Acad Psychiatry DOI 10.1007/s40596-015-0344-7

IN DEPTH ARTICLE: COMMENTARY

General Medicine Training in Psychiatry Residency Aniyizhai Annamalai 1 & Robert M. Rohrbaugh 1 & Michael J. Sernyak 1

Received: 7 October 2014 / Accepted: 7 April 2015 # Academic Psychiatry 2015

Abstract With growing awareness of the need for integrated health care settings, psychiatrists may be required to provide clinical care at the primary care and behavioral health interface. This article discusses the curricular changes that could enhance the development of psychiatrists as leaders in integrated primary and behavioral health care. Psychiatrists may be called upon to provide enhanced collaborative care services at primary care or behavioral health settings. This article focuses on the provision of integrated care in behavioral health settings, especially in the public sector. The authors review the additional training in general medicine that would facilitate these skills. They outline the principles and goals to be considered in building such a curriculum. They examine the curricular building blocks of such training and also discuss challenges in implementing these curricular changes. Finally, they discuss the implications of incorporating integrated health care training on the future of psychiatric practice. Keywords Residents . Primary care . Teaching methods There is growing momentum nationally for integrated primary care and behavioral health in the public sector. This may result in new roles for psychiatrists and may provide them an opportunity to be leaders in health care. Traditionally, physical and mental health care is segregated organizationally as well as culturally, and psychiatry is viewed as separate from other medical specialties [1]. In an effort to improve quality of care, several integrated health care models have been implemented. * Aniyizhai Annamalai [email protected] 1

Yale School of Medicine, New Haven, CT, USA

Early models where behavioral health care is brought into medical settings to treat comorbid depression, anxiety, and substance use disorders have shown improvement in both physical and mental health outcomes [2]. For patients with serious mental illness, the mental health center is often the only point of contact with the health care system [3]. It is well known that this population has a shortened life expectancy from medical causes such as cardiovascular disease, cancers, lung disease, and cerebrovascular disease [4] due to several factors including poor health behaviors, lack of access to health care, and effects of psychotropic treatment. But rates of screening for metabolic risk factors and treatment of chronic medical conditions in mentally ill patients are low [5]. To address this gap, many models integrating primary care into mental health settings are currently being tested for efficacy and clinical outcomes. Given the need for integrated care and the opportunities afforded by health care reform, the role of psychiatrists is shifting to a more collaborative approach. Psychiatry trainees would benefit from additional training to work at the interface of primary care and behavioral health. The purpose of the training would be to enable them to provide behavioral health care in primary care settings and effectively collaborate with primary care providers in mental health settings. They may be required to lead integrated health care teams, especially for seriously mentally ill patients in community mental health centers. A large majority of this population does not receive any primary care and has poor access to primary care practitioners [6]. In spite of many initiatives to integrate primary care practice into behavioral health settings, the mortality gap for these patients has not narrowed [7]. It has been proposed that psychiatrists take on an active role in coordinating medical care, improving health outcomes, and directly providing preventive care, when necessary [8]. The role of psychiatrists would be to actively engage in health maintenance of

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patients, not to take on the role of primary care providers. This likely requires a higher level of knowledge in general medicine than is currently taught during residency. The time spent in general medicine training for psychiatry residents has varied over the past century. Many state licensing boards used to require a year of internship before admission into psychiatry residency [9]. In the 1970s, there was a move to eliminate medical internship as a requirement with a trend towards earlier specialization in psychiatry [9, 10]. Since the 1970s, the amount of time spent on general medicine rotations has varied from a full year to the current allotted time of 4 months. The authors review initiatives in general medicine or primary care education that have been implemented in different psychiatry residency training programs in recent years. They then outline the building blocks for a training curriculum during residency that could improve competence in general medicine. They outline the principles and goals of such a curriculum and provide recommendations for its structure and didactic content.

Current Status of General Medicine Training in Psychiatry Residency Programs The Accreditation Council for Graduate Medical Education (ACGME) states that psychiatry graduates should have a “sound clinical judgment” and “a high order of knowledge” of “all psychiatric disorders, together with other common medical and neurological disorders that relate to the practice of psychiatry.” Current training in psychiatry residency mandates 4 months of primary care in post-graduate year 1 (PGY1) [11]. However, the nature of training in this period is not well defined. And in most programs, there is no structure in place to enhance or maintain these skills in the remainder of residency. A survey of residency programs showed that a majority require only the minimum 4 months in the PGY1 though many do offer electives beyond the first year. And didactics during these rotations are not designed to address medical issues specific to mentally ill patients [12]. However, individual programs have devised mechanisms to enhance general medicine training for psychiatry residents in novel settings. One example is creating an inpatient medical unit for psychiatric patients. Another example is an outpatient primary care clinic for patients with serious mental illness [12]. Many programs also require psychiatry interns to be responsible for providing initial and ongoing medical care for patients while on psychiatric inpatient units. Some training sites have implemented structured clinical and didactic training programs for general medicine training in psychiatry. Examples of notable programs are described below.

Dobscha et al. implemented a psychiatry primary medical care track (PPMC) program at the Portland Veterans Affairs Medical Center [13]. Psychiatry residents provided integrated care in an ambulatory clinic one half day a week and also attended conferences on topics in primary medical care and the primary care-psychiatry interface. Rohrbaugh et al. describe a program at a veterans affairs (VA) mental hygiene outpatient clinic that was implemented as part of the VA Psychiatry Primary Care Education (PsyPCE) initiative [14]. Residents had contact with a primary care team embedded within the psychiatry clinic and were encouraged to provide primary care to a panel of patients. They also attended lectures on health promotion, disease prevention techniques, health screening, and management of common medical disorders in severely mentally ill patients. Onate J et al. describe a program initiated at University of California, Davis School of Medicine (UC Davis) during the required 4 months of primary care in PGY1 [15]. Residents spent two of those months in an ambulatory clinic providing medical care to patients with serious mental illness under supervision by dually trained physicians in general medicine and psychiatry. These programs yielded positive results in resident satisfaction, but further studies are needed to determine if this translates into changes in practice behaviors of residents and improved patient outcomes. As can be seen, there is little general medicine training in psychiatry residency except at sites where specialized programs have been implemented. Within existing programs, there is variability in the content and structure of training. The authors recommend designing a general medicine curriculum for psychiatrists that can be uniformly implemented within the existing structure of training programs.

A Proposed Curriculum for General Medicine Training Core Principles ACGME requires the following core competencies to be incorporated into the resident curriculum: (a) patient care, (b) medical knowledge, (c) practice-based learning and improvement, (d) interpersonal and communication skills, (e) professionalism, and (f) systems-based practice. However, the scope of clinical practice within these competencies is not described. For instance, the extent of knowledge in medical conditions related to psychiatry is not specified. Under systems-based practice is an expectation to “work effectively in various health care delivery settings and systems relevant to their clinical specialty,” “coordinate patient care within the health care system relevant to their clinical specialty,” and “incorporate considerations of cost awareness and risk benefit analysis in patient and/or population-based care as appropriate.” To be competent in providing care, it is reasonable to expect that psychiatrists minimize the deleterious effect of the medications they prescribe and conduct appropriate screening

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for medical conditions that are caused or exacerbated by psychotropic medications. They also need to effectively differentiate conditions related to psychotropic medications from those with other etiologies. Chronic disease management forms a large part of both primary and behavioral health care. Psychiatrists are trained to be experts in behavior change and can be at the forefront of counseling in lifestyle issues, treatment adherence, and self-management of chronic conditions. Psychiatrists’ training in basic medicine as well as behavioral health gives them a unique opportunity to be effective integrated health care providers. In some cases, psychiatrists may be called upon to manage medical conditions for mentally ill patients who are unable or unwilling to access primary care. Even if this does not involve direct clinical care, psychiatrists may need to educate patients and effectively communicate with primary care providers. Physicians, both psychiatrists and internists, believe that psychiatrists with additional training in general medicine can effectively evaluate and manage many common medical conditions [16]. Psychiatrists historically have not been involved in medical care [17, 18] or preventive physical health counseling [19]. Curricula outlining skills, attitudes, knowledge, and approaches to teaching a curriculum with additional training in general medicine have been described [20, 21]. It has not yet been shown that enhancement of general medicine skills in residency results in a change in psychiatrists’ practices. However, education has the potential to improve knowledge and practice, and emerging health care needs dictate that educators consider inclusion of such a curriculum. This should be accompanied by systematic evaluation of effectiveness in changing practice behaviors. This may, at a minimum, retain the education received during medical school. Residents are more likely than practicing psychiatrists to perform medical evaluations [22] suggesting that the skills and attitude learned during medical school and internship may be lost over time. Retraining psychiatrists in general medicine has implications not only for resident training but also for the scope of psychiatric practice. Goals Several goals can be identified for training psychiatrists in general medical care. The following goals are probably met by the existing curricular structure: (a) Learn to evaluate, diagnose, and treat psychiatric inpatients with complicated medical problems (b) Learn to evaluate and treat psychiatric patients with comorbid medical conditions in outpatient settings (c) Learn to adequately screen for deleterious medical effects of psychotropic treatment (d) Learn about psychosocial needs of patients within the context of serious medical conditions (e) Learn systems of care within general medicine in multiple treatment settings

Other goals that are not likely to be met within the mandated four internship months of primary care or in existing psychiatric clinical sites are as follows: (a) Learn to identify true medical emergencies and develop the ability to triage patients appropriately to emergent, urgent, and routine care (b) Learn to diagnose and manage common medical problems in outpatient settings (c) Learn to effectively collaborate with general medicine colleagues and coordinate care in outpatient settings To design a curriculum that enhances the quality of general medicine training and meets these goals, the following principles are helpful: 1. Clinical Experience (a) Relevance for Practice—There should be diversity of clinical settings to emphasize training in settings where psychiatrists are more likely to encounter patients. General medicine inpatient units, emergency rooms, and intensive care units are valuable training sites and residents in most programs gain experience in these settings. Examples of innovative clinical sites, which are available in a minority of programs are medical-psychiatric combined units, outpatient community health centers, outpatient collaborative care clinics, and co-located clinics at veterans affairs (VA) hospitals. (b) Resident Choice—While allowing for diversity, residents should be able to select their clinical sites based on future career choices. Psychiatry residents may be expected to choose medical rotations that are considered “easier” or be assigned to rotations where they are “needed.” However, in the authors’ experience, residents generally prefer clinical experiences that are in line with their interests, even selecting those that are considered “difficult.” (c) Structure of Training—The training should be extended across residency rather than collapsing it all during the internship year. Inpatient and emergent settings are more valuable in internship when residents manage medical emergencies while on call, while outpatient settings are more likely to be valuable in later years. Rather than residents learning general medicine primarily during primary care rotations, it could be incorporated at all levels of training and tailored to specific clinical settings. (d) Tracks Within Residency—For residents who wish to pursue careers in public psychiatry or consultliaison work, additional longitudinal training can be offered, and this can take the shape of a separate

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track or certification within residency. For example, one half day in a primary care clinic may be useful for residents planning to work in community mental health settings. Other sub-specialty tracks can also be designed based on need. The time set aside for electives during third and fourth years can be utilized for this. (e) Supervision—Until the time when the scope of psychiatric practice extends to routinely include general medicine prevention and screening, this training would require additional supervision by primary care practitioners. Psychiatry departments would need to collaborate with internal medicine colleagues to develop new models to provide adequate ongoing supervision for psychiatry residents. This would require medicine consultants to be available beyond the primary care rotations in the first year. An example would be designating a primary care faculty member to provide ongoing consultation for residents in the second through fourth years. 2. Didactics Didactics should be tailored to what is relevant for psychiatry trainees and applicable at that level of training rather than simply participation in didactic lectures designed for general medicine residents. Topics of relevance could be chosen based on conditions commonly encountered by psychiatry trainees in different settings. A proposed didactic curriculum would include education on emergent and urgent care in the first year; illnesses encountered in inpatient units in the second year; and outpatient medical comorbidities in the third year. As described above, some residencies that have implemented specialized primary care-psychiatry programs incorporate didactics relevant to this interface. Teaching the curricula throughout residency training would require support from primary care colleagues. As with clinical training, residents wishing to pursue further competence in primary care can receive additional didactics either as part of a specialized track or within existing didactics for primary care residents. Barriers/Challenges There are several challenges in implementing these curricular changes. Among logistical barriers, the foremost is the need for appropriate clinical settings and adequate supervision by primary care faculty. This shift in training may also cause concern among educators that other traditional areas of training such as psychotherapy will be compromised. The authors believe these are surmountable, though not trivial barriers, given the embedded nature of the proposed training.

There is also a legitimate concern about the time limitations of practicing psychiatrists to provide additional interventions in their circumscribed time with patients. The authors hope that with increasing emphasis on medical homes and reimbursement for outcomes rather than service, future psychiatric care will be delivered in models better suited for integrated care. The issue that is most debatable is defining the scope of psychiatric practice. Psychiatrists are responsible for minimizing psychotropic medication side effects, and screening for adverse physical effects of medications. In addition, the authors believe that psychiatrists can provide initial management of uncomplicated health conditions or, at a minimum, ensure delivery of appropriate medical care. Psychiatrists’ training enables them to be effective health promoters and counsel patients in preventive care. But they are less likely than primary care practitioners to provide counseling on physical health [19] and evidence shows that medical conditions in mentally ill patients are not adequately treated [5]. There may also be concerns about liability for psychiatrists to extend clinical care beyond what is currently practiced. However, if the psychiatric community accepts these additions to training as within the scope of practice, liability concerns are lessened. And it has been suggested that psychiatrists may be liable for failing to recognize and treat medical conditions, especially those that are caused by our pharmacologic interventions [8].

Future of Integrated Care Education As a group, psychiatrists need to determine the boundaries of responsibility for medical care. The extent of direct care provision will depend on the practice setting and access to medical services as well as the specific health condition. This is analogous to primary care practitioners initiating treatment for common psychiatric conditions, especially when access to behavioral health services is limited. It seems necessary for psychiatrists to be involved in medical care to a greater extent than what is currently the practice given that patients with mental illness are under-treated for chronic medical conditions, many of which are caused or exacerbated by pharmacologic treatment of psychiatric illnesses [5]. In addition to enhanced general medicine skills, psychiatrists may need to develop leadership skills to guide integrated health care teams. As leaders of these teams, psychiatrists would be responsible for delivering population-based care. An increased awareness of common medical illnesses seen in the mentally ill population may improve their ability to track health indicators and identify gaps in care delivery and plan appropriate interventions. With training in both psychiatry and basic primary care, they will be well suited to take the lead in merging primary care and behavioral health cultures, which have traditionally been siloed.

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Training programs designed to provide improved general medicine experience to trainees will need to evaluate the effect of the training not simply on participant satisfaction but on translation of that training into clinical practice and medical and psychiatric outcomes of patients. In addition to the potential for improvement in quality of patient care, there may be other benefits to the proposed changes in training. There is perception among medical students that psychiatrists do not draw significantly from their medical training for psychiatric practice [23]. This view may change with the diversification of psychiatric training. If this results in increased recruitment of medical students into psychiatry, this would be an added incentive to expand the scope of psychiatric training. It can help solidify the psychiatrists’ role in the medical profession, which at this time, is unfortunately still viewed as separate from other specialties. With the movement towards integrated care, there is an opportunity for psychiatrists to be leaders but this may require providing additional training. Incorporating general medical care in psychiatric practice will mean a shift in the current view of psychiatric practice. But the goal is for psychiatrists to play an active role in health maintenance and promotion and not to take on the role of primary care providers. The authors recommend that elements of general medicine training be included throughout residency rather in a circumscribed training elective to achieve this goal. Primary care providers would also have to be involved and this would be a joint initiative between residents, faculty psychiatrists, program directors, and internal medicine colleagues. Future research should determine if this change in curriculum results in more effective resident education and improved patient outcomes. Implications for Educators • The emerging need for integrated health care delivery may result in an expanded role for psychiatrists in the primary care behavioral health interface. • In the public mental health sector, it is becoming increasingly necessary to integrate medical services within psychiatric care. • Educators may need to consider enhancing general medicine training in psychiatry residency to meet practice needs in mental health settings. • A curriculum for enhanced general medicine training could be incorporated within the existing structure of psychiatry residency training. • Any curricular change requires a discussion among the psychiatric community on the scope of practice. Disclosures The authors have no conflicts of interest to disclose.

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General Medicine Training in Psychiatry Residency.

With growing awareness of the need for integrated health care settings, psychiatrists may be required to provide clinical care at the primary care and...
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