Acad Psychiatry DOI 10.1007/s40596-015-0332-y
IN BRIEF REPORT
A Brief Examination of Integrated Care in Undergraduate Medical Education Benoit Dubé 1 & Marcia L. Verduin 2
Received: 8 September 2014 / Accepted: 12 March 2015 # Academic Psychiatry 2015
Abstract Objective This study examines how behavioral and physical health are currently integrated in undergraduate medical education, both in the classroom and during clinical rotations. Methods Members of the Association of Directors of Medical Student Education in Psychiatry (n=215) were invited to complete a short survey on the integration of physical and behavioral health at their institution. Results In addition to undergraduate medical courses traditionally taught by psychiatrists, behavioral science topics are often addressed in neurology, reproduction, and doctoring courses. During clinical rotations, behavioral health topics are most likely taught during the family medicine clerkship and, conversely, least likely during the surgery clerkship; furthermore, behavioral health topics are much less likely to be taught by psychiatrists during clinical rotations. Conclusions Integration of behavioral and physical health in medical education is beginning to occur in a meaningful context.
Much attention has been paid to the duration [1] and expense [2, 3] associated with undergraduate medical education. Concurrently, and more recently, much has been written about the Affordable Care Act (ACA), a law whose primary aim is to promote access to health care and improve health promotion through preventive care [4, 5]. As such, the integration of behavioral and physical health is now heavily promoted and invested in under the ACA. Much has also been written about the importance of integrated care models and their impact on the delivery of mental health care [6]. Since, in light of these new initiatives, it is reasonable to expect to see changes in the landscape of our healthcare delivery system, medical educators are wondering about its effect on medical education, both at the undergraduate and graduate levels [7]. We therefore set out to examine how behavioral and physical health are currently integrated in undergraduate medical education, both in the classroom and during clinical rotations.
Methods Keywords Integrated care . Medical student education . Clinical rotations
* Benoit Dubé [email protected] 1
University of Pennsylvania, Philadelphia, PA, USA
2
University of Central Florida, Orlando, FL, USA
All members of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) (n=215) received an email invitation to complete a short survey on the integration of physical and behavioral health at their respective institutions. The survey was approved by the Institutional Review Board of the University of Pennsylvania; the questionnaire took approximately 5 min to complete, and answers were anonymously collected using SurveyMonkey. The survey queried ADMSEP members about the presence of behavioral health topics during the preclinical curriculum in courses other than the traditional human behavior and psychopathology courses. The survey also asked whether or not behavioral health topics were taught during clinical rotations other than psychiatry.
Acad Psychiatry
For the purposes of this study, behavioral health was defined to include mental illness and substance use disorders, health behaviors (including their contribution to chronic medical conditions), and stress-related physical symptoms. The survey also asked whether integrated care models were currently being employed during the psychiatry clerkship or during psychiatry elective rotations. For purposes of this study, we examined three types of integrated care experiences: (1) Psychiatric consultation in primary care and/or other medical/surgical outpatient settings; this may also be called co-located care and consists of primary care and mental health services being located in the same building; in this model, primary care physicians consult psychiatrists in the same manner that they would refer patients to mental health care in a separate building. (2) Population-based approaches such as collaborative care; in this model, psychiatrists work together with primary care providers to manage the behavioral health of a defined population of patients; this may include the use of objective rating scales, adjustment of care based on rating scale results and evidence-based treatment algorithms, and case management involvement. (3) Telemedicine to provide psychiatric consultation or collaborative care for other medical colleagues. These categories were borrowed from a survey by the American Association of Directors of Psychiatric Residency Training (AADPRT) to its membership [8].
Preclinical Courses Doctoring Neurology Reproduction Cardiology Endocrinology Gastroenterology Pulmonology Dermatology Orthopedics
Results Out of the 215 ADMSEP members invited to participate in our study, 58 individuals completed the survey, resulting in a 27 % response rate. Survey respondents indicated that, in addition to the traditional human development and psychiatry preclinical courses, behavioral health topics are most commonly taught during doctoring (or similar course dealing with the practice of medicine), neurology, and reproduction courses (Fig. 1). In these courses, behavioral health topics are primarily taught by psychiatry faculty: 70 % of respondents indicated that psychiatrists did the teaching during doctoring, 55 % during neurology, and 50 % during reproduction. In each of the remaining courses, psychiatry faculty members contribute to less than 15 % of the behavioral health teaching when it is offered. During clinical rotations, behavioral health topics are most likely taught during the family medicine clerkship and least likely taught during the surgery clerkship (Fig. 1). Furthermore, behavioral health topics are much less likely to be taught by faculty from the department of psychiatry: these topics are most commonly taught by psychiatrists during obstetrics and gynecology (44 %) and least commonly taught by psychiatrists during pediatrics and emergency medicine (25 and 23 %, respectively). Lastly, integrated care settings are not commonly used as training sites during the psychiatry clerkship. They are primarily offered as options from which students may choose and generally involve co-located psychiatric consultations in
97 85 75 40 38 33 30 24 18
Clinical Rotations Family Medicine Pediatrics Obstetrics and Gynecology Medicine Neurology Emergency Medicine Surgery
84 72 64 56 55 48 16
0
10
20
30
40
50
60
70
80
90
100
Fig. 1 Percentage of preclinical courses other than human development and psychopathology, and clinical rotations other than psychiatry that include behavioral health content (n=58)
Acad Psychiatry
primary care settings; they are also rarely offered as elective rotations (Table 1).
Discussion In addition to undergraduate medical courses traditionally taught by psychiatrists, our results indicate that behavioral science topics are often addressed in neurology, reproduction, and doctoring courses, as well. Given the overlap of behavioral health with reproductive health issues (e.g., sexual behavior), neurological disorders (e.g., learning and memory), and topics covered in most doctoring courses (e.g., historytaking), this is perhaps not surprising. What is surprising is that, despite an increasing focus on integrated curricula in recent years [9], there is not a greater integration of behavioral health into other areas of the preclinical curriculum. Certainly, one can easily envision areas of overlap with every organ system, including, for example, approaches to behavioral change, motivational interviewing, medication adherence, dealing with chronic illness, stress management, and many others. Additionally, our results indicate that integrated care settings are rarely used in the clinical years of the curriculum. This likely reflects the current (and changing) healthcare landscape, as integrated care is a fairly recent addition to practice settings. We suspect that changes to clinical clerkship settings will lag a bit behind new practice settings, given the importance of providing a high-quality clinical education and an equivalent educational experience across clerkship sites. Educators will want to ensure that a clinical site is well-established and with adequate resources for teaching prior to sending students to that site. We suspect that, as integrated care becomes more common across the nation, psychiatry clerkship directors will increasingly add these settings to the clerkship repertoire. Although our data provide a snapshot of the current state of integrated psychiatry in undergraduate medical education, there are several limitations to this study. First, our sample is one of convenience and consists of general ADMSEP
Table 1
members rather than undergraduate curriculum deans. Most of our respondents, being course directors, are members of the curriculum committee at their respective institutions; as such, most are aware of curricular offering across all 4 years of undergraduate medical education at their schools. A more definitive sampling would have been obtained from curriculum deans who have a broader perspective of which topics are covered in which courses across the entire 4-year curriculum. Additionally, the response rate, while reasonable for emailbased surveys [10], is smaller than we would have liked. Nevertheless, it is anticipated that members from institutions who have championed integrated care efforts were more likely to respond, and thus, we believe our data provide a reasonable overview of the current state of affairs in medical student education as it pertains to the integration of physical and behavioral health. These results suggest the need for greater integration of psychiatry in medical education. Curricular changes and innovations would better prepare medical students to be able to function effectively in evolving healthcare systems. This would also increase the relevance and importance of mental health to some students who would not have otherwise had this exposure. The most natural and immediate opportunities for incorporating integrated psychiatry education are in the psychiatry clerkship, particularly for those academic medical centers affiliated with VA medical centers, many of which have already begun to provide integrated psychiatry services in their primary care clinics. Additionally, psychiatric educators should initiate a conversation with the education deans, curriculum committee, and course directors at their institutions on possible avenues for incorporating integrated care approaches into the curriculum. Many of these individuals are highly motivated to further integrate their curriculum, particularly given the ever-increasing burden of curricular content in medical schools and strain on student contact hours. Integrated approaches, if done collaboratively, can help to “decompress” the overall curriculum, creating a “win-win” approach for all. Additionally, psychiatric educators should seek out interprofessional teaching and learning opportunities for students,
Availability of clinical exposure to psychiatry in integrated care settings (n=58)
Integrated care clinical setting?
Traditional psychiatric consultations in a primary care setting Traditional psychiatric consultations in a non-primary care medical or surgical outpatient setting Collaborative care with primary care providers Telemedicine to provide psychiatric consultations or collaborative care for medical colleagues
Psychiatry clerkship
Psychiatry electives
Yes (mandatory)
Yes (optional)
No
Yes (mandatory)
Yes (optional)
No
12 % 15
44 % 35
44 % 50
2% 3
37 % 28
61 % 69
10 0
30 13
60 87
3 0
30 15
67 85
Acad Psychiatry
which easily lend themselves to integration of care. Our colleagues trained in psychosomatic medicine are also uniquely situated to promote integrated psychiatric care and should be included in discussions of curricular reform. In conclusion, integration of behavioral and physical health in medical education is just beginning to occur in a meaningful context. Changes to the landscape of healthcare delivery across the nation will likely provide greater opportunities to incorporate integrated approaches to behavioral health education in medical school curricula, and psychiatric educators should be proactive about seeking additional opportunities to integrate these topics throughout both the preclinical and clinical curricula. Implications for Educators • Psychiatric educators should explore opportunities to incorporate integrated care into psychiatry clerkships. • Discussions with education deans and curriculum committees present an ideal starting point for incorporating more integration of behavioral sciences and psychiatry into existing curricula. • Interprofessional education offers a potentially robust avenue for providing educational opportunities in integrated care.
Disclosures On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1.
Emanuel EJ, Fuchs VR. Shortening medical training by 30 %. JAMA. 2012;307(11):1143–4. 2. Greysen SR, Chen C, Mullan F. A history of medical student debt: observations and implications for the future of medical education. Acad Med. 2011;86:840–5. 3. Steinbrook R. Medical student debt—is there a limit? N Engl J Med. 2008;359(25):2629–32. 4. Koh HK, Sebelius KG. Promoting prevention through the Affordable Care Act. N Engl J Med. 2010;363:1296–9. 5. Kocher R, Emanuel EJ, DeParle NM. The Affordable Care Act and the future of clinical medicine: the opportunities and challenges. Ann Intern Med. 2010;153:536–9. 6. Croft B, Parish SL. Care integration in the patient protection and Affordable Care Act: implications for behavioral health. Adm Policy Ment Health. 2013;40:258–63. 7. Cowley D, Dunaway K, Forstein M, et al. Teaching psychiatry residents to work at the interface of mental health and primary care. Acad Psychiatry. 2014;38:398–404. 8. Reardon CL, Bentman A, Cowley DS, et al. General and child and adolescent psychiatry resident training in integrated care: a survey of program directors. Acad Psychiatry. 2015. doi:10.1007/s40596015-0315-z. 9. Doukas DJ, McCullough LB, Wear S. Reforming medical education in ethics and humanities by finding common ground with Abraham Flexner. Acad Med. 2010;85(2):318–23. 10. Sheehan KB. E-mail survey response rates: a review. J Comput-Mediat Commun. 2001. doi:10.1111/j.1083-6101. 2001.tb00117.x.
IN BRIEF REPORT
A Brief Examination of Integrated Care in Undergraduate Medical Education Benoit Dubé 1 & Marcia L. Verduin 2
Received: 8 September 2014 / Accepted: 12 March 2015 # Academic Psychiatry 2015
Abstract Objective This study examines how behavioral and physical health are currently integrated in undergraduate medical education, both in the classroom and during clinical rotations. Methods Members of the Association of Directors of Medical Student Education in Psychiatry (n=215) were invited to complete a short survey on the integration of physical and behavioral health at their institution. Results In addition to undergraduate medical courses traditionally taught by psychiatrists, behavioral science topics are often addressed in neurology, reproduction, and doctoring courses. During clinical rotations, behavioral health topics are most likely taught during the family medicine clerkship and, conversely, least likely during the surgery clerkship; furthermore, behavioral health topics are much less likely to be taught by psychiatrists during clinical rotations. Conclusions Integration of behavioral and physical health in medical education is beginning to occur in a meaningful context.
Much attention has been paid to the duration [1] and expense [2, 3] associated with undergraduate medical education. Concurrently, and more recently, much has been written about the Affordable Care Act (ACA), a law whose primary aim is to promote access to health care and improve health promotion through preventive care [4, 5]. As such, the integration of behavioral and physical health is now heavily promoted and invested in under the ACA. Much has also been written about the importance of integrated care models and their impact on the delivery of mental health care [6]. Since, in light of these new initiatives, it is reasonable to expect to see changes in the landscape of our healthcare delivery system, medical educators are wondering about its effect on medical education, both at the undergraduate and graduate levels [7]. We therefore set out to examine how behavioral and physical health are currently integrated in undergraduate medical education, both in the classroom and during clinical rotations.
Methods Keywords Integrated care . Medical student education . Clinical rotations
* Benoit Dubé [email protected] 1
University of Pennsylvania, Philadelphia, PA, USA
2
University of Central Florida, Orlando, FL, USA
All members of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) (n=215) received an email invitation to complete a short survey on the integration of physical and behavioral health at their respective institutions. The survey was approved by the Institutional Review Board of the University of Pennsylvania; the questionnaire took approximately 5 min to complete, and answers were anonymously collected using SurveyMonkey. The survey queried ADMSEP members about the presence of behavioral health topics during the preclinical curriculum in courses other than the traditional human behavior and psychopathology courses. The survey also asked whether or not behavioral health topics were taught during clinical rotations other than psychiatry.
Acad Psychiatry
For the purposes of this study, behavioral health was defined to include mental illness and substance use disorders, health behaviors (including their contribution to chronic medical conditions), and stress-related physical symptoms. The survey also asked whether integrated care models were currently being employed during the psychiatry clerkship or during psychiatry elective rotations. For purposes of this study, we examined three types of integrated care experiences: (1) Psychiatric consultation in primary care and/or other medical/surgical outpatient settings; this may also be called co-located care and consists of primary care and mental health services being located in the same building; in this model, primary care physicians consult psychiatrists in the same manner that they would refer patients to mental health care in a separate building. (2) Population-based approaches such as collaborative care; in this model, psychiatrists work together with primary care providers to manage the behavioral health of a defined population of patients; this may include the use of objective rating scales, adjustment of care based on rating scale results and evidence-based treatment algorithms, and case management involvement. (3) Telemedicine to provide psychiatric consultation or collaborative care for other medical colleagues. These categories were borrowed from a survey by the American Association of Directors of Psychiatric Residency Training (AADPRT) to its membership [8].
Preclinical Courses Doctoring Neurology Reproduction Cardiology Endocrinology Gastroenterology Pulmonology Dermatology Orthopedics
Results Out of the 215 ADMSEP members invited to participate in our study, 58 individuals completed the survey, resulting in a 27 % response rate. Survey respondents indicated that, in addition to the traditional human development and psychiatry preclinical courses, behavioral health topics are most commonly taught during doctoring (or similar course dealing with the practice of medicine), neurology, and reproduction courses (Fig. 1). In these courses, behavioral health topics are primarily taught by psychiatry faculty: 70 % of respondents indicated that psychiatrists did the teaching during doctoring, 55 % during neurology, and 50 % during reproduction. In each of the remaining courses, psychiatry faculty members contribute to less than 15 % of the behavioral health teaching when it is offered. During clinical rotations, behavioral health topics are most likely taught during the family medicine clerkship and least likely taught during the surgery clerkship (Fig. 1). Furthermore, behavioral health topics are much less likely to be taught by faculty from the department of psychiatry: these topics are most commonly taught by psychiatrists during obstetrics and gynecology (44 %) and least commonly taught by psychiatrists during pediatrics and emergency medicine (25 and 23 %, respectively). Lastly, integrated care settings are not commonly used as training sites during the psychiatry clerkship. They are primarily offered as options from which students may choose and generally involve co-located psychiatric consultations in
97 85 75 40 38 33 30 24 18
Clinical Rotations Family Medicine Pediatrics Obstetrics and Gynecology Medicine Neurology Emergency Medicine Surgery
84 72 64 56 55 48 16
0
10
20
30
40
50
60
70
80
90
100
Fig. 1 Percentage of preclinical courses other than human development and psychopathology, and clinical rotations other than psychiatry that include behavioral health content (n=58)
Acad Psychiatry
primary care settings; they are also rarely offered as elective rotations (Table 1).
Discussion In addition to undergraduate medical courses traditionally taught by psychiatrists, our results indicate that behavioral science topics are often addressed in neurology, reproduction, and doctoring courses, as well. Given the overlap of behavioral health with reproductive health issues (e.g., sexual behavior), neurological disorders (e.g., learning and memory), and topics covered in most doctoring courses (e.g., historytaking), this is perhaps not surprising. What is surprising is that, despite an increasing focus on integrated curricula in recent years [9], there is not a greater integration of behavioral health into other areas of the preclinical curriculum. Certainly, one can easily envision areas of overlap with every organ system, including, for example, approaches to behavioral change, motivational interviewing, medication adherence, dealing with chronic illness, stress management, and many others. Additionally, our results indicate that integrated care settings are rarely used in the clinical years of the curriculum. This likely reflects the current (and changing) healthcare landscape, as integrated care is a fairly recent addition to practice settings. We suspect that changes to clinical clerkship settings will lag a bit behind new practice settings, given the importance of providing a high-quality clinical education and an equivalent educational experience across clerkship sites. Educators will want to ensure that a clinical site is well-established and with adequate resources for teaching prior to sending students to that site. We suspect that, as integrated care becomes more common across the nation, psychiatry clerkship directors will increasingly add these settings to the clerkship repertoire. Although our data provide a snapshot of the current state of integrated psychiatry in undergraduate medical education, there are several limitations to this study. First, our sample is one of convenience and consists of general ADMSEP
Table 1
members rather than undergraduate curriculum deans. Most of our respondents, being course directors, are members of the curriculum committee at their respective institutions; as such, most are aware of curricular offering across all 4 years of undergraduate medical education at their schools. A more definitive sampling would have been obtained from curriculum deans who have a broader perspective of which topics are covered in which courses across the entire 4-year curriculum. Additionally, the response rate, while reasonable for emailbased surveys [10], is smaller than we would have liked. Nevertheless, it is anticipated that members from institutions who have championed integrated care efforts were more likely to respond, and thus, we believe our data provide a reasonable overview of the current state of affairs in medical student education as it pertains to the integration of physical and behavioral health. These results suggest the need for greater integration of psychiatry in medical education. Curricular changes and innovations would better prepare medical students to be able to function effectively in evolving healthcare systems. This would also increase the relevance and importance of mental health to some students who would not have otherwise had this exposure. The most natural and immediate opportunities for incorporating integrated psychiatry education are in the psychiatry clerkship, particularly for those academic medical centers affiliated with VA medical centers, many of which have already begun to provide integrated psychiatry services in their primary care clinics. Additionally, psychiatric educators should initiate a conversation with the education deans, curriculum committee, and course directors at their institutions on possible avenues for incorporating integrated care approaches into the curriculum. Many of these individuals are highly motivated to further integrate their curriculum, particularly given the ever-increasing burden of curricular content in medical schools and strain on student contact hours. Integrated approaches, if done collaboratively, can help to “decompress” the overall curriculum, creating a “win-win” approach for all. Additionally, psychiatric educators should seek out interprofessional teaching and learning opportunities for students,
Availability of clinical exposure to psychiatry in integrated care settings (n=58)
Integrated care clinical setting?
Traditional psychiatric consultations in a primary care setting Traditional psychiatric consultations in a non-primary care medical or surgical outpatient setting Collaborative care with primary care providers Telemedicine to provide psychiatric consultations or collaborative care for medical colleagues
Psychiatry clerkship
Psychiatry electives
Yes (mandatory)
Yes (optional)
No
Yes (mandatory)
Yes (optional)
No
12 % 15
44 % 35
44 % 50
2% 3
37 % 28
61 % 69
10 0
30 13
60 87
3 0
30 15
67 85
Acad Psychiatry
which easily lend themselves to integration of care. Our colleagues trained in psychosomatic medicine are also uniquely situated to promote integrated psychiatric care and should be included in discussions of curricular reform. In conclusion, integration of behavioral and physical health in medical education is just beginning to occur in a meaningful context. Changes to the landscape of healthcare delivery across the nation will likely provide greater opportunities to incorporate integrated approaches to behavioral health education in medical school curricula, and psychiatric educators should be proactive about seeking additional opportunities to integrate these topics throughout both the preclinical and clinical curricula. Implications for Educators • Psychiatric educators should explore opportunities to incorporate integrated care into psychiatry clerkships. • Discussions with education deans and curriculum committees present an ideal starting point for incorporating more integration of behavioral sciences and psychiatry into existing curricula. • Interprofessional education offers a potentially robust avenue for providing educational opportunities in integrated care.
Disclosures On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1.
Emanuel EJ, Fuchs VR. Shortening medical training by 30 %. JAMA. 2012;307(11):1143–4. 2. Greysen SR, Chen C, Mullan F. A history of medical student debt: observations and implications for the future of medical education. Acad Med. 2011;86:840–5. 3. Steinbrook R. Medical student debt—is there a limit? N Engl J Med. 2008;359(25):2629–32. 4. Koh HK, Sebelius KG. Promoting prevention through the Affordable Care Act. N Engl J Med. 2010;363:1296–9. 5. Kocher R, Emanuel EJ, DeParle NM. The Affordable Care Act and the future of clinical medicine: the opportunities and challenges. Ann Intern Med. 2010;153:536–9. 6. Croft B, Parish SL. Care integration in the patient protection and Affordable Care Act: implications for behavioral health. Adm Policy Ment Health. 2013;40:258–63. 7. Cowley D, Dunaway K, Forstein M, et al. Teaching psychiatry residents to work at the interface of mental health and primary care. Acad Psychiatry. 2014;38:398–404. 8. Reardon CL, Bentman A, Cowley DS, et al. General and child and adolescent psychiatry resident training in integrated care: a survey of program directors. Acad Psychiatry. 2015. doi:10.1007/s40596015-0315-z. 9. Doukas DJ, McCullough LB, Wear S. Reforming medical education in ethics and humanities by finding common ground with Abraham Flexner. Acad Med. 2010;85(2):318–23. 10. Sheehan KB. E-mail survey response rates: a review. J Comput-Mediat Commun. 2001. doi:10.1111/j.1083-6101. 2001.tb00117.x.
