The prevalence of psychiatric conditions in primary care patient populations is well documented. Nearly one in 10 patients presenting to primary care clinics has clinically significant depression or generalized anxiety (1). Unfortunately, primary care physicians do not always effectively diagnose, document or treat mental illness (2). Approximately only one-quarter of anxiety disorders and only one-half of depressive disorders are recognized and treated by primary care physicians (3). The importance of educating primary care physicians about psychiatric disorders is readily apparent, but the amount of available educational time in primary care training programs is limited. Despite the clear need for educational goals and methods in this area, curricula vary greatly.
This brief report outlines the development, implementation, and initial evaluation of a curriculum designed to teach primary care psychiatry to the residents in the National Capital Consortium Family Practice Residency at Malcolm Grow Medical Center, Andrews Air Force Base, Maryland.
The primary goal of this project was to design a curriculum to teach family practice residents relevant aspects of common behavioral health conditions encountered in family practice clinics. The curriculum development process consisted of five components: literature review, needs assessment, planning, implementation, and initial evaluation.
A search was conducted using PubMed, PsychLit and E.R.I.C. databases from 1950 to 2004 using a wide range of subject headings. More than 200 English language abstracts and articles were reviewed. Thirty-four relevant articles were ultimately identified. The articles reviewed can be separated into one of three categories: 1) psychiatry focused, 2) primary care focused, or 3) integrated focus.
Psychiatry focused curricula are often taught by mental health providers. They emphasize diagnostic and treatment topics that are conducive to a lecture format and are often taken from psychiatry residency curricula, such as Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis and psychopharmacology. An example of this format is found in recommendations to residencies from the Society of General Internal Medicine (4). Although this model curriculum provides an exhaustive list for competency-based learning, it can be too time intensive and does not focus on relevant issues for primary care physicians (5, 6). The former curriculum at the National Capital Consortium (NCC) Family Practice Program was based on the Psychiatry focused curriculum.
Primary care focused curricula are often taught by primary care physicians and emphasize topics relevant to the family practice clinical experience. The topics are conducive to case discussion format and include managing difficult patients, counseling skills, and presentation and treatment of common psychiatric disorders (2). Shienvold and Asken provide an example. In their project, they surveyed family practice residents to rank order the topics they felt were most relevant for their behavioral health training and developed their curriculum based on those responses (7). This format allows the input of those being educated. However it may also permit neglect of relevant psychiatric topics such as pharmacology, dangerousness evaluations and infrequent diagnoses.
Integrated focus curricula emphasize involvement of both primary care and psychiatry physicians in selecting topics and presenting them in a format applicable to a primary care clinical setting. Few articles exist in this category, however. Servis and Hilty wrote a proposal recommending the following: 1) didactics be taught by psychiatry residents and faculty, 2) integrative seminars that involve both psychiatry and primary care residents, 3) combined residency training in psychiatry and primary care, and 4) a "most difficult case" conference (8). This format suggested many elements that our programs already possessed and became the foundation for our curriculum development.
A preliminary satisfaction survey of the NCC family practice residents was completed in January 2002. Their impressions of the prior weekly psychiatric education session, which consisted of loosely organized lectures and case discussions, and its perceived value, relevance, teaching method effectiveness, and effect on practice patterns were assessed. They were asked to provide suggestions for improving the curriculum. Lastly, a topic list was generated by asking family practice residents to identify the topics of greatest importance to them.
The survey demonstrated that the residents queried felt the prior format was not valuable, relevant, helpful, conducive to learning, or likely to change their practice. The most commonly preferred educational formats were difficult case discussions and didactic style lectures as opposed to small group discussions, family practice resident led discussions/presentations, or journal club reviews. The residents preferred teaching by both combined residents and psychiatry staff (t1).
The curriculum utilized an integrated format and was designed to address the concerns raised by the initial needs assessment. The senior combined family practice-psychiatry residents were the primary individuals responsible for developing the new curriculum. Supervision and final approval were provided by both psychiatry and family practice staff. The curriculum was designed for a 6-month period with senior family practice residents as the core audience (F1). The final topic list was developed from multiple sources including: literature review, resident survey, board certification review materials, and a review of the prior 4 years of family practice in-service examinations (Appendix 1). Senior family practice-psychiatry residents were designated to serve as instructors. This afforded them the opportunity to grow as educators and develop their skills as consultants and translators between the specialties.
The lectures were presented by fourth year family practice-psychiatry residents. They were formatted to reinforce newly acquired data focusing on pertinent features for family practice physicians. The lectures integrated board style review questions in a test-teach-retest format and implemented a broad variety of teaching techniques including the use of movie clips, games, group participation, and correlating concepts with commonly encountered primary care disorders.
The challenging case discussions were led by fifth year family practice-psychiatry residents. In advance, family practice residents and staff were emailed or verbally requested to provide case suggestions. The resident facilitator chose the case and developed relevant teaching points (up to 3) for each discussion. The facts of the case were presented by the family practice staff or resident and the facilitator led the discussion. Those in attendance were encouraged to participate through: 1) further history and physical exam questions, 2) formulating differential diagnoses/problem lists, 3) further diagnostic evaluations, 4) final diagnosis choice, and 5) identifying at least one biological, psychological and social treatment option. Both psychiatry and family practice staff attended providing further spontaneous teaching points and clarification.
Initial Curriculum Evaluation
To assess the psychiatric knowledge of the family practice residents, a 25-item multiple choice test was administered prior to and upon completion of the 6 month curriculum. The test included examination questions directly from the lecture series. One point was awarded for each correct response. Pre- and posttest items were identical and residents were not provided feedback on their performance nor the correct answers following pretest administration. All 10 senior family practice residents voluntarily and anonymously participated. The mean score for the pretest was 14.9 (SD=1.6) or 59.6% with a range of 12—17. The mean score for the posttest was 19.9 (SD=2.28) or 79.6% with a range of 16—24. This demonstrated an average improvement of 20%. A t test comparing pretest and posttest scores yielded a t value of −6.45 (p= <0.0005).
The final resident satisfaction survey assessed their perception of the curriculum’s value, relevance, teaching method success, and effect on practice patterns. The results are displayed in t1. The residents overwhelmingly felt able to formulate a psychiatric consult and found the sessions valuable and likely to change their practice. Although they found both types of sessions useful, they found the difficult case discussions more beneficial than the lectures. Lastly, the respondents found it very valuable to have other residents providing the educational sessions whereas they were equivocal about staff instruction.
This integrated focus curriculum utilizes multiple components recommended previously by Servis and Hilty (8). Its administration was associated with improved posttest scores as well as significant support and satisfaction with the educational initiatives. However, the benefit of this curriculum is not only in the raw numbers, but also in the further integration of teaching between the specialties.
Several unique aspects of the curriculum may account for this improvement and increased level of comfort with psychiatric topics. First, creative teaching techniques, including integrative board style review questions, games, movie clips, and group discussion, appealed to the family practice residents. Second, the integrative curriculum was developed by family practice-psychiatry trained residents who are in a unique position to understand what is relevant to a primary care physician.
The hybrid experience of a combined residency may serve as a bridge between the clinical realms of family practice and psychiatry. This can engender a collegial atmosphere and help the educators differentiate, translate, and convey psychiatric knowledge relevant to the family practice arena. Although combined family practice psychiatry residents are more trained to integrate these fields, teaching an integrated curriculum can be a beneficial experience for all psychiatric residents and staff. The experience and educational benefit of learning to translate between specialties, especially at the residency level, can have a number of impacts in the future: 1) create consultants who are able to better communicate with primary care physicians, 2) develop increased collegial relationships between members of the specialties, and 3) lead to more psychiatrically minded primary care physicians.
This pilot study was limited in certain areas. First, the test used was not a validated measure for assessing psychiatric knowledge base. Second, no comparison group made it unclear to what degree other mental health experiences contributed to the 20% improvement. Third, the study did not include independent evaluation of the curriculum content or specific outcomes achievement. Finally, the study did not assess the effect of the curriculum at the point of care—how physicians actually practice.
In response to the final survey and study results, several improvements are proposed for future implementation of this curriculum. 1) Utilize specific assessment methods for an incoming class of family practice residents. Those methods include: simulated patients, patient surveys, self-assessment, and record reviews. These will allow for a better judgment of the fit between the students and the curriculum. 2) Add a validated psychiatric knowledge assessment tool. This will provide a reliable assessment of the curriculum’s impact on the family practice residents’ psychiatric knowledge base. 3) Consider the addition of a comparison group to show that the changes are due to the curriculum as opposed to other psychiatric educational opportunities that residents are encountering during their training. 4) Implement the curriculum with psychiatry residents instructing in place of the combined family practice-psychiatry residents. This allows for determination of the impact of combined residents to translate between the two specialties and demonstrates if the curriculum generalizes to other residency programs.
The views stated in this study are those of the authors and do not represent the views or the policy of the U.S. Department of Defense.
No grants or financial support was used to fund this study.