Psychosomatics 42:377-381, October 2001
© 2001 The Academy of Psychosomatic Medicine
Physicians at the Medicine/Psychiatric Interface
What Do Internist/Psychiatrists Do?
Victor Stiebel, M.D., and
Charles E. Schwartz, M.D.
Received November 27, 2000; revised March 3, 2001; accepted April 6, 2001. From the Departments of Psychiatry and Emergency Medicine, Forbes Regional Hospital, University of Pittsburgh Medical School, Pittsburgh, PA; the Department of Primary Care Psychiatry, Montefiore Medical Center; and the Albert Einstein College of Medicine, Bronx, NY. Address correspondence to Dr. Stiebel, 221 Penn Avenue, Suite 1100, Pittsburgh, Pennsylvania 15221.
|
ABSTRACT
|
Studies have convincingly demonstrated that some 50% of patients in primary care settings have both medical and psychiatric diagnoses requiring dual treatment. The concept of primary care psychiatry has emerged in recent years as one way to address this problem. In 1979 the first combined medicine-psychiatry residency was formed. There are now over 20 such programs, but there is little information on how these doubly trained physicians actually practice. In 1997, the authors surveyed the 268 physicians with board certification in both internal medicine and psychiatry that were listed with the American Board of Medical Specialties. Only 15% practiced any type of medicine at all; the rest were involved only in the practice of psychiatry. Although 75% identified themselves only as psychiatrists and worked predominantly in psychiatry, 95% reported using both their medical and psychiatric training in their professional work. They reported that the dual training made them better physicians, improved their professional credibility, and enhanced their diagnostic skills. Several significant barriers were discovered that directly affect the ability of physicians to practice in two fields. Findings, study limitations, and potential implications for the field and its patients are discussed.
Key Words: Delivery of Care • Health Services • Primary Care
|
INTRODUCTION
|
Studies have demonstrated that some 50% of patients have both medical and psychiatric diagnoses and require dual treatment.1 Some 25% of primary care patients have psychiatric disorders;2 50% of patients with chronic mental illness have significant medical illnesses.3 On October 17, 1991, the Association of Medicine and Psychiatry was established by a group of physicians with a specific interest in this population. These physicians had trained in both medicine (internal medicine, family medicine, neurology, etc.) and psychiatry and met at the annual Academy of Psychosomatic Medicine meeting. It was hoped that this group of "bilingual" physicians would foster clinical cross-fertilization between fields that seem to speak different languages but share overlapping patient populations. In October 1992, after years of effort by a large number of physicians, the American Board of Psychiatry and Neurology joined the American Board of Internal Medicine in approving a 5-year combined residency in medicine and psychiatry.
Historically, small numbers of physicians obtained dual training by completing two separate residencies. In 1966, the Lumis Foundation funded a meeting for all double board certified medicine/psychiatry physicians in the United States, a total of six people attended.4 In 1979, the West Virginia School of Medicine inaugurated the first combined training program. Interest in combined training grew throughout the 1980s, with over 20 programs emerging around the country 20 years later.
What Is the Goal of This Double Training?
Primary care has been called "the de facto mental health service system," since primary care physicians provide the sole mental health care for 60%–70% of patients in the United States with psychiatric disorders.9,10 Like their psychiatric colleagues, who may not be comfortable treating medical pathology, primary care physicians are often uncomfortable with and poorly equipped to diagnose or treat these "out-of-specialty" psychiatric disorders.
In our fragmented health care system, few of these medical/psychiatric dual-diagnosis patients actually get care in both specialties. Eisenberg noted that 45%–90% of significant psychiatric disorders are missed in this cohort. He further found that primary care providers do not have the skills to effectively treat these diseases after identification.11 Other studies have shown that medical illness is overlooked in as many as 50%–75% of the chronic mentally ill in ambulatory and inpatient care settings.1,3,6,7 A recent study showed that only 50% of chronic ambulatory psychiatric patients in a Veterans Administration sample receive any regular medical care.7
Hoffman and Koran5 have described three types of barriers to more comprehensive care.
A) Patient-related: 1) Psychiatrically impaired patients may not understand their medical problems. 2) They may be poorly motivated and disorganized. 3) Medically ill patients may resent psychiatric diagnosis and treatment that make them feel delegitimatized and stigmatized.
B) Physician-related: 1) Medical or psychiatric physicians, essentially specialists, may not take responsibility for providing comprehensive care out of lack of knowledge, skills, interest, time, or simply the assumption that these other needs are being met elsewhere. 2) Physicians may have aversive reactions to patients not within their specialty or may simply not want to treat them at all.
C) Disease-related: 1) Serious medical illnesses often have symptoms that are hard to differentiate from psychiatric disease. 2) Psychiatric diseases may present with an array of medical symptoms.
James Shore12 advocated that psychiatrists should receive more training in primary care so that they could provide first-line, primary medical care for the chronically mentally ill. Lieberman and Rush13 advised a similar redefinition of psychiatric practice, but they remained closer to current psychiatric training guidelines. Similar discussions seem to be occurring in general medicine as reflected in the American Board of Internal Medicine and the Accreditation Council for Graduate Medical Education's increased emphasis on ambulatory care education and psychiatric training for primary care internal medicine.
Physicians trained and board certified in both medicine and psychiatry would appear to be ideally suited to address some of the above issues and provide informed and comprehensive care for these patients. In academic centers they could help develop better models of medical/psychiatric care in medicine-based, psychiatry-based, and integrated care programs. They could help develop new training models that would equip internists and psychiatrists to better meet the needs of the medical/psychiatric patients for whom they would be providing care. In all clinical areas, they could serve as role models for how to provide care to complex and difficult patients with dual diagnoses.
But What Are Doubly Trained Physicians Actually Doing?
Being part of an organization dedicated to dually trained physicians, we were surprised to find that practice patterns were not what we had expected. This led to a number of questions: Are these doctors working exclusively in only one of the fields or are they utilizing both sets of training? Are they exclusively doing clinical work in the community or are they working in academic centers in training, research, and health care systems design? Do they feel that their work justifies a major thrust toward double board training programs, or rather, that this a purely personal choice best left to individual initiative? What do they think about primary care physicians treating the psychiatric disorders of their patients and psychiatrists providing medical care for their mentally ill patients? How much training in "the other field" do they feel these physicians need currently? How much training would they need if they were to assume responsibility for comprehensive, dual morbidity care?
|
METHODS
|
In January 1997, we requested a list of all physicians who were board certified in both internal medicine and psychiatry from the American Board of Medical Specialties. We understood that this list did not include newly trained medical/psychiatric physicians who had not yet completed the dual boarding process, doubly trained physicians who had sought certification in only one field, or physicians trained in family medicine or neurology in addition to psychiatry. In the spring of 1997, we sent a survey to these 268 doubly boarded physicians.
We hypothesized that there would be two subgroups. The first would identify themselves as both psychiatrists and internists, using both sets of knowledge and skills in their daily professional activities. The second group, would consist of former psychiatrists or internists who had become disenchanted with their primary field and who then pursued training in the other. We had no hypothesis about the relative proportion of these two groups.
|
SURVEY RESULTS
|
We received 122 responses to the survey (a 45% response rate). An additional 18 surveys (15%) were returned with no forwarding address, and no additional information was obtainable. Respondents ranged in age from 34–84 with an average age of 50. Two-thirds of the respondents were younger than 50. The group had been in practice an average of 19 years. All but three had graduated from 1 of 49 United States medical schools.
As we had expected, their ages and years in practice indicated that the survey group represented medical/psychiatric physicians who trained before the beginning of formally organized integrated residencies. The vast majority (83%) had done their training in two separate residencies. The remaining 17% had completed combined residencies.
Of those completing two residencies, 93% had done their internal medicine training first and waited, on average, 7 years before their second residency. Interestingly, nine respondents did their second training after more than 20 years of practice. Approximately two-thirds of the respondents reported undertaking a second residency out of interest in both fields. A smaller group (8%) reported that they had not liked the practice of medicine. About half of the respondents obtained additional fellowship training in a wide range of areas.
When asked to identify how much time was spent in professional activities, only 15% (n=16) practiced any medicine at all (range=4–50 hours/week, average=19). Fifteen of these 16 doctors were also quite active in psychiatry (range=2–50 hours/week, average=25). Another 16 physicians (15%) practiced in some combined medical/ psychiatric setting (range=4–30 hours/week, average=13). Seven of these worked in inpatient medical/psychiatric units, and nine were in outpatient medical/psychiatric settings. The remaining 70% (n=72) were involved only in the practice of psychiatry. One-third of these 72 doctors (n=31) was involved in consultation-liaison psychiatry.
Looking at their practice settings more closely, most of those involved in clinical practice were predominantly in outpatient settings. Thirty-five percent were involved in some aspect of administration, 39% were active teachers, and 18% were involved in research. Approximately three-quarters of our respondents identified themselves as psychiatrists. Only one-third saw themselves as both psychiatrists and internists. Only five respondents identified themselves solely as internists.
Despite identifying themselves as psychiatrists and working predominantly in psychiatry, 95% of these physicians reported using both medical and psychiatric training in their professional work. They reported that the dual training made them better physicians, gave them better professional credibility, and enhanced their diagnostic skills. This group was very active in continuing medical education (CME) 83% earned over 50 credit hours/year and most earned over 70 credit hours/year. Thirteen physicians earned over 100 credit hours/year. Almost everyone earned credit hours in psychiatry with two-thirds also earning credit hours in medicine. Despite this commitment to CME, all reported it was hard to keep up in both specialties.
Fully two-thirds stated that double training had been a benefit and that they would double train again if given the option. One-third, however, described double training as a burden. This group almost universally reported that managed care organizations were reluctant, or simply refused, to allow a single provider to receive payment as both an internist and a psychiatrist, forcing them into a specific choice. Additionally, they found themselves facing various types of resistance from their colleagues, who were also reluctant to provide coverage for their patients. They felt their time was squeezed with obligations to both departments. They reported that it was difficult to integrate their professional identities and stated that they might not double train if given the opportunity to begin again. Despite these mixed assessments, virtually all reported that they expected to be doing the same type of work 10 years from now. Three-quarters of the respondents strongly favored the continued availability of combined residency training.
As experts at the medicine/psychiatry interface, we asked these physicians whether they felt that psychiatrists should provide primary care for the mentally ill. Somewhat surprisingly their virtually unanimous answer was a qualified "yes." However, 80% of respondents expressed significant concerns over the ability of psychiatrists to maintain an adequate fund of current medical knowledge and procedural skills. They felt that if psychiatrists were going to provide primary care for their patients, it was essential that they have extensive training in medicine (mode-12 months, mean-18 months). They felt that all psychiatrists, even those not specifically taking responsibility for primary care, should have 12 months of medicine training during their psychiatry residencies. Virtually all respondents felt that internists should be able to provide psychiatric care for general medical patients. They strongly asserted that this was the only way the majority of such patients would get needed care. The consensus was that at least 3–6 months of psychiatric training should be an essential part of internal medicine training.
|
DISCUSSION
|
The American Board of Medical Specialties database permitted us to survey the first generation of internist/psychiatrists. For the most part these individuals created their own combined programs, charted their own professional courses, and defined their own professional roles. Most of these physicians view themselves as psychiatrists and operate from a base in psychiatry, and few actively practice traditional internal medicine. It is possible that those not responding to our survey were practicing mostly medicine and by not responding produced a skewed result. Our respondents use elements of both fields in their day-to-day practice, and in teaching, clinical work, and research. They feel strongly that both internists and psychiatrists must learn to treat patients with dual diagnoses. They state that significantly enhanced training for each specialty in the other field is vital.
In 1995, McCahill and Palinkas14 surveyed the 39 physicians certified by both the American Board of Family Practice and the American Board of Psychiatry and Neurology. Like those in our sample, most had trained separately in both of the specialties. An interesting difference from our group was that fully 60% of the family medicine/psychiatrists reported actively practicing both specialties, with the remainder practicing psychiatry. It may be that the philosophic inclusiveness of family medicine diminishes anxiety about caring for a wide range of pathology, while the traditional exclusiveness of internal medicine increases it.
|
CONCLUSION
|
We would argue that the physicians we surveyed are the experts in caring for medical/psychiatric patients and are truly "bilingual." Their opinions are based on "real world" experiences and are vital to current discussions. It is noteworthy that they feel double training should continue to be available. It is unfortunate that after so much training, the majority find themselves practicing psychiatry almost exclusively. This may be an important finding to factor into the ongoing discussions about the concept of "primary care psychiatry." The financial barriers to reimbursement, identity confusion with peers, and organizational resistance will need to be addressed. If the unique expertise and perspective of this growing body of physicians is to be utilized, a niche will need to be created. Their concerns about remaining clinically competent in two fields, and the lack of medicine training in psychiatric residencies, are especially germane to current discussions.
The professional identities and clinical roles that these new "bilingual" physicians will assume in our health care system clearly remain an unanswered question. Niches will need to be created and supported by the health care system. Now is the right time to reexamine the issues of medical training for psychiatrists and psychiatric training for internists. There are now almost 100 residents in combined programs. It will soon be time to see if the practice patterns of these new physicians will be different. The next survey awaits.
|
REFERENCES
|
-
Kathol R: Integrated medicine and psychiatry treatment programs. Medicine and Psychiatry 1998: 1:10-16
-
Schulberg HC, Burns BJ: Mental disorders in primary care: epidemiologic, diagnostic, and treatment research directions. Gen Hosp Psychiatry 1988; 10:79-87[CrossRef][Medline]
-
Koranyi EK: Undiagnosed physical illness in psychiatric patients. Annu Rev Med 1982; 33:309-316[CrossRef][Medline]
-
Martin MJ: Keynote address to the Association of Medicine and Psychiatry Annual Meeting, November, 1996
-
Hoffman RS, Koran LM: Detecting physical illness in patients with mental disorders. Psychosomatics 1984; 25:654-660[Abstract/Free Full Text]
-
Hall RC, Gardner ER, Popkin MK, et al: Unrecognized physical illness prompting psychiatric admission: a prospective study. Am J Psychiatry 1981; 138:629-635[Abstract/Free Full Text]
-
Felker B, Yazel JJ, Short D: Mortality and medical comorbidity among psychiatric patients: a review. Psychiatr Serv 1996; 47:1356-1363[Abstract/Free Full Text]
-
Felker B, Workman E, Stanley-Tilt C, et al: The psychiatric primary care team: a new program to provide medical care to the chronically mentally ill. Medicine and Psychiatry 1998 1: 36-41
-
Regier DA, Goldberg ID, Taube CA: The de facto US mental health services system: a public health perspective. Arch Gen Psychiatry 1978; 35:685-693[Abstract]
-
Regier DA, Narrow WE, Roe DS, et al: The de facto U.S. mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry 1993; 50:85-94[Abstract]
-
Eisenberg L: Depression and anxiety in primary care: closing the gap between knowledge and practice. N Engl J Med 1992; 326:1080-1084[Medline]
-
Shore JH: Psychiatry at a crossroad: our role in primary care. Am J Psychiatry 1996; 153:1398-1403[Abstract/Free Full Text]
-
Lieberman JA, Rush AJ: Redefining the role of psychiatry in medicine. Am J Psychiatry 1996; 153:1388-1395[Abstract/Free Full Text]
-
McCahill ME, Palinkas LA: Physicians who are certified in family practice and psychiatry: who are they and how do they use their combined skills? J Am Board Fam Pract 1997; 10:111-115; discussion 115-116
This article has been cited by other articles:
|
|
|
|
 
S. K. Dobscha, K. M. Snyder, K. Corson, and L. Ganzini
Psychiatry Resident Graduate Comfort With General Medical Issues: Impact of an Integrated Psychiatry-Primary Medical Care Training Track
Acad Psychiatry,
December 1, 2005;
29(5):
448 - 451.
[Abstract]
[Full Text]
[PDF]
|
|
|
Get information about faster international access.
Privacy Policy
Copyright © 2001
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
