Because of the relative shortage of available child psychiatrists, primary-care providers are increasingly expanding their role in the provision of mental health care. Accordingly, there is an increased need to develop a standardized approach to teaching specialized skills to these providers. One method of doing so is to expand the child psychiatrist's consultative role to include the structured discussion of patient cases. By emphasizing the reasoning behind treatment recommendations, the psychiatrist can assist the primary-care provider in applying this knowledge to other patients in his or her practice. A group setting, or "consultation conference," can be used to involve more providers—who, in turn, become resources for each other. This model of a group conference adapts principles of adult learning (1—5) to facilitate the dual consultative and educational goals. Providers who care for patients in the same (or similar) setting come together as a group to share their experience and knowledge. The psychiatrist assists in that group setting, functioning both as expert resource and facilitator. Participants discuss problem cases, thus learning in their own context while receiving assistance in the understanding and management of actual patients (indirect consultation).
The study group came together at the request of the Southern Illinois University School of Medicine Department of Family and Community Medicine (FCM); they had identified an unmet need for child and adolescent psychiatric services in their rural clinic population. Over a 1-year course, approximately 12 FCM resident physicians at all levels of training attended on a monthly basis in lieu of an hour of didactic lecture. (Approximately three to six FCM faculty members and rotating medical students attended, as availability allowed.) The consultant, a child psychiatrist with a background in pediatrics, led the group, attending first in person and then by video teleconference. FCM clinical therapists also routinely attended, assisting residents with patient presentations and serving as expert resources. A designated staff person scheduled the meetings, and the FCM chief resident coordinated the residents who presented patient cases.
The Role of the Consultant
The psychiatrist functioned in several different roles. Foremost, she was the "expert," who shared knowledge and skills with the group. As a "teacher," she guided the specific structure and content of the discussion, including the learning points to be emphasized. Finally, she was also a "facilitator," who attended to the balance and pace of the group interaction.
Specific techniques for the guided discussion included various combinations of: eliciting information, assessing the group knowledge-base, guiding the thinking process, refocusing, redirecting, clarifying, reframing, giving information, correcting, emphasizing selected points, summarizing, and debriefing. Because group composition varied somewhat in continuity, learning issues were resolved as much as possible during the discussion, rather than left for self-discovery.
The consultant began the conference with a greeting to set the tone and to clarify the expectations for the discussion. All participants were introduced (so that group composition would remain transparent) and instructed to maintain patient confidentiality. The group was informed if a recording was being made (for educational analysis) or if any presenters had conflicts of interest. If teleconferencing was being used, audiovisual quality was confirmed.
Consultant: "The group members will try to problem-solve regarding the patient to be discussed, but also want to emphasize "take-home points" that everyone will be able to use in his or her practice. Questions and constructive comments are encouraged."
The FCM resident provided a brief synopsis of a patient with whom they were having difficulty, and discussed what assistance they desired from the consultant. The consultant clarified a valid and useful "consult question," which assisted in shaping the course of the ensuing discussion.
Resident: "The patient is a 4-year-old girl who was brought in by her mother because the school thinks she has ADHD [attention-deficit hyperactivity disorder]. So I guess my question is [whether] you can diagnose ADHD in someone this young … and when would you consider treatment?"
The remainder of the consultation conference consisted of a discussion guided by the consultant. The group obtained additional patient information as needed, and determined relevant learning issues. Referring back to the case as appropriate, the consultant engaged the entire group of participants, who brought up their own experiences for comparison/contrast and problem-solving.
Consultant: "So you have a bright and likable young girl who is hyperactive compared to her peers. Is this causing any problems for her? … Could it in the future?"
At the conclusion of the conference, the consultant briefly summarized the material reviewed, highlighting key points. The presenting resident was asked to identify his or her "next steps" in patient management—essentially, a resolution to the consult question. Other group participants were asked to identify learning points that were transferable to their own practice.
Consultant: "So the ‘pearls’ for you today are that development is variable, but the parents need to watch closely if developmental issues appear to be interfering with her day-to-day functioning or relationships…."
Resident: "I will talk to the mom about this. I should probably see [the child] back soon after she gets settled into kindergarten…."
Finally, attendance information was collected; logistics for the next conference were confirmed; and (if using teleconferencing) audio/video connections were rated.
The psychiatrist worked with education specialists to routinely review conference notes and videotapes to determine content areas, analyze group dynamics, and critique teaching style. Several trends emerged.
Group composition clearly changed the dynamic of the interaction. If faculty members were in attendance, the consultant needed to intervene more frequently to encourage the participation of the less-assertive members of the group. Presenting residents tended to be very thorough, oftentimes covering information chronologically, with excessive detail, or with a sense of needing to express their frustration with the case. Other group participants, however, repeatedly asked for a very brief synopsis, wanting to have the case unfold during the discussion (as it might in his or her own practice). Teaching was most effective when the consultant could preview the case (ranging from "chief complaint" to a more complete "history of present illness") ahead of time to identify key issues, anticipate the outline and pace of the interaction, and build upon previous discussions. Analysis of conference content helped to identify strengths and weaknesses of the participants and to coordinate a type of customized programming. Flexibility was important so as to meet the ongoing needs of the group. On occasion, recurrent themes (i.e., aggression, bipolar disorder) were identified for more in-depth topical presentations. The presentation and management of mental health problems in the primary-care setting was often ill-defined and variable when compared with the psychiatric setting, in which most problems are severe enough to be readily detected and identified. The authors found it extremely helpful to maintain the perspective of "expanding primary care" rather than "teaching child psychiatry," and it was well received. Nonetheless, the "bio-psycho-social" approach appeared to be helpful for the residents in understanding the cases, in treatment planning, and in defining the boundaries of their care. The mental status examination was reviewed informally when discussing office presentations. The therapists took on an expanded teaching role as the residents began to seek them out. They independently verified that each presenter did act on his or her stated intentions ("next steps") for patient management (unless the patient was lost to follow-up). Residents reported back on outcome at a subsequent conference—to the marked interest of the group.
The group needed an initial description of the scope of psychiatric care before participants felt comfortable selecting patients to discuss, especially as they were hesitant to "label" their patients. They were encouraged to consider children with "problems" in behavior, emotions, interpersonal interactions, and/or learning. Diagnostic uncertainty was acknowledged and expected. Residents also had difficulty defining a consult question, often beginning with "I do not know what to do…" or "What should I do with the medication?" With Socratic questioning, a more defined consult question emerged, typically in one of several categories:
The main goal of this preliminary work was to determine whether primary-care physicians, who traditionally transferred the care of mental health patients to psychiatric providers, would be receptive to the concept of the consultation conference. At the end of the training year, the FCM residents unanimously voted to continue the conference and to keep the original format. The concept of a teaching conference involving indirect consultation was readily accepted in this academic setting, in part because participants did not have the expectation of transferring patient care to the consultant; they were familiar with using case-based presentations, and routinely worked together as a group. Although this model appears to be replicable, various settings may not be this receptive, especially if participants mainly desire the transfer of patient care or have discomfort utilizing the group format. Also, because the residency program was at a site remote from the consultant, the conference was possible only through the use of videoconferencing (with which they were familiar), which is not universally available. The authors are currently working with additional groups to study differences between academic- and community-provider settings, as well as between on-site and videoconferences. The inclusion of educational specialists was exceptionally helpful in developing the teaching skills of the consultant. This is highly recommended if possible, but is not an absolute necessity for the process of conducting the conference. Similarly, the consulting psychiatrist had previous experience in primary-care practice, but this would not necessarily be a requirement for other consultants. During this preliminary work, there was a general sense of improvement in participant independence, knowledge, abilities, and applied behaviors, but this was not formally measured. Likewise, there was no formal evaluation of the impact on physician practice or patient outcome. Measures for these are currently under development.
These preliminary results suggest that the Consultation Conference is a well-received model of consultation that combines adult-learning principles with guidance regarding patient management. More work is needed to assess the actual effect on mental health care provided in the primary-care setting. If the concepts discussed during the conference are applied to physician practice, this modality has significant potential to increase access to psychiatric care.
At the time of submission, the authors reported no competing interests.