Acad Psychiatry 32:504-509, November-December 2008
doi: 10.1176/appi.ap.32.6.504
© 2008 Academic Psychiatry
Teaching Psychiatry in Primary Care Residencies: Do Training Directors of Primary Care and Psychiatry See Eye to Eye?
Hoyle Leigh, M.D.,
Ronna Mallios, M.P.H. and
Deborah Stewart, M.D.
Received April 23, 2007; revised August 5, 2007; accepted August 22, 2007. Drs. Leigh and Mallios are affiliated with the Department of Psychiatry at the University of California, San Francisco; Dr. Stewart is affiliated with the Department of Pediatrics at University of California, Davis. Address correspondence to Hoyle Leigh, M.D., University of California, San Francisco, Department of Psychiatry, UCSF Fresno, 155 N. Fresno St., Fresno, CA 93701; hoyle.leigh{at}ucsf.edu (e-mail).
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ABSTRACT
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OBJECTIVE: This study compares the views of psychiatry residency training directors about psychiatry and mental health training in the primary care programs in their institutions with those of the primary care residency training directors. METHODS: A 16-item questionnaire surveying specific areas of training and perceived adequacy of current teaching was distributed to 1,544 U.S. primary care and psychiatry program directors. RESULTS: The response rate was 53%. Among psychiatry training directors, 85% responded that psychiatry training in their primary care programs was minimal to suboptimal, while 68% of family practice training directors responded that their psychiatry training was optimal to extensive. Among psychiatry training directors, 89% were dissatisfied with the psychiatry training in their primary care programs, and only 8% were satisfied. In contrast, almost half of primary care training directors were satisfied. However, within the primary care programs, there was a marked difference between family practice (majority satisfied) and the rest (internal medicine, obstetrics and gynecology, pediatrics, mostly unsatisfied). All primary care and psychiatry training directors agreed that most basic psychiatric skills and diagnoses were taught in the primary care programs. For all skills and syndromes examined, psychiatry training directors consistently and significantly rated the training to be less adequate than did primary care training directors. There was general agreement that primary care physicians should be able to treat most uncomplicated cases in patients with psychiatric disorders, and some but not other psychiatric conditions. CONCLUSION: Psychiatry and primary care training directors, except in family practice, generally agree that psychiatry training in primary care programs is inadequate and should be significantly enhanced. There should be more communication between psychiatry and primary care training programs for optimal curriculum development.
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INTRODUCTION
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An estimated 20% to 40% of patients in primary care settings have one or more psychiatric disorders (1–6). Patients with comorbid psychiatric and medical illnesses are considered to be more difficult to treat and more disabled and tend to use more resources than patients with medical illnesses only. Only 50% of patients with psychiatric illnesses will receive treatment for them, usually by primary care physicians and often inadequately (7–10).
The American Council for Graduate Medical Education (ACGME) has mandated inclusion of behavioral sciences in the curricula of all primary care residency programs, including internal medicine, family practice, pediatrics, and obstetrics and gynecology, but the contents of the behavioral science curricula have not been well defined. We surveyed primary care residency training directors concerning the nature and status of psychiatry and behavioral science training in their programs and found that although most programs offered such training, the training directors (except for those in family practice) were generally dissatisfied with their training in psychiatry and behavioral science (11, 12). We also surveyed psychiatry residency training directors about their assessment of mental health training in the primary care programs in their institutions. We now report their views and compare them with the views of the primary care training directors.
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Methods
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All 1,409 directors of accredited primary care residency training programs in internal medicine, family practice, pediatrics, and obstetrics and gynecology with valid addresses received a 16-item anonymous questionnaire about psychiatry training in their programs. A similar 16-item questionnaire that assessed views about psychiatry training in the primary care residency programs in their institutions was sent to 135 psychiatry training program directors based in general hospitals. Questionnaire responses were entered into a Microsoft Access database and Excel spreadsheets. SPSS was utilized to analyze categorical variables with the chi-square test for independence (SPSS 16.0 for Windows, Chicago, 2008). Responses from primary care residency directors were compared with those of psychiatry residency directors.
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Results
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The overall response rate of valid addresses was 53% (n=751). The response rate in primary care was 58% (n=689), broken down to 43% internal medicine (n=166), 65% family practice (n=317), 34% obstetrics and gynecology (n=87), 54% pediatrics (n=111), and 46% psychiatry (n=62). More than 85% of the psychiatry training directors who responded to the questionnaire (n=52) had at least one primary care training program in their institutions, and more than 69% had all primary care residencies (internal medicine, family practice, pediatrics, and obstetrics and gynecology) in their institutions (n=42). Among the psychiatry respondents, 92% were based in medical schools or institutions with major medical school affiliations (n=55), as compared with 62% of all primary care residencies (n=288): 46% family practice (n=89), 69% internal medicine (n=72), 82% obstetrics and gynecology (n=45), and 85% pediatrics (n=56).
Overall Adequacy and Satisfaction with Psychiatric Training
Among the psychiatry training directors, 85% considered the psychiatry training in their institutions’ primary care programs to be minimal to suboptimal (n=51), as compared with 5% who thought they were optimal to extensive (n=3) (p<0.001). Eighty-nine percent were dissatisfied with training (n=48) and only 8% were satisfied (n=5). The primary care training directors, in contrast, had an overall dissatisfaction rate of 54% (n=221), and almost half (46%, n=188) were satisfied (p<0.001). However, within the primary care programs, there was a marked difference between family practice (64% satisfied, n=200) and the rest: 33% satisfied in internal medicine (n=57), 36% in obstetrics and gynecology (n=26), and 27% in pediatrics (n=22).
Specific Skills and Syndromes
Table 1 shows the percentages of all primary care and psychiatry residency directors who considered the training of specific skills and syndromes to be adequate. For interviewing technique, diagnostic interview, counseling, psychotherapy, and psychopharmacology, psychiatry training directors consistently and significantly considered the training to be inadequate compared with primary care training directors.
For all syndromes queried, psychiatry training directors consistently and significantly rated the training to be inadequate. Internal medicine, obstetrics and gynecology, and pediatrics training directors tended to rate the adequacy of their psychiatric training lower than family practice training directors. The overall assessment of the psychiatry training directors concerning psychiatric training was similar in pattern (much current training, but deemed inadequate, and desiring more training) to that of internal medicine, obstetrics and gynecology, and pediatrics training directors and differed from that of family practice training directors, who considered their training to be adequate and thus saw little need for more (Figure 1). However, for eating disorders, family practice training directors did not differ from all others in considering their training to be inadequate (50%, n=93) and desiring more training (Figure 2). As might be expected, a large majority of pediatric programs responded that their training in psychiatric conditions of childhood and adolescence was adequate except for conduct disorders, for which only 38% believed that it was adequate (n=35). Surprisingly, there was no significant difference among psychiatry, family practice, and pediatrics program directors in considering their training in conduct disorders to be inadequate (Table 1).
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FIGURE 1. Responses Regarding Primary Care Training on Mood Disorders
p<0.001
Current=training occurs currently; Adequate=the training director views the training as being adequate; Desire=the training director desires more training in the particular area
A similar U-shaped pattern appeared for psychosis, anxiety disorders and posttraumatic stress disorder, substance use/abuse, personality disorders, somatoform and pain disorders, psychological factors affecting medical illness, physical factors affecting emotional/psychiatric condition, adjustment disorders, and grief/bereavement.
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FIGURE 2. Responses Regarding Primary Care Training on Eating Disorders
p<0.01
Current=training occurs currently; Adequate=the training director views the training as being adequate; Desire=the training director desires more training in the particular area
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Psychiatry and internal medicine training directors responded similarly for current training and adequacy, but psychiatry training directors considered that there was less interviewing, counseling, and dementia training than did internal medicine; however, they both agreed that current training was less than adequate in most conditions except for dementia and delirium, anxiety, posttraumatic stress disorder, substance use, and physical factors affecting psychiatric conditions. For these conditions, internal medicine training directors responded that they were doing a more adequate job than psychiatry training directors responded that they were. Most striking is the assessment of psychiatry and internal medicine training directors about the adequacy of teaching concerning the dying patient; 72% of internal medicine training directors (as well as 75% of family practice training directors, n=146) responded that it was adequate (n=75) compared with only 32% of psychiatry program directors (n=16) (Figure 3).
Psychiatry Department Contributions
There were no significant differences between psychiatry and primary care training directors in their estimation of psychiatry department contributions to primary care training. The directors did not significantly differ on issues of provision of faculty for didactic courses and clinical supervision or rotation of primary care to psychiatry, but 50% of psychiatry training directors (n=31) responded that primary care residents were rotating to their departments, while only 33% (n=137) of primary care directors responded that their residents rotated to psychiatry departments (p<0.001). This probably indicates that many primary care residencies are based in hospitals without psychiatry training programs.
Treating Patients with Psychiatric Problems
A majority of psychiatry (58%, n=36), internal medicine (71%, n=119), and family practice (87%, n=281) training directors and a plurality of obstetrics and gynecology (31%, n=31) and pediatrics (47%, n=47) training directors disagreed with the statement "All patients with psychiatric problems should be referred to a psychiatrist." A majority of psychiatry (51%, n=32) and pediatrics (55%, n=55) training directors and a plurality of obstetrics and gynecology (42%) training directors disagreed and a majority of family practice (52%, n=165) and a plurality of internal medicine (37%, n=61) training directors agreed with the statement "Primary care physicians should treat most patients with psychiatric conditions." A majority of both psychiatry (71% n=44) and all primary care (internal medicine, 89% n=137; obstetrics and gynecology, 59% n=48; pediatrics, 57% n=57; family practice, 88% n=282) training directors agreed with the statement "Primary care physicians should treat uncomplicated psychiatric conditions." A majority of psychiatry (65% n=40), internal medicine (61% n=61), pediatrics (53% n=53) and obstetrics and gynecology (50% n=40) training directors disagreed and a plurality (44% n=139) of family practice training directors agreed with the statement "Primary care physicians should treat most patients with psychiatric conditions before referring them to a psychiatrist." An overwhelming majority of both psychiatry (76% n=47) and primary care (all >72%) training directors agreed with the statement "Primary care physicians should treat some but not other psychiatric conditions."
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Discussion
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Because psychiatry training directors are often consulted in designing the behavioral science curriculum of primary care training programs, their views concerning the current state of psychiatry training in primary care has considerable relevance. To our knowledge, ours is the first study to compare psychiatry training directors’ views on such training in their own institutions with those of the primary care training directors.
Our study has several limitations. First is the relatively low response rate of psychiatry training directors, even though our survey was sent to those in programs based at general hospitals. Several psychiatry training directors who did not complete the questionnaire communicated to us that they did not have much contact with their primary care programs; thus the lower response rate may be a function of the unfamiliarity of psychiatry training directors with the psychiatry training in their primary care programs. Another limitation is that we could not compare the views of psychiatry and primary care training directors within the same institutions because of the anonymous nature of the survey. Some primary care programs, particularly family practice programs that are not affiliated with universities or do not have a psychiatry department within their hospitals, hire their own mental health professionals. Psychiatry training directors are obviously in no position to assess the adequacy of mental health training in such programs.
Our overall findings indicate that psychiatry training directors agree with the assessments of primary care training directors (other than those in family practice, who are generally satisfied with their psychiatry training) that psychiatry training in primary care programs is inadequate and unsatisfactory. Furthermore, psychiatry training directors consistently assessed the training to be less adequate and less satisfactory than did their counterparts in primary care. On one hand, this may be due in part to differing expectations based on expertise, with psychiatrists naturally expecting more psychiatry training than internists, who may expect more of their trainees than do family practitioners. On the other hand, psychiatry training directors may actually underestimate the degree of actual training. The astounding differences in assessments of the dying patient between internal medicine and family practice training directors on one hand and psychiatry training directors on the other may indeed indicate this. It may be important for educators in psychiatry to note that primary care programs indeed do teach well some aspects of psychiatry and behavioral science. Furthermore, some psychiatry program directors may underestimate the amount of training that some family practice programs provide by hiring their own mental health professionals and not utilizing psychiatrists from their psychiatry departments.
There seems to be general agreement that some psychiatric conditions, such as eating disorders, are in need of increased training in primary care programs. Specific primary care programs may desire augmentation in particular skills and syndromes, as we noted in our earlier publications (e.g., diagnostic interview, somatoform/pain disorders, psychological factors affecting physical condition, conduct disorders, and adjustment disorders for pediatrics; diagnostic interview, psychotherapy, counseling, and psychopharmacology for obstetrics and gynecology; and training in a variety of psychiatric techniques and disorders for internal medicine) (11, 12). Most pediatric programs responded that their training in psychiatric disorders of childhood and adolescence was adequate, except for conduct disorders, which may indicate a gap in their current curriculum.
Responses regarding the degree and extent of psychiatry department contributions to psychiatry education in primary care programs did not differ between primary care and psychiatry training directors, except for primary care residents rotating to psychiatry. Because psychiatry departments accept residents from both internal medicine and family practice programs, this difference is not surprising. Furthermore, a number of primary care departments, especially in family practice, are based in hospitals without psychiatry training programs.
The training directors generally agree that primary care physicians should be able to treat most uncomplicated psychiatric cases and that primary care physicians should treat some but not other psychiatric conditions. In hindsight, it would have been interesting to ask which conditions should or should not be treated by primary care physicians. A future study might attempt to define the psychiatric conditions that primary care physicians should attempt to treat first, which may be an important teaching point in the psychiatry curriculum of primary care training programs. Active participation of psychiatric educators would be crucial in this endeavor.
Because greater psychiatry department contributions to psychiatry training in primary care programs is associated with increased satisfaction of primary care training directors (12), and satisfaction is associated with a tendency for primary care physicians to be more willing to treat psychiatric patients before referral, increasing psychiatry department contributions may better prepare primary care physicians to treat psychiatric conditions.
Do psychiatry and primary care training directors see eye to eye concerning psychiatric training in primary care? Yes, but only partially. Psychiatry, internal medicine, obstetrics and gynecology, and pediatrics training directors agree that there is considerable psychiatry training in their programs, but regard it to be inadequate. Family practice training directors consider the psychiatry training in their programs to be extensive and adequate. However, there are areas where even psychiatry and family practice training directors see eye to eye. Psychiatry training directors tend to underestimate the adequacy of primary care training even in subjects that are very frequently encountered in primary care. For collaboration in developing optimal mental health training programs in primary care, there should be better communication and understanding of the current status and future needs between psychiatry and primary care training programs.
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ACKNOWLEDGMENTS
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The authors thank Javier Garza for assistance in data gathering and analysis.
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REFERENCES
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- Regier DA, Narrow WE, Rae DS, et al: The de facto U.S. mental and addictive disorders service system. Arch Gen Psychiatry 1993; 50:85–94[Abstract/Free Full Text]
- Regier DA, Boyd JH, Burke JD, et al: One month prevalence of mental disorders in the United States. Arch Gen Psychiatry 1988; 45:977–986[Abstract/Free Full Text]
- Barrett JE, Barrett JA, Oxman TE, et al: The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry 1988; 45:1100–1106[Abstract/Free Full Text]
- Kessler L, Burns BJ, Shapiro S, et al: Psychiatric diagnoses of medical service users: evidence from the epidemiologic catchment area program. Am J Public Health 1987; 77:18–24[Abstract/Free Full Text]
- Didden DG, Philbrick JT, Schorling JB: Anxiety and depression in an internal medicine resident continuity clinic: difficult diagnoses. Int J Psychiatry Med 2001; 31:155–167[CrossRef][Medline]
- Jackson JL, Passamonti M, Kroenke K: Outcome and impact of mental disorders in primary care at 5 years. Psychosom Med 2007; 69:270–276[Abstract/Free Full Text]
- Borus JF, Howes MJ, Devins NP, et al: Primary health care providers’ recognition and diagnosis of mental disorders in their patients. Gen Hosp Psychiatry 1988; 10:317–321[CrossRef][Medline]
- Schulberg HC, Burns BJ: Mental disorders in primary care: epidemiologic, diagnostic and treatment research directions. Gen Hosp Psychiatry 1988; 10:79–87[CrossRef][Medline]
- Blazer D: Depression in the elderly. N Engl J Med 1989; 320:164–166[Medline]
- Von Korff M, Shapiro S, Burke JD, et al: Anxiety and depression in a primary care clinic: comparison of diagnostic interview schedule, general health questionnaire, and practitioner assessments. Arch Gen Psychiatry 1987; 44:152–156[Abstract/Free Full Text]
- Leigh H, Stewart D, Mallios R: Mental health and psychiatry training in primary care training programs: who teaches, where, when, and how satisfied? Gen Hosp Psychiatry 2006; 28:189–194[CrossRef][Medline]
- Leigh H, Stewart D, Mallios R: 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? Gen Hosp Psychiatry 2006; 28:195–204[CrossRef][Medline]
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P. R. Muskin
The Teaching of Psychiatry to Non-Psychiatrists: The Patient as a Person
Acad Psychiatry,
November 1, 2008;
32(6):
460 - 462.
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ABSTRACT
INTRODUCTION
