Over the past 50 years, the breadth of pharmacotherapy has increased enormously. This has allowed for improved management of mental illness and its symptoms, particularly where comorbidities and Axis II disorders are concerned. Also, due to the complicated nature of mental illness, there may be a tendency to give multiple diagnoses for a kaleidoscope of symptomology.
For psychiatric residents whose knowledge base and experience level are probably not as robust as supervising attending physicians, the temptation for both multiple diagnoses as well as extensive polypharmacy may be particularly strong. As a past resident trainee of our program and now an assistant training director, one of our authors (TS) has noted that trainees often feel that their patients are “more difficult, complex,” and possibly are less likely to respond to treatment. The training clinic has had a shift in third party reimbursement over the last several years from a predominantly public insurance clinic to a clinic that now receives approximately half of its revenue from the private sector. Despite this shift toward a higher socioeconomic patient-base, trainees often still echo the same sentiment that their patients are more complex and difficult to treat when compared to attending private patients. In order to evaluate this claim we attempted a literature search to determine if others have attempted to define the difference between trainees’ and attendings’ patients. However, no articles have looked at a comparison of both diagnostic attributes as well as pharmacotherapy difference in supervising physicians compared to their psychiatric residents. This article attempts to determine if there are differences in diagnoses and pharmacotherapy broadly in a random sample of psychiatric residents and supervising attendings in a university outpatient setting.
Prior to looking at our sample’s use of multiple medications, we reviewed the problem of polypharmacy to understand if extensive use of psychopharmacologic treatment by residents is due to lack of clinical experience, or because of complex patients with extensive symptoms. This finding is not confined to the United States, but is also seen in the United Kingdom and Japan as well (1–3). Some of these articles suggest that polypharmacy may be evidence of “poor clinical care.” One study states that polypharmacy may be a detriment to adherence in maintenance therapy and prevention of hospitalization (3). Other studies have found that there is a need for polypharmacy for psychosis prevention and reduction of concomitant affective symptoms, like depression and suicidality (1, 2).
This study investigated whether two patient population groups, under the care of either resident physicians or supervising attendings, are equivalent or different by comparing the distribution of patient characteristics and diagnoses. If the two groups were determined to be equivalent, we wanted to compare prescribing practices regarding polypharmacy. No article has examined differences in patient complexity or polypharmacy tendencies between attendings and psychiatric residents. Our study was designed to provide a more objective perspective on the influence of supervising academic physicians on resident physicians. The authors attempt to quantify and qualify the differences in prescribing and diagnostic trends between these two groups.
We retrospectively reviewed a total of 200 active, randomly chosen charts in the Department of Psychiatry at SUNY Upstate Medical University in Syracuse, N.Y. (100 resident charts, and 100 charts of supervising attendings). The psychiatric residents (N=12) treat outpatients through the university hospital public clinic, which is about 60% public entitlement patients receiving Medicaid or Medicare, whereas the attending psychiatrists (N=5) work through an independent practice group where billing of public entitlements is quite limited and private insurance or fee-for-service is the usual billing modality. Psychiatric diagnoses for all charts were based on conventional psychiatric evaluations and not on the use of semistructured interviews such as the Structured Clinical Interview for DSM-IV. Psychiatric residents have very little control over the assignment of patients to be treated as outpatients; these decision are most often made by clinic administration. In contrast, attendings exert full control over which patients they choose to accept into practice.
We collected and tabulated chart information, including demographic data (age and gender), length of treatment, the number and DSM-IV code of all psychiatric diagnoses, and psychotropic prescription data (Table 1
and Figure 1
). The prescription data included a record of all psychiatric medications for each individual patient. The clinic’s electronic medical record (ClinicTracker™ by JAG products) database software was used for collecting data on residents’ patients, using the first one hundred charts in the database after an alphabetical sort. Hard copies of attending charts were provided by individual attending psychiatrists. Attending psychiatrists were asked to provide access to “20 random charts for a research study” from their independent practice without explanation of the study. Diagnoses collected were from the most recent note in each chart and not the intake diagnosis. Both collection processes were certified by Institutional Review Board. The resident charts came from 12 individuals in the postgraduate-year 3 (PGY-3) and PGY-4 resident group; the attending charts came from five supervising attending psychiatrists (three employed faculty and two volunteer faculty members). Each of 12 residents had been supervised by at least one of the five attending psychiatrists. We included active patients with at least one Axis I diagnosis, with no other inclusion or exclusion criteria.
We analyzed the data for differences in demographics, absolute number, and percentages of various DSM-IV diagnoses, absolute number of various prescriptions, and prescriptions of specific drugs within each category of psychotropics. Resident and attending pharmacological management was psychiatric, and not generally medical in nature, therefore we did not include “nonpsychiatric” medications in our data set. Statistical measures included using the Student’s one-tailed t test and chi-squared analysis. Analysis of data was completed using Microsoft Excel 2002™ software.
Our findings show that resident cases had significantly more female patients (76% compared to 24% male) than attending cases (65% compared to 35% male) (Table 1
). The average treatment time was 61 months for attending charts, and 26 months for resident charts (Table 1
) which reflects the short nature of residency training.
The authors found strong similarities between the outpatient diagnoses and use of medications, comparing the care of patients of psychiatric residents and the care provided by their attending psychiatrists. There was a statistically significant difference in the average number of Axis I diagnoses (2.0 for residents compared to 1.6 for attendings) that may not be clinically relevant, as these are one half of a diagnosis in difference. There was no significant difference in the percentage of each sample with an Axis II component (16% and 17%) (Table 1
). In both sets, major depressive disorder, posttraumatic stress disorder, bipolar disorder, generalized anxiety disorder, and alcohol and/or drug dependence are all in the top five of all Axis I diagnoses (Figure 1
). Borderline personality disorder is the most common axis II diagnosis (Figure 1
). There were no statistically significant differences in diagnostic counts by chi-square analysis.
Finally, we wanted to determine if psychiatric residents were more likely to prescribe greater numbers of medications for a given patient than their supervising attending counterparts. This was a mixed result; we found that residents prescribed more total prescriptions than their supervisors, but they also had more patients on no medications, by chi-square analysis (Table 1
). Finally, there were no significant differences in the ratios of different classes of medications being prescribed (Table 1
Polypharmacy and multiple diagnoses patients are commonplace in modern psychiatric practice. However, psychiatric residents may assume that supervising attendings “cherry pick” patients that are higher functioning patients or refer the more difficult and disabled patients to their trainees. Also, there may be supervisor assumptions suggesting that psychiatric residents overmedicate patients due to pharmaceutical industry influence and/or lack of experience with psychopharmacologic management of psychiatric patients on an outpatient basis. This study hoped to address both of these assumptions which have been noted by training directors.
This study found strong similarities comparing psychiatric resident and supervising attending diagnoses and psychopharmacologic management of outpatient mental illness. Our study further suggests a strong influence of supervisors on psychiatric residents. Residents prescribed more medications than their attending counterparts, but they also had more patients on no medications as well. Furthermore, there have been a number of editorials about the influence of the pharmaceutical industry on the prescribing habits of house staff. These editorials point out that resident prescribing habits are particularly vulnerable to pharmaceutical marketing, without strong evidence to support such claims.
There are two possible conclusions that can be reached regarding the increased average number of Axis I diagnoses in the resident chart sample. It may be that indeed supervising attendings select higher functioning patients or refer patients with multiple diagnoses to their trainees. However, this difference in the average number of Axis I diagnoses can be explained by a greater number of patients with three Axis I diagnoses in the resident chart sample. There were no differences in either the number of Axis II diagnoses patients, or the number of patients with one or two Axis I diagnoses. This suggests that the difference in average number of Axis I diagnoses is a minor finding.
We need to address the limitations of this study. The patients were randomly selected; however, this was a retrospective not prospective chart review. A study of resident diagnoses and treatment regimens on a multicenter level may provide more information on subtle differences between supervising and psychiatric residents over time. Also, the sample size was rather small; greater numbers may shed light on subtle differences that we were not able to determine with our sample size. This is particularly noteworthy given the lack of focus on a particular drug class or specific diagnosis. Finally, this study was conducted in one university outpatient clinic setting; it may just be representative of local university treatment culture. Inclusion of local community outpatient clinics, other statewide clinics, or out-of-state outpatient clinic settings would provide a broader sense of the standardization of our results.
In summary, both in diagnosis, as well as prescribing tendencies, our psychiatric residents and their supervising attendings are very similar.
FIGURE 1. Top 10 Axis I and Axis II Diagnoses (n=100)
Diagnostic and polypharmacy trends among residents and supervising psychiatrists. Panel A is a comparison of the most common Axis I and Axis II diagnoses in two different chart samples. This figure illustrates the ten most common Axis I and three most common Axis II diagnoses within two different chart samples. Panel B is a comparison of the number of medications prescribed in two different chart samples. In both panels, the black bars illustrate the number of drugs prescribed per patient in a sample of 100 patients treated by psychiatric residents. The gray bars illustrate a similar illustration, except the patient population is being treated by supervising attending physicians.