The movement to create combined training in family practice and psychiatry was originally conceived in response to the growing number of psychiatric disorders being treated in the Primary Care clinics in the U.S. (1, 2). The combined training track was established in 1995. Combined training requires 5 years, after which graduates are eligible for board certification in both family practice and psychiatry.
To our knowledge, there are only six published articles specifically addressing combined family practice-psychiatry training issues (3—8), and none address the issues discussed in this article. Under current guidelines, each combined family practice-psychiatry residency is separately reviewed by the supervisory committees of the American Board of Family Practice and the American Board of Psychiatry and Neurology but not individually accredited by the American College of Graduate Medical Education Residency Review Committee (RRC). With such variation and lack of standardization, inevitable disparities arise from program to program. Perhaps most concerning to faculty and program directors is the challenge of providing supervision and practice guidelines for these residents with no historical precedent to follow. Most faculty members are board certified in either psychiatry or family practice, and very few have dual training. Thus, the faculty of a combined program may not know how to provide appropriate supervision and guidelines for the boundaries of practice within each specialty. In this article, we share our experience of providing such guidance and hope to generate dialogue and movement toward standard practices.
The NCC combined family practice-psychiatry residency program was started in 1996 as a joint venture between the Malcolm Grow Air Force Medical Center Family Practice Residency (on Andrews Air Force Base, Maryland) and the NCC categorical psychiatry residency. The participating institutions include the Uniformed Services University of the Health Sciences, Malcolm Grow Air Force Medical Center, Walter Reed Army Medical Center, and the National Naval Medical Center. Our residents include members of the Air Force, Army, and Public Health Service. By the end of academic year 2003—2004, we had eight graduates and averaged one to three members per class, depending on the applicant pool and allotted military training slots.
The curriculum for our program at our medical center consists of 5 years (Appendix 1), during which each year has a mixture of family practice and psychiatry rotations. At the end of the 5 years, residents will have completed 30 months of each specialty. Each resident maintains a psychiatry clinic from year three to the end of residency and follows a panel of family practice outpatients for all 5 years that increases in size over the final 2 years of the program. Needless to say, their family practice panel includes a significant number of patients with psychiatric problems so that they have a longer-term psychiatric experience than any categorical psychiatry resident.
Providing supervision to combined family practice-psychiatry residents is challenging due to their complex schedule and varied responsibilities. In our program, both family practice and psychiatry supervision is performed just as it is for categorical residents. On their own, the individual supervision practices work well. However, the differences in supervision philosophies and policies sometimes create tension and confusion for resident and faculty alike.
Family practice and psychiatry supervision are both intense during internship. On inpatient rotations, the supervising physician and senior resident provide supervision. In the family practice clinic, an assigned preceptor-for-the-day supervises each patient encounter. Family practice residents are given an increasing degree of autonomy beginning with the second year of training and seek immediate supervision from a preceptor for difficult clinical cases or for additional guidance. Clinical charts are reviewed to monitor quality of care. Clinical deficiencies are addressed by increasing the level of supervision if the standard of care or quality of documentation is not met. This family practice supervision "mind-set" stands in marked contrast to that of psychiatry.
In psychiatry, supervision usually remains intense for a longer duration. During the outpatient year, every clinical case is closely supervised. Every psychotherapy case receives dedicated supervision after each appointment, usually an hour each week throughout the duration of the program. Combined residents must adjust to these different approaches to supervision and follow the guidelines for each, depending on where they are working at any given time.
Two distinct boundary issues lead to supervision difficulties: individual doctor-patient boundaries and boundaries of practice. The personal boundaries in family practice are more relaxed than those of psychiatry. In family practice, physicians are more open about their marital and family status, as well as things such as hobbies and events in their lives. It is common for family practitioners to receive small gifts or baked goods at holidays or when moving to another location (a common occurrence in our military system). Finally, they routinely touch their patients in the course of a physical examination and as a means of encouragement and support. Routine family medicine involves invasive physical examinations and touch that could confound psychotherapeutic interventions and set the stage for boundary violations.
In psychiatry, empathic yet firm boundaries are of paramount importance due to their effects on patient treatment and on the unconscious and conscious motivations and expectations of patients. While some self-disclosure may be therapeutic, this is generally minimized and discouraged lest the treatment become more about the doctor than the patient.
The initial policy of our residency was to let residents treat the same patients in both the family practice and mental health clinics. This seemed to be a reasonable approach since our goal was to integrate the two specialties. When he or she saw a patient in both clinical settings, he or she referred the patient to a colleague for invasive physical examinations, such as pelvic, genital and breast examinations. We called this "self-referral" or "dual-management." In dual-management, the resident as family physician seeing a patient in the family practice clinic, refers a patient to himself as psychiatrist and also sees the patient in the mental health clinic for longer appointments and more extensive evaluations or vice versa. This allows for proper supervision to occur in each setting and for sufficient time scheduling to deal with more difficult psychiatric issues. We had some successes with this approach and innovative care was delivered. For example, one of our residents managed a very complicated patient with multiple psychiatric disorders and terminal cancer as both her family physician and her psychiatrist (9). The role of this resident, as both her medical and psychiatric physician, facilitated the application of a flexible approach to her care. Because the clarity of boundaries was established early on in treatment, there was little difficulty with blurred boundaries in spite of the mixed doctor-therapist role. The fact that one physician assumed both roles decreased opportunities for "splitting," comforted the patient and improved her quality of care. She eventually died a peaceful death with her family at her side. There are other examples of this type. For instance, one of our residents successfully treated two adolescent girls with challenging behavioral problems as both their psychiatrist and their family physician. Both cases were supervised by family practice and psychiatry faculty over 2 years of treatment. As in the case discussed above, the dual management of these cases led to smoothly coordinated and comprehensive care.
Nevertheless, dual management can confuse the personal and practice boundaries for both resident and patient. It may not be clear to either resident or patient which role the doctor is in at any given moment in treatment. Our residents sometimes find themselves utilizing their still developing psychotherapy skills while in the family practice clinic; and if the occasional supportive psychotherapeutic role is assumed, it can be quite helpful to their patients. However, in our program, the family practice clinic has historically had no on-site psychiatric faculty to provide appropriate supervision. And it is not unusual for a resident to become deeply entangled in psychosocial issues with a family practice patient. This entanglement could divert their focus from other serious medical issues.
Another problem involves the application of family practice supervision rules in the treatment of psychiatric cases in the mental health clinic. The advanced resident spends a growing amount of time in the family practice clinic as residency progresses. In their fourth and fifth years, our residents spend 2 and 3 half days per week in the family practice clinic with an increasing degree of autonomy. Meanwhile, they are still required to obtain individual supervision for psychiatric medication and psychotherapy patients. In some cases residents have referred patients to themselves from family practice to mental health for dual management but continued to apply the family practice supervision rules.
In one case, a resident saw a patient in family practice who needed a more thorough psychiatric evaluation. He wanted to refer the patient to the mental health clinic where another physician would handle that aspect of care, but the patient insisted that he would see no other psychiatrist. He did a reasonable 15-minute primary care assessment with a provisional diagnosis of alcohol dependence and antisocial personality disorder but could not rule out bipolar disorder in that short time frame and was concerned for the patient. He saw the patient in the mental health clinic to perform a thorough evaluation and render appropriate treatment. However, he was in the "FP mind—set." Being busy with multiple clinical duties, he deferred supervision on the case and did not discuss it with any psychiatric staff. It seemed routine enough to him. Ten days later, the patient committed a murder-suicide and the case was investigated. While the resident was judged to have performed good care in this case, the lack of supervision was concerning to the faculty. Psychiatric cases require more intensive supervision. Combined residents are confident, capable, want to provide comprehensive health care and are given substantial autonomy in the family practice clinic. They may easily "slip" into their "family practice supervision mind—set" in a psychiatric setting resulting in inadequate supervision of complex cases.
In another case from early in the development of our program, one of our residents was caring for a patient in both the family practice clinic for her medical needs and in the mental health clinic for monthly medication management and supportive psychotherapy. The patient needed a pelvic examination and wanted the resident to perform it. She stated that this resident was the one she trusted most and felt uncomfortable with any other physician performing the examination. Not wanting to traumatize her patient by having another doctor do the exam, she performed the examination (without prior approval). While the examination had no adverse sequelae, there existed a definite potential for causing emotional harm. The patient could have easily felt violated by the one doctor she trusted the most. One could argue that this is an example of crossing a boundary without violating it (9).
Integration of Psychiatry and Family Practice
While it is essential for residents to learn the content material of both family medicine and psychiatry, it is equally important for them to learn the processes of boundary setting, both personal and professional, and the subsequent skill of appropriate integration of two distinct skill sets. As our program has evolved, both the psychiatry and family practice faculty determined that the boundary between the two specialties must remain firm during training in order to model clear boundaries and to ensure that the training in each specialty is not compromised.
Most psychiatric rotations do not place the resident in the position of primary care physician. Managing primary care problems is simply not part of the culture, scope of practice, or skill set of psychiatrists. On the other hand, psychiatric care is an integral component of family medicine. A large percentage of primary care patients have psychiatric and/or behavioral problems (1, 2, 11). Therefore, the most natural place for the integration of psychiatric and family practice skills and knowledge is within the family practice clinic. However, if the boundary between the two specialties is not maintained, combined residents can find themselves feeling overwhelming pressure to do "everything for every patient." They easily become inundated with "difficult" patients in the family practice clinic as colleagues gladly refer the most challenging patients to them. Because of their increasing skill and mastery of psychiatric pathology and treatment, residents are tempted to provide more extensive psychiatric treatment in the family practice clinic than is prudent. But because of their relative inexperience, they may not realize that this is the case. The biopsychosocial mind-set integral to family practice may lead residents to feel as though they should be able to provide both primary and psychiatric care for all of their patients, all of the time. Residents sometimes feel guilty referring a patient to the mental health clinic for care when they believe they could easily do the job themselves and that they "should" do so. This internal pressure is compounded by the pressure placed on the residents by patients who selected them as their "Primary Care Manager" because of their combined training.
These internal and external pressures notwithstanding, residents must be allowed to master their family practice skill set without being unduly burdened with an excessive proportion of psychiatric cases. The RRC requires that family practice residents must care for an "undifferentiated" family practice patient population as part of their training. Likewise, they must master their psychiatric skills without being burdened with becoming their psychiatry patients’ primary care doctor. If our residents become "FP-Psych" specialists while still in training, their family practice experience could be compromised. We eventually realized that we must protect our residents, not only from the external pressures, but also from their own desire to do too much too soon in a well-intentioned effort to help their patients.
All family practice physicians practice a certain amount of psychiatry. Certain types of psychiatric interventions are within the scope of practice of family medicine (Appendix 2). These are usually performed during 15—30 minute appointments, sometimes longer if scheduling permits, as a part of overall patient care. Psychotherapeutic treatments rendered in this setting are relatively simple, focus on psychotherapeutic content rather than process, and emphasize supportive techniques. It is our contention that complex psychiatric treatments are inappropriate for our residents to practice in the family practice clinic. In our program, difficult patients are referred to mental health if they require psychiatric evaluation or management that exceeds the family practice scope of care. It is expected that, as combined residents advance in training, they will naturally incorporate their psychiatric knowledge and skills into accepted primary care psychiatric interventions. In order to assure the understanding of appropriate limits for psychiatric care in the family practice clinic, combined residents are required to discuss psychiatric diagnosis and treatment with a family practice preceptor whenever utilizing psychiatric modalities. This allows the resident to focus on psychiatric treatment as it is usually conducted within family practice clinics rather than as practiced in a specialty setting. At the resident or faculty’s discretion, he or she may discuss psychiatric patient care issues with a psychiatric faculty member. Thus, while in the family practice clinic, residents practice within the family practice scope of care but with a greater depth of psychiatric skill and knowledge than other family practitioners. In exceptional cases, the resident may engage in more complex psychiatric treatment in the primary care setting, but in order to do so, he or she must obtain prior approval and supervision from both family practice and psychiatry faculty. One example of this seen in our program is dual psychiatric and medical management of an adult with developmental disabilities, or chronic but stable schizophrenia or bipolar disorder. Dual supervision ensures that both the psychiatric and family medicine standards of care are met.
At one time or another, all of us have had a psychiatric patient ask us to renew a medication initially prescribed by a physician from another specialty—such as an antihypertensive, lipid lowering agent or sulfonylurea. And with our current knowledge of the association of mental illness, psychotropic medication effects, and elevated rates of impaired glucose regulation, psychiatrists should develop their knowledge base and competence in treating some common primary care problems. It is no surprise that our combined residents encounter this type of request often during their time spent in the psychiatry clinic and that they again feel these are medical problems they are able to and should competently treat. However, we have required them to act solely in the role of psychiatrist in the mental health clinic, again, so that appropriate boundaries are maintained and appropriate supervision can be rendered. If a patient requires assistance with a primary care medical problem, the combined resident is able to facilitate the referral to an appropriate primary care provider. In addressing this with our combined residents, we have found it helpful to discuss the potential impact on the patient’s transference and on their psychiatric treatment, as well as stressing that there are no physical exam rooms, and that only height, weight and vital signs are obtainable in our mental health clinic.
Graduates from our program are both Army and Air Force physicians (though our first graduate was in the public health service). They are required to spend their first assignment as a psychiatrist, with small amounts of time allotted to practice family medicine at the discretion of the needs of their command. After that, they may create their own path, whether psychiatry, family medicine, or some combination of both. For example, most of our graduates are in psychiatry positions at this time. These positions range from being the sole psychiatrist at a small base, teaching faculty in family practice residencies, and running psychiatric consultation services. Almost all of them maintain a small primary care panel or work part-time in flight medicine or ambulatory medicine clinics. The practice of family practice-psychiatrists is bound to have a different quality to it and be distinct from either pure family medicine or pure psychiatry. As one of our graduates has said, "When you do both at the same time, it might not look like either" (Charles Motsinger, M.D., personal communication). However these graduates integrate the two specialties is only limited by their desire and creativity. It is our hope that however they choose to do so, they will integrate these skills as competent physicians who clearly understand the boundaries and roles of each individual specialty.
The goal of the program is to create physicians who can integrate the two skill sets and knowledge bases of psychiatry and family medicine. It is a challenge for educators to determine the best way to teach residents how to do this. As we progressed from a new to a more mature program, we tried different approaches. We wanted the residents to integrate two skill sets and yet maintain appropriate boundaries. If training was to be successful, they had to learn the personal and professional boundaries specific to each specialty. We concluded that the most effective way for them to do so was by practicing each specialty separately and receiving supervision and mentorship by the respective supervisors. Our experience suggests that only when they learned the appropriate practice of each specialty could they then successfully integrate the two without boundary confusion. Overall, the residents have felt protected by this policy. They report that it is easier for them to avoid some of the external pressures placed on them and that the policy relieves them of the internal pressure to be all things to all patients.
The result of combined training in family practice and psychiatry is still unknown. Balancing patient care activities in two specialties during and after training remains an ongoing challenge. Setting rules for supervision and boundaries of practice is essential and there are no currently accepted standards. We believe that our approach is a reasonable one but certainly not the only one. We further expect that our approach will evolve as the program and the specialty mature. We hope that the ideas shared in this article will stimulate discussion by those involved in combined training programs and to the eventual development of standards and guidelines.