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Gyn residents as primary care providers: implementing a new curriculum for diagnosing and treating depression and anxiety
HONORABLE MENTION MANUSCRIPT
OB/GYN RESIDENTS AS PRIMARY CARE PROVIDERS: IMPLEMENTING A NEW CURRICULUM FOR DIAGNOSING AND TREATING DEPRESSION AND ANXIETY Jennifer C. Stevens, MD, and Sandra J. Diehl, MPH
The Accreditation Council for Graduate Medical Education (ACGME) guidelines on resident work hours were created in 2002 in an effort to improve patient care. However, these changes may have a negative impact on resident education. Finding time to adequately prepare Ob/Gyn residents in core curriculum topics has become a challenge. Primary care topics such as behavioral medicine often become a lesser priority, yet Ob/Gyn physicians are expected to be competent in diagnosing and treating mental illness. Depression affects as many as 30% of all pregnant or postpartum women. When we evaluated the screening practices of a southeastern North Carolina residency program, we found that only 8% of prenatal patients were screened for symptoms of depression at their first visit and only 23% were screened at their postpartum visit. Education, screening, and treatment practices need to be addressed to ensure thorough management of Ob/Gyn patients. This paper suggests ways to do so. (Prim Care Update Ob/Gyns 2003; 10:297–299. © 2003 Elsevier Inc. All rights reserved.)
From the Coastal Area Health Education Center, Wilmington, North Carolina.
Volume 10, Number 6, 2003
In June 2002, the Accreditation Council for Graduate Medical Education (ACGME) proposed guidelines that limit resident work hours stemming from public concerns about sleep deprivation and its effects on patient safety and resident clinical and educational performance. The ACGME will start enforcing these guidelines in July 2003.1 While reduced work hours will likely result in less resident fatigue and possibly fewer medical errors, the policy presents a new challenge to Ob/Gyn residency programs that are incorporating primary care into their education and training scheme. Primary care topics may become secondary to other core curriculum topics in the interest of balancing work hour limits and educational priorities. Furthermore, the policy may limit resident participation in didactic activities during time off. As the scope of Ob/Gyn practice evolves into holistic medicine for women and with the inclusion of Ob/Gyns as defined primary care providers, primary care education and training assumes increased importance for residents. Anxiety and depression are common complaints among women seeking care from Ob/Gyns that fall within the realm of primary care. Studies report the prevalence of de-
© 2003 Elsevier Inc., all rights reserved. 1068-607X/03/$30.00
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pression and anxiety to be as high as 30% during pregnancy and the puerperium.2 Left untreated, depression and anxiety lead to functional and social impairment and worsen medical prognoses.3–5 Maternal depression and anxiety have also been shown to affect the cognitive development of children.6 The Council on Resident Education in Obstetrics and Gynecology (CREOG) recognizes the important role behavioral science training plays in resident education. According to the latest edition of the core curriculum in Obstetrics and Gynecology, residents are expected to “describe and identify risk factors for depression, use screening instruments for the identification of depression, and treat depression with interventions, such as counseling and administration of antidepressants.” Further, “residents should be able to treat mild anxiety with counseling and anxiolytic agents.”7 These educational objectives for residency programs are mandatory and reflect current opinion about the practice of Ob/Gyn. However, in a climate of competing educational priorities, training on mental health may not be adequately addressed and residents may be ill prepared to recognize and treat common psychiatric problems. With no planned changes in the length of training, residents may
doi:10.1016/S1068-607X(03)00072-6
297
STEVENS AND DIEHL
struggle with learning an infinite amount of knowledge and residency programs may struggle with deciding which topics warrant the most educational attention. When we examined the clinical practices in our Ob/Gyn residency training program in southeastern North Carolina to determine how we address diagnosis of depression and anxiety among pregnant women, we found results that warrant attention. While 24% of our patients had previous mental health diagnoses and 18% were perceived to be at high risk for development of a mental health disorder, only 8% were screened at their initial prenatal visit and only 10% of patients were diagnosed with depression or anxiety during the course of their prenatal care according to medical record data. Only 23% were screened postpartum.8 These statistics suggest an incongruity between accepted rates of depression and anxiety among pregnant and postpartum women and rates among our study participants. With a greater number of risk factors for the development of psychiatric disease among our population, this difference most likely indicates lower rates of screening and recognition of disease rather than a true lower prevalence among our participants. We clearly have work to do in screening for and diagnosing anxiety and depression. With an increase in the amount of information to be learned, decreased time to learn information, and an unchanging patient load, residency training program changes need to be made to accompany the ACGME policy change. Residency programs must develop ways to adequately prepare residents in core curriculum topics. There are several ways our institution can address training and screening practices for depression and anxiety. We believe that these ideas could apply to other programs as well. 298
1. Develop standard institutional protocols to screen for depression and anxiety using appropriate instruments. Protocols can eliminate deviation in patient care and can serve as a screening prompt. Documentation that accompanies protocols can help ensure a truer assessment of the prevalence of depression and anxiety. Research has shown that employing standardized screening protocols helps increase detection in other clinical areas.9 Setting institutional guidelines will help ensure widespread implementation of a screening protocol. 2. Integrate mental health specialists into our training program. This would serve to optimize resident education and patient care. Our patients often are at greater risk for the development of psychiatric disorders and have fewer resources for treatment. Adding a staff psychologist to the residency program faculty or adding a designated behavioral sciences department would meet many needs. This addition would serve to improve resident education with didactic lectures, development of treatment protocols, and brief counseling of indigent patients. A staff psychologist could also serve as a resource for intensive counseling by providing those services to patients. If full integration is not possible, referral relationships could be developed with local providers or cooperative agreements in which mental health professionals could deliver services privately on site. 3. Equip residents with basic knowledge with respect to treatment and counseling. Expecting residents to have time to provide patients with comprehensive mental health care is unrealistic and will likely result in an unsatisfactory experience for the patient. However, resident train-
ing in screening, diagnosis, and treatment is needed. Training should include information on effective screening techniques and instruments, brief counseling techniques, referral (under what circumstances and where), pharmacological therapy, and follow-up protocols. This training can be offered by internal/ external faculty who specialize in mental health issues through didactic lecture and journal club. Improving the mental health of pregnant patients can improve obstetric outcomes as previous research has shown.6 There is a delicate balance between academic medicine and clinical medicine. Although resident education is a priority, patient care must be the primary goal. If patient care in resident training programs fails to meet established standards, training should be changed. By improving resident training in behavioral sciences, residents will be better equipped to treat mental illness and provide more comprehensive care to patients. References 1. Accreditation Council for Graduate Medical Education. Statement of justification/impact for the final approval of common standards related to resident duty hours. September 2002. Available from: URL: www. acgme.org/dutyhours. 2. Brown CS. Depression and anxiety disorders. Obstet Gynecol Clin North Am 2001;28:241–68. 3. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients. Results from the medical outcomes study [comment]. JAMA 1989;18:262:914 –9. 4. McLeod CC, Budd MA, McClelland DC. Treatment of somatization in primary care. Gen Hosp Psychiatry 1997;19:251–8. 5. Yonkers KA, Chantilis SJ. Recognition of depression in obstetric/gynecology practices. Am J Obstet Gynecol 1995;173:632–8. 6. Chung TK, Lau TK, Yip AS, Chiu HF, Lee DT. Antepartum depressive symptomatology is associated with adPrim Care Update Ob/Gyns
DEPRESSION AND ANXIETY verse obstetric and neonatal outcomes. Psychosom Med 2001;63:830 –4. 7. Council on Resident Education in Obstetrics and Gynecology. Educational objectives: Core curriculum in Obstetrics and Gynecology. 7th ed. 2002. 8. Galvin SL, Diehl SJ, Cassell CH, McDonough LC, Stevens JC, Lin L. Di-
Volume 10, Number 6, 2003
agnosing depression and anxiety in Obstetrical patients seeking prenatal care in Ob/Gyn residency program clinics. 4th Annual UNC/AHEC Reproductive Health Research Network Teleconference; 2003 Feb 13; Chapel Hill, North Carolina. 9. Covington DL, Diehl SJ, Wright BD, Piner M. Assessing for violence dur-
ing pregnancy using a systematic approach. Matern Child Health J 1997;1:129 –33. Address correspondence and reprint requests to Sandra J. Diehl, MPH, Coastal Area Health Education Center, PO Box 9025, Wilmington, NC 28402-9025.
299
OB/GYN RESIDENTS AS PRIMARY CARE PROVIDERS: IMPLEMENTING A NEW CURRICULUM FOR DIAGNOSING AND TREATING DEPRESSION AND ANXIETY Jennifer C. Stevens, MD, and Sandra J. Diehl, MPH
The Accreditation Council for Graduate Medical Education (ACGME) guidelines on resident work hours were created in 2002 in an effort to improve patient care. However, these changes may have a negative impact on resident education. Finding time to adequately prepare Ob/Gyn residents in core curriculum topics has become a challenge. Primary care topics such as behavioral medicine often become a lesser priority, yet Ob/Gyn physicians are expected to be competent in diagnosing and treating mental illness. Depression affects as many as 30% of all pregnant or postpartum women. When we evaluated the screening practices of a southeastern North Carolina residency program, we found that only 8% of prenatal patients were screened for symptoms of depression at their first visit and only 23% were screened at their postpartum visit. Education, screening, and treatment practices need to be addressed to ensure thorough management of Ob/Gyn patients. This paper suggests ways to do so. (Prim Care Update Ob/Gyns 2003; 10:297–299. © 2003 Elsevier Inc. All rights reserved.)
From the Coastal Area Health Education Center, Wilmington, North Carolina.
Volume 10, Number 6, 2003
In June 2002, the Accreditation Council for Graduate Medical Education (ACGME) proposed guidelines that limit resident work hours stemming from public concerns about sleep deprivation and its effects on patient safety and resident clinical and educational performance. The ACGME will start enforcing these guidelines in July 2003.1 While reduced work hours will likely result in less resident fatigue and possibly fewer medical errors, the policy presents a new challenge to Ob/Gyn residency programs that are incorporating primary care into their education and training scheme. Primary care topics may become secondary to other core curriculum topics in the interest of balancing work hour limits and educational priorities. Furthermore, the policy may limit resident participation in didactic activities during time off. As the scope of Ob/Gyn practice evolves into holistic medicine for women and with the inclusion of Ob/Gyns as defined primary care providers, primary care education and training assumes increased importance for residents. Anxiety and depression are common complaints among women seeking care from Ob/Gyns that fall within the realm of primary care. Studies report the prevalence of de-
© 2003 Elsevier Inc., all rights reserved. 1068-607X/03/$30.00
●
pression and anxiety to be as high as 30% during pregnancy and the puerperium.2 Left untreated, depression and anxiety lead to functional and social impairment and worsen medical prognoses.3–5 Maternal depression and anxiety have also been shown to affect the cognitive development of children.6 The Council on Resident Education in Obstetrics and Gynecology (CREOG) recognizes the important role behavioral science training plays in resident education. According to the latest edition of the core curriculum in Obstetrics and Gynecology, residents are expected to “describe and identify risk factors for depression, use screening instruments for the identification of depression, and treat depression with interventions, such as counseling and administration of antidepressants.” Further, “residents should be able to treat mild anxiety with counseling and anxiolytic agents.”7 These educational objectives for residency programs are mandatory and reflect current opinion about the practice of Ob/Gyn. However, in a climate of competing educational priorities, training on mental health may not be adequately addressed and residents may be ill prepared to recognize and treat common psychiatric problems. With no planned changes in the length of training, residents may
doi:10.1016/S1068-607X(03)00072-6
297
STEVENS AND DIEHL
struggle with learning an infinite amount of knowledge and residency programs may struggle with deciding which topics warrant the most educational attention. When we examined the clinical practices in our Ob/Gyn residency training program in southeastern North Carolina to determine how we address diagnosis of depression and anxiety among pregnant women, we found results that warrant attention. While 24% of our patients had previous mental health diagnoses and 18% were perceived to be at high risk for development of a mental health disorder, only 8% were screened at their initial prenatal visit and only 10% of patients were diagnosed with depression or anxiety during the course of their prenatal care according to medical record data. Only 23% were screened postpartum.8 These statistics suggest an incongruity between accepted rates of depression and anxiety among pregnant and postpartum women and rates among our study participants. With a greater number of risk factors for the development of psychiatric disease among our population, this difference most likely indicates lower rates of screening and recognition of disease rather than a true lower prevalence among our participants. We clearly have work to do in screening for and diagnosing anxiety and depression. With an increase in the amount of information to be learned, decreased time to learn information, and an unchanging patient load, residency training program changes need to be made to accompany the ACGME policy change. Residency programs must develop ways to adequately prepare residents in core curriculum topics. There are several ways our institution can address training and screening practices for depression and anxiety. We believe that these ideas could apply to other programs as well. 298
1. Develop standard institutional protocols to screen for depression and anxiety using appropriate instruments. Protocols can eliminate deviation in patient care and can serve as a screening prompt. Documentation that accompanies protocols can help ensure a truer assessment of the prevalence of depression and anxiety. Research has shown that employing standardized screening protocols helps increase detection in other clinical areas.9 Setting institutional guidelines will help ensure widespread implementation of a screening protocol. 2. Integrate mental health specialists into our training program. This would serve to optimize resident education and patient care. Our patients often are at greater risk for the development of psychiatric disorders and have fewer resources for treatment. Adding a staff psychologist to the residency program faculty or adding a designated behavioral sciences department would meet many needs. This addition would serve to improve resident education with didactic lectures, development of treatment protocols, and brief counseling of indigent patients. A staff psychologist could also serve as a resource for intensive counseling by providing those services to patients. If full integration is not possible, referral relationships could be developed with local providers or cooperative agreements in which mental health professionals could deliver services privately on site. 3. Equip residents with basic knowledge with respect to treatment and counseling. Expecting residents to have time to provide patients with comprehensive mental health care is unrealistic and will likely result in an unsatisfactory experience for the patient. However, resident train-
ing in screening, diagnosis, and treatment is needed. Training should include information on effective screening techniques and instruments, brief counseling techniques, referral (under what circumstances and where), pharmacological therapy, and follow-up protocols. This training can be offered by internal/ external faculty who specialize in mental health issues through didactic lecture and journal club. Improving the mental health of pregnant patients can improve obstetric outcomes as previous research has shown.6 There is a delicate balance between academic medicine and clinical medicine. Although resident education is a priority, patient care must be the primary goal. If patient care in resident training programs fails to meet established standards, training should be changed. By improving resident training in behavioral sciences, residents will be better equipped to treat mental illness and provide more comprehensive care to patients. References 1. Accreditation Council for Graduate Medical Education. Statement of justification/impact for the final approval of common standards related to resident duty hours. September 2002. Available from: URL: www. acgme.org/dutyhours. 2. Brown CS. Depression and anxiety disorders. Obstet Gynecol Clin North Am 2001;28:241–68. 3. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients. Results from the medical outcomes study [comment]. JAMA 1989;18:262:914 –9. 4. McLeod CC, Budd MA, McClelland DC. Treatment of somatization in primary care. Gen Hosp Psychiatry 1997;19:251–8. 5. Yonkers KA, Chantilis SJ. Recognition of depression in obstetric/gynecology practices. Am J Obstet Gynecol 1995;173:632–8. 6. Chung TK, Lau TK, Yip AS, Chiu HF, Lee DT. Antepartum depressive symptomatology is associated with adPrim Care Update Ob/Gyns
DEPRESSION AND ANXIETY verse obstetric and neonatal outcomes. Psychosom Med 2001;63:830 –4. 7. Council on Resident Education in Obstetrics and Gynecology. Educational objectives: Core curriculum in Obstetrics and Gynecology. 7th ed. 2002. 8. Galvin SL, Diehl SJ, Cassell CH, McDonough LC, Stevens JC, Lin L. Di-
Volume 10, Number 6, 2003
agnosing depression and anxiety in Obstetrical patients seeking prenatal care in Ob/Gyn residency program clinics. 4th Annual UNC/AHEC Reproductive Health Research Network Teleconference; 2003 Feb 13; Chapel Hill, North Carolina. 9. Covington DL, Diehl SJ, Wright BD, Piner M. Assessing for violence dur-
ing pregnancy using a systematic approach. Matern Child Health J 1997;1:129 –33. Address correspondence and reprint requests to Sandra J. Diehl, MPH, Coastal Area Health Education Center, PO Box 9025, Wilmington, NC 28402-9025.
299