There is a growing body of evidence suggesting that collaborative mental health care between family doctors and psychiatrists will enhance patient care (1–3). In primary care, the need for mental health support from psychiatry exceeds available resources, and patients may be reluctant to access psychiatric support, even if it were available to them. The literature on collaborative mental health care is becoming more robust as clinicians write of new ways to “share care” with colleagues possessing varied levels of skill and with those from different disciplines (4–6). A recent randomized controlled study (3) found collaborative care (mental health professionals working in a primary-care practice) to be effective in treating common mental disorders and significantly more efficient than usual care on indicators such as referral delay, duration of treatment, number of appointments, and costs related to treatment. Another study (6) compared the perspectives of residency training directors in psychiatry and primary care on the primary-care mental health programs at their institutions. The results showed that although there was general agreement that primary-care physicians should be able to treat most uncomplicated psychiatric cases, there was overall dissatisfaction with the psychiatric training in primary-care residency programs.
In 2005, the Departments of Family Medicine and Psychiatry at Mount Sinai Hospital in Toronto developed a resident Collaborative Mental Health (CMH) program. The goal was to teach and model “shared care” between psychiatry residents and family medicine (FM) residents during their training. The program was evaluated with a survey over 2 academic years. Details of the program and results of the evaluation are described here, with the hope that other training programs may be interested in replicating ideas from this important endeavor during residency training.
During the 2005/6 and 2006/7 academic years, FM residents and psychiatry residents were "buddied" with one another to form the Mount Sinai Hospital family medicine and psychiatry resident CMH program. At the beginning of each academic year, an orientation session for the psychiatry and family medicine residents was conducted by the CMH program coordinators. The purpose of this session was to introduce residents to each other, explain the philosophy behind a collaborative mental health program, and explain the methods for communication and documentation between family medicine residents, psychiatry residents, and supervising psychiatry staff. Residents were given a summary of the principles of shared care, which emphasized the patient-centered aspect, options for consultation, appropriate documentation, and patient confidentiality; e-mail addresses and phone numbers were exchanged and FM residents were encouraged to e-mail their psychiatry buddies whenever they had questions on management, psychopharmacology, challenging clinical encounters, or the availability/suitability of specific mental health resources. It was specified that urgent clinical matters should not be addressed through e-mail but should be referred to proper channels, including on-site clinical supervisors or the Emergency Room. Psychiatry residents were each assigned a clinical supervisor within the Department of Psychiatry. Residents were asked to review their email replies with their supervisor before sending them. The goal was to turn around replies within 48 to 72 hours; often, an ongoing dialogue about patient care ensued.
To evaluate this program, two questionnaires (one for psychiatry and one for FM residents) were developed by the program coordinators (a family physician, psychiatrist, social worker, and research associate). The questionnaires were tested and revised by a family physician and psychiatrist who were not part of the CMH program. The goal of the survey was to obtain information about resident satisfaction with the program, its usefulness, and areas for program enhancement. Ethics approval was received from the Mount Sinai Hospital Ethics Board, and completion of the questionnaires implied consent. The questionnaires were returned anonymously, using a coding system to match FM buddies with their corresponding psychiatry buddies. An e-mail reminder was sent to non-responders.
Most of the FM residents and all of the psychiatry residents attended the introductory and orientation session offered by the program coordinators. All residents found this face-to-face introduction to be useful. A total of 22 first- and second-year FM residents participated in 2005/6, and 21 FM residents participated in 2006/7. Two psychiatry residents each year volunteered to participate after the program was presented to them by the staff psychiatrist involved with collaborative mental health care (Year 1: one third-year, one fifth-year resident; Year 2: two second-year residents). The involvement of only two psychiatry residents per year for this pilot project reflected senior-resident availability, as the involvement was voluntary, and in addition to other required duties. The psychiatry residents were buddied with 10–11 family medicine residents for the year; 30 of the FM residents and all 4 of the psychiatry residents completed the survey, for an overall response rate of 34/47, or 72%.
Most of the FM resident respondents (80%) had consulted their psychiatry buddy about a FM patient during the academic year. Those who had not had either forgotten about contacting him/her, or had patients who were already being followed by a psychiatrist. The number of cases on which each FM resident did consult with their psychiatry buddy ranged from 1 to 6 cases. The most common reasons for the consultation were medication advice, resources for referral/support services, management issues other than medication, diagnosis, and psychotherapy questions.
Most FM residents (87.5%) preferred to contact their psychiatry buddies by e-mail; the remaining residents preferred to contact them by phone. All of the psychiatry residents indicated that they preferred to be contacted by e-mail. The number of communication exchanges between FM residents and their psychiatry buddies ranged from 1 to 3 per case, with 2 exchanges the most common (62.5% of cases). According to the FM residents, they usually received a response to their questions within 24 to 72 hours. The psychiatry residents reported that their typical response time was within 24 to 48 hours. Few FM residents (13%) claimed that they contacted their psychiatry buddy each time before making each formal psychiatry consultation.
During the orientation session, FM residents were instructed to print e-mail exchanges with their psychiatry buddy and file the correspondence in the specific patient’s health record. Psychiatry residents were also asked to print the exchanges (although they had only the patient’s initials and date of birth in order to maintain confidentiality in the context of e-mail) and to keep them in a file folder maintained by the program coordinator. When surveyed, it was found that FM residents kept a record of their exchanges filed in the patient’s record about half of the time. Only one psychiatry resident in the 2 years agreed that they always kept a record of their exchanges. This is an important reminder that further attention needs to be paid to appropriate documentation of exchanges, while emphasizing the importance of protecting patient privacy and confidentiality.
In 2006, 93% of FM residents stated that their psychiatry buddy answered their questions to their satisfaction. In 2007, this number fell to 50%. This difference could be attributed to the fact that the psychiatry residents in 2006 were more experienced than those in 2007. Also, senior psychiatry residents have more flexibility in their schedules, whereas the second-year psychiatry schedule is very structured. Senior residents would have had more time to research and respond to questions. The perception of the quality and availability of supervision to psychiatry residents was not polled, but would be useful information to obtain in a future survey.
All of the psychiatry residents reported that the resident CMH program is valuable. Half of these residents agreed that the program enhanced their knowledge of managing psychiatric issues. The most common reasons for exchanges between buddies were medication advice, asking about resources for patients, and other management issues. Upon graduation, 75% of psychiatry and 90% of FM residents stated they would like to be involved in a similar CMH program in practice. Similarly, 75% of psychiatry residents and 89% of FM residents recommended continuing the CMH program during residency training.
Overall, this resident CMH program provides an exciting, reproducible opportunity for family medicine and psychiatry programs to consider. According to the residents who evaluated the program, the resident CMH program has been helpful in patient management, and has provided psychiatry residents with the opportunity to put knowledge into practice in another clinical setting. The program models collaborative mental health care for future practice, and establishes an excellent venue to support the high load of mental health problems seen by FM residents at large teaching centers.
Our advice to others in setting up a CMH program is to offer this program to more senior psychiatry residents, as they typically have more flexibility in their schedules, and have had more time to develop their skills. It is important to offer an orientation session where residents have an opportunity to meet face to face, socialize, exchange contact information, and learn about shared care together. It is also important to define parameters of exchange (e-mail versus fax versus case conference), confidentiality, documentation, timeliness of responses, and supervision of responses by psychiatry faculty.
To keep the program active, it is useful to send reminders to residents and faculty midway through the year to reinforce the use of the program. It is also important to provide education about the program through faculty development with FM teachers to reinforce use of the CMH program when supervising FM residents.
Future research questions to address could include whether CMH programs in residency training better prepare psychiatry residents to meet the needs of family physicians who consult them after graduation. Also, do these programs lead to future system efficiencies and cost savings? Are family doctors better able to formulate their consultation questions after this exposure? Will this exposure enhance family physicians’ skill in managing similar situations in the future?
In 2009, the Royal College of Physicians and Surgeons of Canada introduced new training requirements for residents completing their specialty training in psychiatry (7). A shared-care experience with family physicians, specialist physicians, and other mental health professionals has become mandatory. We believe that this CMH model will be applicable and easily implemented in most training settings. In the future, there will be opportunities to evaluate system-wide implications of resident CMH programs, such as involvement in collaborative care in future practice, provider and patient satisfaction, and change in health-system efficiencies and costs.