Acad Psychiatry 29:416-418, December 2005 2005
doi: 10.1176/appi.ap.29.5.416
© 2005 Academic Psychiatry
Combined Family Practice and Psychiatry Residency Training: A 10-Year Appraisal
Mark Servis, M.D.
Received June 2, 2005; accepted July 28, 2005. Dr. Servis is affiliated with the University of California Davis, Psychiatry and Behavioral Sciences, Sacramento, California. Address correspondence to Dr. Servis, Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, 2230 Stockton Boulevard, Sacramento, CA 95817; meservis{at}ucdavis.edu (E-mail). Copyright © 2005 Academic Psychiatry.
It has been 10 years since the American Board of Family Practice (ABFP) and the American Board of Psychiatry and Neurology (ABPN) established the requirements for combined training in both specialties. A dozen combined programs have been established during this period, a sufficient number to provide an opportunity to assess the results of this educational experiment, conceptualized as a helpful response to the "de facto" mental health care provided in primary care clinics (1). The two papers in this issue do just that, sharing the results of a survey of program directors in existing combined programs and thoughtfully addressing the unique boundary and supervision issues raised by combined training.
James Rachal et al. (2) outline the current characteristics of combined programs as determined in a survey completed by 10 combined program directors. Interestingly, only one of the program directors is dually boarded in both family practice and psychiatry, highlighting one of the inherent challenges in combined training—the lack of faculty expertise and the paucity of role models for combined residents striving to learn to integrate the two specialties. Rachal et al. note the "lack of established role models" as one of the challenges for combined training programs, adding the "recruitment of medical students" and the "retention of residents" as two additional challenges. The recruitment challenge is primarily due to a lack of awareness about combined training, since medical students are often attracted to the notion of maintaining their "white coat" identity as a doctor while practicing as a psychiatrist. In our experience in recruiting to a combined training program at UC Davis for 10 years, we have found that many students see combined training as a solution to the stigma issue of choosing psychiatry and the anticipated loss of hard earned medicine skills acquired in medical school. This phenomenon leads to the retention challenge noted by Rachal et al., since such students are likely to overcome their concerns about stigma and to successfully "mourn the loss of medicine" as they advance in their professional and personal development during combined residency training, leading them to later switch into psychiatry. Rachal et al. also note the high attrition rate in combined residents during training, most of who switch into psychiatry training. High attrition rates in small programs are a significant problem for combined programs that affects resident morale and cohesion within a cohort already stressed by the challenge of dual training and reliant on peer support for coping with the stresses of residency (3). We have been cautious at UC Davis to select only those applicants whose commitment to combined training appears robust and who are not predominantly drawn to one or the other specialty, or who are "sneaking" into psychiatry under the more acceptable "cloak" of family practice.
Rachal et al. point out the modest increase in numbers of combined trainees over the past 10 years. The relatively small growth may be related to the decreasing number of medical students interested in primary care in recent years. Fewer students appear drawn to the currently demanding nature of primary care practice and are more interested in "lifestyle" specialties, with psychiatry benefiting modestly from this trend (4). Combined training is a more challenging residency experience with yet to be established practice opportunities and whose likely resemblance to primary care practice may be unattractive to students. Despite these trends established programs have been able to attract interested students, and Rachal et al.’s survey suggests that the quality of training and of the graduates appears good. Combined residents’ skills in family practice are rated better than their peers by program directors, but skills in psychiatry are only equal to those of peers. This may be due to a greater reduction in total time for psychiatry training than for family practice training when compared to noncombined peers. Combined trainees have 30 months of family practice rotations and 30 months of psychiatry rotations, but noncombined peers in family practice have 36 months of family practice rotations while peers in psychiatry who begin as PGY1s typically have 42 months of psychiatry rotations. These differences are mitigated somewhat by the continuity clinics in both specialties common to most combined programs but exacerbated, as pointed out by Rachal et al., by the difficulty combined residents have in attending all didactic seminars, especially in psychiatry.
Rachal et al. point out many of the significant benefits of combined programs. Most relate to the synergistic benefits of collaboration between different disciplines. Combined residents act as a valuable resource to both the faculty and residents in each department for the knowledge and skill they bring from another specialty. As Lacy et al. (5) describe in their paper, this tendency to use combined residents as "curbside consultants" can lead to role confusion and interfere with their own training as residents. Still, with appropriate attention to this danger, combined residents can add much to the expertise in primary care medicine in a psychiatry training clinic, and to the psychiatric care and education provided in primary care training clinics.
Timothy Lacy et al. address many of the unique challenges of simultaneously training residents in two very different disciplines from their experience of administering a combined program with 8 graduates in 9 years. As previous articles on combined training programs have suggested, the administrative complexity of managing combined programs is not to be underestimated (6). Lacy et al. address the issues of supervision, boundaries, and integration of skills. They correctly point out that the level of supervision in family practice provides a greater degree of autonomy to residents earlier than that provided in psychiatry. Combined residents accustomed to significant independence in their primary care rotations have to adjust and give up this autonomy when on psychiatry rotations. At UC Davis we have found that the combined residents’ sense of independence extends not only to clinical issues, but at times to administrative and educational issues. Combined residents used to the greater autonomy of family practice training may feel unduly constrained by the more restrictive nature of psychiatry training, which is experienced by them as paternalistic and regressive at times.
Lacy et al. also identify and discuss the complicated boundary issues for combined residents who must learn the more restrictive nature of physician-patient boundaries in psychiatry when compared to the more relaxed boundaries in family practice. This difference comes into sharp focus when combined residents simultaneously see the same patient in both family practice and psychiatric settings, a practice that Lacy et al. label "self-referral." While simultaneously addressing both the medical and psychiatric problems of patients may appear to be the very essence of combined training, it may present a confusing challenge to the combined resident who is still learning and adjusting to the very different boundary issues in the two specialties. Lacy et al. provide good examples from their experience to illustrate this challenge and suggest that doing anything but limited supportive psychotherapy with patients to whom you also provide medical care is problematic. These differences in boundaries and in supervision are two of many cultural differences between family practice and psychiatry training, which cumulatively add to the "switch stress" for residents going back and forth between clinical rotations and didactics in two different programs (7). The resulting challenges to the professional development of combined residents, who may also lack faculty role models with dual training, are substantial.
Lacy et al. believe that it is best to maintain clear differences and boundaries between the two disciplines in combined programs so as not to compromise the training in each specialty and to ensure the proper professional development unique to each discipline. Besides muddying the waters around supervision and boundary differences, "premature" integration during residency training results in combined residents being used as psychiatric consultants to family practice colleagues or being given the "difficult" psychiatric patients in the family practice training clinic. The pressure to provide needed specialty care in a primary care clinic setting is strong, but the combined residents’ real priority on their family practice rotations is to learn the fundamental skills of the primary care physician. As combined residents mature, they can begin the process of integrating the two specialties, in anticipation of the extraordinary medical-psychiatric care they will be capable of as fully trained family practitioners and psychiatrists.
The unanswered question around the integration of psychiatry and family practice as advanced by combined training programs is whether graduates will find sustaining roles that utilize the two specialties. The experience to date with a limited number of graduates suggests that the pull to practice psychiatry is strong, perhaps due in part to the shortage of psychiatrists and the modest financial incentives for practicing psychiatry over family practice. The challenge for combined graduates who practice predominately in one specialty is maintaining certification in a second specialty. Maintenance of dual certification without continuing practice opportunities will be difficult and probably unlikely. There are clearly some unique settings where combined training will be used and may be an advantage such as psychosomatic medicine, rural practice, community psychiatry with the severely and persistently mentally ill, and academic medicine, but will it be an advantage sufficient to justify combined training? Especially in light of the fact that residents can always gain dual board certification the "old fashioned way," by pursuing sequential residency training in both specialties.
Lacy et al. conclude with an intriguing suggestion that the synergy of combined training may result in a clinical practice with a quality different and distinct from either discipline alone. "When you do both at the same time, it might not look like either" (5). It is the potential creative results of collaboration between different specialties that makes combined training a worthwhile experiment. These papers provide helpful lessons from the early experience of those who have established combined training programs and are invaluable to those developing their own combined programs. The early results are promising, but more data and thoughtful analysis are needed. Particularly helpful will be outcome data on graduates to demonstrate that the cost of combined training is justified by the development of a unique and successful practitioner who provides simultaneous medical and psychiatric care.
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- Rachal J, Lacy T, Warner C, et al: Characteristics of combined family practice-psychiatry residency programs. Acad Psychiatry 2005; 29:419–425[Abstract/Free Full Text]
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