Since the 1970s, the American Board of Psychiatry and Neurology has required psychiatry residents to complete 4 months of training in internal medicine. This requirement is completed during postgraduate year 1 (PGY-1), or the internship year. Often the clinical assignments involve an inpatient internal medicine rotation at a general hospital.
We discovered through periodic meetings with residents in PGY-1 during the 2004–2005 academic years that residents were often assigned to the intensive care unit or the coronary care unit. It was thought that such experience was not appropriate for the ambulatory care type of medicine that the residents would use as clinical psychiatrists. In addition, the department had recruited several faculty members who had training in both internal medicine and psychiatry or family medicine and psychiatry. After consultation with these faculty members, we decided to attempt a more innovative program that would allow first-year psychiatry residents the opportunity to work in an ambulatory care setting collaboratively with the jointly trained attendings.
Description of the Program
Most of the faculty in the Department of Psychiatry and Behavioral Sciences at the University of California, Davis School of Medicine (UC Davis), work in clinical settings operated by the Sacramento County Division of Mental Health. Recently, from State of California tobacco tax revenues, Sacramento County built a new ambulatory care building near the campus. This facility provides medical care for Sacramento County patients who have no insurance coverage and meet county eligibility requirements. Because the chair of the department of psychiatry also serves as the Medical Director for Mental Health Services for Sacramento County, one of us (REH) contacted the Director of Mental Health for Sacramento County to ask for her support in developing a pilot project in which county psychiatry patients who met primary care eligibility criteria could receive their medical care from a first-year psychiatry resident and a jointly trained internist/psychiatrist or family medicine/psychiatrist in the county’s Primary Care Clinic. With the support and active collaboration of the Director of Primary Care for Sacramento County, the pilot project was organized.
During 2 of their 4 months in internal medicine, psychiatry residents provide medical care to eligible patients in the Primary Care Clinic. Supervision is provided by three jointly trained internists/psychiatrists and one family medicine/psychiatrist. In addition, the director of the program (JO) developed a consultation program county-wide in which physicians who work at any of the four county-operated clinics, homeless intervention programs, or other intensive service programs could refer psychiatric patients who had no insurance and met other eligibility criteria to the Primary Care Clinic to have medical evaluations.
There is an extensive literature about the increased rates of medical illness in psychiatric patients (1). This is especially true for psychiatric patients with chronic and severe mental disorders (2). Consequently, we thought that establishing such a referral program could considerably reduce the medical comorbidity of psychiatric patients receiving care in Sacramento County. Another pressing problem is that psychiatric disorders in medical patients are often going unrecognized by primary care physicians (3–5). An additional purpose of this combined service was to develop a collaborative consultation arrangement with primary care physicians so that they could refer patients with psychiatric disorders for evaluation and treatment (6–8).
An educational program was also established in which the jointly trained faculty give bimonthly presentations to county primary care physicians, internal medicine residents, medical students, and rotating psychiatry residents on the assessment and management of common psychiatric problems encountered in the primary care or medical setting. This education program has been quite successful. In addition to the primary care attendings, internal medicine residents who rotate through the clinic also attend these sessions.
Another educational program was recently established in which the jointly trained attendings go out to the psychiatry clinics bimonthly and provide educational programs on common medical problems that the psychiatry attendings will encounter in their patients. This aspect of the educational program has just been established.
For the 2005–2006 academic year, the attendings and residents conducted 550 psychiatric consultations, both formal and informal, for the primary care attendings. Furthermore, during 2005–2006, 1,255 uninsured patients from the county psychiatry clinics, substance abuse treatment centers, jail, and community were seen by combined faculty and psychiatry residents, with the majority being treated for both psychiatric and medical disorders. In addition, we held six conferences for primary care physicians addressing common psychiatric issues such as hepatitis C in the dual-diagnosis patient population, anxiety disorders, geriatric psychiatry, the mental status examination in the primary care setting, psychosomatic disorders, and depression treatment in the primary care setting.
During the first year, the most common medical conditions encountered in psychiatric patients were diabetes type 1 and 2, hypertension, hypercholesterolemia, coronary heart disease, chronic renal insufficiency, hypothyroidism, hepatitis C, gastroesophageal reflux disease, seizure disorders, migraine headaches, and community-acquired methicillin-resistant Staphylococcus aureus skin infections.
The psychiatry residents’ responses to this new program were quite enthusiastic. A review of evaluations by residents after completing the rotation from the UC Davis performance analysis report showed that the rating of supervision offered through the service had an average score of 4.29 out of 5 (n=7, SD=0.76), and that the overall rating of training site and rotation had an average score of 4.43 out of 5 (n=7, SD=0.53).
Here are representative comments on the rotation from the residents:
“The diversity of the patient population, the quality of the attendings and their teaching, and the general work environment made for one of the best atmospheres for learning medicine and primary care that I could hope for. This rotation is not simply a less painful way to satisfy our board requirements for medicine. It is a shining example of the importance of maintaining a strong base of medical knowledge and the inextricable interface between medical illness and psychiatric illness.”
“Great site to learn [from] medicine-interested, enthusiastic faculty who seemed to care about our learning medicine as much as … noncombined, medicine faculty … Enjoyed having combined faculty teach us medicine.”
The residents found the rotation, compared with other medicine rotations, to provide both training and clinical experiences that were more applicable to psychiatry residency.
Training psychiatry residents in internal medicine can be accomplished in a creative fashion when the teaching and supervision is provided by jointly trained attendings in internal medicine/psychiatry or family medicine/psychiatry. The positive results of this pilot project led to another unexpected initiative: a joint internal medicine/psychiatry residency that began to recruit residents beginning with the July 1, 2007, academic year. The primary care-psychiatry initiative played a large role in bringing together the six jointly trained attendings in the department to develop a medicine/psychiatry division that seeks to integrate the educational and clinical research opportunities in this area. The department already has a family medicine/psychiatry residency program that was established in 1995. This program has two residents in each year of training, and the internal medicine/psychiatry residency will also have two residents in each year.
The next initiative that will be instituted sometime in the 2008–2009 academic year will be the provision of the other 2 months of psychiatry residents’ medicine rotation at an internal medicine/psychiatry inpatient unit. This program is being established by the Northern California Veterans Administration, located at Mather Air Force Base, a 15-minute drive from the UC Davis Medical Center. The rotation is scheduled to begin in the early part of 2009. The medical director of this new facility will be a jointly trained family medicine/psychiatrist. The training and supervision of the other 2 months of the psychiatry residents’ medicine rotation will be provided at this facility. Consequently, the 4 months of the psychiatry residents’ medicine experiences will consist of 2 months of ambulatory care medicine and 2 months of inpatient internal medicine, both at facilities in which the training and teaching are provided by jointly trained attendings.