Psychosomatics 41:53-57, February 2000
© 2000 The Academy of Psychosomatic Medicine
Sharing Mental Health Care
Training Psychiatry Residents to Work With Primary Care Physicians
Nick Kates, M.B., B.S., F.R.C.P.C.
Received January 15, 1999; revised March 22, 1999; accepted July 28, 1999. From the Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada. Address correspondence and reprint requests to Dr. Kates, Hamilton-Wentworth HSO Mental Health Program, 40 Forest Avenue, Hamilton, Ontario, L8N 1X1 Canada.
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ABSTRACT
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Overcoming problems in communication between psychiatry and primary care requires new models of collaboration. Their success will depend upon the ability of participants to work productively with each other, which will require psychiatry residency programs to offer appropriate preparation for future graduates in working with primary care physicians. This article, based on the training at McMaster University in Hamilton, Ontario, describes a brief curriculum for training psychiatry residents to work effectively with primary care physicians that can be easily integrated with current training rotations and looks at adjustments academic departments need to make to support such programs.
Key Words: Mental Health Care • Primary Care • Residency Training
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INTRODUCTION
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A continuing challenge for psychiatry residency programs is to ensure training programs prepare graduates for the changing realities of practice.1,2 An example of this is in the changing relationship between psychiatry and primary care. In most communities, the family physician plays a significant role in managing mental health problems.3–6 Recent attempts to reform health care systems in both the United States7 and Canada8 have emphasized the role of primary care, highlighting the need for better links between primary and specialized health services, including psychiatry.9,10
Establishing these links is particularly important for psychiatry, as surveys of family physicians in a number of jurisdictions have identified dissatisfaction with the accessibility of psychiatrists/mental health services and the lack of communication between primary care and mental health providers.11–16
In attempting to respond to these changing demands, many mental health services and academic departments of psychiatry are exploring new models for working collaboratively with primary care providers. These approaches are often based upon the concept of "shared care," in which primary care providers and mental health services work together to ensure that a patient receives the services he/she requires from the most appropriate provider, with a minimum of obstruction or disruption.
Examples of such initiatives include programs that aim to improve communication between mental health and primary care providers,17,18 meetings between psychiatrists and primary care providers to review cases,19 and the integration of mental health care providers within primary care settings.10,20–24
Whatever the nature of the project, its success will depend upon the ability of participants from different backgrounds to work collaboratively. This success, in turn, will depend upon the understanding each participant has of 1) the demands faced by colleagues in other disciplines, 2) the problems they encounter, and 3) the kind of assistance they are seeking. These steps are strongly influenced by the preparation practitioners receive during their training, which shapes their ability to work effectively with other professional groups.25
In most family medicine residency programs, learning to manage mental health problems and work with mental health providers figures prominently in a resident's training.26–28 In stark contrast to this approach, in most psychiatry residency programs the preparation that residents receive that will assist them in working with primary care providers is often inadequate and sometimes nonexistent. A study of psychiatry residency programs in Canada29 found many gaps in the training residents receive in this area. Only 4 of 16 programs devoted any formal teaching time to this topic, the average being less than 2 hours in a 4-year program.
With an emerging consensus that one of the "new" professional values for a psychiatrist will be a readiness to work in primary care settings alongside primary care physicians and nurse practitioners,2,8,29 the emphasis on collaborative mental health care in clinical practice needs to be reflected in residents' training experiences.2,25,30 This article, based on the experiences of the psychiatry residency program at McMaster University in Hamilton, Ontario, over the last 10 years, outlines the core content of a curriculum titled "Working Collaboratively With Primary Care Providers" and describes the steps a department of psychiatry can take to implement and support this training.
Although the term "curriculum" is used, it is neither necessary nor desirable to identify this as yet another subspecialty area to be squeezed into an already crowded program. The concepts and clinical experiences outlined next can be easily integrated into existing clinical rotations, such as outpatient, child psychiatry, geriatric psychiatry, and rehabilitation/care of the mentally ill, taking advantage of links that may already exist between these services and local family physicians. This approach reinforces the idea that working closely with family physicians is not a specialized activity but an integral part of all clinical practice.
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TRAINING GOALS
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The goals of the program are 1) to provide residents with an understanding of the role of primary care providers in delivering mental health care and how mental health providers/psychiatrists can support and enhance this role and the care their patients receive and 2) to teach skills that will enable the residents to work collaboratively and productively with primary care providers.
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CURRICULUM
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The curriculum can be divided into knowledge, skills, and attitudes.
Knowledge
1. Context.
Context includes the organization and demands of primary care models of primary care and funding mechanisms, as well as the (changing) role of the family physician in managed care and other health care systems, and the potential impacts of health care reform on primary care.
2. Mental Health Problems in Primary Care.
This area includes the prevalence and detection rates of mental health problems in primary care; the role of the family physician in treating, referring, and managing commonly encountered mental health problems; and the course of psychiatric disorders in primary care, including similarities/differences, with cases being seen in the secondary and tertiary settings used as teaching centers.
3. Sharing Care.
This area includes the principles and models of shared mental health care, including relevant guidelines or planning documents produced by state (provincial) or federal governments, and models of psychiatric consultation to family physicians and other primary care providers.
4. Ways to Achieve Effective Communication With Primary Care Providers.
Frequently overlooked in residency programs, effective communication involves specific guidelines on problems that commonly arise in communication between family physicians and psychiatrists, information a family physician may require from a psychiatrist, and confidentiality issues.
5. General Medical Conditions.
The physician should be familiar with commonly encountered general medical conditions that can have psychiatric sequelae and their treatments.
Skills
1. Communication.
This area should cover how and when to communicate regularly and effectively with primary care providers, especially at admission to and discharge from a mental health service; how to write a consultation note or report tailored to the needs/expertise of the consultee; and how to develop a clinical plan in partnership with a primary care provider, in which responsibilities for delivering mental health care are shared according to the needs of the patient.
2. Ability to Work as a Consultant Within a Primary Care Setting.
This ability includes clarifying the nature and expectations of the consultant's role; adapting an interview to limitations imposed by the physical surroundings; clarifying and answering a consultation question; presenting a rapid, understandable, jargon-free explanation of a problem and management plan; writing a brief, practical note with an easy-to-follow treatment plan; providing ongoing support for the consultee; and working in a non–mental-health setting as a "visitor."
3. Case Discussions/Reviews.
This area includes how to review cases and provide consultative advice to family physicians, either in person or by phone, without needing to see the patient.
Attitudes
This area involves fostering proper attitudes: a respect for the role of the primary care provider in delivering primary care, respect for the role of the primary care provider in delivering mental health care, readiness to deliver services where needed, willingness to work collaboratively with other providers, and willingness to learn from providers from different backgrounds.
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METHODS
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The ideas listed next do not require dedicated rotations, but can (and should) be integrated with other training experiences or rotations. In this way, the resident learns that collaborating closely with a primary care provider/family physician is not an esoteric activity for a few committed practitioners but an integral part of the management of every case he or she sees. Experiences at McMaster suggest that the most important and effective educational activity is the opportunity to observe supervisors (role models) who work collaboratively and respectfully with their colleagues from primary care.
As with other clinical areas, a resident's exposure should be graded, from working under close supervision in the early stages of a rotation to working much more autonomously in the later stages of training, once competence has been demonstrated. Specific approaches to consider include the following.
1. Increased Contact With Family Physicians and Family Residents During the Entire Residency Program
Ways to increase this contact include 1) joint rounds (regularly or on an ad hoc basis) on topics of common interest attended by residents or both residents and faculty from each department; 2) inviting family physicians/residents to case conferences held by mental health services; 3) joint educational seminars with family medicine residents; 4) a psychiatry resident can meet with a group of family medicine residents or family physicians regularly to discuss cases and provide advice about management (usually in conjunction with a supervisor); and 5) being encouraged to use every opportunity to speak to and get to know one or more family physicians during rotations, or when on call.
2. Activities During Clinical Placements
With appropriate backup, a psychiatry resident can be identified as a contact for a group of family physicians who have questions about particular problems and provide regular and relevant information for family physicians on all cases seen in consultation or treatment.
3. Making Presentations in Teaching Sessions for Family Medicine Residents
These sessions can also include presentations at continuing medical education days for family physicians, although residents usually need assistance to ensure that their material is relevant to the needs of their audience.
4. Didactic Seminars
These seminars need not be lengthy and can be integrated either into current rotations or seminar series. At McMaster, only 6 hours of formal tutorial time is devoted to these topics, part of which focuses on the role of the psychiatrist as a consultant, but these tutorials are reinforced by teaching during clinical rotations.
5. Visits to Primary Care Settings
These visits usually involve a resident accompanying a staff person. The purpose of the visit can be to see cases, to discuss problems, to make an educational presentation to a group of primary care providers, or all of the above. More senior residents are able to work relatively independently or visit primary care settings on their own.
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THE McMASTER PROGRAM
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The training at McMaster has four major components.
1. Tutorials
Residents at McMaster attend two 3-hour sessions, usually in the second year of training. The first addresses the role of the psychiatrist as a consultant. The second reviews the role of the family physician in delivering mental health care, the relationship between psychiatry and primary care, and new models for collaboration. The tutorials end with a description of a successful local program that brings counselors and psychiatrists into the offices of 90 family physicians in the surrounding community, and the lessons learned from that experience. This is the same program that offers opportunities for residents to accompany their supervisors on visits to primary care settings. Also, all residents receive an annotated bibliography on shared mental health care and collaborative projects.
2. Opportunities to Work in Primary Care Settings
All residents in the McMaster Psychiatry Residency Program are now able to spend a part of a rotation working in a primary care setting. This training is usually done on an outpatient rotation in which they will accompany their supervisor or another faculty member who is already consulting to a primary care practice. Half a day per week during a 6-month rotation is usually sufficient to give a resident an appreciation of the demands and needs of primary care and develop the necessary consultative and communication skills. Senior residents choosing to spend time in these practices will take on additional responsibilities for consultation to the practice's physicians. Child and geriatric placements also offer opportunities to work with primary care physicians.
3. Educational Presentations to Family Physicians/Residents
Residents can accompany psychiatrists who are working in academic family medicine units and participate in the academic half-days organized for family medicine residents. A well-organized continuing medical education program for family physicians also provides many opportunities for psychiatry residents to make presentations to groups of family physicians.
4. Reinforcement of These Concepts in Clinical Rotations
McMaster has a lengthy tradition of collaboration between psychiatrists and family physicians and the departments of psychiatry and family medicine. Supervising psychiatrists, many of whom have spent some time working in primary care settings, appreciate the challenges faced by family physicians and how mental health services can be most helpful. For residents, this interaction offers positive role modeling, creates an atmosphere that supports and encourages collaborative activities during placements, and demonstrates how concepts discussed in tutorials can be applied in practice.
The seminars and training opportunities have received consistently high evaluations by the participants. Although no data are available on the impact this program has on a graduate's ability to work collaboratively, the majority of psychiatrists currently working in primary care settings in Hamilton are graduates of this program.
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PROGRAM/DEPARTMENT ADJUSTMENTS
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For this training to succeed, it needs to be supported by the sponsoring department of psychiatry. In practice, this means 1) The department needs to believe this to be a valued clinical activity and thus an important part of a resident's training. 2) The department needs to have established a productive relationship with the department of family medicine in the same faculty/medical school. This relationship can lead to participation of faculty from each department in planning educational programs in the other department, collaborative research projects, joint academic rounds, and the modeling for learners of effective collaborative partnerships. 3) The department needs to recruit and support faculty who are themselves respectful and supportive of the role of the primary care provider, who can model this in their clinical activities, and who can develop academic/educational programs in this area.
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OVERVIEW AND CONCLUSIONS
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With an increasing need for psychiatric services to work more closely with primary care providers, the curriculum outlined in this article will provide a solid foundation for residents graduating from psychiatry training programs. This curriculum will be particularly beneficial for those graduates who are intending to practice in underserviced areas where, with fewer formal mental health services, the primary care physician plays a more central role in delivering mental health care. The activities outlined can be easily integrated into existing rotations, without requiring much additional time. For the training to be most effective, however, academic departments of psychiatry need to be committed to this kind of collaborative activity and faculty must support and model these activities in their own practices.
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REFERENCES
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- Ginsburg E: Health care reform: where are we going and where should we be going? N Engl J Med 1992; 327:1310–1312
- Beigel A, Santiago J: Redefining the general psychiatrist: values, reforms and issues for psychiatric residency education. Psychiatr Serv 1995; 46.8:769–774
- Goldberg D: The treatment of mental disorders in general medicine settings (editorial, comment). Gen Hosp Psychiatry 1992; 14:83–85[CrossRef][Medline]
- Jones L, Badger L, Ficken R, et al: Inside the hidden mental health network: examining mental health care delivery of primary physicians. Gen Hosp Psychiatry 1987; 9:287–293[CrossRef][Medline]
- Lin E, Goering P, Offord DR, et al: The use of mental health services in Ontario: epidemiologic findings. Can J Psychiatry 1996; 41:572–577[Medline]
- Wilkinson G: The role of primary care physicians in the treatment of patients with long-term mental disorders. International Review of Psychiatry 1991; 3:35–52
- Health Security Act HR–3600. Federal Register, November 20, 1993
- Reform of Canada's Primary Care System— Statement by Canada's Deputy Ministers of Health. Ottawa, Ontario, Canada, 1995
- Quirk M, Strosahl K, Todd J, et al: Quality and customers: type 2 change in mental health delivery within health care reform. Journal of Mental Health Administration 1995; 22:414–425[CrossRef][Medline]
- Royal College of Psychiatrists and Royal College of General Practitioners: Shared Care of Patients With Mental Health Problems. Report of a Joint Royal College Working Group. London, UK, Royal College of General Practitioners, 1993
- Goldberg D, Huxley P: Mental Illness in the Community: The Pathway to Psychiatric Care. London, UK, Tavistock Press, 1980
- Balestrieri M, Willimas P, Wilkinson G: Specialist mental health consultation and referral in ambulatory primary care: a research lacuna. Gen Hosp Psychiatry 1987; 9:111–117[CrossRef][Medline]
- Von Korff M, Myers L: The primary care physician and psychiatric services. Gen Hosp Psychiatry 1987; 9:235–240[CrossRef][Medline]
- Creed F, Gowrisunkur J, Russell E, et al: General practitioner referral rates to district psychiatry and psychology services. Br J Gen Pract 1990; 40:450–454[Medline]
- Kates N: Psychiatric consultation in the family physician's office: advantages and hidden benefits. Gen Hosp Psychiatry 1988; 10:431–437[CrossRef][Medline]
- Stansfeld SA, Leek CA, Travers WM, et al: Attitudes toward community psychiatry among urban and rural general practitioners. Br J Gen Pract 1992; 42:322–325[Medline]
- Strathdee G: Primary care–psychiatry interaction: a British perspective. Gen Hosp Psychiatry 1987; 9:69–77
- Katon W, Von Korff M, Lin E, et al: Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995; 273:13:1026–1031
- Kates N, Craven M, Webb S, et al: Case reviews in the family physician's office. Can J Psychiatry 1992; 37:2–6[Medline]
- Tyrer P, Ferguson B, Wadsworth J: Liaison psychiatry in general practice: the comprehensive collaborative model. Acta Psychiatr Scand 1990; 81:359–363[Medline]
- Carr VJ, Donovan P: Psychiatry in general practice: a pilot scheme using the liaison-attachment model. Med J Aust 1992; 156:379–382[Medline]
- Jackson G, Gater R, Goldberg D, et al: A new community mental health team based in primary care: a description of the service and its effect on service use in the first year. Br J Psychiatry 1993; 162:375–384[Abstract/Free Full Text]
- Nickels M, McIntyre J: A model for psychiatric services in primary care settings. Psychiatr Serv 1996; 47:522–526[Abstract/Free Full Text]
- Kates N, Craven M, Crustolo A, et al: The psychiatrist in the family physician's office. Can J Psychiatry 1997; 42:960–965[Medline]
- Goldsmith J, Miller N: Training of the resident in psychiatry and primary care: liaison and collaboration. Psychiatric Annals 1997; 27:417–424
- Burns B, Scott J, Burke J, et al: Mental health training of primary care residents: a review of recent literature. Gen Hosp Psychiatry 1983; 5:157–169[CrossRef][Medline]
- Kates N, Toews J, Leichner P: Psychiatry training in Canadian family medicine residency programs. Can Fam Physician 1985; 31:172–177
- Royal College of General Practitioners and Royal College of Psychiatrists: General Practitioner Vocational Training in Psychiatry. London, UK, 1992
- Kates N: Training psychiatric residents to work with primary care physicians: results of a national survey. Can J Psychiatry 1993; 38:79–82[Medline]
- Sabin J: The role of the psychiatrist in a clinical managed care setting. Directions in Psychiatry 1994; 14:1–8
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ABSTRACT
INTRODUCTION
