiatric patients have greater medical morbidity and mortality than the general population.¹² Although such medical problems may be well diagnosed and treated by nonpsychiatric physicians,¹³ patients with severe and chronic psychiatric disorders and/or low socioeconomic status are more likely to have medical illnesses go undiagnosed.^14,15 For these patients, having a primary care physician does not guarantee adequate medical assessment.^16–18 The diagnoses typically missed are just those less severe but more chronic conditions that are commonly treated in primary care practices.¹⁹ The idiosyncratic way in which psychiatric patients perceive and describe their illnesses,^20,21 aversion of nonpsychiatric physicians to psychiatric patients,^22,23 and failure of psychiatrists and primary care physicians to collaborate adequately²⁴ may all contribute to underdiagnosis and undertreatment of medical problems.

Given that medical care of psychiatric patients is often less than ideal, it may be worthwhile to explore whether, with appropriate training, psychiatrists might better provide primary care, especially for patients with chronic mental illness and low socioeconomic status. Furthermore, despite the common concern, it is not clear that giving medical care is inimical to psychiatric treatment. For example, psychiatrists who perform physical examinations report that their working relationships with patients are more likely to be enhanced than to be disrupted.⁴

Primary care by psychiatrists is already a reality in some public institutions. A recent survey of administrators estimated that psychiatrists provide primary care functions, or would be encouraged to provide them, in about half of Veterans Administration (VA) and state mental health systems.²⁵ For a "principal care" role, in which psychiatrists triage and coordinate medical care but do not directly provide it, the comparable figures are over 80%. However, these systems have not yet developed consistent standards for patient selection, scope of practice, training, or continuing education for psychiatrists working as primary care providers

Evolving training programs for psychiatrists as primary care providers must address the following questions: 1) What medical competencies should be required of all psychiatrists? 2) What training would psychiatrists need to be competent as primary care providers? 3) Can such knowledge and skill be acquired within a regular four-year residency? 4) What range of psychiatric patients and medical illnesses is appropriate for primary care psychiatric treatment? 5) In what venues will psychiatrists perform primary care functions? 6) What certification procedures would be needed for psychiatrists in primary care roles? 7) How would psychiatrists keep current with primary care medicine?

We are just beginning to explore answers to these questions. Shore²⁶ points out that skill in diagnosing common medical, neurological, and surgical disorders, and providing limited medical care are currently accepted training goals for first-year psychiatry residents. However, in practice, formal training in medical skills is generally limited to the PGY-1, with little subsequent attention to retaining them. Shore suggests that combined medical-psychiatric treatment will be an increasingly important type of practice in the future and proposes that primary care tracks in psychiatry residencies, which would devote available elective time to supervised experiences in primary care medicine, would be adequate training for such practice.

In developing such programs, psychiatry may benefit from the history of family practice. Establishing family practice as a specialty required defining scopes of practice in internal medicine, pediatrics, obstetrics and gynecology, surgery, and psychiatry and structuring training programs that appropriately balance specialty rotations with those in family medicine.²⁷ Current RRC requirements for family practice residencies include 4 months of pediatrics, 2 months of surgery, and 2 months of obstetrics, in addition to ongoing experience treating primary care patients in these modalities.²⁸ The success of such programs suggests that the current psychiatry requirement of a 4-month rotation on internal medicine or family medicine, when coupled with longitudinal experiences providing primary care, might be adequate training for psychiatrists to practice in the primary care specialist mode.

A number of programs have begun to train residents for practice in this model. Possibly the most fully developed is that at Case-Western Reserve University, which operates in collaboration with the VA Prime initiative, a multidisciplinary model of primary care in which psychiatrists may function as primary care providers. In this model, residents in their second through fourth years follow selected patients for both medical and psychiatric problems, with supervision by internists as well as psychiatrists. Hypertension, diabetes, obesity, upper respiratory infections, urinary tract infections, and medical sequelae of substance abuse are handled routinely by the psychiatry resident. More complex problems are referred, and procedures such as PAP smears or colonoscopy are done in the medicine clinic but by the psychiatry resident. Supervision includes discussions about when to treat and when to refer. Half-time PGY-4 electives are available in research, education, administration, and advanced clinical skills.

Six residents completed this program over its first 3 years. All went on to practice in the public sector and spend 50% or more of their time in primary medical care activities. As of this writing, there have been no problems with credentialling or liability.

Programs with more limited time and resources have developed electives in which residents may follow patients in ambulatory primary care clinics. Recent changes in HCFA regulations, which, for the first time, allow Medicare educational pass-through funds for training in nonhospital settings (e.g., primary care offices), may be an important stimulus for developing more such programs.

As yet, psychiatry has no plan for certifying the competence of residents in primary care, but an "added qualification" examination might support credentialling in such practice. Because of the need to keep current in many areas, family medicine was the first specialty to require periodic Board recertification.²⁹ Psychiatry has now adopted this rule, which could be applied to certification in primary care medicine. In addition to periodic examinations, formal certification would entail developing standards for continuing medical education and minimum proportion of practice time devoted to primary care activities. Such standards might be necessary for reimbursement from insurers and protection against legal liability.

Although primary care tracks might be appropriate training for primary care specialists, dual board certification would probably be necessary for practice in the full primary care physician role.⁸ Psychiatric multiple board programs were initiated with the psychiatry-child psychiatry-pediatrics program in 1986 and have since been expanded to include combined programs with psychiatry and internal medicine, neurology, and family practice. Such programs tend to attract highly motivated, highly competent residents who fare very well in the job market upon graduation. Dual board programs are difficult to organize and administer because they require part-time residency positions in each participating department and integrated interdepartmental rotations in each year of training. However, HCFA supports dual specialty-primary care programs by fully funding the final year of training as an exception to rules limiting funding beyond the time of first board eligibility.

A salient but unanswered question is how graduates of multiple board programs use their training. Because such graduates are still very few in number, there is almost no systematically collected information about them. The impression of program directors has been that the majority of dually trained graduates practice some form of psychiatry. By contrast, a recent survey of physicians certified in both psychiatry and family medicine (but not through dual-board programs) found that only about one-third practice psychiatry alone, while about 50% practice both specialties.³⁰ This suggests that there are motivated physicians who have found viable settings for practice in the full primary care-psychiatry model.

Among the questions that must be answered to shape future policy are how the quality, cost, and efficiency of primary care by psychiatrists would compare with those of traditional primary care. Programs for training psychiatrists to provide primary care may provide opportunities to answer such questions. Among potential research issues are rates of detection of medical illness, effect on cost of clinical services, and effect on volume of psychiatric service delivery when the primary care physician is a psychiatrist compared to when medical and psychiatric treatment are split. Such studies could potentially be done on a relatively small scale, supported by internal university funds or private foundation grants.

Primary care may be an appropriate aspect of psychiatric practice in the coming decades. The primary care role would not be universal, but may become a viable career track within psychiatry, especially for clinicians working with the severely and chronically ill. The literature on medical illness in psychiatric patients presents good reason to test the proposition that some patients may be better served by appropriately trained psychiatrists than by nonpsychiatrists as their primary physicians. Although training programs and standards for primary care by psychiatrists are at an early stage of development, the success of family medicine provides evidence that such breadth of practice is viable and offers a useful model for teaching and maintaining primary care skills within the practice of psychiatry.

REFERENCES

1. World Health Organization: Psychiatry and Primary Medical Care. WHO 1973
2. Strathdee G, Williams SP: A survey of psychiatrists in primary care: the silent growth of a new service. Journal of the Royal College of General Practice 1984; 34:615–618
3. Gordy T: Psychiatrists are not meant to be primary care providers. Psychiatric News, January 19, 1996, p.16
4. McIntyre J, Romano J: Is there a stethoscope in the house (and is it used)? Arch Gen Psychiatry 1977; 34:1145–1151
5. Detre T, McDonald M: Managed care and the future of psychiatry. Arch Gen Psychiatry 1997; 54:201–204[Abstract/Free Full Text]
6. Sandifer ME: The education of the psychiatrist as a physician. Am J Psychiatry 1977; 134:50–53[Abstract/Free Full Text]
7. Fink P, Oken D. The role of psychiatry as a primary care specialty, Archives of General Psychiatry, 1976, 33:998–1003.
8. Bloom JD: Psychiatry: three models in search of a future. Psychiatr Serv 1996; 47:874–875[Abstract/Free Full Text]
9. Streim JF, Katz IR: The psychiatrist in the nursing home, part II: consultation, primary care, and leadership. Psychiatr Serv 1995; 46:339–341[Free Full Text]
10. Summers WK, Munoz RA, Read MR, et al: The psychiatric physical examination. II: findings in 75 unabled psychiatric patients. J Clin Psychol 1981; 42:99–102
11. Roca RP, Breakey WR, Fischer PJ: Medical care of chronic psychiatric outpatients. Hosp Commun Psychiatry 1987; 38:741–745[Abstract/Free Full Text]
12. Felker B, Yazel J, Short D: Mortality and medical comorbidity among psychiatric patients: a review. Psychiatr Serv 1996; 47:1356–1363[Abstract/Free Full Text]
13. Honig A, Pop P, deKemp E, et al: Physical illness in chronic psychiatric patients from a community psychiatric unit revisited: a three-year follow-up study. Br J Psychiatry, 1992; 161:80–83[Abstract/Free Full Text]
14. Koranyi E: Morbidity and rate of underdiagnosed physical illness in a psychiatric population. Arch Gen Psychiatry 1979; 36:414–419[Abstract/Free Full Text]
15. Johnson DW: The evaluation of routine physical examination in psychiatric cases. Practitioner 1988; 200:686–691
16. Burke AW: Physical disorder among day hospital patients. Br J Psychiatry 1978; 133:22–27[Abstract/Free Full Text]
17. Hall RC, Popkin MK, Devaul RH, et al: Physical illness presenting as psychiatric disorders. Arch Gen Psychiatry 1978; 35:1315–1320[Abstract/Free Full Text]
18. Barnes RF, Mason JC, Greer C, et al: Medical illness in chronic psychiatric outpatients. Gen Hosp Psychiatry 1983; 5:191–195[Medline]
19. Maricle RA, Hoffman WF, Bloom JD, et al: The prevalence and significance of medical illness among chronically mentally ill outpatients. Hosp Commun Psychiatry 1987; 38:141–145
20. Bunce DF, Jones LR, Badger LW, et al: Medical illness in psychiatric patients: barriers to diagnosis and treatment. South Med J 1982; 75:941–944[Medline]
21. Talbott JA, Linn L: Reactions of schizophrenia to life-threatening disease. Psychiatr Q 1978; 50:218–227[Medline]
22. Goodwin JM, Goodwin JS, Kellner R: Psychiatric symptoms in disliked patients. JAMA 1979; 241:1117–1120[Abstract/Free Full Text]
23. Garai T, Goldsmith W: Medical treatment in a psychiatric clinic: a system that works. Hospital and Community Psychiatry 1979; 30:848–849[Free Full Text]
24. Lima BR, Brooks ML: Coordination of services for outpaitents under concurrent medical and psychiatric care. Gen Hosp Psychiatry 1985; 7:330–333[Medline]
25. Silberman EK: A survey of state and VA policies on psychiatrists as primary care providers. Psychiatr Serv 1997; 48:946–947[Abstract/Free Full Text]
26. Shore JH: Psychiatry at a crossroad: our role in primary care. Am J Psychiatry 1996; 153:1398–1403[Abstract/Free Full Text]
27. Lewy RM: The emergence of the family practitioner: an historical analysis of a new specialty. J Med Educ 1977; 52:873–881[Medline]
28. Accreditation Council for Graduate Medical Education: Essential and Information Items: 1997–1998. Washington, DC, American Medical Association, 1997
29. Young PR: A brief history of the American Board of Family Practice: the second annual Nicholas J. Pisacano, MD, Memorial Lecture. Journal of the American Board of Family Practice 1996; 9:109–113
30. McCahill M, Palinkas LA: Physicians who are certified in family practice and psychiatry: who are they and how do they use their combined skills? Physicians in Family Practice and Psychiatry 1997; 10:111–116

This article has been cited by other articles:

				G. E Gray Integrated medical care in a mental health clinic improved quality of care and outcomes in serious mental disorders Evid. Based Ment. Health, May 1, 2002; 5(2): 46 - 46. [Full Text] [PDF]

Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via HighWire Citing Articles via Google Scholar Articles by Silberman, E. K. Search for Related Content PubMed Citation Articles by Silberman, E. K. Primary Care

Get information about faster international access.

Privacy Policy

Copyright © 1999 Academy of Psychosomatic Medicine. All rights reserved.

Home | Search | Current Issue | Past Issues | Subscribe | All APPI Journals | Help | Contact Us