Acad Psychiatry 29:448-451, December 2005
doi: 10.1176/appi.ap.29.5.448
© 2005 Academic Psychiatry
Psychiatry Resident Graduate Comfort With General Medical Issues: Impact of an Integrated Psychiatry-Primary Medical Care Training Track
Steven K. Dobscha, M.D.,
Kristen M. Snyder, M.D.,
Kathryn Corson, Ph.D. and
Linda Ganzini, M.D.
Received August 31, 2004; revised April 15, 2005; accepted June 15, 2005. Drs. Dobscha, Snyder, and Ganzini are affiliated with Portland VA Medical Center, Behavior Health and Clinical Neurosciences Division, Portland, Oregon and Oregon Health & Science University, Psychiatry, Portland Oregon. Dr. Corson is affiliated with the Portland VA Medical Center, Research Service, Portland, Oregon and Oregon Health & Science University, Psychiatry, Portland Oregon. Address correspondence to Dr. Dobscha, Portland VA Medical Center, P.O. Box 1034 (P3MHDC), Portland, Oregon 97207; steven.dobscha{at}med.va.gov (E-mail). Copyright © 2005 Academic Psychiatry.
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ABSTRACT
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OBJECTIVE: To determine if a psychiatry-primary medical care (PPMC) training track impacts comfort and behaviors related to addressing general medical issues after residency. METHOD: Thirty five psychiatry resident graduates completed mailed surveys; nine of them had completed the PPMC track. RESULTS: Compared to non-PPMC participants, PPMC participants felt better prepared to address medical issues and tended to perform more consultations and feel more comfortable referring patients to general medical providers. They were not more likely to perform routine health screenings. Conculsion: Integrated training tracks may impact resident preparedness and career choice but may be insufficient to influence practice behaviors related to delivering general medical care.
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INTRODUCTION
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Delivery of general medical and psychiatric treatment has traditionally been separated in the U.S., creating barriers to care and to coordination of treatment for patients with psychiatric illnesses. This separation especially undermines general medical care for people with chronic mental illness, who often have substantial medical morbidity and struggle to maintain relationships with health care providers (1, 2). One approach to this problem has been to create dual board training programs (3, 4) and special tracks in psychiatry residency programs to train physicians to provide both psychiatric and primary medical care (5–7).
The success of these training programs in developing a cadre of mental health professionals who are comfortable addressing medical problems is largely unknown; there have been few published studies evaluating outcomes of these programs. Stiebel and Schwartz (3) surveyed 268 dually boarded psychiatrist/internists. Of 140 respondents, only 15% practiced any type of general medicine, and 75% identified themselves as practicing psychiatry only. McCahill and Palinkas (8) surveyed 39 dually boarded family practitioner/psychiatrists and found that 60% of respondents considered themselves actively practicing both specialties; the remainder identified themselves as practicing psychiatry only.
In 1998 the Portland VA Medical Center Psychiatry Primary Medical Care (PPMC) program was created to teach Oregon Health & Science University (OHSU) Psychiatry residents to provide integrated care to patients with chronic mental illness (7). PPMC residents are responsible for delivering all ongoing primary medical and psychiatric care for most of the patients in their panels. Interviews suggest that residents enter the program through a desire to retain their identity as physicians and because they enjoy practicing medicine. All OHSU residents also complete 6 months of inpatient medicine and neurology, 6 weeks of inpatient consult-liaison psychiatry, and 3 months of outpatient consultation in medical clinics.
PPMC takes place for one half day per week in Portland VA primary care clinics, where PPMC residents typically work side by side with OHSU medicine residents. Psychiatry residents enter the PPMC track during their second or third postgraduate years and usually remain in the program for the duration of their residencies. Psychiatry and medical faculty preceptors provide on-site supervision. Residents attend a 30-minute preclinic conference on one of 50 topics in primary medical care.
PPMC patients must have at least one chronic psychiatric disorder (most often schizophrenia) and may have any—and multiple—medical diagnoses. The most common medical condition is hypertension, but diagnoses also include diabetes, thyroid disease, coronary artery disease, congestive heart failure, chronic hepatitis, peptic ulcer disease, and benign prostatic hypertrophy. Medical and mental health care is based on a solo-practitioner model. The goals of this study were to compare PPMC and non-PPMC graduates’ comfort and behaviors in addressing medical issues after residency.
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Method
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Fifty-six OHSU adult psychiatry residents graduated between 1998 and 2004. We excluded residents who had completed a previous residency training program before psychiatry training (N=6). Forty-five of 50 potential participants were located (all nine PPMC and 36 non-PPMC) and were mailed surveys. The Portland VA institutional review board approved the study, and participants gave informed consent.
The study questionnaire consisted of 47 questions, measured either categorically or using 5-point Likert scales grouped into four categories: 1) demographic information including whether subspecialty training was obtained and current practice activities (6 items), 2) level of comfort with knowledge of common general medical conditions and screenings (12 items), 3) frequency of discussing, evaluating or treating common medical problems and performing health screenings with current patients (25 items), and 4) level of preparedness to manage common medical issues and comfort with discussing medical issues with general medical providers (4 items). Two-sample t tests and the Mann-Whitney U were used for comparisons between resident graduates who participated in PPMC and resident graduates who had not. The chi-square test was used to compare proportions.
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Results
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Of the 45 resident graduates mailed surveys, 35 (78%), including all nine PPMC residents, returned surveys. Forty percent of all respondents had subspecialty training, 29% worked in public psychiatry, 20% in inpatient settings, 11% in consultation settings, and 36% in independent practice. There were no significant differences between PPMC and non-PPMC participants in subspecialty training or practice settings. There was a trend for PPMC residents to more frequently perform in- and outpatient consultations (median 10% versus 0%, Mann-Whitney U=44, p=0.095), and PPMC graduates tended to spend less time working in independent practice. For example, 8 of 19 (42%) non-PPMC participants reported spending 80% or more time in independent practice, as compared to only one of eight PPMC graduates (12.5%).
Each of the two subscales, comfort with general medical knowledge and discussing, evaluating or treating medical problems, demonstrated high internal consistency (Cronbach alpha = 0.89 and 0.94, respectively). Table 1 summarizes levels of comfort with knowledge and self-reported practice behaviors related to general medical issues. As an overall group, resident graduates reported a moderate degree of comfort with their knowledge of medical conditions and rarely to sometimes engaged in behaviors such as discussing, screening for and treating general medical conditions. Graduates rated themselves as somewhat to very comfortable with their knowledge of drug interactions (89%), obesity (86%), smoking risks and treatment (86%), and medical problems that might cause psychiatric symptoms (89%). Only 23% and 26% of graduates, respectively, rated themselves as somewhat to very comfortable with their knowledge of cancer screening and vaccination guidelines. Many graduates reported "frequently" or "always" evaluating or treating smoking (48%), diet and exercise (54%) and facilitating screening for thyroid problems (74%) and high cholesterol (40%). In contrast, "never" was a common modal response for screening or arranging for cancer (63%) or prostate screening (69%) and vaccinations (71%).
PPMC graduates reported a greater sense of preparedness to address medical problems, and there was a trend for PPMC participants to report more comfort in knowing when to refer patients with medical problems (Table 1). PPMC participants and nonparticipants, however, did not differ in their overall levels of comfort and knowledge regarding common medical conditions nor the overall frequencies at which they discussed, evaluated or treated medical conditions or performed routine health screenings. The two groups did not significantly differ in their levels of comfort communicating with other medical providers.
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Discussion
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Our main finding is that PPMC training increased participants’ sense of preparedness to handle medical problems and comfort in knowing when to refer patients for medical problems. This compares well with previous studies showing that dual-board training results in psychiatric practitioners who feel better prepared to address medical issues with their patients. However, PPMC training was insufficient to increase the rate of performing medical screenings or treating medical conditions, which lies in contrast with the results of a previous survey of dually boarded family practitioner/psychiatrists (8). It is possible that the residents’ intellectual interest in PPMC training is greater than their desire to use the training after residency or that postresidency work settings are not conducive to such practices.
This study has several limitations: 1) Our sample size is small; 2) data are derived from self-report and may not accurately reflect knowledge or practice behaviors; 3) results may have limited generalizability due to the specific characteristics of our training program, clinic (VA hospital) and patient population (>90% male and veterans); and 4) the differences we did find between PPMC participants and nonparticipants could reflect self-selection to enter integrated care training tracks. In other words, PPMC graduates may have felt better prepared to address general medical issues before starting the training track. We note that validity of our results could be enhanced by surveying graduates of other programs with integrated training tracks; however, combining and analyzing data from these heterogeneous programs would be an extensive and challenging project.
That resident graduates overall felt only a moderate degree of comfort addressing general medical issues and screenings with their patients is worth highlighting. It might be argued that as specialists, this is appropriate. On the other hand, because patients with mental illness are at higher risk for medical complications and poor general medical care (1), training in routine health screening should be emphasized in general adult psychiatry training programs, and psychiatrists should learn to incorporate general health screenings into their practices.
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ACKNOWLEDGMENTS
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Research reported in this study was supported by the Department of Veterans Affairs, Veterans Health Administration, Mental Illness Research and Education Clinical Center (MIRECC), Portland, Oregon.
The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States Government.
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REFERENCES
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- Carney CP, Pitkin AK, Malis R, et al: Combined internal medicine/psychiatry and family practice/psychiatry training programs 1999-2000: residents’ perspectives. Acad Psychiatry 2002; 26:110–116[Abstract/Free Full Text]
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- Cope DW, Sherman S, Robbins AS: Restructuring VA ambulatory care and medical education: the pace model of primary care. Acad Med 1996; 71:761–771[Medline]
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ABSTRACT
INTRODUCTION
