Mental health training of primary care residents: A review of recent literature (1974–1981)

Mental Health Training of Primary Care Residents: A Review of Recent Literature (1974-1981)* Barbara J. Burns, Ph.D. Chief, Primary Cure Research

Section, National Institute of Mental Health, Rockville,

Maryland

Jack E. Scott, M.H.S. Social Science Analyst,

Primary Care Research Section, National Institute of Mental Health, Rockville,

Maryland

Jack D. Burke, Jr., M.D., M.P.H. Research Psychiatrist,

Primary Care Research Section, National Institute of Mental Health, Rockville,

Maryland

Larry G. Kessler, Sc.D. Statistician,

Primary Care Research Section, National lnstitute of Mental Health, Rockville,

Abstract: As the mental health role of primary care physicians has been formally recognized in recent years, educational efforts have also been directed toward the development of mental health atfitudes, knowledge, and skills. To assess gains in the latter area, recent literature (1974-81) on mental health training for primary care residents was reviewed. Although shifts from the pre-1975 literature in the training objectives, content, teaching methods and setting were observed, further needs were noted. These include more systematic instruction in the diagnosis and management of mental disorder, evaluation ofsuch training and more extensive collaboration among primary care, psychiatric, and behavioral science disciplines in the teaching of mental health content to primary care physicians.

Primary care medicine has dramatically reemerged during the 1970s. With this revitalization has come renewed interest in providing mental health training to primary care physicians. While there is a long tradition of psychiatric participation in the education of primary care physicians (l), the current reemergence of interest reflects shifting perspectives and policy initiatives relevant to the American health and mental health care system.

*Presented at the Annual Meeting of the American Psychiatric Association, New Orleans, May 1981 General Hospital Psychiatry 5, 157-169, 1983 0 Elsevier Science Publishing Co., Inc. 1983 52 Vanderbilt Avenue, New York, NY 10017

Maryland

Both public and professional dissatisfaction with a purely biomedical approach to the delivery of health care influenced these developments. The public had come to experience health care services as increasingly fragmented, impersonal, diseaseoriented, costly, and complex (2). Many medical educators, reacting to the scientific and technological emphasis of modern medical education, began to argue in favor of a more balanced biopsychosocial model of medicine (3,4), with an emphasis on treatment of the “whole patient” in the context of his or her social environment. The rebirth of family practice as a formal medical specialty in 1969 represented an early attempt to put a holistic model of health care into practice. At the same time, it represented an effort to address the growing specialist-generalist imbalance within the health care system. By the early 197Os, specialists had come to outnumber generalists (including primary care physicians) by a 4:l ratio (5). In an attempt to increase the number of primary care physicians (and decrease the number of new specialists), Congress passed several acts, notably the Health Professions Educational Assistance Act of 1976, to support training for primary care physicians. The mental health care system was also affected. Federal support for training mental health special157 ISSN 0163~8343/83/$3.00

B. J. Burns et al.

ists, notably psychiatrists, began to reflect this shift in focus. Mental health services utilization studies indicated that the great majority of mental health needs were not being met in the specialty mental health sector and that an estimated 54% of persons with mental disorders were seen only in primary care settings (6). In response to the prospects of declining specialist mental health manpower and recognition of the potential role of the primary care physician as a provider of mental health services, the President’s Commission on Mental Health (7) recommended increased funding for the mental health training of primary care practitioners. The NIMH identified, as one of three ‘basic training priorities, “. . . the development of mental health skills and knowledge for general health care personnel and preparation of mental health specialists to work more effectively with the health care field’ (8). Although medical educators clearly recognized the need for mental health training of primary care residents, they were hampered in part by the lack of consensus concerning an appropriate mental health service delivery role for the primary care physician (9-13). Consequently, prior to 1975, the goals and content of many of the early training programs were unclear (14). With the emergence of new federal training priorities in 1975 and funding to foster their development, a multitude of primary-care-mental-health training programs appeared. Today, however, given reductions in federal funding for clinical training, continued expansion of primary care training and associated mental health components may not occur. If future primary care physicians are to provide adequate mental health services for their patients, we need to (1) identify and consolidate recent successful primary care-mental health training advances, and (2) delineate gaps in current training efforts. To assess current practices and recent developments in mental health training for family practice, internal medicine, and pediatric residents, and to provide a resource for training programs, we have reviewed the primary care-mental health training literature published since 1975. This review has identified about 170 papers on training in the recognition and management of emotional problems and mental disorder. These papers describe overall programs, specific courses, and teaching methods at the residency level. The majority present mental health training in family practice (15-92), with a smaller number pertaining 158

to internal medicine (93-113), pediatrics (114-148), and joint primary care programs (149-155).

Training

Review

Structural Features of Mental Health Training in Primary Cure Residency Programs Mental health training is provided through general behavioral sciences instruction and more specific psychiatric education within primary care residency programs. Such training typically occurs in behavioral sciences seminars and case conferences taught by primary care physicians and mental or on consultation-liaison health professionals, and psychiatric inpatient rotations taught primarily by psychiatrists. The primary care-mental health training literature suggests considerable variability in the content, amount, internal organization, training setting, and degree of evaluation conducted from one primary care residency program to another. One example of this variability lies in the scope of mental health training offered; it can vary from a brief one-month rotation on a psychiatric inpatient unit to a comprehensive behavioral science curriculum integrated into inpatient and outpatient rotations over the three years of residency training.

Objectives of Mental Health Training The content of mental health training stems from the objectives and requirements established by the professional educational organizations and accrediting bodies. During the past six years, there has been a growing congruence between the training objectives proposed by psychiatrists for primary care physicians and those established by the primary care professional organizations for themselves (see Table 1). The American Academy of Pediatrics (156), the American Board of Internal Medicine (157), the American Medical Association (158), and the Group for the Advancement of Psychiatry (159) have each published statements on graduate mental health training. While a comparison of the training aims set forth by these groups is complicated by the brevity of the statements and by differences in the language used, three common themes emerge: (1) an emphasis on the physician-patient relationship as a therapeutic tool, (2) an awareness and understanding of the behavioral and psychosocial aspects of illnesses, and (3) the recognition and management of psychiatric disorder and emotional problems. The three primary

Training of Primary Care Residents

Table 1. Mental Health Training:

Organizational

Family Practice (158) 1. Recognition,

diagnosis,

and management KNOWLEDGE AND SKILLS

of

emotional

and mental

disorders

alone or as

components

of organic

diseases.

Recommendations

and Standards

Internal Medicine (157, 158) 1. Effective

communication

Pediatrics (156, 158) 1 Management

with patient/family. 2. Psychosocial,

preventive

and rehabilitative

aspects of

skills.

disorders

organic illnesses.

(family crises, depression,

school phobias,

learning

disabilities).

psychopharmacology,

2

of signs

and symptoms

members,

2. Psychotherapy,

1. Identification

and developmental illness or death of family

illness 3. Interpersonal

of biosocial

GAP (159)

of factors

affecting

patient’s

response

to stress.

3. Development

Counseling,

anticipatory

and psychiatric

guidance

developmental

counseling.

appraisal,

referral,

consultation, screening

2. Evaluation

and use of

procedures.

of

of

comprehensive treatment

plans.

4. Psychopharmacology. 5. Short-term supportive

and verbal

therapy. 6. Community

resources.

7. Referral to mental health specialists. 8. Communication

SETTING

Ambulatory and psychiatric service treating acute care patients.

Primarily hospital-based, with electives in care of ambulatory

patients.

STRUCTURE

At least a l-month psychiatric rotation; integrate with other training throughout residency years.

At least one full-time rotation during first two years of residency, supplemented by case conferences and rounds.

TEACHING

Family practice, behavioral scientists, psychiatrists

Qualified pediatric faculty assisted by the mental health disciplines.

DISCIPLINES

care specialties differ in the degree of emphasis on the three themes. Family practice is most explicit about psychiatric diagnostic and management skills, and therefore more closely resembles the objectives set forth by the Group for the AdvancePediatrics understandably ment of Psychiatry. places a stronger emphasis on developmental issues than the other specialties. Internal medicine has been less explicit about the management of specific mental disorders except as this occurs through the physician-patient relationship.

Framework for Describing the Content of Primary Care-Mental

skills.

Inpatient

Health Training

Much of the actual mental health training provided through behavioral science and consultationliaison psychiatry programs emphasizes instruction in the communications and interpersonal skills as-

Psychiatrists

and others

pects of the physician-patient relationship. In conceptualizing the content of this training, Johnson (50) has suggested that the content ranges along a communications skills continuum, anchored at one end by unstructured conversation and moving through increasing degrees of control and direction by the physician to include the more directive intervention and management skills. The idea of a communications skills continuum was used in part to conceptualize the content of training and to function as the basic organizing principle for the subsequent review of the literature. However, there are other major areas that have to be incorporated in a model for mental health training. These include specific knowledge about the mental health problems dealt with in practice, attitudes of the physician, and the behavioral science background necessary for mastering the preceding types of skills, knowledge, and atti159

B. J. Burns et al.

MENTAL HEALTH KNOWLEDGE DIMENSION I

I Social/Cutural Issues

I

I

I

I

r Minor Mental Disorders

Psychological Aspects of Medical Illnesses

Psychosocial Problems and Life Crises

Major Mental Disorders

MENTAL HEALTH SKILLS DIMENSION

I Interviewing and Interpersonal Relationships

I Patient

Education and General Counseling

I Detection and Diagnosis

I Clinical Management (e.g., therapy, psychotropics, referral)

Figure 1. Dimensions of mental health training for primary care residents tudes. Consequently, we have proposed a mental health skills dimension and a mental health knowledge dimension (see Fig. 1) and then made several additional assumptions. First, attitudes are taught (both overtly and covertly) in conjunction with teaching skills and knowledge rather than separately; and second, most of the formal behavioral science teaching (e.g., growth and development, family dynamics, psychosocial factors affecting health) occurs prior to residency training. Within this oversimplified model, the skills and knowledge dimensions operate somewhat differently. The mental health skills dimension is a continuum, extending from general communications skills to the more specific types of psychiatric interventions, with each skill area providing the foundation for a more complex subsequent one. While the mental health problem dimension ranges from problems that are essentially social in origin to the more explicit medical and psychiatric diagnoses, the training is not likely to flow in a continuum-type fashion, and the level of difficulty will vary between and within problem areas. For example, teaching the diagnosis of psychosis under serious mental disorders may be more clear-cut than teaching how to assess vaguely defined anxiety and depressive symptoms under minor psychiatric disorders; also, identifying secondary depression in serious burn cases is likely to be fairly easy, while differentiating secondary depression from major affective disorders in a patient with a chronic medical condition may be more complex. The preceding issues have implications for the sequence of training and the need for constant attention to the points where 160

mastering of mental health skills interact with knowledge about problems and disorders. For the purposes of this paper, the literature is organized along the skills dimension, with the exception of a limited review of papers on part of the mental health knowledge dimension, namely individual and family growth and development. Descriptions of training pertinent to other areas of mental health knowledge, found rather infrequently in the literature, are incorporated into the appropriate skills area.

Individual and Family Growth and Development Published descriptions of the content of primary care-mental health residency training in individual and familial growth and development have only recently begun to appear in the primary care residency training literature. Most of this work is found in the pediatric and family practice literature. One recent focus has been on the design of comprehensive pediatric residency curricula relevant to the developmental needs of children with and without handicaps. The 1979 Conference on Pediatric Education and the Needs of Young Exceptional Children (124) recognized this need, and examples of such programs have appeared in the recent literature. The developmental disabilities component of the University of Iowa (144,146) uses a competency-based approach in its mandatory one-month rotation, combining didactic presentations with one-to-one placements in which each pediatric resident is assigned resposibility for the ongoing daily care of a residential child in a hospi-

Training of Primary Care Residents

tal-school facility. At the University of Washington (116) a three-month residency curriculum in child development and exceptional children stresses experiences in the Well-Child Clinic to enable pediatric residents to compare normal and abnormal development. Richardson et al. (134) have proposed a comprehensive curriculum in child development and handicapping conditions that emphasizes interdisciplinary collaboration among pediatricians, educators, and mental health professionals . In addition to learning about child development, the curriculum stresses awareness of community resources for the care of exceptional children, the promotion of positive attitudes toward exceptional children, and the development of effective communicative and educational skills to facilitate work with other health care professionals and with the parents of exceptional children. Many family practice programs have recognized the importance of instruction in the development processes of the entire life cycle. The University of North Carolina (46) integrates much of its mental health training into a 12-month conference curriculum based on the eight-stage life cycle concepts of Erik Erikson; at the University of Western Ontario (39) topics are organized around the concepts of psyErikson, Piaget, and other developmental chologists. Family practice residencies emphasize the dynamics of the family and its influence on health. For example, family practice residents at the Bowman Gray program (28) are taught to “map” their patients’ family systems as a way of demonstrating that what affects one family member also affects the others. Residents are also taught to look for habitual interactional patterns among family members, and to be aware of the ways families under stress try to regain a homeostatic balance. At the family practice residency at the Madigan Army Medical Center (29), residents participate in small group seminars where the interpersonal dynamics within the group are used to teach the dynamics of family life. Other developmental topics receiving special emphasis in family practice residency programs include sexual functioning (21,40,87,88) and, more recently, the special problems of the elderly (25,55,64-66,91).

Interviewing,

Counseling

and Patient Education

Central to assessment and treatment are interviewing, general counseling, and patient education

skills. Within the primary care residency training literature there appears to be roughly equal emphasis on interviewing and interpersonal skills training across the three specialties. A recent national survey of family practice residency programs (53) showed that about 88% of these programs now offer training in interviewing and interpersonal skills through formal courses, most of which have been instituted since 1977. Four types of skills that are commonly taught include interpersonal processes, information gathering, information giving (patient education), and various psychological interventions (counseling techniques). The use of videotape recordings of actual resident interviews with patients, followed by discussion and feedback on interviewing styles and behaviors is a common method of instruction. Models for teaching counseling are described more frequently in the family practice than in the medicine and pediatrics literature. Many of the family practice courses combine instruction in psychological assessment and counseling interventions. For example, the University of Minnesota (22,23,26,27) offers a 15-hour short-term counseling course that teaches the use of Ireton and Cassata’s Psychological Systems Review (45) as a patient assessment approach. A patient’s current psychological status is classified into one of four categories: functional, ambiguous, crisis, or dysfunctional. Residents are then taught specific intervention techniques applicable to patients in each category. The University of Wisconsin (20) offers an 8-12hour course in behavioral assessment and behavioral modification techniques that equips family practice residents to manage a variety of emotional and behavioral problems. The Medical University of South Carolina (50,51) offers a course in microcounseling. Residents participate in a variety of role-playing exercises designed to help them acquire a range of skills, including the use of empathy, active listening, reflection, and supportive therapy. Some programs employ an eclectic approach; at the Medical College of Georgia (43) residents are taught to use a nondirective approach for interviewing, along with the use of more directive behavior modification techniques. While the videotape-and-feedback format using actual patients is often used for teaching interviewing skills, trained actors who stimulate patient problems are also used to teach patient education techniques. Pediatric residents at the University of Iowa (147) are taught to work with emotionally laden patient interactions and situations in this 161

B. J. Burns et al.

fashion. Actors portray a variety of roles, such as parents suspected of child abuse, or a mother whose newborn infant has Downs Syndrome, thus allowing residents to develop patient education skills.

Detection, Diagnosis, and Management of Mental Disorder Descriptions of instruction in the detection, diagnosis, and management of mental disorder occur less frequently than the preceding topics in the training literature. In one of the few experimental studies in this area, Goldberg (33-36) and his colleagues at the Medical University of South Carolina recently tested a training package designed to improve the ability of family practice residents to detect patients with psychological distress in primary care settings. Residents’ assessments of the degree of psychological distress among their patients were compared against the patients’ scores on the General Health Questionnaire (GHQ). Residents in the treatment group took part in four training sessions, during which they were taught to use a simple model of psychological assessment through a lecture, role rehearsal exercises, and videotape with feedback of their actual interviews with patients. The treatment group, which achieved significant changes in interviewing styles, significantly improved its overall accuracy of detection of psychological distress. Residents learned to apply a “funneling” process in their interviews, using openended questions initially to explore new problem areas with patients, followed by close-ended questions to examine problems more closely. An important indirect finding of this study was that residents were more receptive to instruction in diagnostic skills when this was combined with advice on patient management. The latter finding suggests that residents may perceive training as more clinically relevant when instruction in these two sets of skills is combined. Another approach for improving the diagnostic skills of residents involves the use of feedback from various psychological screening instruments. Recent studies suggest that residents who receive the results of screening tests such as Zung’s Self-Rating Depression Scale (67,79) are more likely to recognize and note the finding of depression among their patients. A national survey of family practice residency programs (70) reported that 47.5% use psy162

chological tests and screening instruments in their family practice centers, and that 53.1% teach the use of such tests in the residency curriculum. Pediatric residents also receive exposure to the use of diagnostic and developmental screening tests; at the University of Washington (116) residents are routinely familiarized with the appropriate use of such widely accepted developmental screening instruments as the Denver Developmental Screening Test. Richardson et al. (134) recommend that training in the appropriate use of diagnostic and screening tests be a standard component of a comprehensive curriculum on child development and handicapping conditions. In the absence of clear agreement about the specific psychotherapeutic and management skills deemed appropriate for use by primary care physicians, a variety of approaches are taught, including individual, group, family, marital, couples and sexual counseling, brief psychotherapy, crisis intervention, and behavior modification skills. While these skills are relevant to the wide spectrum of social and emotional problems that are encountered in primary care settings, the clinical management of specific mental disorders is not often described in the residency training literature. However, one example of a training package designed to improve family practice residents’ knowledge and skill in evaluating and managing the hypochondriacal patient has been subjected to a controlled trial (30). The package includes eight 90-minute lectures on the diagnosis and management of hypochondriacal patients, supplemented by case supervision by a consultation-liaison psychiatrist during a twomonth rotation. Although the training package did not improve the residents’ diagnostic skills, the experimental group exhibited significant improvement in its ability to develop a comprehensive treatment plan for hypochondriacal patients. Although the use of psychotropic medications is a major form of psychiatric intervention in primary care medical settings, the published literature contains only sporadic reference to the existence of such training in primary care residency training programs. A number of authors have noted the need to improve instruction in psychopharmacology at all levels of medical education and practice (160-163). Geyman (31) has outlined a model curriculum for family practice residency programs, and experimental work in the computerized teaching of psychopharmacology to family practice residents is presently underway at the University of Wisconsin.

Training

Discussion Achievements This brief review, covering the past six years of the published literature, presents many examples of creative and thoughtful developments relevant to the mental health training of primary care residents. The increasing specification and congruence of training objectives for interpersonal and mental health skills development during residency training by both the primary care and psychiatric professional organizations seems to be consistent with the emergence of more ambitious mental health curricula in many programs. Well-developed training packages for teaching specific content have started to become available, reflecting the interdisciplinary contributions of primary care educators, behavioral scientists, and psychiatrists. These packages frequently take advantage of current technological innovations in mental health instruction, such as the use of videotape recordings and the computer. The shift in locus of primary care training from hospital wards to community-based and outpatient settings parallels a similar trend in psychiatric teaching and practice. Primary care residents are thus exposed to patient populations that exhibit the kinds of mental health problems and service needs that more closely resemble their future practices. This shift in training setting has been accompanied by a shift from the general behavioral science instruction of the early 1970s toward more specialized mental health skills and knowledge. Whereas the literature of the early 1970s focused on the resident’s own self-awareness and communications and interpersona skills, the post-1975 literature addresses psychosocial assessment and specific intervention techniques (crisis counseling, behavior modification, and supportive therapy) applicable to the problems of living presented in the primary care setting. Educators have begun to realize the importance of careful evaluation studies (164). Developments in research measures have occurred during the past six years, such as Houpt’s (165) unobtrusive measurement of the learning behaviors of residents in psychiatric consultation-liaison activities, and Barsky et al’s (166) instrument for the analysis of the psychosocial dimensions of the primary care physician-patient interview. The designs of evaluation studies are beginning to move beyond the simple pre- and post-training studies to examples of con-

of Primary Care Residents

trolled comparisons (3034) and even longitudinal studies (51) that follow residents into practice.

Gaps and Future Directions Although the training literature documents considerable evolution in the mental health training for primary care residents since 1975 (14), the type of changes differ across primary care specialties. Much of the reported development has taken place in family practice, where the current emphasis is on integrating the psychosocial assessment of the patient with the diagnosis of his or her organic illness (89). In pediatrics, the recent emphasis is on the design of an appropriate child development curriculum (124). The published literature on internal medicine is limited, although some innovative approaches have been implemented, such as the combined internal medicine-psychiatry residency program at the University of West Virginia (109). In terms of the two dimensions presented earlier, it is apparent from the literature reviewed that progress in systematic instruction in the detection, diagnosis, and the clinical management of mental disorder has not paralleled the advances in teaching communications, interpersonal, patient education and general counseling skills (see Fig. 1). The design of well-defined replicable training packages for instruction in the diagnosis and management of mental disorder represents the next frontier for primary care-mental health educators. In this vein, major attention should be given to the less severe problems and disorders (life crises, anxiety, and depressive symptoms), which are most likely to be clinically managed entirely by primary care practitioners (167). Recent advances in the classification of mental disorder could facilitate the teaching of diagnostic skills. The more explicit diagnostic criteria of DSMIII (168) should be particularly helpful with respect to major mental disorders. Efforts to improve the detection of social problems and psychological symptoms in primary care are proceeding in a joint project between the World Health Organization, the National Institute of Mental Health, and the Rockefeller Foundation (169). Another collaborative research project between the World Health Organization and the Alcohol, Drug Abuse and Mental Health Administration, which is examining overall issues in the classification of mental disorder also, plans to clarify and delineate the minor psychiatric syndromes and disorders seen in primary health care. These projects should contribute to a 163

B. J. Burns et al.

more logical and practical framework for teaching diagnosis in primary care. The teaching of patient management skills should be advanced through both clinical and primary care research developments. The development and validation of standard clinical protocols that link diagnosis to management is one example of an approach that could facilitate progress. A preliminary model for managing mental illness in primary care has been proposed by Essex for the developing countries (170). Research on the effectiveness of various psychotherapeutic interventions, such as the use of brief therapy in primary care, would have implications for training. Evaluation and research on the mental health training of primary care residents must be conducted more systematically than it has been to date. For example, there are a variety of approaches for teaching interviewing and interpersonal skills to residents; many of these approaches will produce short-term improvements in residents’ interviewing skills, as measured along a variety of cognitive and affective dimensions (171). Controlled comparisons of different instructional methods are needed (127,172); so too are longitudinal studies that examine the duration of these changes. The following structural issues require attention: the optimal sequence of mental health training courses and experiences within the residency program; the appropriate duration of such training; the most effective methods for delivering particular types of training; the effects of training settings; and the effects of maturation of residents on the development of mental health skills. The impact of mental health training on the health outcomes of patients (164) needs to be assessed through studies like those of Inui et al. (173).

Conclusions In conclusion, although the recent literature on the mental health training of primary care physicians has shown some promising developments, there is enormous diversity regarding content, teaching approaches, and type of educator. Because reports that appear in the scientific literature are more likely to be exemplary than representative of practice, the authors have identified four areas that require extensive further consideration and action: 1. increased interdisciplinary collaboration at national and local levels: Collaboration among the primary care, behavioral science, and psychiatric fields is 164

essential to design comprehensive mental health training. At a national level, cross-fertilization among the appropriate professional organizations is needed to provide leadership and serve as a model for the local level where the education actually occurs. 2. The development of s tandards for prima y care-mental health training: Ultimately, in order to attain some consistency across training programs, standards are needed that specify the basic content required to meet the needs of patients seen in practice. The development of such standards could emerge from joint efforts among the various professional organizations. A special focus on the diagnosis and management of 3. mental disorders: While the human relations aspects of training have been given increased attention, systematic approaches to teaching the recognition, diagnosis, treatment, and referral of patients with mental disorders are notably sparse or lacking. Despite the continuing controversy over the mental health role of primary care, the need for careful adaptation of clinical approaches that are efficacious in mental health settings to primary care is long overdue. Again, joint efforts between psychiatrists, other mental health professionals, and primary care educators will be necessary to take such a forward step. 4. Evaluation of the impact of mental health training on physician practice and patient outcome: Concurrent with efforts to upgrade mental health training for primary care physicians, it is essential that the improved technology for evaluating such training be utilized to assess whether the intended goals are being achieved. Such evaluation research is complex and will require committed researchers to invest in this work on a long-term basis.

References Robertson RL, Shriver BM: The general practitioner

training program of the National Institute of Mental Health: Fiscal years 1959-1962. J Med Educ 39:925-934, 1964 Lewis CE: Family practice: The primary care specialty. In Lewis CE, Fein R, Mechanic D (eds.), A Right to Health: The Problem of Access to Primary Medical Care. New York, Wiley, 1976 Engel GL: The need for a new medical model: A challenge for biomedicine. Science 196:129-136, 1977 Eisenberg L: Interfaces between medicine and psychiatry. Comp Psychiatry 20:1-14, 1979

Training of Primary Care Residents

5. Geyman JP: Family Practice: Foundation of Changing Health Care. New York, Appleton-CenturyCrofts, 1980 6. Regier DA, Goldberg ID, Taube CA: The de facto US mental health services system. Arch Gen Psychiatry 35:685-693, 1978 7. President’s Commission on Mental Health. Report of the President’s Commission on Mental Health, Volume I. Washington, D.C., Superintendent of Documents, U.S. Government Printing Office, 1978 8. National Institute of Mental Health. Mental Health Services Manpower Development and Training Grants Announcements. Division of Manpower and Training Programs. Rockville, Md, 1980 (unpublished) 9. Callen KE, David D: The general practitioner: How Psychosomatics education? much psychiatric 19:409-413, 1978 10. Drossman DA: Can the primary care physician be better trained in the psychosocial dimensions of patient care? Int J Psychiatry Med 8:169-184, 1977-1978 11. Eaton JS Jr: Psychiatry for the general physician: An imperative. Psychosomatics educational 20:552-556, 1979 12. Fink PJ: The relationship of psychiatry to primary care. Am J Psychiatry 134:126-129, 1977 13. Pardes H, Daniels RS: The primary care dilemma. J Psychiatr Educ 1:123-134, 1977 14. Hankin J, Oktay JS: Mental Disorder and Primary Care: An Analytical Review of the Literature. National Institute of Mental Health, Series D, No. 5, DHEW Pub. No. (ADM)78-661. Washington, D.C., Superintendent of Documents, U.S. Government Printing Office, 1979 15. Adsett CA, Rudnick KV: Psychiatric liaison with family practice teams. Psychiatr Opinion 51:29-33, 1978 16. Aluise JJ: Human relations training for family practice residents: A four year retrospective review. J Fam Pratt 4:881-888, 1977 17. Bergstrom C: Concerns and challenges facing social workers in family practice. J Fam Pratt 9:659-663, 1979 18. Bergstrom C: The teaching social worker in family medicine: A prototype for the hospital social worker? Sot Wk Health Care 4:409-421, 1979 19. Bibace R, Frey J, Demick J, Candib L, Catlin RJO, Commons J, Damon W, Earls S, Pickens SC, Rosenfield DA: Case oriented group discussions for family physicians. J Fam Pratt lo:8399843, 1980 20. Brockway BS: Behavioral medicine in family practice: A unifying approach for the assessment and treatment of psychosocial problems. J Fam Pratt 6:545-552, 1978 21. Carmichael LP, Tanner L: Teaching human sexuality in family practice training. J Fla Med Assoc 61:576-577, 1974 22. Cassata DM, Conroe RM, Clements PW: A program for enhancing medical interviewing using videotape feedback in the family practice residency. J Fam Pratt 4:673-677, 1977 23. Cassata DM, Kirkman-Liff BL: Mental health ac-

24.

25.

26.

27.

28.

29.

30.

31.

32. 33.

34.

35.

36.

37.

38.

39. 40.

41.

tivities of family physicians. J Fam Pratt 12:683-692, 1981 Cauthen DB, Turnbull JM, Lawles WR, Friedman PC: A teaching program in family dynamics. J Fam Pi-act 9:954-955, 1979 Cefalu CA, Gehringer GR, McKnight GT: Geriatric training in family practice residencies. J Fam Pratt 11:971-972, 1980 Conroe RM, Cassata DM: Teaching short-term psychological counseling to primary care residents. A course description Pat Counsel Health Educ 1:26-29, 1978 Conroe RM, Cassata DM, Racer HJ: A systematic approach to brief psychological intervention in the primary care setting. J Fam Pratt 7:1137-1142, 1978 Elliot S, Hemdon A: Teaching family systems theory to family practice residents. J Med Educ 56:139-141, 1981 Fitzgerald RD: Group process in teaching family dynamics to family practice residents. J Fam Pratt 9:631-635, 1979 France RD, Houpt JL, Orleans CS, Trent PJ: Teaching psychotherapy interventions to family practice residents: A controlled study. Am J Psychiatry 136:1596-1597, 1979 Geyman JP: Psychopharmacology and the family physician. In Jarvik ME (ed), Psychopharmacology in the Practice of Medicine. New York, AppletonCentury-Crofts, 1977 Geyman JP: Mental health care in family practice. J Fam Pratt 12:615-616, 1981 Goldberg D: Detection and assessment of emotional disorders in a primary care setting. Int J Ment Health 8:30-48, 1979 Goldberg D: Training family physicians in mental health skills: Implications of recent research. In National Institute of Mental Health, Series DN No. 2, Mental Health Services in Primary Care Settings. Report of a Conference, April2-3,1979. DHHS Pub. No. (ADM)80-995. Washington, D.C., Superintendent of Documents, U.S. Government Printing Office, 1980 Goldberg DP, Steele JJ, Smith C: Teaching psychiatric interview techniques to family doctors. Acta Psychiatr Stand Suppl62:41-47, 1980 Goldberg DP, Steele JJ, Smith C, Spivey L: Training family doctors to recognize psychiatric illness with increased accuracy. Lancet II (8193):521-523, 1980 Guttman HA, Sigal JJ: Teaching family psychodynamics in a family practice center: One experience. Int J Psychiatry Med 8:383-391, 1977-1978 Guy LJ: The social work component of a universitybased family practice residency. J Fam Pratt 5~463-464, I977 Hanna EA, Schacter JG: An integration of psychosocial concepts into the education of general practitioners. Sot Wk Health Care 4:393-408, 1979 Harrison HF, Houge DR: The family practice resident as sexual counselor. J Fam Pratt 5:783-785, 1977 Hornsby JL: Teaching behavioral science in a family practice residency program. J Clin Child Psycho1 7:80-83. 1978

165

B. J. Burns et al.

42. Hornsby JL, Kerr RM: Behavioral science and family practice: A status report. J Fam Pratt 8:299-304, 1979 43. Hornsby JL, Payne FE: A model for communications skills development for family practice residents. J Fam Pratt 8:71-76, 1979 44. Hove B, Kruse K, Wilson JL: The social worker’s role in family practice education. J Fam Pratt 8:523-527, 1979 45. Ireton HR, Cassata D: A psychological systems review. J Fam Pratt 3:155-159, 1976 46. Jelly EC, Curtis I’, Warren SL: A family medicine conference curriculum based on the life cycle concept. J Fam Pratt 9:730-732, 1979 47. Johnson AH: Behavioral science in family practice: An ethical imperative. J Fam Pratt 4:525-528, 1977 48. Johnson AH: Resident self-awareness through group process. J Fam Pratt 4:681-684, 1977 49. Johnson AH, Fisher JV, Guy LJ, Keith JA, Keller AH, Sherer LM: Developing behavioral science for a family practice residency. J Fam Pratt 4:319-324, 1977 50. Johnson AH: Teaching attitudes and skills in microcounseling. J Fam Pratt 9:255-263, 1979 51. Johnson AH: Assessing counseling skills and attitudes in family practice residents. J Fam Pratt 9447-452, 1979 52. Jones LR, Knopke HJ, Parlour RR, Maxwell AJ, Davis LJ, Anderson RL: Shaping the mental health role of family physicians. J Fam Pratt 12:697-702, 1981 53. Kahn G, Cohen B, Jason H: Teaching interpersonal skills in family practice: Results of a national survey. J Fam Pratt 8:309-316, 1979 54. Kahn NB, Schaeffer H: A process group approach to stress reduction and personal growth in a family practice residency program. J Fam Pratt 12:10431047, 1981 55. Kelly JT, Garetz F. Hanson RG, Houge D, Spencer D, Ciriacy EW: An operational model for teaching geriatric medicine in a family practice residency program. J Fam Pratt 4:1103-1106, 1977 56. Ketai R: Family practitioner’s knowledge about treatment of depressive illness. JAMA 235:26002603, 1976 57. Leaman TL, Geyman JP, Brown TC: Graduate education in family practice. J Fam Pratt 5:47-61, 1977 58. Lesser A, Wakefield JG: Using the psychiatrist: A different approach to consultation. Can Fam Physician 21:79-85, 1975 59. Lochman JE, Dain RN, Fogleman JD, Sullivan DH: Interviewing skills training in a family practice residency program. J Fam Pratt 12:1080-1081, 1981 60. Lurie HJ: Videotape demonstrations and exercises in the psychological training of family physicians. In Berger MM (ed), Videotape Techniques in Psychiatric Training and Treatment. New York, Brunner/Mazel, 1978 61. Maguire PH, Asken MJ: Psychological problems in family practice: Implications for training. J Clin Child Psycho1 7:13-16, 1978 62. Martin LR: Liaison psychiatry and the education of the family practitioner. In Pasnau RO (ed), Con-

166

63.

64.

65.

66.

67.

68. 69. 70.

71.

72.

73.

74. 75. 76.

77.

78. 79.

80.

81. 82. 83.

sultation/Liaison Psychiatry. New York, Grune and Stratton, 1975 Mebane BG: Instructing family physicians in dealing with prevalent psychological problems. J Clin Child Psycho1 778-80, 1978 Moore JT, Bobula JA: A conceptual framework for teaching geriatrics in a family medicine residency. J Med Educ 55:339-344, 1980 Moore JT, Kane WJ: Geriatric training in family medicine: The natural history of a developing program. J Fam Pratt 8:79-83, 1979 Moore JT, Friedman SW, Warshaw GA: Geriatric medicine training in a family medicine residency. J Med Educ 56:492-496, 1981 Moore JT, Silimperi DR, Bobula JA: Recognition of depression by family medicine residents: The impact of screening. J Fam Pratt 7:509-513, 1978 Novik BR: Teaching hypnosis in a family medicine residency. J Fam Pratt 10:647-650, 1980 Ornstein PH: The family physician as a “therapeutic instrument.” J Fam Pratt 4:659-661, 1977 Phillips WR, Rosen GM: Psychological testing in family practice residency programs. J Fam Pi-act 9:504-506, 1979 Reifler BV, Okimoto JT, Heidrich FE, Inui TS: Recognition of depression in a university-based family medicine residency program. J Fam Pratt 9:623-628, 1979 Residency Assistance Program Project Board: Family Practice Residency Assistance Program Criteria. Kansas City, Missouri, 1979 Rittelmeyer LF Jr, MacKintosh A: Psychiatric education in a family practice residency. Virginia Med Monthly 101:629-631, 1974 Roger IS: Teaching normal patient coping styles in a family practice setting. J Fam Pratt 12:865-867,198l Scheingold L: A Balint seminar in the family practice residency setting. J Fam Pratt 10:267-270, 1980 Schmidt DD, Messner E: The use of videotape techniques in the psychiatric training of family physicians. J Fam Pratt 5:585-588, 1977 Schmidt DD, Messner E: The use of videotape techniques in the psychiatric training of family physicians. In Berger MM (ed), Videotape Techniques in Psychiatric Training and Treatment. New York, Brunner/Mazel, 1978 Schneeweiss R: Requirements for residency training in family practice. J Fam Pratt 12:1085-1086, 1981 Schuman SH, Kurtzman SB, Fisher JV, Groth MJ, Poston JH: Three approaches to the recognition of affective disorders in family practice: Clinical, pharmacological, and self-rating scales. J Fam Pratt 7:705-711, 1978 Seller RH, Blascovich J., Lenkei E: Influence of stereotypes in the diagnosis of depression by family practice residents. J Fam Pratt 12849854, 1981 Shapiro J: A revisionist theory for the integration of behavioral science into family medicine departments. J Fam Pratt 10:275-282, 1980 Sheinvold A, Asken M, Cincotta J: Family practice residents’ perceptions of behavioral science training, relevance and needs. J Fam Pratt 8:97-101,1979 Smarr ER, Berkow R: Teaching psychological medi-

Training of Primary Care Residents

84. 85.

86.

87.

88.

89.

90.

91. 92.

93.

94.

95.

96.

97.

98.

99. 100. 101.

tine to family practice residents. Am J Psychiatry 134:98&987, 1977 Smarr ER, Berkow R: Multi-level teaching and primary care. Psychiatr Opinion 15:18-21, 1978 Smilkstein G, Kleinman A, Chrisman N, Rosen G, Katon W: The clinical social science conference in biopsychosocial teaching. J Fam Pratt 12347-353, 1981 Soreff S: A family practice rotation on a psychiatric service: The experience, the opportunity and the challenge. J Fam Pratt 5:799-802, 1977 Steinert Y, Levitt R: The teaching of human sexuality in a family medicine training program. J Fam Pratt 7933-997, 1978 Tanner LA, Hoff R, Carmichael LP: Teaching sex education and counseling for the primary physician. South Med J 69:1591-1594, 1976 Task Force on Behavioral Sciences: Behavioral Science in Family Medicine. Kansas City, Society of Teachers of Family Medicine, 1979 Waters DB: The place of family therapy in a family practice training setting. In Manderscheid RW, Manderscheid FE (eds), Systems Science and the Future of Health. Washington, Groome Center and the Metropolitan Washington Chapter, Society for General Systems Research, 1976 Webber CF: Family practice. Gerontology Geriatr Educ 1:103-105, 1980 Williams JI, Bishop FM, Hennen BK, Johnson TW: The teaching of behavioral sciences in the family medicine residency programs in Canada and in the United States. Sot Sci Med 8:565-574, 1974 Brody DS: Feedback from patients as a means of teaching nontechnological aspects of medical care. J Med Educ 55:34-41, 1980 Brody DS: Physician recognition of behavioral, psychological and social aspects of medical care. Arch Intern Med 140:1286-1289, 1980 Cohen-Cole SA, Boker J, Bird J, Freeman A: Developing a psychosocial educational program for primary care physicians: Needs assessment and evaluation baseline. Ann Conf Res Med Educ 19:275280, 1980 Gale MS, Levy R: A model for training physicians to deal with difficult patients. Hosp Community Psychiatry 17:736-738, 1977 Kauss DR, Robbins AS, Abrass I, Bakaitis RF, Anderson LA: The long-term effectiveness of interpersonal skills training in medical schools. J Med Educ 55:595-601, 1980 Kleinman A, Eisenberg L, Good B: Culture, illness and care-clinical lessons from anthropologic and Med research. Ann Intern cross-cultural 88:251-258, 1978 Levin EM, Scurry MT, Bosshart DA: The teaching of interviewing and counseling skills to internal medicine residents. J Med Educ 54:819-821, 1979 Libow LS: A geriatric medical residency program: A four year experience. Ann Intern Med 85641647, 1976 Linn LS, Yager J: The effect of screening, sensitization, and feedback on notation of depression. J Med Educ 55:942-949, 1980

102. Linn LS, Young RT, Heinrich RM, Lewis MA, Yager J, Cope DW: A behavioral medicine course for postgraduate trainees in internal medicine. J Med Educ 55:133-135, 1980 103. Ludden JM, Winickoff RN, Steinberg SM: Psychological aspects of medical care: A training seminar for primary care providers. J Med Educ 54:720-724, 1979 104. Ramsdell JW, Shaffer JH: Psychiatry for general internal medicine residents: The liaison model. J Med Educ 54~243-245, 1979 105. Reichsman F: Teaching psychosomatic medicine to medical students, residents, and postgraduate fellows. Int J Psychiatry Med 6:307-316, 1975 106. Robbins AS, Kauss DR, Heinrich R, Abrass I, Dreyer J, Clyman B: Interpersonal skills training: Evaluation in an internal medicine residency. J Med Educ 54:885-894, 1979 107. Rosenberg G: Internal medicine. Gerontology and Geriatrics Education 1:37-40, 1980 108. Shanfield SB: Teaching psychiatry to medical house staff: Report of a weekly conference. J Med Educ 53:151-153, 1978 109. Shemo JPD, Withersty DJ, Spradlin WW, Waldman RH: Psychiatry as an internal medicine subspeciality: An educational model. J Med Educ 55:354-361, 1980 110. Siegal B, Donnelly JC: Enriching personal and professional development: The experience of a support group for interns. J Med Educ 53:908-914, 1978 111. Starkman MN, Hall GG: Teaching medical gerontology: Utilization of a psychiatry consultation program. J Med Educ 54643-648, 1979 112. Strain JJ: Hamerman D: Ombudsmen (medical-psychiatric) rounds: An approach to meeting patient-staff needs, Ann Intern Med 88:550-555, 1978 113. West ND, Brown PH, Woodley D: Psychiatrists and non-psychiatrists working together in a general hospital. Resident and Staff Physician 22:113-125, 1976 114. Anders TF: Child psychiatry and pediatrics: The state of the relationship. Pediatrics 60:616-620, 1977 115. Axelrod BH, Rothenberg MB: A teaching service on the psychosocial aspects of primary care pediatrics. Resident and Staff Physician 22:72-81, 1978 116. Bennett FC: A three-month residency curriculum in child development and handicapped children. In Guralnick MJ, Richardson HB Jr (eds), Pediatric Education and the Needs of Exceptional Children. Baltimore, University Park, 1980 117. Bergman AB, Rothenberg MB, Telgrow RW: A “retreat” for pediatric interns. Pediatrics 64:528-532, 1979 118. Collins EW, O’Shea JS: Involving pediatric residents in the care of children with behavior problems. J Med Educ 54:814-816, 1979 119. Delaney DW, Bartram JB, Olmsted RW, Coops SC: Curriculum on handicapping conditions. Implications for residency, fellowship, and continuing education of pediatricians. In Guralnick MJ, Richardson HB Jr (eds), Pediatric Education and the Needs of Exceptional Children. Baltimore, University Park, 1980

167

B. J. Bums et al.

120. Eckhardt LO, Rabin RA: A proposed new model for training pediatric residents in the psychosocial aspects of pediatrics. J Clin Child Psycho1 7:73-77, 1978 121. Farsad I’, Galliguez P, Chamberlin R, Roghmann K: Teaching interviewing skills to pediatric house officers. Pediatrics 61:384-388, 1978 122. Froese AI’, Kamin LE, Levine CA: Teamwork: A multi-disciplinary pediatric-liaison service. Int J Psychiatry Med 7:47-56, 1976-1977 123. Greenberg LW, Rice HW: A pediatric-child psychiatry liaison program in a community hospital. J Med Educ 55:112-119, 1980 124. Guralnick MJ, Richardson HB Jr (eds): Pediatric Education and the Needs of Exceptional Children. Baltimore, University Park, 1980 125. Harding RK, Mattson A, Nathan M, Kavanaugh J: The psychiatrist’s role in behavioral pediatrics training programs. Gen Hosp Psychiatry 1:234-239,1979 126. Honig PJ, Liebman R, Malone C, Koch CR, Kaplan S: Pediatric-psychiatric liaison as a model for teaching pediatric residents. J Med Educ 51:929-934, 1976 127. Jewett LS: A comparison of structured and self-directed approaches to teaching interviewing and interpersonal skills to pediatrics residents. Ann Conf Res Med Educ 19:70-75, 1980 128. Jewett L, Richardson G, Richardson L: History taking and interpersonal skills training for pediatric residents. Clin Proc 35:346-352, 1979 129. Kaplan SL, Rosman BL, Liebman R, Honig I’: Predicting performance in a child psychiatry program for pediatric residents. J Med Educ 54:42-50, 1979 130. Levine SV, Froese AI’, Stewart DA: Child psychiatry and pediatrics: An integrated approach. Can Psychiatr Assoc J 20:47-53, 1975 131. Richardson HB Jr, Guralnick MJ: Pediatric residents and young handicapped children: Curriculum evaluation. J Med Educ 53~487-492, 1978 132. Richardson HB Jr, Guralnick MJ, Tupper DB: Training pediatricians for effective involvement with handicapped preschool children and their families. Ment Retard 16:3-7, 1978 133. Richardson HB Jr, Guralnick MJ: An evaluation strategy for pediatric rotations on the needs of exceptional children. In Guralnick MJ, Richardson HB Jr (eds), Pediatric Education and the Needs of Exceptional Children. Baltimore, University Park, 1980 134. Richardson HB Jr, Guralnick MJ, Taft LT, Levine MD: A comprehensive curriculum in child development and handicapping conditions. Prospects for implementation, design, and evaluation. In Guralnick MJ, Richardson HB Jr (eds), Pediatric Education and the Needs of Exceptional Children. Baltimore, University Park, 1980 135. Rothenberg MB: Child psychiatry-pediatrics consultation-liaison services in the hospital setting. A review. Gen Hosp Psychiatry 1:281-286, 1979 136. Schildkrout E: Medical residents’ difficulty in learning and utilizing a psychosocial perspective. J Med Educ 55:962-964, 1980 137. Smith RD: The use of developmental screening tests

168

138.

139.

140.

141.

142.

143.

144. 145.

146.

147.

148.

149.

150.

151. 152. 153. 154.

155.

by primary-care pediatricians. J Pediatr 93:524-527, 1978 Stabler B: Emerging models of psychologist-pediatrician liaison. J Pediatr Psycho1 4:307-313, 1979 Stillman PL, Sabers DL: Using a competency-based program to assess interviewing skills of pediatric house staff. J Med Educ 53:493-496, 1978 Trent PJ, Hock RA, Yancy WS: Evaluation strategies for residency training in behavioral pediatrics, or, “Overcoming organizational hurdles.” Ann Conf Res Med Educ 18:32-37, 1979 Vaughan VC III: Evaluating competencies. Relationship to content of a developmental disabilities curriculum for physicians. In Guralnick MJ, Richardson HB Jr (eds), Pediatric Education and the Needs of Exceptional Children. Baltimore, University Park, 1980 Weston W III, Lawrence LE: An educational strategy for teaching psychosocial pediatrics. South Med J 68:395-398, 1975 Wolff SL, Shelov SP: Resident participation in the development of an ambulatory pediatric discussion series. J Med Educ 53:853-855, 1978 Wolraich M: Pediatric training in developmental disabilities. Ment Retard 17:133-136, 1979 Wolraich M, Reiter S: Training physicians in communications skills. Dev Med Child Neurol 21~773-778, 1979 Wolraich ML: A one-month pediatric rotation in developmental disabilities. In Guralnick MJ, Richardson HB Jr (eds), Pediatric Education and the Needs of Exceptional Children. Baltimore, University Park, 1980 Wolraich M, Albanese M, Reiter-Thayer S, Barratt W: Teaching pediatric residents to provide emotionladened information. J Med Educ 56:438-440, 1981 Zuckerman B, Carper J, Alpert JJ: Mental health training for pediatricians. J Clin Child Psycho1 743-46, 1978 Adams GL, Brochstein JR, Cheney CC, Friese JH, Tristan Ml? A primary care/mental health training and service model. Am J Psychiatry 135:121-123, 1978 Adams GL, Cheney CC, Tristan Ml’, Friese JH, Schweitzer LR: Mental health in primary care training and practice: An innovative approach. Int J Psychiatry Med 9:49-60, 1978-1979 Berg JK, Garrard J: Psychosocial support in residency training programs. J Med Educ 55:851-857, 1980 Lazerson AM: The psychiatrist in primary medical care training: A solution to the mind-body dichotomy? Am J Psychiatry 133:96&966, 1976 Lazerson AM: The psychiatrist as teacher in primary care residency training: The first year. Int J Psychiatry Med 7:165-178, 1976 Moffic HS, Cheney CC, Adams GL, Chacko RC, Tristan MI’, Gomez EA: Mental health, the poor, and the promised land: The Houston Consortium training program. Int J Ment Health 8:74-88, 1979 Stevenson JH, Waldman RH: Combined IM and psychiatry residency program: How will it change medical practice? Behav Med 8:17-23, 1981

Training of Primary Care Residents

156. American Academy of Pediatrics: The Future of Pediatric Education. A Report by the Task Force on Pediatric Education. Evanston, IL, American Academy of Pediatrics, 1977 157. American Board of Internal Medicine: Clinical competence in internal medicine. Ann Intern Med 90:402-411, 1979 158. American Medical Association: Essentials of Accredited Residencies. Chicago, American Medical Association, 1980 159. Group for the Advancement of Psychiatry (Committee on Preventive Psychiatry): Mental Health in Primary Medical Care. Volume X, Publication No. 105, June 1980 160. Gerbino L, Gershon S: Status of psychopharmacology teaching and practice: impact on health care delivery. Psychopharmacol Bull 15:55-58, 1979 161. Gottlieb RM, Nappi T, Strain JJ: The physician’s knowledge of psychotropic drugs: Preliminary results. Am J Psychiatry 135:29-32, 1978 162. Weiner J, Schumacher GE: Psychotropic drug therapy knowledge of health care practitioners. Am J Hos Pharm 33:237-241, 1976 163. Wienckowski LA: The status of clinical psychopharmacology in residency training programs. Psychopharmacol Bull 13:36, 1977 164. Cohen-Cole SA: Training outcome in liaison psychiatry: Literature review and methodological proposals. Gen Hosp Psychiatry 2:282-288, 1980 165. Houpt JL: Evaluating liaison program effectivenes: The use of unobtrusive measurement. Int J Psychiatry Med 8:361-370, 1977-1978 166. Barsky AJ, Kazis LE, Freiden RB, Goroll AH, Hatem CJ, Lawrence RS: Evaluating the interview in primary care medicine. Sot Sci Med 14:653-658, 1980

167. Lawrence RS: The primary care physician: Mental health issues. In Parron DL, Solomon F (eds), Mental Health Services in Primary Care Settings: Report of a Conference April 2-3, 1979. National Institute of Mental Health, Series DN No. 2, DHHS Pub. No. (ADM)80-995. Washington, D.C., Superintendent of Documents, US Government Printing Office, 1980 168. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, D.C., American Psychiatric Association, 1980 169. Lipkin M, Kukpa K (eds): Psychosocial Factors Affecting Health. New York, Praeger, 1982 170. Essex B: A problem-oriented approach to management of mental illness in developing countries. J R Co11 Gen Pratt 30:648-655, 1980 171. Carroll JG, Monroe J: Teaching medical interviewing: A critique of educational research and practice. J Med Educ 54:498-500, 1979 172. Reifler B, Eaton JS: The evaluation of teaching and learning by psychiatric consultation-liaison training programs. Psychosom Med 40:99-106, 1978 173. Inui TS, Yourtee EL, Williamson JW: Improved outcome in hypertension after physician tutorials: A controlled trial. Ann Int Med 84:646-651, 1976 Direct reprint requests to: Barbara J. Burns, Ph.D. Primary Care Research Section, Division of Biometry and Epidemiology National Institute of Mental Health Parklawn Building, Room 18C-14, 5600 Fishers Lane Rockville, MD 20857

169