Academic Psychiatry 24:124-132, September 2000
© 2000 Academic Psychiatry
Training Psychiatry Residents as Consultants in Primary Care Settings
Deborah S. Cowley, M.D.,
Wayne Katon, M.D. and
Richard C. Veith, M.D.
Dr. Cowley is Professor and Director, Psychiatry Residency Program, Dr. Katon is Professor and Vice Chair for Health Services Research, and Dr. Veith is Professor and Chair, Department of Psychiatry and Behavioral Sciences, all at the University of Washington, Seattle, Washington. Address reprint requests to: Deborah S. Cowley, M.D., Department of Psychiatry and Behavioral Sciences, Box 356560, University of Washington, Seattle, WA 98195-6560. e-mail: dcowley{at}u.washington.edu
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ABSTRACT
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Patients seen in primary care medical settings often have psychiatric disorders that often go undetected by their primary care physicians. It is important that psychiatry residents be trained in the specific skills necessary to work as consultants in primary care settings. The authors describe 2 years of primary care consultation–liaison rotation experience for 4th-year psychiatry residents (16 rotations, one-half day per week for 12 months or 1 day per week for 6 months). Residents' evaluations of their experience were generally positive. The presence of a supervising attending psychiatrist who worked in the same clinic resulted in higher satisfaction and effectiveness ratings. Other issues identified by residents included need for specific preparation for working in such settings, frequent misunderstanding of the psychiatry resident's role by primary care providers, and the difficulty of establishing relationships and communicating with multiple clinic providers. Authors discuss modifications of this rotation and recommendations for the establishment of similar rotations elsewhere.
Key Words: Primary Care • Consulting Psychiatry
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INTRODUCTION
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Several studies have documented high rates of mental health problems among patients in primary care settings, with rates of diagnosable psychiatric disorders ranging from 15% to 36% (1–4). Notably, Regier et al.'s 1978 finding that over 50% of individuals with psychiatric disorders are seen only in primary care led to their description of general-medical practice as "the de facto U.S. mental health services system" (3). Increasingly, research studies and clinical experience support the value of psychiatric consultation and liaison activities within primary care clinic settings in improving the outcomes of primary care patients with common mental disorders such as major depression (5). This article describes a training experience designed to prepare psychiatric residents to work as effective consultants within primary care settings, treating this majority of patients with mental health problems who seek care from primary healthcare providers.
Depressive and anxiety disorders in medical patients are not only common, but also have been associated with increased medical care utilization and costs, greater functional impairment, and poorer adherence to self-care regimens in patients with chronic medical illness. Primary care patients with major depression have significantly higher healthcare costs than control patients matched for age, gender, and chronic medical illness (6,7). Katon et al. (8) found that 10% of primary care patients account for almost one-third of all outpatient primary care visits, one-half of hospital days, one-half of specialty visits, and one-quarter of prescriptions. Of these high utilizers, 50% had significant psychological distress, and of distressed high utilizers, three-quarters had lifetime anxiety or depressive disorders (8). Wells et al. (9) found that depressed patients had greater disability than patients with chronic medical illnesses, such as hypertension, diabetes mellitus, arthritis, back problems, lung problems, and gastrointestinal disorders. Patients with comorbid depression and chronic medical conditions had the greatest disability, and depression has been shown to be associated with decreased adherence to self-care activities, such as medication, diet, and exercise.
Despite the high prevalence of psychiatric morbidity in the primary care setting, primary care providers commonly underdiagnose psychiatric conditions (10,11), detecting fewer than half of cases of major depression. Furthermore, treatment of major depression in primary care settings is frequently suboptimal, with only 40%–60% of patients receiving therapy fulfilling Agency for Health Care Policy and Research (AHCPR) guidelines for antidepressant dose and duration and fewer than 10% receiving empirically validated psychotherapies (12–16).
These findings have led to proposals for increased mental health training for primary care providers (17) and to the discussion of several models for more effective treatment of psychiatric disorders in primary care patients (18–21). These models, first described in Britain, include having psychiatrists as independent specialists who can be consulted as needed; increasing referrals from general practitioners to psychiatrists; and an attachment-liaison or integrated team model, in which the psychiatrist and other mental health providers work alongside their primary care colleagues in primary care settings. This latter model is particularly attractive, given the desire of most patients to receive care from their primary care system (22), the high rates of somatization and medical comorbidity in psychiatrically ill primary care patients (8,23), the low rate of follow-through with referrals to mental health providers working outside primary care systems (24), and the increased emphasis on primary health care in managed healthcare systems (25).
Such liaison-attachment or collaborative models of care by mental health and primary care providers can significantly improve outcomes in the treatment of depression. Katon et al. (5,26) have demonstrated the effectiveness of two different collaborative models of care designed to treat depression in primary care. In the first intervention (5), the primary care provider and psychiatrist shared the treatment, with the patient seeing each provider for two visits (to total four outpatient visits) in the first 6 weeks of treatment. In the second (26), patients received 4–6 sessions of cognitive–behavioral therapy by a psychologist and antidepressant medication from their primary care physician. A supervising psychiatrist also made recommendations regarding medication treatment on the basis of the report of the psychologist regarding the patient's progress, symptoms, and side effects. Both of these interventions significantly improved treatment adherence and outcomes, while lowering costs per successfully treated patient (5,26). Other published reports also support the value of psychiatric consultation within primary care settings (27–30).
Given these data and the growth in primary care-centered managed healthcare, psychiatry residents must be trained to work within an integrated healthcare delivery system and to collaborate with their colleagues in primary care fields. There is a specific set of skills that psychiatry residents must learn in order to be effective working in liaison in primary care. In response to this training need, the University of Washington Psychiatry Residency Program instituted a 4th-year rotation in primary care consultation in July 1997. This article describes the development of this rotation, results of evaluations of the experience by residents who have completed it, and problems and challenges that have arisen during the past 2 years.
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DEVELOPMENT OF THE ROTATION
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In July, 1997, five interested 4th-year residents (of a total of 11 PGY-4s) were each assigned to spend one-half day per week for 12 months providing psychiatric consultation within one of four University-affiliated primary care clinics. Clinics included the University of Washington Family Medicine, Women's, and General Internal Medicine (GIMC) clinics, and the Family Medicine Clinic at Harborview Medical Center, a University-affiliated medical center operated jointly by the county and the University and serving a predominantly indigent population. A member of our faculty with a longstanding liaison relationship with the University Family Medicine Clinic spent one-half day per week working in the clinic himself, met with clinic staff monthly, and established an hour per week to supervise the senior resident, who worked in the clinic on a different day. The Medical Director of the GIMC was supportive of and enthusiastic about having psychiatry residents within the clinic. The two residents assigned there were supervised together for 1 hour per week by a faculty member with prior experience consulting in an Internal Medicine clinic, but who was not working in the GIMC. The resident assigned to the Women's Clinic began working there at the same time as did her supervisor, a Primary Care Psychiatry fellow. Finally, one resident arranged with the Director of the newly established Harborview Family Medicine Clinic to serve as a psychiatric consultant within the clinic. This resident was supervised by a psychiatry faculty member who did not work in the Family Medicine Clinic.
In the second year, 9 of 11 PGY-4s spent either one-half day per week for 12 months or 1 day per week for 6 months in one of eight University-affiliated primary care clinics. The eight clinics included the University of Washington Family Medicine, Women's, and GIMC clinics, as well as the GIMC at the Veterans Affairs Puget Sound Health Care System (VAPSHCS) in Seattle, and the Harborview Adult Medicine, Women's, International (Refugee), and Madison (HIV/AIDS) clinics. The psychiatry service at the VAPSHCS had a longstanding liaison relationship with the GIMC, with two consultation–liaison and geriatric psychiatry attending psychiatrists providing care within the clinic. Similarly, the Madison clinic was already staffed by several part-time psychiatrists, one of whom, a University of Washington faculty member, took primary responsibility for supervising the resident.
In 1997–98, our Department successfully applied for additional funding from Harborview Medical Center for psychiatry faculty consultants to work within selected ambulatory-care clinics. Previously, patients referred to psychiatry had been seen in the Behavioral Medicine Clinic, located in the psychiatry department. The long waiting list and high demand for services in this clinic, in addition to the fact that many patients refused or failed to go to their initial appointment at this psychiatry clinic, led to this proposal. Residents were assigned to two of these clinics (Adult Medicine, Women's) and started working there at the same time as did the attending psychiatrists. Finally, a resident with a particular interest in cross-cultural psychiatry established a rotation consulting within the International Clinic, with the support of the Medical Director, an internist with a strong interest in promoting mental health consultation. This resident was supervised by a clinical faculty member who had worked in this clinic several years earlier.
The University of Washington Medical Center clinics (General Internal Medicine, Family Medicine, Women's) served a predominantly middle-class, insured population, which was 91% Caucasian, 5% African American, 3% Asian, and 1% Hispanic. Most patients referred to psychiatry were 20–50 years old, and 61% were women, except in the exclusively female patient population in the Women's Clinic. Harborview Medical Center, a county hospital, served an indigent population. Patients seen by psychiatry in the Harborview clinics (Family Medicine, Adult Medicine, Women's, International, HIV/AIDS) had an average age of 37; were 66% Caucasian, 21% African American, 5% Asian, 4% Hispanic; and were 46% female, with the exception of patients seen in the International Clinic, which served a predominantly Southeast Asian refugee population, and the Women's Clinic, where the patients were all female. Patients seen in the Seattle Veterans Affairs Medical Center General Internal Medicine Clinic ranged in age from 20 to 85 (average age 40–50); were 75% Caucasian, 10% African American, 8% Asian, 2% Hispanic, 2% Native American; and were predominantly male. Most were unemployed. Each clinic had social work support.
The psychiatry resident's schedule was managed by the clinic staff, who scheduled patients referred by the primary care providers within the clinic. Residents were encouraged to evaluate referred patients, and either to refer them back to their primary care provider after acute stabilization or make further referrals as indicated to the outpatient psychiatry clinic, community mental health centers, or other community resources. As appropriate, residents were encouraged to refer patients needing longer-term care to their own long-term care clinic. All residents were supervised for 1 hour per week. Two 1-hour didactic sessions in the early fall, given by consultation–liaison faculty, were devoted to issues in primary care consultation, such as the presentation of psychiatric disorders in primary care, somatization, and communication with primary care providers. The goals and objectives of the rotation are shown in Table 1.
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RESIDENT EVALUATION OF THE ROTATION
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As of June 1, 1999, 14 4th-year residents had completed the primary care consultation rotation in 16 different clinic settings. One resident elected to spend half-time in primary care consultation in three different primary care settings. All 14 residents were asked to complete a brief questionnaire evaluating the rotation. They were asked to rate quality of supervision, clarity of their role in the clinic, acceptance by primary care providers, acceptance by clinic staff, interest/uniqueness of the patient population, the relevance of this rotation to their future goals, the effectiveness of the rotation in preparing them to be a psychiatric consultant in a primary care setting, and the overall quality of the rotation. Each item was rated on a five-point scale (Poor, Fair, Good, Very Good, Excellent), and residents were asked to give any additional comments about strengths and weaknesses of the rotation (see Emerging Issues, below).
Ratings were converted to a numerical scale (1=Poor, 5=Excellent), and mean scores were computed for each item. On the basis of preliminary feedback about this experience, we expected that resident satisfaction would be greatest in clinics with a supervising attending psychiatrist who had a prior, established relationship working in that setting. To examine the effect of having a supervising attending psychiatrist with an established working relationship with the clinic and of having one who was present working in the clinic (even though he or she might have just started in the clinic with the resident), mean ratings of rotation characteristics were compared by t-test between groups with different attending psychiatrist–clinic relationships. Effects of site (University vs. Harborview vs. VAPSHCS) were examined with one-way analysis of variance (ANOVA).
Thirteen of 14 residents (93%) completed the questionnaire, rating 15 clinic experiences. Of note, only two residents had previous experience in primary care, one as a Naval flight surgeon and the other as a family physician. Mean ratings are shown in Table 2. Overall, residents rated the rotation fairly highly, with average scores closest to "Very Good." In clinics with an established attending psychiatrist, there was a trend for higher ratings of clarity of resident's role (4.1±0.9 vs. 3.0±1.5; t[13]=1.74; P=0.10) and effectiveness of the rotation in preparing the resident to be a psychiatric consultant in a primary care clinic (4.3±0.8 vs. 3.4±1.2; t[13]=1.74; P=0.10). Having the attending psychiatrist working in the clinic was also associated with a trend for higher ratings on these two items (clarity of role: 4.0±1.1 vs. 2.8±1.5; t[13]=1.75; P=0.10; effectiveness of rotation: 4.2±0.8 vs. 3.2±1.2; t[13]=2.0; P=0.06), as well as significantly higher ratings for quality of supervision (4.7±0.7 vs. 3.3±1.4; t[13]=2.5; P<0.03). There were no significant or trend differences between sites in ratings of any variable.
Emerging Issues
Despite the relative ease with which these resident rotations were established initially, and despite the overall "very good" ratings of the rotation by the resident group, several problems unique to having psychiatry residents work in this setting became apparent over the course of the first 2 years. These problems, identified through the written comments on the resident evaluations, through verbal feedback from residents, and from observations of supervising faculty, are discussed below, as are modifications that have been or are being made to the rotation as a result of this feedback.
Some residents felt inadequately prepared to function as a psychiatric consultant in a busy primary care clinic. They commented that the didactic sessions were too theoretical, focusing on the epidemiology of psychiatric disorders in primary care rather than on a pragmatic approach to communicating with primary care physicians. Some had very little previous experience in doing both an outpatient diagnostic evaluation and formulating a treatment plan within a single session. Most importantly, a tension emerged between, on the one hand, the residents' understanding that they were consultants who would see the patient for an evaluation and perhaps 2 or 3 follow-up sessions while giving recommendations to the primary care provider and, on the other hand, the frequent assumption by many primary care providers that the psychiatry resident would take over the care of the patient and become the patient's psychiatrist. This confusion about the resident's role was, as might be expected, less common in clinics with a longstanding psychiatry attending consultant, who had already negotiated expectations regarding the scope of psychiatric consultation, who could educate the clinic providers about the psychiatry resident's role, and who could model for the resident effective interactions with primary care providers.
Initially, residents' caseloads were usually very low, until clinic providers learned that they were available. Even then, it was often difficult for clinic providers or staff to identify appropriate patients to refer and to decide, in clinics with multiple mental health consultants, whether a given patient should be scheduled to see a social worker, psychologist, or psychiatry resident. Many of the patients referred to the psychiatry residents were actually quite complex, both medically and in terms of their mental health issues, and were indigent. In some clinics, residents found it difficult to find appropriate referrals for these patients for the longer-term psychiatric care that they needed. This again caused frustration for some residents, who had the expectation that they should be seeing referred patients for only short-term consultation.
In general, residents reported that the referring primary care providers were appreciative and collaborative when approached, but that they were busy, did not seek out the psychiatry resident, and, in some clinics, took almost the entire year to accept the psychiatry resident as a clinic provider. This, again, was most pronounced in clinics without an established psychiatry attending presence. Because psychiatry residents were only in the clinic for a small fraction of the time, they did not have face-to-face contact with many of the referring providers, especially the primary care residents, who were scheduled for clinics on other days, rotated in and out of the clinic, or changed clinic day each week to accommodate their call schedule. Several psychiatry residents commented that they found, or would have found, the experience more satisfying when they had time to teach, provide "curbside" consults, and discuss patients face-to-face with referring providers. In one clinic, the lack of a common workroom for clinic providers made contact with primary care providers especially difficult. One resident solved the difficulty of reaching physicians who were not in the clinic by using the medical center's confidential e-mail. In two clinics, psychiatry residents attended regular conferences, both of which were highly rated. However, in neither case was the conference a primary care case conference. In one case, it was a journal club. In the other, internists gave lectures about common outpatient medical problems.
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MODIFICATIONS TO THE ROTATION
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In response to the evaluations and feedback detailed above, we have made several modifications to this rotation. First, we now require that PGY-4 residents work only in primary care clinics with a supervising psychiatry attending physician who has an established consultation–liaison relationship with the clinic. This facilitates acceptance of the resident and a clearer understanding by the clinic staff and providers of the resident's role within the clinic. The attending psychiatrist is able to address issues as they arise and to model effective interactions with both patients and primary care providers. Also, in clinics with multiple mental health providers, the attending psychiatrist can help with triage decisions, so that the resident is seeing appropriate patients.
The didactic sessions have been expanded, made more pragmatic, and moved to the very beginning of the PGY-4 year. We are now developing a PGY-3 experience as part of the outpatient year, specifically designed to teach residents to do one-time diagnostic evaluations, treatment planning, and referral, under the close supervision of an attending psychiatrist, who sees patients with them. We have also enhanced the ease of referral from the primary care clinics to long-term psychiatric treatment settings within our department. In addition, the rotation would be improved by establishing joint case conferences and teaching opportunities related to mental health issues within the primary care settings.
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DISCUSSION AND RECOMMENDATIONS
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In this preliminary assessment of a primary care clinic consultation rotation, 4th-year psychiatry residents responded positively to having the opportunity to work as consultants and collaborators in primary health care outpatient settings. Overall, they saw the rotation as relevant to their future careers and effective in preparing them for the consultant role. In most clinics, they felt accepted and appreciated by clinic staff and providers. As might be expected, the presence of a supervising attending psychiatrist working in the same clinic increased satisfaction with the rotation, resulting in higher ratings of the clarity of the resident's role in the clinic, the effectiveness of the rotation in preparing the resident to collaborate with primary care providers, and the quality of supervision. Problems that were identified included lack of understanding of the resident's role by primary care providers and clinic staff; lack of optimal preparation for the rotation; lack of face-to-face contact with many primary care providers; and the complexity of many of the patients referred, which made it difficult to see them within the short-term framework established for the rotation.
Several earlier reports indicate that the "attachment" of a psychiatrist to a primary care clinic has advantages over referral to separate psychiatric services, including easier access to psychiatric consultation, less stigma and greater convenience for patients, increased recognition of mental health problems, greater communication between primary care providers and psychiatrists, and opportunities for mutual teaching and professional development (28–30). Mental health providers are usually viewed very positively by primary care providers (31).
However, there are also significant challenges involved in this "interfaith marriage" (28) of psychiatry and primary care. Psychiatrists and primary care providers operate within quite different "cultures" and working environments. Psychiatrists usually see outpatients who have at least some acceptance of being treated in a mental health specialty setting; see them for long and well-defined visits; and pay careful attention to factors such as quiet, lack of interruptions, and boundaries within the therapeutic relationship. In contrast, patients in primary care settings frequently somatize and have chronic medical illness, presenting with unexplained or amplified somatic symptoms or complaints about their medical condition, rather than with psychological distress, and resist psychiatric diagnoses or treatment. Primary care settings are marked by brief visits, frequent interruptions, and an emphasis on rapid diagnosis and treatment planning. Specialists are expected to be prompt, clear, and directive in their recommendations. Brown and Zinberg (32) have described primary care as goal-oriented, rather than process-oriented, and have outlined differences between primary care medical and psychological practices, including the role and authority of the physician, the handling of affect, and the expectations of patients. Furthermore, primary care physicians differ widely in their attitudes toward, knowledge of, and skills in psychiatry and behavioral medicine, with some being interested in and sensitive to psychosocial issues in their patients and others having few skills in this area. It takes time for the psychiatrist working within a primary care setting to become familiar with each primary care physician's skills and level of interest in psychiatry, and thus to develop an effective way of relating to individual providers.
The resulting challenges for a psychiatrist working in a primary care setting are likely to be magnified in the case of psychiatry residents, who have limited time to establish relationships with their primary care collaborators and adjust to the "culture" of primary care. Comments by the residents regarding the need for more practical information and preparation probably reflect, at least in part, these predictable and anxiety-provoking challenges in entering a different medical culture. The current findings reinforce the value of having a supervising attending psychiatrist who works as a psychiatric consultant within the clinic to ease the resident's transition, forge long-term personal relationships with the primary care attending physicians, educate clinic staff and providers as to the resident's role within the clinic, and model effective behavior of a psychiatrist within a primary care setting. Unfortunately, the number of residents who have completed the rotation in our program is presently too small to assess other possible factors influencing the ease or difficulty of making this transition, such as previous experience or training of the resident in primary health care or characteristics of individual clinics. In this preliminary assessment of this rotation, there is also as yet no information regarding how much residents learned about issues in primary care, patient and primary care provider satisfaction with their services, and the degree to which having residents within these clinics improved care or reduced total health care costs. These are all questions warranting further study.
There are few other reports in the literature of training programs for psychiatrists in primary care settings. Steinberg et al. (33) have described a consultation–liaison fellowship in outpatient primary care, emphasizing close working relationships between the fellows and individual, psychologically minded primary care practitioners, who allow fellows to see patients with them in their practices. Paulsen (30) outlines several needs in order for psychiatry residents to function effectively in a primary care setting. These include having a primary care psychiatrist to identify with and to observe in action, a factor supported by the survey results reported here. In addition, he includes the residents' need to feel that they have a valuable contribution to make to the clinic; primary responsibility for some patients; enough time on the service to develop relationships with clinic providers and staff; the ability to follow some patients for longer periods to assess outcomes of their interventions; and access to the same physical space, computerized medical records, and communication systems as their primary care colleagues.
These earlier reports, together with the current observations from a 2-year experience of a 4th-year psychiatry resident rotation in primary care, reinforce several measures important in establishing and improving this and other such rotations. Most important is the presence of a strong mentor and supervisor in all clinics in which residents take on the consultant role. In fact, before introducing a psychiatry resident into a primary care clinic, the psychiatry department should have a faculty member with a well-established liaison role within the clinic, who, ideally, has worked within the clinic for a year or more. Residents should be educated regarding the differences between the cultures of psychiatry and primary care and should receive practical training in how to perform rapid assessments and communicate and work with primary care providers. The attending psychiatrist working within the clinic should educate clinic providers and staff about the resident's role and may need to take an active part in triaging referred patients. Communication with primary care providers may involve providing "curbside" consultations and a flexible approach toward communication, using e-mail or a computerized medical record, as well as more traditional methods, such as face-to-face and telephone contact. Residents should be provided with clear expectations regarding the type and duration of treatment that they will be providing within the primary care clinic. This may range from brief, single consultations with referral back to the primary care provider to longer-term treatment until appropriate referrals can be found for more complex patients. Case conferences and other interdisciplinary teaching opportunities, both for the resident, and in which the resident can teach primary care providers, would be valuable. Also, models of psychiatric consultation within primary care may include working with other mental health providers, such as psychologists, social workers, and chemical dependency counselors (21,29,30). For example, the primary care consultation services at the University of Washington increasingly are moving toward organization into multidisciplinary teams incorporating other mental health providers and trainees, such as psychology interns. With these changes, it will become important to train residents to work as a member of such integrated psychosocial treatment teams within primary care settings.
Given the high prevalence of psychiatric conditions and psychological distress in patients seen in primary care settings, the effectiveness of psychiatric consultation and treatment in reducing distress, functional impairment, and healthcare costs in these patients, and the recently increased emphasis on the primary care provider as the "gate-keeper" making referrals for specialty services, it is imperative that the psychiatrists of tomorrow are trained to work at the interface of psychiatry and primary care in an integrated, collaborative treatment team. Rotations such as this one are a valuable first step in accomplishing this goal.
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ABSTRACT
INTRODUCTION
