Psychosomatics 41:412-417, October 2000
© 2000 The Academy of Psychosomatic Medicine
Psychiatric Training in Primary Care Medicine Residency Programs
A National Survey
H. Paul Chin, M.D.,
Gemma Guillermo, M.D.,
Steve Prakken, M.D., and
Stuart Eisendrath, M.D.
Received September 21, 1999; revised November 18, 1999; accepted April 4, 2000. From the Consultation and Brief Intervention Services, Division of Adult Psychiatry, Department of Psychiatry and Langley Porter Psychiatric Institute University of California, San Francisco School of Medicine, San Francisco, California. Address reprint requests to Dr. Chin, 2340 Clay Street, Suite 715, San Francisco, CA 94115.
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ABSTRACT
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The authors conducted a national survey to investigate the current status of psychiatric training in primary care/internal medicine residencies. Fifty-four residency training directors completed and returned the survey. The survey results show that an average of 99 hours (69.5 hours clinical plus 29.8 hours didactics) is devoted to psychiatric training during the 3 years of primary care/internal medicine residency training. Responding residency training directors indicated that psychiatric training is important (an average of 7 out of 10 on a 10-point rating scale), and 63% of respondents indicated that more training in psychiatry is needed.
Key Words: Primary Care • Residency Programs • Psychiatric Training
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INTRODUCTION
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Psychiatrists are not the primary practitioners of psychiatry in the United States. Primary care physicians provide up to 74% of psychiatric care in this country.1 Approximately 36% of the general medical outpatient population have significant mental health problems.2,3 Yet, no more than half of these cases are recognized in the primary care setting, and those that are diagnosed are often inadequately treated.4–7
Further complicating this picture is the significant link between psychiatric and medical problems. This comorbidity is broad, ranging from chronic fatigue to acute cardiac events, with studies showing worse medical outcomes and increased use of health care in those patients with undertreated psychiatric conditions.8 The rapid expansion of biological psychiatry has required the primary care physician (including those in internal medicine, family practice, pediatrics, and obstetrics/gynecology) to gain skill in using an ever expanding array of antipsychotics, antidepressants, and other psychopharmacologic agents. As the population ages, there is a greater need for the use of psychiatric medications, with psychotropics being the third most common class of drugs prescribed in the geriatric population, behind analgesics and cardiac medications.9,10 Because of these factors, it is crucial for primary care physicians to devote adequate time in psychiatric training.
In a 1997 review article by Goldsmith and Miller,11 the authors proposed a standard training model for primary care/internal medicine residents, suggesting "rotations designed for a psychiatric outpatient clinic that includes well- supervised, comprehensive diagnostic psychiatric evaluations, a chance to discuss implications of the evaluation data, and a treatment planning session." We have modeled our psychiatry clinic's educational experience under these guidelines.
Second-year residents from the University of California San Francisco-Mount Zion primary care/internal medicine residency program are required to do the following: complete a 2-month rotation through our outpatient consultation clinics; perform psychiatric evaluations, provide medication management; and plan treatment under the direct supervision of a postgraduate year-4 resident or attending in psychiatry. Given our experience in teaching primary care/internal medicine residents and our awareness of the residents' limitations, we became interested in how other primary care/internal medicine programs trained their residents in psychiatry. A review of the current literature describes the need for this type of training12 and its effectiveness,13 but the literature fails to comprehensively characterize psychiatric training as it exists today. Thus, our study aimed to remedy this gap by revealing how training in psychiatry is addressed in primary care training, specifically at primary care/internal medicine residencies across the country.
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METHODS
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Our study was approved by the Committee on Human Research of the University of California, San Francisco. The data were collected by a survey mailed to the residency training directors of the 101 primary care/internal medicine residencies in the United States (a listing of directors was obtained through the Association of Directors of Internal Medicine Residencies). Along with the survey, the mailing also included a brief cover letter describing our study, with a statement regarding consent, as well as a self-addressed stamped return envelope.
The survey consisted of 7 detailed questions on a 1- page questionnaire regarding the residency program and its psychiatric training. The survey included types of clinical and didactic education offered in psychiatry. For the complete questionnaire, please refer to Appendix 1.
After receipt of completed surveys from training directors, a member of the research team separated any identifying information (to preserve anonymity) before the surveys were transferred to another member of the research team for data collection and analysis. Responses indicating time spent in a clinical activity, which was represented as number of hours per week per number of months, was converted to hours spent over 3 years of residency. Mean values for hours spent in clinical or didactic training were calculated; because of the wide range in reported hours, we also determined a median. Results were charted on a frequency distribution graph. For total number of clinical hours and didactic hours, a 95% confidence interval for the population mean was calculated; similar figures for subtypes of clinical activity (i.e., inpatient or outpatient psychiatry, inpatient or outpatient consultation/liaison activity) could not be determined, given the number of responses and skewed (non-normal) distribution of reported hours. All data were analyzed using Microsoft Excel 1997 Statistical Tools Package.
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RESULTS
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Of the 101 surveys distributed to primary care residencies, 54 (53%) were completed and returned. The residency programs train an average of 35.4 residents per program. Of the respondents, 44 programs (81.5%) offer a clinical rotation in psychiatry; such a rotation is required in 31 programs (57.4%). Outpatient psychiatry (23 programs, 52.3%) was offered most often, followed by inpatient consultation-liaison (C-L) psychiatry (14 programs, 31.8%), inpatient psychiatry (7 programs, 15.9%), and outpatient C-L psychiatry (5 programs, 11.4%). Five programs offer training experience in more than one setting. These results are summarized in Table 1.
Thirty-two programs reported number of hours spent in clinical training; among these programs, an average of 69.5 hours over the 3 years of residency is spent in clinical psychiatric training (median value was 32 hours). Actual average of all programs was estimated with a 95% confidence interval to be between 39.3 and 99.7 hours. Most of this clinical psychiatric training time was spent in outpatient psychiatry (average 23.4 hours), followed by inpatient C-L psychiatry (17.5 hours), with equal time spent in outpatient C-L psychiatry (7.5 hours) and inpatient psychiatry (7.5 hours). Median value for time spent in each of these four clinical subtypes was zero hours. These results are summarized in Table 2.
Didactic training in psychiatry is offered in nearly all the respondents' programs (53 programs, 98%), with an average of 29.8 hours spent in this training (48 programs reported the specific number of hours); 95% confidence interval for mean didactic hours was 16.2 to 43.4 hours. A majority of programs (44 programs, 83%) offer lectures, although smaller numbers offer seminars (12 programs, 22.6%) and interviewing courses (10 programs, 18.9%). These results are summarized in Table 3. These didactics are taught mostly by psychiatrists (46 programs, 86.8%), followed by primary care physicians (37 programs, 69.8%), psychologists (15 programs, 28.3%), social workers (11 programs, 20.8%), or other disciplines (1 program, 1.9%). These results are summarized in Table 4. Hours reported for clinical and didactic training were charted on a frequency distribution graph (see Figure 1).
Twenty-three programs (42.6% of respondents) evaluate their residents' skill and knowledge in psychiatry. Real- time supervision is used most frequently (17 programs, 73.9%), followed by video taping (15 programs, 65.2%), case conferences (10 programs, 43.5%), written tests (7 programs, 30.4%), and other methods (1 program, 4.3%). These results are summarized in Table 5.
Significantly, 63% of respondents, or 34 training directors, indicated that their programs needed to have more psychiatry training. Only 2 programs out of the 54 respondents (3.7%) offer a combined psychiatry and medicine residency. On a scale from 1 to 10, responding residency training directors rated psychiatric training at an average of 7.0 in terms of importance.
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DISCUSSION
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Our survey results indicate that clinical training in psychiatry is available in a majority (81.5%) of primary care/ internal medicine residencies and is a requirement in over half (57.4%) of responding programs. The average number of hours spent in clinical training is 69.5 hours through 3 years of primary care medicine residency; this is roughly the equivalent amount of time our program devotes to the clinical training of the Mount Zion primary care residents (a 2-month rotation consisting of 8 hours per week of clinical training). The majority of training seems to take place in outpatient settings, which would seem to correlate well with the types of patients seen in the primary care setting. However, inpatient psychiatry (7.5 hours) claimed about as much time as outpatient C-L psychiatry (7.5 hours), which does not seem to reflect the psychiatric load in a typical general medicine population.
Almost all programs surveyed offered some kind of didactic training in psychiatry, averaging about 29.8 hours over 3 years. The majority of didactic time was spent in lectures (83%), with the remainder of time divided equally into seminars and interviewing courses. A psychiatrist (86.8%) or a primary care physician (69.8%) taught most didactics. Less than half of responding programs (23 programs, 42.6%) evaluate their resident's performance in psychiatric training, with real-time supervision (73.9%) or video tape (65.2%) being used most often. Written tests (30.4%) are the least used method.
Despite a large percentage of responding programs devoting some time to psychiatric training, a majority of programs (63%) indicated that more psychiatric training is needed at their program and that obtaining psychiatric training is important overall (an average of 7 on 10-point rating scale). We should note here that these results may be skewed by the characteristics of those programs that responded to our survey (i.e., programs that returned the survey may have been more likely to have any psychiatric training and to view psychiatric training as important). Also, our study was limited by not examining other primary care fields, such as family practice. Because of our emphasis on the brevity of the survey (to enhance return rate), questions may have been interpreted in varied ways by respondents, thus affecting results further; specifically, our results may overestimate the number of hours spent in clinical training (e.g., a few respondents included number of hours spent as medical consultants for psychiatric services as part of their psychiatric training). Those programs that reported time spent in a training activity indicated a wide range of hours (from 0 to 400), thus skewing results further (see Figure 1). This is reflected in the wide interval for estimated actual average time in clinical (39.3 to 99.7 hours) and didactic (16.2 to 43.4 hours) training. Median values may thus be more representative of results, in which case total time spent in psychiatric training (32 clinical+20 didactic hours=52 hours total) diminishes even further.
Despite these biases and limitations, our study points to both a perceived importance of and deficit in psychiatric training in primary care/internal medicine residencies. Other studies have indicated similar results; opinion surveys of practicing physicians indicated that primary care physicians report inadequate training in diagnosis and treatment of mental disorders.12 Cohen-Cole et al.13 found that before receiving psychiatric training, 26 medical residents evaluated through oral examinations revealed "severe and worrisome knowledge deficits concerning organic brain syndromes, depression, chronic pain, and doctor-patient relationship issues." However, the study went on to show an improvement in psychiatric knowledge of these same residents after exposure to psychiatric rotations.
Although our study raises the issue of improving psychiatric education and training for primary care/internal medicine residents, it does not provide answers. Our interest in this particular teaching endeavor grew out of our initial experience during the 1997–98 training year, when we were struck by the potential educational gap in these residents' knowledge of psychiatry if our rotation had not been developed. Currently, we administer written tests before and after the residents' rotation to test both basic psychiatric knowledge as well as attitudes toward psychiatry. In addition, real-time supervision is extensively used, with a supervisor present during most patient interactions. In our experience, we have found that primary care/internal medicine residents are eager to gain clinical experience in diagnosis and treatment formulations and are open to improvement in interview style and psychodynamic thinking. Moreover, residents expressed a particularly keen interest in psychopharmacologic treatments. To meet this need, we have included a medication management clinic and case conference seminar to their rotation. Whether this change may address primary care/internal medicine residencies' perceived needs in psychiatric training or meets actual clinical needs are two separate questions that must be addressed in further studies.
Reluctance to improve and increase psychiatric training in primary care training may stem from various attitudes and beliefs. Psychiatry and psychiatric patients continue to suffer from a social stigma; many psychiatric problems seen in the general medical settings are often considered diagnostically nebulous, or emotionally taxing to treat. Because skills in psychiatric diagnosis and treatment often draw on a practitioner's personal experiences, a particular discomfort may be experienced in facing psychiatric illness; or, conversely, a belief that competence in psychiatry is equivalent to naturally acquired "social skills" may persist, thus minimizing the need for formal training. Clearly these and other factors may be impeding psychiatric education and must be addressed if improvements in education are to be made.
Although the vast majority of psychiatric patients are not seen by mental health care workers, psychiatrists can nevertheless make a significant and positive impact on the care of the mentally ill. As our study indicates, psychiatrists are the main educators of primary care/internal medicine physicians. Thus, it is the psychiatric physicians' duty not just to teach but to understand the training needs of our colleagues and thus provide for the care of those patients we may never see. Only through further investigation and improvements can we find success in this educational endeavor.
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ACKNOWLEDGMENTS
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We thank Drs. Robert Baron and Nancy Marks for their contributions in the development of this training program. We also thank Dr. Kevin Delucchi for his assistance with this study.
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REFERENCES
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Regier DA, Boyd JH, Burke JD, et al: One month prevalence of mental disorders in the United States. Arch Gen Psychiatry 1988; 45:977–986[Abstract]
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Barrett JE, Barrett JA, Oxman TE, et al: The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry 1988; 45:1100–1106
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Kessler L, Burns B J, Shapiro S, et al: Psychiatric diagnoses of medical service users: evidence from the epidemiologic catchment area program. Am J Public Health 1987; 77:18–24[Abstract/Free Full Text]
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Schulberg HC, Burns B J: Mental disorders in primary care: epidemiologic, diagnostic and treatment research directions. Gen Hosp Psychiatry 1988; 10:79–87[CrossRef][Medline]
-
Blazer D: Depression in the elderly. N England J. Med 1989; 320:164–166[Medline]
-
Von Korff M, Shapiro S, Burke JD, et al: Anxiety and depression in a primary care clinic: comparison of diagnostic interview schedule, general health questionnaire, and practitioner assessments. Arch Gen Psychiatry 1987; 44:152–156[Abstract]
-
Borus JF, Howes MJ, Devins NP, et al: Primary health care providers' recognition and diagnosis of mental disorders in their patients. Gen Hosp Psychiatry 1988; 10:317–321[CrossRef][Medline]
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Cole S, Raju M: Overcoming barriers to integration of primary care and behavioral healthcare: focus on knowledge and skills. Behav Healthc Tomorrow 1996; 5:30-37[Medline]
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Jenike MA: Geriatric Psychiatry and Psychopharmacology: A Clinical Approach. Chicago, Year Book Medical Publishers, 1989
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Calahan CM, Nienaber NA, Hendrie HC: Depression of elderly outpatients: primary care physicians' attitudes and practice patterns, J Gen Intern Med 1992; 7:26–31
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Goldsmith R, Miller NS: Training the resident in psychiatry and primary care liaison and collaboration. Psychiatric Annals 1997; 27:417–424
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Fisher, JV: What the family physician expects from the psychiatrist. Psychosomatics 1978; 19:523–527[Free Full Text]
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Cohen-Cole SA, Boker J, Bird J, et al: Psychiatric education improves internists' knowledge: a three-year randomized, controlled evaluation. Psychosomatic Medicine 1993, 55:212–218
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ABSTRACT
INTRODUCTION
