Psychiatric training in primary care medicine residency programs. A national survey

Antidepressant Prescription Behavior Among Primary Care Clinician Providers After an Interprofessional Primary Care Psychiatric Training Program

Primary care providers (PCPs) are increasingly called upon to screen for and treat depression. However, PCPs often lack the training to diagnose and treat depression. We designed an innovative 12-month evidence and mentorship-based primary care psychiatric training program entitled the University of California, Irvine (UCI) School of Medicine Train New Trainers Primary Care Psychiatry (TNT PCP) Fellowship and examined whether this training impacted clinician prescription rates for antidepressants. We retrieved information on 18,844 patients and 192 PCPs from a publicly insured health program in Southern California receiving care between 2017 and 2021. Of the 192 PCPs, 42 received TNT training and 150 did not. We considered a patient as exposed to the provider's TNT treatment if they received care from a provider after the provider completed the 1-year fellowship. We utilized the number of antidepressant prescriptions per patient, per quarter-year as the dependent variable. Linear regression models controlled for provider characteristics and time trends. Robustness checks included clustering patients by provider identification. After PCPs completed TNT training, "exposed" patients received 0.154 more antidepressant prescriptions per quarter-year relative to expected levels (p < 0.01). Clustering of standard errors by provider characteristics reduced precision of the estimate (p < 0.10) but the direction and magnitude of the results were unchanged. Early results from the UCI TNT PCP Fellowship demonstrate enhanced antidepressant prescription behavior in PCPs who have undergone TNT training. A novel, and relatively low-cost, clinician training program holds the potential to empower PCPs to optimally deliver depression treatment.

Train New Trainers Primary Care Psychiatry Fellowship-Optimizing Delivery of Behavioral Health Care Through Training for Primary Care Providers

OBJECTIVE

To expand and optimize the behavioral health workforce, it is necessary to improve primary care providers' (PCPs) overall knowledge and clinical skills in primary care-based psychiatry. Studies on the effects of postgraduate psychiatric education programs for PCPs on psychiatric knowledge are limited.

METHODS

A total of 251 PCPs completed a 1-year fellowship. Data from program development and evaluation were analyzed for 4 fellowship years (2016-2019). Fellows were surveyed at baseline, midpoint, and postfellowship about mental health stigma, perceived competency, attitudes about psychiatry, satisfaction with current psychiatric knowledge, confidence and comfort to treat psychiatric illnesses, and program satisfaction. Psychiatric knowledge was evaluated at baseline, midpoint, and postfellowship.

RESULTS

Large effects were noted on perceived competency/self-efficacy and confidence in the treatment of common psychiatric disorders encountered in primary care settings. Positive effects were observed on attitudes of mental health stigma, and even more robust effects were found with improvement in psychiatry clinical knowledge. Knowledge improved by 12% at postfellowship (P < .0001). Correlations of the degree of change in attitude with improved psychiatric literacy demonstrated significant relationships with reduction of stigma total score (r = -0.2133, P = .0043), increased willingness (r = 0.1941, P = .0096), and increased positive attitudes (r = 0.1894, P = .0111).

CONCLUSION

Innovative initiatives to improve and expand psychiatric knowledge and clinical skills among those who provide the most behavioral health care (PCPs) can have marked impacts on attitudes toward mental health care delivery, stigma, and competency/self-efficacy. Future studies are necessary to consider the impact of this program on clinical practice pattern outcomes on a larger scale.

Addressing the need for forensic psychological evaluations of asylum seekers: The potential role of the general practitioner

Asylum seekers who have survived torture and other abuses may experience a wide range of psychological symptoms associated with depression, anxiety, and posttraumatic stress disorder. During the asylum process, attorneys might refer their clients to clinicians who document these psychological sequelae of human rights violations. However, the need for forensic psychological evaluations exceeds the number of mental health clinicians available to provide these assessments. It has been suggested that primary care physicians, professionals who already play essential roles in the identification and treatment of mental health issues, may be able to conduct these evaluations. Yet, there is little empirical knowledge of what prior training and clinical experiences support mental health and non-mental health professionals who engage in this work, and what is needed to prepare general practitioners to provide forensic psychological evaluations to asylum seekers. This pilot study found non-mental health practitioners with experience in psychological forensic evaluations reached a level of confidence in conducting evaluations of asylum seekers comparable to general mental health practitioners. The study also identified clinicians' perceptions of training that supports them in their forensic psychological evaluations, their professional development needs, and the potential for general practitioners to leverage their current skill sets in this work.

A Primary Care Prevention System for Behavioral Health: The Behavioral Health Annual Wellness Checkup

Behavioral health problems are involved in the majority of primary care visits. These behavior disorders (e.g., depression, anxiety, smoking, insomnia, etc.) are costly, burdensome to both the patient and the healthcare system, and result in greater medical utilization/cost and poorer future health outcomes. Integrated behavioral healthcare has been proposed as a model for more efficiently addressing the burden of behavioral health problems. While this model has demonstrated some promise in the treatment of behavioral health problems, as well as in the reduction in costs and improvement in healthcare outcomes, the primary prevention of behavioral health problems in this delivery model has been relatively neglected. The present paper discusses the potential value of incorporating the prevention of behavioral health problems into the annual physical/wellness checkup and proposes a detailed system for how this might be accomplished. Limitations, future research, and costs associated with increased prevention in a primary care context are discussed.

A research coding method to evaluate medical clinicians conduct of behavioral health care in patients with unexplained symptoms

OBJECTIVE

Develop a reliable coding method of a Behavioral Health Treatment Model for patients with Medically Unexplained Symptoms (BHTM-MUS).

METHODS

Two undergraduates trained for 30h coded videotaped interviews from 161 resident-simulated patient (SP) interactions. Trained on 45 videotapes, coders coded 33 (20%) of 161 study set tapes for the BHTM-MUS. Guetzkow's U, Cohen's Kappa, and percent of agreement were used to measure coders' reliability in unitizing and coding residents' skills for eliciting: education and informing (4 yes/no items), motivating (2), treatment statements (5), commitment and goals (2), negotiates plan (8), non-emotion patient-centered skills (4), and patient-centered emotional skills (8).

RESULTS

60 items were dichotomized a priori from analysis of the BHTM-MUS and were reduced to 33 during training. Guetzkow's U ranged from .00 to .082. Kappa ranged from 0.76 to 0.97 for the 7 variables and 33 individual items. The overall kappa was 0.87, and percent of agreement was 95.7%. Percent of agreement by item ranged from 85 to 100%.

CONCLUSIONS

A highly reliable coding method is recommended to evaluate medical clinicians' behavioral care skills in patients with unexplained symptoms.

PRACTICE IMPLICATIONS

A way to rate behavioral care in patients with unexplained symptoms.

Mental health from the perspective of primary care residents: a pilot survey

OBJECTIVE

Primary care physicians are increasingly providing psychiatric care in the United States. Unfortunately, there is limited learning opportunity or exposure to psychiatry during their residency training. This survey was conducted to assess primary care resident interaction with mental health professionals and their satisfaction, knowledge, preference, and comfort with the delivery of mental health care in primary health care settings.

METHOD

On the basis of available published literature, a 20-question survey was formulated. Following receipt of the institutional review board's approval, these questions were sent via e-mail in February 2012 to internal and family medicine residents (N = 108) at 2 teaching hospitals in southwest Virginia. Analysis of the electronically captured data resulted in a response rate of 32%. Descriptive analysis was used to examine the results.

RESULTS

The responses were equally divided among male and female residents and family medicine and internal medicine residents. There were several interesting findings from the survey. No correlations were noted between the gender of residents, type or location of the medical school, or having had a psychiatric rotation during residency and the reported comfort level treating patients with psychiatric illness or the desire to see psychiatric patients in the future. A positive correlation was found between the residents' training level and their belief about the percentage of mental health providers who have mental health problems.

CONCLUSIONS

The current training model to acclimate primary care residents to the field of mental health appears to have major limitations. RESULTS of this pilot survey can serve as a guide to conduct prospective, multicenter studies to identify and improve psychiatric training for primary care residency programs.

Addressing mental health issues in primary care: an initial curriculum for medical residents

OBJECTIVE

Many express concern that modern medicine fails to provide adequate psychosocial and mental health care. Our educational system has not trained the primary care providers who care for most of these patients. Our objective here is to propose a quantum change: prepare residents and students during all years of training so that they are as effective in treating psychosocial and mental health issues as they are medical problems.

METHOD

We operationalize this objective, following Kern, by developing an intensive 3-year curriculum in psychosocial and mental health care for medical residents based on models with a strong evidence-base.

RESULTS

We report an intensive curriculum that can guide others with similar training interests and also initiate the conversation about how best to prepare residency graduates to provide effective mental health and psychosocial care.

CONCLUSION

Identifying specific curricula informs education policy-makers of the specific requirements they will need to meet if psychosocial and mental health training are to improve.

PRACTICE IMPLICATIONS

Training residents in mental health will lead to improved care for this very prevalent primary care population.

An evidence-based patient-centered method makes the biopsychosocial model scientific

OBJECTIVE

To review the scientific status of the biopsychosocial (BPS) model and to propose a way to improve it.

DISCUSSION

Engel's BPS model added patients' psychological and social health concerns to the highly successful biomedical model. He proposed that the BPS model could make medicine more scientific, but its use in education, clinical care, and, especially, research remains minimal. Many aver correctly that the present model cannot be defined in a consistent way for the individual patient, making it untestable and non-scientific. This stems from not obtaining relevant BPS data systematically, where one interviewer obtains the same information another would. Recent research by two of the authors has produced similar patient-centered interviewing methods that are repeatable and elicit just the relevant patient information needed to define the model at each visit. We propose that the field adopt these evidence-based methods as the standard for identifying the BPS model.

CONCLUSION

Identifying a scientific BPS model in each patient with an agreed-upon, evidence-based patient-centered interviewing method can produce a quantum leap ahead in both research and teaching.

PRACTICE IMPLICATIONS

A scientific BPS model can give us more confidence in being humanistic. In research, we can conduct more rigorous studies to inform better practices.

Mental health and psychiatry training in primary care residency programs. Part II. What skills and diagnoses are taught, how adequate, and what affects training directors' satisfaction?

OBJECTIVE

The purpose of this study is to describe the psychiatric skills and diagnostic categories taught in primary care training programs, their adequacy, the perceived needs and desires for curriculum enhancement and the factors affecting training directors' satisfaction.

METHOD

All 1365 directors of accredited residency training programs in Internal Medicine (IM), Family Practice (FP), Obstetrics and Gynecology (Ob/Gyn), Pediatrics (Peds) and psychiatry received a 16-item anonymous questionnaire about psychiatry training in their program. Responses to the questionnaire to items concerning the skills and diagnostic categories taught, assessment of adequacy of teaching and desires for curriculum enhancement for specific skills and diagnostic categories were analyzed. The factors affecting training directors' satisfaction were explored.

RESULTS

Interviewing skills were taught by a majority of all training programs and were considered adequate by 81% of FP and 54% of IM programs, in contrast to less than a majority of Ob/Gyn and Peds programs (P<.001). A majority provided diagnostic interviewing and counseling training, but only FP considered it adequate. A majority taught psychopharmacology and various psychiatric diagnoses, but only in FP did a majority consider them adequate. Both Peds and FP programs teach child psychiatry; significantly, more Peds compared to FP consider their training to be adequate. A vast majority of IM, Ob/Gyn and Peds programs, and 50% of FP programs desired more training in interviewing techniques and diagnostic interview. A majority of all programs desired more counseling and psychopharmacology training and more training in disorders of childhood and adolescence. The overall satisfaction rate for psychiatric training across specialties was 46% (n=657). Sixty-four percent of FP programs were satisfied compared to 31% of non-FP programs. Satisfaction was associated with increased amount of psychiatric training, diversity of training formats, venues, faculty and settings, the amount of contribution to teaching by psychiatry departments and the presence of current teaching in interviewing skills. There were specialty-specific differences in factors associated with satisfaction. In general, a smaller size of residency program was associated with satisfaction except in IM, where larger size was associated with satisfaction. Satisfaction was associated with the opinion that primary care physician should be ready and willing to treat more psychiatric conditions.

CONCLUSION

Most primary care training programs currently offer training in most psychiatric skills and disorders, but a majority of training directors are dissatisfied with their psychiatry training. There is a difference in the estimation of adequacy concerning training between FP, which consistently rates their teaching to be adequate, and all other primary care programs, which consider their teaching inadequate. This difference may be partly due to actual differences in amount and diversity of training as well as differences in the threshold for satisfaction. A vast majority of primary care training programs desire more training in almost all aspects of psychiatry, and there may be specialty-specific needs and areas of curriculum enhancement. To enhance satisfaction, we should improve the quality as well as the quantity of training, as well as the diversity in training formats, venues and faculty.

Mental health and psychiatry training in primary care residency programs. Part I. Who teaches, where, when and how satisfied?

OBJECTIVE

Some 40% of patients treated by primary care physicians have significant mental health problems. Only about half eventually receive mental health care, usually by the primary care physicians, often inadequately. Recently, there has been an increased attempt to incorporate psychiatry in primary care training programs. The authors sought to assess the current status of psychiatry training in Internal Medicine (IM), Family Practice (FP), Pediatrics (Peds) and Obstetrics and Gynecology (Ob/Gyn) residency programs.

METHOD

All 1365 directors of accredited residency training programs in IM, FP, Ob/Gyn and Peds received a 16-item anonymous questionnaire in 2001-2002, collecting descriptive data concerning their psychiatry training.

RESULTS

A great majority of IM (71%), Ob/Gyn (92%) and Peds (85%) training directors felt that the training was minimal or suboptimal, as compared to 41% of FP training directors (P<.001). Sixty-four percent of FP program directors were satisfied with their training (P<.001). In contrast, 54% of other PC program directors were dissatisfied with their psychiatry training. All programs utilized ambulatory care setting extensively. Family Practice programs had more types of mental health teachers, teaching formats and teaching settings (P<.001). A majority of IM (57%) and Peds (70%) residencies desired more psychiatry training in their programs compared to only a third of FP and 40% of Ob/Gyn programs (P<.001). Teaching in clinical settings was preferred by all except Ob/Gyn programs (P<.001). Psychiatry departments contributed more to IM and Peds programs than others.

CONCLUSION

A majority of primary care training programs are dissatisfied with the current status of their psychiatric training except for FP programs. Family Practice programs have the most variety in training formats, venues and teachers. There are some specialty-specific differences in perceived needs and desires in psychiatric training.

Changing habits of practice. Transforming internal medicine residency education in ambulatory settings

PURPOSE

The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change.

METHODS

The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance.

RESULTS

Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education.

CONCLUSION

This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident's level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia.