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So You Want to Train Psychiatry Residents in Ambulatory Primary Care Settings

A Primer and Guide for Program Directors

Dr. Yudkowsky is Associate Director of Faculty Development, Department of Medical Education, University of Illinois College of Medicine. At the time this article was written, she was Director of Education, Department of Psychiatry, Evanston Hospital, and Associate Director for Graduate Medical Education, Department of Psychiatry and Behavioral Science, Northwestern University Medical School. Address reprint requests to Dr. Yudkowsky, Department of Medical Education MC 591, University of Illinois College of Medicine, 808 S. Wood Street, Chicago IL 60612-7309. e-mail: rachely{at}uic.edu

ABSTRACT

TOP ABSTRACT INTRODUCTION GOALS AND OBJECTIVES EDUCATIONAL METHODS DISCUSSION CONCLUSIONS REFERENCES

 
Providing mental health services in primary care surroundings has potential advantages for both patient care and resident education. On the basis of the growing understanding of learning issues in ambulatory settings and the few descriptions of ambulatory primary care (APC) psychiatry rotations in the literature, the author proposes practical guidelines for consultation/liaison rotations in APC settings. Recommendations and references are given for educational objectives, the role of the resident, supervision and teaching, the format and funding of the rotation, and evaluation. Program directors contemplating new rotations should plan to evaluate and publish their efforts in order to add to our evidence-base in this area.

Key Words: Outpatients • Ambulatory Care • Consultation/Liaison

INTRODUCTION

TOP ABSTRACT INTRODUCTION GOALS AND OBJECTIVES EDUCATIONAL METHODS DISCUSSION CONCLUSIONS REFERENCES

 
In recent years, there has been a growing consensus on the need to move psychiatry into the ambulatory primary care (APC) setting (1–7). The majority of persons with mental illness are seen exclusively in outpatient medical settings (6). Between 20% and 40% of all primary care visits involve a significant psychiatric component; psychiatric conditions have an increased prevalence in many common medical disorders and may adversely affect their outcome (7). Nonetheless, missed diagnoses and undertreatment by primary care physicians are common (7,8), and efforts to improve care by educating the primary care physician have generally not been encouraging. On the other hand, collaborative models, with the psychiatrist actively participating in the assessment and treatment of the patient in the primary care setting, have been shown to be much more effective in improving patient outcomes (1,9,10). Psychiatrists are increasingly asked to work in primary care settings as mental health services are "carved in" rather than "carved out" (1).

Significantly, 77% of psychiatrists who graduated between 1992 and 1996 felt that their training on collaborating with primary care was not sufficient to prepare them for their current practice; 52% stated that they had no training specifically directed at integrating psychiatry with primary care (11). Wulsin (1), in his article "Comprehensive Agenda for Primary Care Psychiatry," recommends establishing primary care psychiatry clinics on site in primary care settings and training psychiatry residents in these clinics. Similarly, the "Recommended Guidelines for Consultation/Liaison Psychiatry Training" (12) suggest that a portion of the training in Consultation/Liaison (C–L) psychiatry should take place in outpatient sites. Patients can benefit from increased access to competent psychiatric care in a convenient and less stigmatizing setting, enhancing the quality of their health care; psychiatry residents can benefit from increased access to patients not usually seen in the hospital, thus enhancing the quality of their education. How should our residents be trained to practice in these settings? Does each residency program need to design rotations from scratch, or is there some data with which to practice "evidence-based" education?

Fortunately, there is a wealth of knowledge on teaching and learning medicine in the APC setting, summarized in Irby's excellent review article published in 1996 as well as in other recent reviews (13–15). There is an extensive literature on consultation–liaison psychiatry conveniently compiled into a database by Hammer et al. (16), although the educational focus of this literature has been on the training of primary care physicians and the training of psychiatry residents in non-APC settings. There are also several early reports on teaching psychiatry residents in APC settings (17–20). It is this diverse literature that provides the evidence-base for the curriculum plan that follows.

Tyler (21) set out the basic principles of curriculum design: first decide on the educational goals and objectives, then design learning experiences to allow the learners to practice the desired behaviors and accomplish these objectives; organize these experiences into an integrated whole, and provide a means for evaluating the outcome. How might such a curriculum look for an APC psychiatry rotation?

GOALS AND OBJECTIVES

TOP ABSTRACT INTRODUCTION GOALS AND OBJECTIVES EDUCATIONAL METHODS DISCUSSION CONCLUSIONS REFERENCES

 
The primary educational goal of an APC psychiatry rotation is to produce a psychiatrist who is able to collaborate effectively with the primary care physician and team in the diagnosis and treatment of psychiatric problems in APC settings. Although much of the general C–L psychiatry curriculum is relevant to this goal, some objectives are especially salient in the ambulatory primary care setting. Indeed, many of these objectives have become difficult or impossible to accomplish in the traditional inpatient C–L rotation. As the practice of medicine has moved toward predominantly outpatient treatment, the vast majority of medical patients with psychiatric problems never present to the inpatient setting, and when they do, their inpatient stay is far too brief to allow for meaningful follow-up.

Attitudinal Objectives (12,22)

1. Understanding the value of working collaboratively with the primary care team.
   
2. Appreciating the culture of medical practice in APC settings, including time and fiscal constraints, and the PCP's need for a timely and focused response.
   

Knowledge Objectives (12,17,22–24)

1. Presentation and treatment of common psychiatric disorders in APC settings, especially depression, anxiety, somatization, substance abuse, and dementia.
   
2. Psychiatric manifestations of patients with medical illness (e.g., AIDS, Parkinson's, chronic fatigue syndrome).
   
3. Psychiatric presentations due to nonpsychiatric medications (e.g., glucocorticoids).
   
4. Use of psychiatric medications in altered physiological conditions (e.g., pregnancy, liver compromise, elderly patients, etc.)
   
5. Medical complications in patients with psychiatric illness (e.g., alcoholism, eating disorders, primary polydipsia).
   

See the model curricula in psychiatry for primary care physicians by Stoudemire (23) and by Cole et al. (24) for detailed lists of specific syndromes that could usefully be included in the curriculum.

Skills Objectives (6,18)

1. Accomplish rapid diagnosis and assessment.
   
2. Communicate effectively with the primary care physician (PCP) and team.
   
3. Assess the needs of the APC team for crisis management, consultation, conjoint treatment, and referral.
   
4. Carry out brief crisis intervention, and/or brief focused interventions.
   
5. Work conjointly with PCP and team, including nurses and nonpsychiatric mental health workers; share responsibility and treatment of patient, pass patient back to team.
   

In addition to these educational objectives, there may be departmental or institutional goals, such as increasing referrals from PCPs (or decreasing referrals in capitated systems), increasing access to care for patients who normally refuse referrals to psychiatry, improving patient outcomes, increasing visibility of the psychiatry department, and research (1).

EDUCATIONAL METHODS

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What learning experiences can most effectively accomplish these objectives?

Ambulatory Medicine During the "Internship" Year
The months of training in general medical care are most often accomplished exclusively in the inpatient setting, sometimes on subspecialty units such as the ICU. Providing some APC experiences, such as a block rotation in family medicine or a longitudinal half-day per week in a primary care clinic or office, could serve a dual purpose. On the one hand, residents would experience the culture of ambulatory primary care firsthand, from the perspective of the PCP. At the same time, residents would become familiar with the presentation and course of common medical problems that do not generally require hospitalization, perhaps decreasing their tendency to overlook such problems in their own psychiatric patients (2,22). Funding of such ambulatory care rotations may be easier than in the past, now that Medicare allows for reimbursement of nonhospital training sites.

The APC Psychiatry Rotation
Essential features.
The most consistently noted features of successful APC rotations are the presence of PCPs with an interest in the psychosocial issues of their patients; shared hallway space, creating a shared "neighborhood;" and targeting services to the needs of the PCP and APC team (17,19,20). The particular APC setting is probably less crucial: residents in hospital clinics, community clinics, or primary care medical offices see approximately the same mix of medical problems (13). The specific needs of the PCP team may vary both across and within settings, and indeed one of the tasks of the psychiatrist—and learning objectives of the residents—is to determine what those needs are and how the resident can be most helpful to the team. Interestingly, PC residents are notably less interested in psychosocial issues than attending-level physicians, perhaps because of their preoccupation, at that level of training, with the medical complexities of their patients (19), which suggests that psychiatry residents should be paired with APC faculty, and not trainees.

Resident role.
The role of the resident varies according to the needs of the particular setting. In an inclusive model, the resident may accompany the PCP in an unselected way, seeing all of the patients scheduled that day, and spending more time with individual patients when indicated. This model, preferred by PCPs who were joined by residents in their private offices, has the advantage of exposing the resident to a broader range of problems (not limited to those identified by the PCP) as well as increased case finding (19). In clinic situations, residents more often see referrals from the PCP; activities requested by the PCP can range from traditional consultation to crisis intervention, short-term therapy, or ongoing collaborative management (18). Improving patient outcomes for psychiatric problems in APC settings requires ongoing involvement of the psychiatrist in the management of the patient, not just front-end consultation (1,7,9,10), so residents should be encouraged to use a collaborative, shared management approach whenever possible. In all cases residents need to preserve and support the continuing relationship between the patient and the PCP: although PCPs vary widely in the support they desire, they consistently want to stay involved with the management of the patient (4,18).

Supervision and teaching.
Primary care clinics and offices are busy places where primary care residents generally see patients on their own and present perhaps one-third of the patients to the attending supervisor. Presentations average 4 to 6 minutes in length, with about 1 minute devoted to discussion of the assessment and treatment plan (13). How might a psychiatry resident learn in such a setting?

Ideally, an APC psychiatry rotation would include a primary care psychiatry faculty member, to supervise the resident and serve as a role model (17). Supervising a resident does not necessarily decrease faculty productivity in the clinic or the office setting (13,14). Nonetheless, time and funding constraints do limit faculty availability for teaching, and much of the learning about what is seen in the clinic must take place outside of clinic time. Self-directed learning methods that encourage residents to take responsibility and control of their own learning might be ideally suited to such a setting. An example would be to have the resident come up with an objectives-related learning issue each week, research that issue, and write a brief 1–2-page report that could be presented at a teaching conference or team meeting if appropriate. Curricular modules with readings and review questions about the most common disorders could supplement formal teaching time (13,23). The presence of an organized curriculum of this sort, with explicit expectations that specified objectives are met, can make the difference between an "exposure" to APC and a true learning experience (25).

An alternative to the APC clinic model is to place a senior psychiatry resident in the private office of an interested primary care physician. This model does not require the funding of a primary care psychiatry faculty member to supervise the clinic, but thus does not provide the resident with a role model or mentor on site. However, if the PCP is invested in the linkage, these partnerships can be very satisfying to both resident and faculty member and can result in professional relationships that continue long after the resident graduates (19). As in the clinic model, self-directed learning modules and curriculum supplements may facilitate the resident's learning experience.

Organization
Timing.
Given the diverse roles that may be played by the resident, it seems most appropriate to limit APC rotations to fairly senior residents in their 3rd or 4th year, who have already acquired basic diagnostic and treatment skills (12). A senior resident is sufficiently skilled to make a substantive contribution to the PC treatment team, while taking advantage of the unique opportunities of the APC setting.

Format.
The rotations described in the literature used either a half-time block rotation or a longitudinal day (or half-day) per week, ranging from 4 to 18 months (17,19,20,26). Although the "Guidelines" (12) suggest that C–L rotations of less than half-time may compromise continuity of care, this may be less of an issue in outpatient settings, where patients are not likely to return on a daily basis. To facilitate the implementation and acceptance of a new rotation, it may be easier to begin with an elective rotation for senior residents, but as these are necessary skills for all psychiatry residents, the rotation should quickly evolve into a required one.

Funding.
Major costs include providing space in the APC clinic or office, and faculty time. Locating the resident on-site with shared hallway space and easy avenues for communication with the primary care team is essential to creating a "neighborhood" that facilitates access, responsiveness, availability, and hallway consults (17). Space may be funded by the primary care department or institution, but can be hard to find. Funding for psychiatry faculty time may be provided by the primary care program or its funders, based on the cost-offset effects, improved treatment outcome, and patient satisfaction. Family Medicine residency programs are required to have (hence fund) a "behavioralist" faculty member, who may be able to supervise both the family medicine and psychiatry residents in the clinic. Primary care physicians who host medical students in their private offices are usually compensated with perks such as faculty status and e-mail privileges rather than monetary emoluments and might agree to host residents under a similar arrangement. Funding by the department of psychiatry may be based on direct billing and increased referrals of noncapitated patients or by research grants such as Oxman's program, funded by a grant to improve primary care of geriatric patients (1,17,20). The primary care department generally does not provide salary support for the psychiatry residents.

Leadership.
Full integration of psychiatry into the primary care clinic may require shared administrative responsibility for clinical care and outcomes, including dual appointment to the departments of medicine and psychiatry, involvement in the clinic's budget and planning committees, and fiscal risk-sharing (17).

Evaluation
The primary purpose of evaluation is to determine whether the intended outcomes (objectives) of the rotation have been achieved—from both the educational and institutional perspective. However, attention to unintended outcomes is especially important when implementing a new program. Effects on the primary care faculty, support staff, residents, and on patient satisfaction, although not part of the formal educational objectives, may make or break the rotation. Unintended benefits, such as increased diagnosis of medical problems in residents' patients in other settings, may occur. Methods of evaluating C–L residents and programs have been fully discussed elsewhere (1,27,28). Direct observation of residents is especially important for both education and patient care; here, as elsewhere, faculty who observe residents directly tend to rate them less highly and frequently change either the resident's diagnosis or treatment plan (13).

DISCUSSION

TOP ABSTRACT INTRODUCTION GOALS AND OBJECTIVES EDUCATIONAL METHODS DISCUSSION CONCLUSIONS REFERENCES

 
The recommendations presented in this article (Table 1) are preliminary, based on the literature on training primary care residents in APC settings, and on the very few published reports on training psychiatry residents in these settings. True evidence-based education requires much more evidence! Additional naturalistic descriptions of programs, especially any that are structured differently from those already described, would add to our repertoire of possibilities and our knowledge of what works well and what doesn't.

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TABLE 1. Recommendations for psychiatry rotations in ambulatory primary care settings

Evaluation of outcomes is especially important. Von Korff et al. (27) named the establishment of effective methods of assessing increased physician skill as the most important agenda item for research in C–L psychiatry. Research priorities for ambulatory rotations have been described as well (29), and those for psychiatry rotations in APC settings might include the following questions: What is the effect of the rotation on residents' attitudes, knowledge, skills, and satisfaction with their training? What is the impact of specific educational interventions on the desired outcomes? What are the effects on patient care and on the attitudes and skills of the PCP and team? Residency directors should keep in mind that the ideal time to plan the evaluation is at the time the rotation is being designed, in order to best exploit the fleeting opportunity for pre–post measures of change.

This article focuses on teaching psychiatry residents to provide consultations and direct psychiatric services in ambulatory primary care settings. We do not address here the parallel question of training psychiatrists as providers of primary care for selected populations, such as chronically mentally ill patients (1,2,30). However, many of the curricular objectives and educational experiences recommended here are also applicable to training residents to provide basic medical care (22); they can lead to increased familiarity and proficiency with primary care medicine, and, as such, can facilitate enhanced medical screening and basic medical care of psychiatric patients.

CONCLUSIONS

TOP ABSTRACT INTRODUCTION GOALS AND OBJECTIVES EDUCATIONAL METHODS DISCUSSION CONCLUSIONS REFERENCES

 
The provision of mental health services in primary care surroundings has potential advantages for both patients and residents. Program directors planning psychiatry rotations in ambulatory primary care settings need to define educational and institutional goals and design learning experiences to achieve those goals. They must navigate the administrative waters of the institution to provide shared hallway space and fund faculty time to implement the rotation. Program directors designing new rotations can make plans from the outset to evaluate intended and unintended outcomes of the rotation, thus adding to the "evidence-base" of psychiatric education, enhancing the quality of residency training, and ultimately benefiting our patients, as well.

ACKNOWLEDGMENTS

 
Many thanks to Ed Silberman, Steve Weiler, Nathan Smith, and other members of AAP and AADPRT's Primary Care Interest Group for comments and suggestions on earlier versions of this article. Some of the material in this article was presented during workshops at the AAP and AADPRT annual meetings, 1996–98; my thanks to all the participants in those workshops for their insightful and encouraging comments.

REFERENCES

TOP ABSTRACT INTRODUCTION GOALS AND OBJECTIVES EDUCATIONAL METHODS DISCUSSION CONCLUSIONS REFERENCES

 

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