Medical training in psychiatry resisdency

FLSEVIER

Commentary

and Perspective

From time to time, the Journal receives manuscripts that can be thought of as opinion pieces, essays, or editorial comment on matters of topical interest. Such submissions will be refereed in the usual fashion and, if suitable, published in this section. The Editorial Board invites Letters to the Editor or rebutting commentary with the understanding that all submissions are subject to editing.

Medical

Training

in Psychiatry

Residency

A Proposed Curriculum Steven D. Kick, M.D., M.S.P.H., Roger G. Kathol, M.D.

Mary

Abstract: During the coming decades, psychiatrists will be asked to participate to a greater extent in the physical evaluation and treatment of patients with behavioral or emotional problems. Despite the high frequency with which psychiatric symptoms are caused or exacerbated by organic disease, psychiatrists have been reluctant, and in some ways, even discouragedto include physical assessments. Psychoanalysis and concerns about boundary issues have influenced psychiatrists to cede physical assessment and physical illness to other physicians. To help overcome these barriers to improved care of psychiatric patients, a curriculum is proposed for psychiatry residents. It will allow them to better use their medical backgrounds while increasing their contributions as mental health specialists. 0 1997 Elsevier Science Inc.

Introduction It is time for psychiatrists to assume their role as physicians in providing mental health care. They alone among mental health professionals have the potential to integrate medical causes of emotional and behavioral problems. In order to do this, they need to define the duties for which they will be responsible and then alter residency training to prepare themselves, all in a rapidly changing medical environment. This challenge is not novel. Over 100 years ago, Mitchell [l], himself a psychiatrist, chastised his

University of Colorado Health Sciences Center, Denver, Colorado (SDK); University of Pennsylvania Medical Center, Philadelphia, Pennsylvania (MM); and University of Iowa Hospitals and Clinics, Iowa City, Iowa (RGK). Address reprint requests to: Steven D. Kick, M.D., M.S.P.H., University of Colorado Health Sciences Center, 4200 E. Ninth Ave., Box C261-72, Denver, CO 80262.

General Hospital Psychiatry 19, 259-266, 1997 0 1997 Elsevier Science Inc. All rights reserved. 65.5 Avenue of the Americas, New York, NY 10010

Morrison,

M.D., and

psychiatrist colleagues for their lack of physical study of patients. He could not even find a stethoscope in an insane asylum where his colleagues worked. Though psychiatrists have remained aligned with medicine since that time, particularly with the introduction of psychotropic medications, training programs do not encourage the application of physical assessmentas a part of psychiatric practice. As a result, the discipline’s claim that it alone is capable of including medical causes of psychiatric syndromes produces a hollow tone to nonpsychiatrist physicians who observe their practice. In this paper, we review the frequency with which physical illness causesor exacerbates psychiatric symptoms, describe the status of psychiatristinitiated physical assessment during the past 20 years, list the barriers that contribute to psychiatrists’ reluctance to include an organic work-up, and propose a residency training curriculum designed to address these issues. We will propose that psychiatrists augment their involvement in the medical care of their patients through enhanced recognition of important concurrent medical illnesses, especially through the physical exam and examination of diagnostic tests. We also believe that improved collaboration with medical colleagues and consideration for the limited provision of direct medical care are essential. We raise difficult questions about the identity of psychiatry and suggest charting a new course, one that will improve mental health care to our patients and, by so doing, preserve and foster the integrity and growth of the discipline for the next decade.

259 MN 0163-8343/97/$17.00 PI1 ‘3X63-X343(97)00092-8

S. D. Kick et al

Physical Illness

in Psychiatric

Patients

The prevalence of physical illness among psychiatric inpatients ranges from 33% to 46% [2-51. It is also seen in 9%-43% of outpatients [2,6-lo] and 50% of day treatment patients [ll]. Just how clinically meaningful is this high prevalence? In a study by Koranyi [7], 43% of 2090 psychiatric outpatients who were screened for medical illness had a concurrent physical disease. In 18% the organic disorders were causally related to the patient’s psychiatric symptoms, and in 51% the psychiatric disorder was aggravated by the medical illness. In a study in Denmark by Licht et al. [5], the risk of death among psychiatric inpatients was fourfold higher than the general population. The authors stated “Improved medical management and follow-up of physical health are necessary.” Koran et al. [2] reported that 39% of 529 patients in the California state mental health system had a medical illness that required intervention once identified, a finding similar to that documented by Koranyi. In 14% of the patients, the medical condition either caused or exacerbated their psychiatric symptoms. However, only 47% of these medical illnesses were detected by the mental health system. Koranyi [12] determined that 28 of the patients included in his original study had died within 3 years, which was twice the age-adjusted community mortality rate during that time period. Five of the deaths were considered medically/surgically preventable had the medical illness been appropriately recognized and treated. Similarly, in a study by Chatham-Showalter 1131 among military inpatient psychiatric patients, almost half the patients had medical illnesses, and of those, 75% had a disorder that was either new or had been neglected. Many of these disorders were treatable with appropriate care. The author noted that these patients’ health was not good, even when they had access to free medical care. These studies suggest that psychiatric populations are especially vulnerable to medical illness and this is not solely because of financial barriers to medical care.

Psychiatrists’ Physicians

Perceived

Roles as

Psychiatrists are arguably physicians first and mental health specialists second. They complete medical school, and in some cases, an internship similar to

260

their colleagues in medicine. It is not until the second year of residency that psychiatric housestaff are truly removed from a setting in which medical illness is addressed. Despite the fact that the last 3 years of residency largely take place outside of a setting where physical disease is a matter of concern, psychiatrists believe that including an organic differential is a critical skill in the assessmentof patients. Langsley and Hollender [14], in a manuscript entitled “The Definition of a Psychiatrist,” reported that of psychiatric teachers and practitioners surveyed, 99.2% agreed that the ability to distinguish organic from functional illness was the most important skill that a psychiatrist should possess.A similar survey by Krummel and Kathol [16] confirmed that psychiatrists view this skill as an important way to distinguish psychiatrists from nonphysician mental health specialists. Despite the presumed importance of this skill, 63% of inpatient and 95% of outpatient psychiatrists did not perform physical examinations on their patients [16]. Those who did not do physical examinations indicated three main reasons why: 1) the exams were too time consuming, 2) they had already been done by a referring physician, or 3) because they did not consider it an essential part of the psychiatric examination [16]. Lack of competence in doing a physical examination was not a stated reason for omitting the exam. More disturbing was the fact that 25% of the psychiatrists who did not do physical examinations did not rely on nonpsychiatrists to do them either [16]. Psychiatrists are the most logical medical professionals to evaluate physical as well as mental care to their patients, particularly those with chronic mental illness. Psychiatric patients are often only seen in mental health settings because of restrictive insurance coverage, poor access to nonpsychiatrist physicians, and barriers to acceptance of psychiatric diagnoses by nonpsychiatrists. The role of the psychiatrist in the provision of medical care for these patients is undeniable. Why then do many psychiatrists evade this role?

Reluctance by Psychiatrists Medical Care

to Provide

Although there have been recent calls for the consideration of psychiatry as a primary care specialty [17,18], the dichotomy of practice expectations between psychiatrists and nonpsychiatrists makes it evident that most psychiatrists do not practice as

Medical

primary care physicians. They do not ask medical questions in their histories. They do not do physical examinations [16]. They often do not perform, or as importantly, look at the results of medical tests performed on their patients, particularly outpatients [16]. When they suspect any level of medical illness, they refer their patients to a nonpsychiatrist physician if one is available. Only when no other options are available will they take responsibility for the medical needs of their psychiatric patients. What are some of the reasons psychiatrists choose to avoid medical assessmentand treatment? First, many psychiatrists enter the field because they wish to limit their practice to primary mental illness. This means a focus on psychological, social, or even biological factors leading to emotional and behavioral disorders often to the exclusion of the physical. If the cause of mental illness has primarily psychosocial origins, of what utility is a medical history and physical examination? Even “biological/genetic” primary psychiatric disorders, such as bipolar affective disorder or alcoholism, are managed as though the neurotransmitter deficits affecting behavior, psychotropic drug interactions, and psychoactive medication side effects are all that is necessary for a psychiatrist to understand. The second reason for psychiatrists’ reluctance to provide medical care has to do with their patients’, society’s, and their own perception of their scope of practice. Patients do not expect a psychiatrist to include questions about their ulcer, broken arm, or even sexually transmitted disease in the interview about psychiatric symptoms, even if they may be related to their psychiatric condition. They also do not expect to have a physical examination. Many patients do not even know that a psychiatrist has medical training. Because patients do not expect a physical examination, it is easy to eliminate this time-consuming function from the assessmentprocess. Society has also defined the psychiatrist’s practice to exclude medical assessment. The most poignant portrayal of society’s expectations is found in the medical reimbursement system of the United States. Psychiatrists are paid to provide psychotherapy or medical therapeutics (medication checks). They are not paid by most payment systems if they perform physical examinations, treat hypertension, or order laboratory tests or x-ray studies unless they are directly related to a psychiatric illness. Psychiatrists who choose to do so automatically reduce their earning capacity and limit the number

Training

111Psychiatry

of patients they can be expected to see in a limited time frame. Psychiatrists themselves identify their purview of practice by what they do. They inhabit standalone clinics or hospitals in which it is difficult, if not impossible, to perform medical work-ups. Many do not even have examination rooms in their offices [161.They refer patients who they think need a medical evaluation to medical physicians. Many will not even see seriously physically sick patients with psychiatric symptoms until they are well because the patient would be unable to cooperate with or be safely given the psychotherapy needed. With this, is the concern by psychiatrists regarding boundaries with patients. In a time when litigation is common, psychiatrists are understandably reluctant to do physical assessments.This reluctance is pervasive. In a review of boundart issues by Gutheil and Gobbard [19], the authors-implied that the practice of performing physical exams (by psychiatrists) had declined so markedly as to not be a concern. The psychiatrists’ interests and expectations of practice, as well as the expectations of others, play a role in why they do not treat the medical conditions of their patients, however, inadequate residency training contributes to the problem. Psychiatry residency programs emphasize treatment of primary psychiatric disease. This in itself is important but needs to be balanced with training on how to include a medical history, physical examination, and performance of basic laboratory tests so that the differential can include psychiatric syndromes related to medical disease or nonpsychiatric medications (secondary psychiatric disease). Currently, psychiatry residencies are only required to have 4 months of inpatient primary care experience, and only 2 months of consultation-liaison (C-L) psychiatry [20]. A recent report for C-L guidelines, developed by a task force from the Academy of Psychosomatic Medicine, recommended at least 3 months’ experience [21]. The authors of this task force noted that curricula across programs were idiosyncratic, with “minimal sharing of practices across programs” [21]. Such also seems to be the case with medical curricula among psychiatry residencies. Psychiatrists completing training programs today are unprepared to accept the challenge of performing medical examinations despite their documented value [22]. Although the medical history can and should be easily acquired by psychiatrists, the physical exam is more problematic. Patterson [23] notes that among 98 psychiatrists he surveyed,

261

S. D. Kick et al. 58% had another physician do the exam to save time, 53% did not feel competent to do the exam, 49% avoided it because of perceived problems with transferencelcountertransference, and 42% just did not like doing physicals. Others [24] concur with the impressions of Patterson. Thus, there are significant obstacles to the provision of medical assessments by psychiatrists, including adequacy of examination rooms, concerns for altered transference/countertransference, lack of reimbursement, and issues of liability. However, if we fail to train residents in the recognition, assessment, and even treatment of medical conditions, then we cannot even begin to address these other barriers. What follows is a proposal to first improve the adequacy of residency training in these areas.

Proposed Medical Curriculum Psychiatry Residents

for

This represents a draft curriculum for training psychiatry residents that includes a medical assessment, differential, and treatment in their psychiatric evaluations. It includes attitude, knowledge, and skills, objectives that are necessary to address medical problems in psychiatric patients. Since psychiatrists will likely choose the level of their involvement in the medical care of their patients, residency programs might wish to consider whether different “tracks” within the curriculum make sense. Psychiatrists who may be providers of basic medical care for their patients may wish a continuity medical clinic setting in which to learn how to provide medical care, whereas those interested in C-L work might wish to work in consultative settings, both inpatient and outpatient. The curriculum simply provides a broad overview of objectives. Will improved education change physician behavior? Unfortunately, the education of primary care physicians in the area of psychiatry has not necessarily resulted in improved patient outcomes [25]. However, education can enhance recognition of disorders, and in the absence of a literature to the contrary, we would first advocate improving the education of psychiatric residents, as opposed to doing nothing. Although there have been published recommended guidelines for C-L training within psychiatry residencies [21], we advocate an expansion of that curriculum to broaden the medical knowledge

262

and skill base of psychiatry residents. C-L psychiatry rotations can and should be continued in residency programs, but perhaps augmented to include other aspects of medicine in psychiatric patients. Currently, there are no accepted standards for training residents in C-L psychiatry or the medical aspects of psychiatry. The following represents a list of those knowledge, attitude, and skill objectives that we feel are important to the field of psychiatry.

Attitude

Objectives

A. To understand the importance uations in psychiatric patients

of medical

1. Need 2. Setting 3. Impact on other facets of psychiatric Transference/countertransference Patient expectations Patient attitude 4. Psychiatrist as primary care-giver 5. Competence to perform examination

eval-

care

B. To learn the importance of developing psychiatrist/nonpsychiatrist physician alliances in the primary care setting C. To recognize that there are differences in the perception of mental disorders between psychiatrist and nonpsychiatrist physicians and the importance of helping nonpsychiatrist physicians deal with their perceived needs D. To understand how to deal with the “stigma” of being a psychiatrist in a primary care setting E. To recognize the importance of the psychiatrist in coordinating and supervising mental health teams in a primary care setting

Knowledge

Objectives

A. Medical

differential

1. 2. 3. 4. 5. 6. 7. 8. 9.

for psychiatric

Depression Anxiety Psychosis/Delirium Eating disorder Personality change Somatoform disorders Dementia Substance abuse/dependence Sexual dysfunction

syndromes

Medical Training in Psychiatry 10. Sleep disturbance B. Recognition and maintenance treatment of common and uncomplicated medical disorders, e.g., hypertension, diabetes, headaches, sore throats, gall bladder disease, chronic obstructive lung disease, ischemic heart, congestive heart failure, gastric ulcers, in chronic psychiatric patients C. Guidelines for prevention and health nance of psychiatric patients

mainte-

D. How to include a medical history in the assessment of a psychiatric patient that helps differentiate medical and psychiatric causes of symptoms 1. Medical questioning in a psychiatric setting 2. Physical examination and laboratory/x-ray assessment 3. Developing a medical/psychiatric differential 4. Treatment adjustments based on medical contributions E. Psychiatric manifestations ical illness or symptoms

of patients

with

med-

1. General medical Delirium Chronic fatigue syndrome 2. Neurology Temporal lobe epilepsy Stroke Parkinson’s disease Multiple sclerosis Huntington’s disease Wilson’s disease Head injury Syncope/“Spells” 3. Endocrinology Hyper or hypothyroidism Glucocorticoid excess or deficiency Carcinoid syndrome Pheochromocytoma 4. Infectious diseases Acquired immune deficiency syndrome Syphilis Lyme disease 5. Metabolic disorders Diabetes Acute intermittent porphyria 6. Cardiology Chest pain Coronary artery disease Palpitations

7. Pulmonary Dyspnea Cough 8. Gastrointestinal Irritable bowel syndrome Hepatic failure 9. Surgical Postoperative delirium Self-induced injury Suicide attempt Factitious 10. Obstetric/Gynecology Normal pregnancy/delivery Chronic pelvic pain F. Medical manifestations atric illness

in patients

with

psychi-

1. Emergent Hepatic encephalopathy due to aicoholism Dehydration/malnutrition due to catatonia / eating disorders Hyponatremia due to primary polydipsia Hypokalemia due to eating disorder Suicide attempts or serious self-mutilation 2. Nonemergent Primary polydipsia Medical complications of alcoholism Gastrointestinal bleeding Pancreatitis Delirium tremens Seizures Ascites/chronic liver failure Medical complications of eating disorders Edema Parotid gland enlargement Amenorrhea Laboratory abnormalities (leukopenia, anemia, hypokalemia, hypoalbuminemia) Bradycardia, hypotension Prolonged QT interval on EKG G. Psychiatric medication 1. 2. 3. 4.

presentations

due to nonpsychiatric

Glucocorticoids Levodopa Reserpine Others

H. Identification and treatment of side effects, complications, and adverse medical reactions of psychiatric medications 1. Emergent MAOI-induced

hypertensive

crisis

263

S. D. Kick et al. 1. Screening/preventive care tests 2. Symptom specific tests and x-rays/neuroradi-

Neuroleptic malignant syndrome Acute dystonia Medication intoxication/overdose 2. Nonemergent Antidepressants Tricyclics Serotonin-reuptake inhibitors Stimulants Anxiolytics Benzodiazepines Buspirone Antipsychotics Phenothiazines Butyropherones Newer nonphenothiazine antipsychotics Alcohol/substance dependence prophylaxis Antabuse Methadone Naltrexone Mood stabilizers Divalproex Carbamazepine Lithium Others I. Use of psychiatric logical conditions 1. 2. 3. 4. 5. 6.

medications

OlOtsY C. Medical dures 1. 2. 3. 4.

Educational

in

1. Informed consent 2. Forced medical care 3. Restraining patients K. Fiscal 1. Billing for mixed medical/psychiatric

services

Skills Objectives A. Physical

evaluation

in a psychiatric

setting

1. General medical examination 2. Neurological examination 3. Genital/Rectal examinations B. Use of laboratory chiatry

264

and x-ray procedures

psychiatric

in psy-

proce-

neurolep-

and referral

1. Effective communication with leagues 2. Appropriateness and timing

in altered physio-

and commitment

before

Pre-electroconvulsive therapy Pre-amytal interview Pre-lithium therapy Pre-intravenous haloperidol (rapid tization)

D. Use of consultation

Pregnancy Liver compromise or failure Respiratory compromise or failure Renal compromise or failure Cardiac compromise or failure Elderly

J. Competence assessments medical patients

evaluations

medical

col-

Settings

In order to accomplish the knowledge and skill base described above, several changes will be required in the structure and emphasis of the current residency requirements for psychiatry. These can be made during a 4-year training experience but will require better utilization of time during the first year of residency, with a wider range of clinical experiences in medicine and supervision by psychiatrists with expertise in medical contributions to psychiatric presentations and treatment. During the last 3 years of residency, didactics would include more information on medical contributions to psychiatric symptoms, expected inclusion of medical histories and physical examinations during psychiatric assessments, and use of laboratory and x-ray examinations when appropriate. Consultation psychiatry would receive greater attention during the training experience. The 4 months of primary care required during the first year are often completed in the inpatient setting, although this may not be the best setting for residents to learn the objectives described above. Four months is also an insufficient time to expect the objectives to be achieved. On the surface this might be threatening to program directors who are already trying to reorganize their residencies, however, we feel that the additional training needed in medicine would not substantively affect the other key components of residency. The most impressive gains could occur by restructuring the first year of residency with cross-over electives later in training. This article serves as a springboard for discussion about how to help psychiatry trainees adapt to new diverse needs. Though some residents may simply

Medical

wish to have improved medical knowledge or consultation skills, others might want to participate in medical continuity clinics by administering both direct medical care to chronic psychiatric patients and assisting with the psychiatric care of medical patients. Residency programs might consider developing clinical tracks within their residency programs which would allow graduates to work collaboratively with other specialties in a changing medical environment. Resident Evaluations No training program is complete without an evaluation of the success with which necessary attitude, knowledge, and skills have been obtained. Residents should be expected to demonstrate mastery of both medical and psychiatric examination skills during their clinical rotations. If necessary, the medical skills assessments can be completed by the nonpsychiatrist primary care physicians with whom the residents work since they are usually already involved in this activity with their own residents. As practicing psychiatrists become more comfortable with this part of psychiatric practice, they can assume greater responsibility in this evaluative process. Attitude-based objectives should also be documented during clinical rotations. Through the course of the residents’ training, they should be continuously monitored in clinical work and lectures for an understanding of the medical as well as psychiatric differential and interventions of psychiatric syndromes. Written board examinations should include questions confirming acquisition of the medical knowledge-based objectives.

Conclusion We argue for more stringent training in the medical aspects of psychiatric disease. Medical illness among psychiatric patients is common. It often relates to psychiatric symptoms but is commonly overlooked by both psychiatrist and nonpsychiatrist. Since psychiatrists are often the only medical providers for psychiatric patients, it is advisable for them to improve their skills in the recognition and treatment of medical co-morbidity in their patients. They will also be called upon with increasing frequency to contribute to the mental health care of patients in the primary care setting. Though they do not supplant the primary care physician in addressing medical needs in these patients, they must be

Training

In Psychiatry

prepared to use their medical background and expertise to assist other medical providers. Only by introducing these attitudes, knowledge, and skillsbased objectives in an updated curriculum will graduates from residency training programs be able to contribute effectively in a new health care environment.

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S. D. Kick et al. 20. Accreditation Council for Graduate Medical Education (ACGME): Essentials of Approved Residencies and Fellowships. Directory of Graduate Medical Education Programs. Chicago, IL, American Medical Association, 1996 21. Gitlin DF, Schindler BA, Stern TA, et al: Recommended guidelines for consultation-liaison psychiatric training in psychiatry residency programs. Psychosomatics 37:3-11,1996 22. Hampton JR, Harrison MJG, Mitchell JRA, Prichard JS, Seymour C: Relative contributions of historytaking, physical examination, and laboratory investi-

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gation to diagnosis and management of medical outpatients. Br Med J 2:486489, 1975 23. Patterson CW: Psychiatrists and physical examinations: a survey. Am J Psychiatry 135:967-968,1978 24. Victoroff VM, Mantel SJ, Bailetti A, Bailetti M: Physical examinations in psychiatric practice in Ohio. Hosp Community Psychiatry 30:536-540, 1979 25. Magruder-Habib K, Zung WWK, Feussner JR, Alling WC, Saunders WB, Stevens HA: Management of general medical patients with symptoms of depression. Gen Hosp Psychiatry 11:201-206, 1989