In 1894, Dr. Silas Weir Mitchell, one of the progenitors of modern neurology (¹), was invited to address the annual meeting of the American Medico-Psychological Association, the organization of mental asylum superintendents that later became APA. Mitchell spoke, but only reluctantly. He lambasted the "alienists" for isolating their patients and profession in asylums and neglecting the emerging scientific method of general medicine. Mitchell was amazed by the "lack of complete physical study" and "failure to see obvious lesions" that he noted in the records of asylum patients. Mitchell implored his audience to return to its medical roots. He suggested that asylum heads should have "large general hospital experience" and be knowledgeable in both psychology and pathology (especially neuropathology). He also suggested that residents spend the first 3 months of their 2-year term training in nonpsychiatric medicine in a general hospital before coming to an asylum (²).

One wonders what Mitchell would think of 21st century American psychiatry. Would he see a profession geographically and philosophically reunited with general medicine? Would he feel that psychiatrists are bringing the full benefits of modern medicine to their patients? Would he think modern psychiatric training has an adequate basis in general medicine?

Given the explosion in neurobiological research and proliferation of effective somatic treatments over the last half-century, it is clear that psychiatry has embraced the scientific method. Many in the profession would contend that neurobiological sophistication and emphasis on pharmacological and other somatic treatments have reunited psychiatry with the larger medical profession (³). A number of other factors, including the rise of consultation-liaison psychiatry and psychiatry’s need to qualify for reimbursement from medical insurance payers, have strengthened ties between psychiatry and general medicine. The continued operation of approximately 400 freestanding psychiatric hospitals (⁴) in the United States, though, suggests the geographic, and possibly conceptual, reunification of psychiatry and general medicine is far from complete. While many factors likely contribute to this, we must wonder if negative attitudes toward general medicine among psychiatrists, or deficiencies in psychiatrists’ general medical knowledge and skills, play roles. Freestanding psychiatric facilities often insist they cannot care for patients with acute or complex medical concerns (⁵) and sometimes delay needed psychiatric treatment because they are unable to address even basic medical problems. The frequent insistence by some psychiatrists that patients be "medically cleared" by an emergency medicine or primary care physician before entering the psychiatric arena suggests an unwillingness or inability to do general medicine, especially given evidence suggesting "medical clearance" is a relatively simple task that nonpsychiatrists are not always thorough in handling (⁶—⁸). It is clear from studies showing significant medical comorbidity in patients with primary psychiatric illnesses and a significant prevalence of secondary psychiatric illnesses (⁹—¹⁶) that good care of the mentally ill requires a good knowledge of general medicine, but it is not clear if today’s psychiatrists are totally willing or able to bring the full benefits of modern medicine to their patients.

In the United States, the training psychiatric residents receive in primary care medicine and neurology (nonpsychiatric medicine; NPM) is determined by requirements for practitioner certification set by the American Board of Psychiatry and Neurology (ABPN) and training program requirements established by the psychiatry Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME). The current scheme has been in place since 1977 when, after a 7-year hiatus, the ABPN reinstituted a requirement for a year of internship training (¹⁷, ¹⁸).

The ABPN’s training requirements are aligned with the ABPN Core Competencies (last updated June, 2004; 19). In terms of NPM, the core competencies mandate that a psychiatrist should be able to obtain a past medical history, carry out a review of systems, and perform "situationally germane" general and neurological examinations. These guidelines further state that a psychiatrist should be able to develop a patient evaluation plan including appropriate laboratory and imaging studies. The ABPN Core Competencies pertaining to neurology require an understanding of common neurological disorders (including movement disorders, stroke, dementia, and seizure disorders), psychiatric manifestations of common neurological disorders, and the "interplay between psychiatric and neurological conditions." Familiarity with common neurological medications and possible neurological complications of psychiatric medications is also required. The ABPN’s NPM training requirements call for a 1-year internship in internal medicine, family medicine, or pediatrics, or a transitional year (with a minimum of 4 months of primary care experience) or an internship year done under the auspices of a psychiatry department that includes 4 or more months of training in internal medicine, family medicine, or pediatrics. An emphasis is placed on comprehensive and continuous clinical care.

The ACGME Program Requirements for Graduate Medical Education in Psychiatry (effective July 1, 2007; 20) pertinent to NPM state that psychiatrists should have "sound clinical judgment, requisite skills, and a high order of knowledge about the diagnosis, treatment, and prevention of … common medical and neurological disorders that relate to the practice of psychiatry." Like the ABPN, the ACGME requires familiarity with specific neurological conditions including dementia, traumatic brain injury, movement disorders, seizure disorders, stroke, and intractable pain. The ACGME requires competency in general physical and neurological examination and familiarity with appropriate laboratory and imaging studies. The ACGME’s internship requirements are the same as those given by the ABPN, but the ACGME further mandates that psychiatry trainees receive 2 months of training in neurology, 2 months of training in consultation-liaison psychiatry, 1 month of training in geriatric psychiatry, and 1 month of training in addictions.

Psychiatrists who desire training in NPM over and above this mandate can pursue their interests in a number of ways. Elective time during psychiatric residencies can be used for additional NPM training. Primary care-focused training tracks within psychiatric residency programs have been proposed and implemented (²¹—²³). Graduates of these programs have reported a sense of increased competence in general medicine, but it is not clear that this training has actually increased the quality or quantity of general medical care given to mentally ill patients. A number of physicians have completed residency training in both psychiatry and an NPM specialty sequentially over the years, and formal residency programs combining psychiatry with family medicine, internal medicine, neurology, or pediatrics/child and adolescent psychiatry have existed for over two decades. The literature on psychiatrists who are trained in other specialties paints a largely positive picture. Some physicians who entered psychiatry after practicing in another specialty felt that their first specialty gave them an advantage—they "knew how to be a doctor" before entering psychiatric training (²⁴). A study of physicians trained in both psychiatry and neurology before the inception of combined programs (²⁵) found these physicians dealing with behavioral and medical dimensions of CNS disease. Most of these physicians found their dual training valuable, and 78% were in favor of forming combined training programs. A study of physicians who had done separate residencies in family medicine and psychiatry (²⁶) found the clinical activities of 60% involved both general medicine and psychiatry, but a more recent study of graduates of combined psychiatry/family medicine programs found respondents spending about 70% of their time in psychiatry; only 11% of respondents were engaged in fully integrated practice (²⁷). A study of physicians trained in internal medicine and psychiatry found that 95% reported using both their medical and psychiatric training in their work, but 85% practiced only psychiatry (²⁸). A 2001 survey of psychiatry/family medicine and psychiatry/internal medicine programs (²⁹) found wide variations in program curricula and an 11% trainee attrition rate. A 2006 study of physicians trained in psychiatry/child and adolescent psychiatry/pediatrics (³⁰) found most of these physicians satisfied with their training and practicing child and adolescent psychiatry; only 36% were board-certified in all three areas. Fellowship training done after a psychiatric residency (e.g., in neuropsychiatry) is another way in which interest in combining psychiatry and NPM can be pursued (³¹). In summary, physicians trained in psychiatry and one or more other medical specialties seem to value their multidisciplinary training but vary with respect to how much time they actually practice their NPM specialty.

The ABPN and ACGME requirements for training in primary care are very general in nature and can be fulfilled in any primary care specialty and in numerous practice settings. Any training in which residents learn to perform physical examinations and interpret appropriate laboratory and imaging studies while providing comprehensive and continuous clinical care would seem to fulfill the requirements. The requirements for training in neurology are more specific in terms of subject matter. Though difficult at this time to comment on the adequacy of these requirements in the absence of needs assessments, more specific outcome goals, and outcome measures, several lines of thought suggest a number of benefits that could be realized by improving training in NPM (Table 1).

Perhaps most importantly, improved training in NPM would make psychiatrists more adept at the application of the "medical model" to primary psychiatric illness. This model emphasizes the definition of discrete disorders and their unique symptom patterns, natural histories, pathophysiologies, comorbidities, and effective treatments (³²). While the medical model is not appropriate for all patient needs (³³), it is the approach that psychiatrists, as physicians, are best equipped to take and it is the most effective approach to the major psychiatric disorders.

The high rate of comorbid medical illnesses in patients with psychiatric disorders and the negative consequences of these illnesses, including increased mortality, are very worrisome. The failure of health care systems to adequately detect and address these conditions has been documented (³⁴). Improving psychiatrists’ proficiency in NPM could lead to improved detection of medical illnesses in patients, and improved detection could lead to more timely treatment. More timely treatment of medical illnesses in patients with psychiatric illness could in turn improve patients’ psychiatric illnesses and decrease health care costs. It is not clear that 4 months of primary care training done during residency adequately prepares psychiatrists to diagnose and treat common medical illnesses, especially when this training can be done in a wide variety of settings (e.g., a resident who rotates only on an inpatient medical service may leave residency with little understanding of common ambulatory medical problems such as obesity and hyperlipidemia).

Psychiatrists believe that familiarity with mental manifestations of medical illnesses is one of the most important attributes of a competent practitioner (³⁵, ³⁶), but outside of the required 2 months of consultation-liaison training little attention is paid to this topic in residency. Enhanced training in NPM with emphasis on mental manifestations of physical illnesses would make psychiatrists more proficient in assessing and treating secondary mental illnesses.

Medical complications of psychiatric illnesses and treatments (e.g., alcoholic cirrhosis, metabolic syndrome related to atypical antipsychotic treatment) are obviously of paramount importance to psychiatrists. Improved understanding of these complications could enable psychiatrists to improve the mental and physical health of their patients.

Enhanced training in NPM could benefit our nonpsychiatrist colleagues and our profession as well. Psychiatrists need to be fluent in NPM to communicate effectively with colleagues in other specialties and to understand their clinical and educational needs (³). Recruitment of medical students into psychiatry has been a concern for many years (³⁷). A number of factors, including income potential, undoubtedly influence recruitment, and we should wonder if a perception that psychiatrists do not use all of their hard-earned medical knowledge and skills may dissuade some medical students from entering psychiatry (³⁸). If so, an increase in emphasis on NPM could attract more students into the field (³⁹). One of the goals of residency training is integration of the trainee into the medical profession. A total of 6 months of training in NPM may not provide enough exposure to fully integrate trainees into the profession, especially if this training is done in more specialized settings. Increased NPM training during the psychiatric residency could lead to an increased sense of "ownership" of the medical profession among psychiatrists. Lastly, psychiatrists are unique among mental health care providers in their ability to combine biomedical knowledge and skills with psychosocial assessments and treatments. Health care systems that value efficiency and cost-containment avoid duplication of services, and psychiatry will only thrive within such systems by emphasizing its unique biomedical contribution to mental health care. Increased proficiency in general medicine could help psychiatrists do this.

When the ABPN eliminated the internship requirement in the early 1970s, some in psychiatry felt this change had been made without due consideration of the pertinent issues (⁴⁰). Today’s psychiatric educators should enhance training in nonpsychiatric medicine only if thorough needs assessments show a need for such a change. A need for a shift in training could be shown if psychiatrists perceive deficiencies in their NPM training and skills. Simply assessing psychiatrists’ attitudes toward the adequacy of their training may be insufficient, though, since past studies have suggested psychiatrists may not deliver general medical care even when they report feeling comfortable with general medical issues (²³). A need for enhanced NPM training could be shown if studies of psychiatric practice suggest psychiatrists are not adequately detecting medical illnesses, differentiating between primary and secondary psychiatric illnesses, or treating medical illnesses. Studies of psychiatry resident and practitioner performance on examination questions relating to NPM could also be helpful. Enhancement of NPM training might also be considered if studies of medical student specialty choice reveal student concerns about underemphasis of NPM in psychiatric training and practice. Information regarding specialty choice, examination performance, and practice gathered from psychiatrists who trained in the 1970s without doing an internship would be of special interest.

If a need for enhanced NPM training is shown, this could potentially be accomplished in a number of ways. Psychiatric training could be eliminated from the first postgraduate year, and future psychiatrists could be required to do straight internships in internal medicine, family medicine, or pediatrics, or a transitional year as they were prior to the 1970s (¹⁷, ⁴¹, ⁴²). A monolithic year of NPM training may provide a good professional indoctrination for medical school graduates and significant experience in NPM, but separating this year from the rest of psychiatric training could hinder conceptual integration of psychiatry and NPM (⁴³). The general nature of straight internships and variability in training settings could also lead to underemphasis of certain NPM topics important for psychiatrists. Cases have been made, for example, for enhancing psychiatrists’ training in basic neuroscience, pain management, genetics, geriatrics, and specific areas of neurology including dementia, movement disorders, sleep disorders, and stroke (⁴⁴—⁴⁸). Cases could likewise be made for improving psychiatrists’ knowledge of hepatology (with emphasis on medication metabolism and viral hepatitis; 49), other infectious diseases (with emphasis on HIV/AIDS), cardiac toxicity of medications (⁵⁰), care of pregnant and breastfeeding women, neuroimaging, neuropsychological testing, and functional neurosurgery (⁵¹). Instead of isolating NPM training in the first postgraduate year, distributing training throughout the 4 years of the psychiatric residency might be considered. A "longitudinal internship" could fulfill the ABPN requirement for "comprehensive and continuous care" while better-integrating NPM and psychiatric training. In contrast to "one size fits all" internship years, longitudinal NPM training could potentially incorporate scientific advances more rapidly and be tailored to the needs of trainees (⁵², ⁵³). Other ways of enhancing NPM training would include encouraging NPM electives, creating new residency "tracks" focused on NPM (²¹), increasing time spent in consultation-liaison psychiatry training, and emphasizing combined residencies and fellowships devoted to the psychiatry/NPM interface. Combined residencies should only be promoted if outcomes research shows graduates put their NPM training to significant use. In addition to formal rotations, training in NPM could be improved by devoting grand rounds and other didactic time to NPM topics, emphasizing maintenance of basic medical skills like Advanced Cardiac Life Support (ACLS), and involving psychiatric residents in the teaching of medical student courses relevant to NPM (e.g., physical examination). Since practitioners "use or lose" knowledge and skills obtained in training, there would be a need for continuing medical education focused on this area. Psychiatrists’ proficiency in NPM could be assessed (and encouraged) by adding NPM questions to the ABPN Part 1 written and recertification examinations.

Any increase in training in NPM for psychiatric residents would come at some cost. Any shift of training time away from traditional areas (e.g., long-term psychotherapy) would immediately raise concerns among some psychiatrists about a loss of competency in these areas. There are suggestions in the literature, though, that residents in combined psychiatry/primary care residencies perform as well in psychiatry as their peers in straight psychiatry residencies despite spending 12 fewer months in traditional psychiatric training (⁵⁴). While the literature suggests the medical problems of the mentally ill are inadequately addressed in the current medical system, it has not been conclusively shown that enhancing the general medical knowledge and skills of psychiatrists would translate into an improvement in patients’ health. Until this is shown, significant changes in psychiatric training should not be made since increasing psychiatrists’ general medical proficiency may be a costly duplication of primary care training. Increasing interspecialty training for psychiatric residents would also increase the training burden for our nonpsychiatric colleagues and increase interdepartmental administrative challenges. These challenges could lessen with time, though, as psychiatry faculty members become more proficient in NPM and are able to assume some NPM training responsibilities from their nonpsychiatrist colleagues. Lastly, psychiatrists may not be reimbursed by third-party payers for NPM care, and this could dissuade psychiatrists from delivering such care. Changes would likely have to be made in reimbursement policies before psychiatrists would enhance training in NPM and increase delivery of general medical services.

Physicians currently in psychiatric training in the United States are required to spend only 12.5% of their time in residency on rotations devoted exclusively to nonpsychiatric medicine. These rotations can vary widely in terms of subject matter addressed. It is not clear that meeting this minimum requirement adequately integrates residents into the medical profession or prepares them to meet the needs of their future patients. Studies are needed to clarify these issues.

At the time of submission, the author disclosed no competing interests.