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Psychiatric training in medicine residencies
ELSEVIER
Psychiatric
Training
in Medicintz
Current Needs, Practices, and Satisfaction Mark D. Sullivan, M.D., Ph.D., Steven A. Cole, M.D., Geoff Gordon, M.D., Steven R. Hahn, M.D., and Roger G. Kathol, M.D.
Abstract:
Introduction
Department of Psychiatry and Behavioral Sciences, RP-10, Universitv of Washinrrton, Srattle, Washinaton (M.D.% Deuartment of &ychiatry, tong Island’Jewish I%spital, Long Island, New York (S.A.C.), Department of Medicine, Oregon Health Sciences University, (G.G.), Department of Medicine, Albert Einstem College of Medicine, Bronx, New York (S.R.H.1, Departments of Medicine and Psychiatry, University of Iowa, Iowa City, Iowa (R.K.) Presented at the American Psvchiatric Association 1994 An, nual Meeting. Address reprint requests to: Mark D. Sullivan, M.D., Department of Psychiatry and Behavioral Sciences, RP-10, University of Washington, Seattle, WA 98195.
The recognition of psychiatric disorders as an important factor in primary care medical practice is now well established. Approximately 25% of primary care patients meet diagnostic criteria for a psychiatric disorder on structured interview [1,2J. Depressive disorders are most commun, with major depression seen in 5%-10% of primary care patients [3]. These depressed patients demonstrate functional impairment equivalent to or greater than the associated chronic medical illness such as diabetes and arthritis [41 and utihze health care at three times the rate of nondepressed controls [51. Most depressed patients are never seen by mental health practitioners [61. Many of these psychiatric disorders are not recognized in the primary care setting because the patients present with physical symptoms PI or have a concurrent chronic medical illness [SJ. These unrecognized disorders show a protracted course with respect to both symptoms and social disability [91. Despite these facts, primary care physicians, especially internists, receive little training in the diagnosis and management of common psychiatric problems [lo]. Recently, a calf has been issued to “close the gap between knowledge and practice” with respect to the treatment of commun psychiatric disorders in primary care [ll]. The advent of health care reform, with its proposed role for primary care physicians as gatekeepers for all forms of health care, makes improved recognition of mental disorders by these physicians even more important. Among primary care specialties, training in psychiatric disorders is more developed in family prac-
Thepurposeof this study wasto determinethe CUYrent level of psychiatrictraining in internal medicine residencies,satisfactionwith this training, and perceivedneed,if any, for more training. Surveysweremailedto all training directors of accredited prima y care(N = 178)andcategorical(N = 410) internalmedicineresidencies in the UnitedStates;110primary care (62%) and 238 categorical(58%) training directorsreturned the surveys, Seventy-five percentof categoricaland 66% of primary caretraining directorsthought their program shouldspendmoretime on psychiatricdisorders.For all categoriesof psychiatricdisorder,training intensity wasgreater and satisfactionwith training higherin the primary carePYOgrams,but lessthan half of the directorsweresatisfiedwith their current levelof training, e.g.,33% of categorkaland47% of primary care directorswere satisfiedwith their residents training concerningdepression. Trainingin somatofinm disorders,psychotropicdrugs,and officepsychotherapyweremost frequently identifiedasdeficient.Themostfavoredadditionsto thecurriculum werepsychiatricconsultantsin medicalclinics and on medicalwards.Although mostoutpatientcarefor psychiatricdisordersisgiven by primary carephysicians,internal medicinetraining directorsperceivecurrent levelsof training in their residencies as inadequate.Innovative collaborations betweenmedicineand psychiatry deparfmentswill be necessay if treatmentof psychiatricdisordersin primay careis to beimproved.
General Hospital Psychiatry 18,95-101, 1996 0 1996 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
95 ISSN Ol63-8%3/96/$15.00 SSDI 0163-H943(95)00129-8
M. D. Sullivan et al. tice residencies than in internal medicine residencies, due in part to board requirements for a behavioral scientist in the residency curriculum. Family physicians have been demonstrated to employ more counseling and antidepressants for depression than internists [121. The general pattern of depression care by family physicians more closely parallels that of psychiatrists than does that of internists. The extent of training offered to internal medicine residents in psychiatry is not well known. To assess the preparation of internal medicine residents to recognize and manage the psychiatric disorders most commonly encountered in primary care practice, we surveyed all internal medicine residency program directors. We report here their perceived needs, current practices, and degree of satisfaction with psychiatric training in their residency programs. We consider these training directors conservative but well-informed judges of the need for psychiatric training for internists. Members of the Working Group on Psychiatric Disorders in Primary Care of the American Academy on the Physician and Patient (formerly the Task Force on the Doctor and Patient of the Society for General Internal Medicine (SGIM)) conducted this survey as the first step in the development of a model curriculum in psychiatric disorders for internal medicine residencies.
Method Subjects Survey forms were mailed to all training directors of accredited primary care (178) and categorical (410) internal medicine residencies in the United States. Each training director received a copy of the survey, a letter explaining the purpose of the survey, and a promise to send the results of the survey and model curriculum eventually developed. No other incentives for reply were offered. If a training director directed both primary care and categorical residencies, he or she received a survey for each residency. One follow-up letter was sent to those directors who had not responded after 3 months.
survey The survey contained frequency of teaching
five questions assessing 1) concerning nine psychiatric
topics in grand rounds, ward rounds, clinic precepting, and resident didactics; 2) perceived general need for more or less psychiatry curriculum time; 3) satisfaction with teaching in each of the nine topic areas; 4) favored additions to psychiatry curriculum; and 5) barriers encountered in implementing a psychiatry curriculum. The nine topics were chosen as those most common in primary care: depression, anxiety, substance abuse, somatoform disorders, organic mental disorders, psychiatric emergencies, psychotropic drugs, office psychotherapy (counseling during a regular clinic visit), and geriatric psychiatry.
Analysis Teaching frequency was grouped into dichotomous categories using cutoff frequencies closest to the median response for that group of items. For lecture settings, i.e., grand rounds and resident didactics, those programs reporting at least one session per year were compared with those who reported no sessions. For clinical settings, i.e., attending ward rounds and clinic precepting, those programs reporting more than three sessions per yeur were compared with those with less than three sessions. Primary care programs were compared with categorical programs using unpaired t-tests on the percentage of respondents endorsing a given item. Significance is reported at the p < 0.05 level in order to highlight those areas where primary care and categorical programs appear to diverge. A more conservative criterion of p < 0.01 would be more appropriate, given the multiple comparisons made, if this survey were to be used to prove the existence of specific disparities between programs.
Results Training directors from categorical programs returned 238 surveys (58% response); those from primary care programs returned 110 surveys (62% response). Less than 5% of questions were left unanswered in surveys returned except for the questions concerning training frequency for specific psychiatric topics, where 15%-25% of responses were missing. Table 1 shows the general need for psychiatric training in medicine residencies as perceived by the training directors. Two-thirds of primary care and
Psychiatric Training in Medic YW Residencies Table 1. Perceived need for psychiatric training Time for psychiatry
Primary care (%)
Traditional (o/o)
Much more time More time
6 60
9 66
Sametime asnow
34
23
,DD % of training /
directors
reporting at least _______---_-._-
1 sessiQrVyr. .--.--.--
_-
t = 2.13, p 5 0.03 Psychiatric
three-fourths of categorical training directors think their program should devote more time to psychiatric training. The difference in perceived needs between program types is significant at p s 0.03. Figure 1 shows the frequency with which psychiatric topics are addressed at medical grand rounds (estimated time 60-90 minutes). Depression and substance abuse are the only topics addressed by more than half of the programs in an average year. Somatoform disorders, psychiatric emergencies, and office psychotherapy received the least attention, each being addressed in less than 30% of programs. Though all psychiatric topics were more frequently addressed in the primary care programs, the difference was significant (p < 0.05) only for anxiety. Figure 2 shows the frequency with which psychiatric topics are addressed in didactic sessions directed at residents (estimated time 60 minutes). Most programs have at least one session on each topic, with the exception of office psychotherapy. Training frequency is again higher in the primary care programs, with all except depression and substance abuse reaching statistical significance (p < 0.05).
% of training 70 r-----p 60
directors
reporting
at least
m
Primary
care
Disorders m
Traditioval
2. Intensity of psychiatric trainiq:---resident didactics. “p i 0.05. Figure
Figure 3 shows the frequency with which psychiatric topics are addressed in attending ward rounds (estimated time 5-10 minutes). Less than half of programs have more than three sessionsper year. Differences between primary care and categorical programs are less dramatic in this inpatient setting and none achieved statistical significance, Figure 4 represents the frequency with which psychiatric topics are addressed through precepting in ambulatory clinic settings (estimated time 5-10 minutes). There is considerable variability in those reporting more than three sessionsper year by both program and topic. Significant differences (p =c0.05) between primary care and categorical programs are noted for those topics taught at a high frequency in primary care programs, e.g., depression and substance abuse, and those taught at a very low frequency in categorical programs, e,g , psychiatric emergencies.
1 session/yr.
60 40
30
30
20
20 10
10 0
Dapr
Anx
SubAbu
Somat
Organlo
Psychiatric m
Primary
1. Intensity rounds. *p 4 0.05. Figure
oare
Emerg
PsydrugPsyther
G&at
0
Depr
Anx
SubAbu
Disorders @
Traditional
of psychiatric training-grand
Soe~tt
m&e
Psychiatric m
Primary
care
Ellraf#
Pefltur&YtfWr
Gerfat
Disorders m
Traditiona!
3. Intensity of psychiatric training-attending ward rounds. Figure
97
M. D. Sullivan et al. Figure 5 displays percent of training directors who are satisfied with their current psychiatric teaching by topic. Over half of directors in each type of program thought there should be more teaching on every psychiatric topic assessed. Categorical program directors more often saw a need for increased psychiatric teaching than primary care directors, with depression (p < O.Ol), anxiety (p < O.Ol>,and geriatric psychiatry (p < 0.05) differences reaching statistical significance. Figure 6 shows the psychiatric curriculum additions favored by medicine training directors. Most popular were psychiatric consultants in medical clinics or wards. Significantly more categorical programs desired more lectures in psychiatry. Barriers identified to the implementation of an expanded psychiatry curriculum were the familiar issues of time, money, and resident interest. Significantly more categorical program directors identified time (55% vs 42%, p < 0.05) and internal medicine faculty interest (16% vs 6%, p < 0.01) as barriers.
i of training
directors
reporting
frequent
sesalons
reporting
SubAb
‘should
Somat
Organic
m
Primary
oare
have
more’
Emerg PsydrugPsyther
Psychiatric
Qerlat
Topics m
Traditional
Figure 5. Satisfaction with teaching by psychiatric topic. *p s 0.05; **p s 0.01.
in internal medicine training. For example, it appears that less curriculum time is spent on depression than on other disorders of equal prevalence, such as hypertension. The results of this survey help specify the intensity of current psychiatric training and the areas thought to be deficient by medicine training directors. Current program directors value training during the residency experience in depression, anxiety, substance abuse, organic mental disorders, and psychotropic medications, for 60%-80% of programs include lectures on these topics. These topics should be included in a basic psychiatric curriculum for internal medicine residents to insure their inclusion in residency training. Information about unexplained somatic symptoms, emergency psychiatry, and geriatric psychiatry is provided less frequently (40%-60% of existing programs). Psycho-
Two-thirds to three-fourths of training directors think that there should be more curriculum time devoted to psychiatric topics. Psychiatric training occurs at a lower level in categorical than in primary care residencies and these training directors more often think that it should be increased. There is evidence of a gap between the epidemiologic importance of psychiatric problems in medical practice and the time accorded to psychiatric problems
% of training
Anx
Depr
Discussion
70,
dlreotora
(Wyr.) I 6.
60
% of training directors lawring addiion I
60
50
40
40
30
30
20
20
10 n -
I
10
Depr
Anx
SubAbu
Som8t
Organlo
Psychiatric m
Primary
oare
Enter
~yDru@eyther
Gerlat
Disorders a
0
Clink consunant
WWd consultant
Mont IedWflS
Pay tonsil required
w WY eleclive
lnpt PY required
Additions to Curriculum
Tradltlonal
4. Intensity of psychiatric training-ambulatory precepting. *p d 0.05.
Pay con& elective
I
Ptimaly care
Traditional
Figure
Figure
6. Favored additions to curriculum in psychiatry.
Psychiatric Training in Medicine Residencies therapy is given little attention (5%40%). The low level of attention that these topics receive is likely related to a variety of factors including time constraints, perceived seriousness or treatability of psychiatric illness, or seeing these problems as outside the scope of the internist’s practice. When considering the results of this survey, certain limitations of the method utilized should be kept in mind. First, only 60% of those surveyed responded to the survey It is not known how responders compare to nonresponders, so there is the possibility of response bias in our sample. Those responding to this survey may be more interested in psychiatry than those who did not. This could produce an inaccurate estimate of both the frequency of psychiatric teaching and the desire for more teaching. Second, there was a high rate of missing responses concerning teaching of specific psychiatric topics in specific settings. These have been treated as not having teaching in these areas, but this may have produced a low estimate of the teaching that is occurring. Third, residency program directors have detailed knowledge of the state of training programs but their views may not reflect the opinions of most of internists, or even academic internists, concerning the proper role of psychiatric training in medicine residencies. Previous surveys concerning mental health education in primary care specialties have focused upon the determinants of time spent on mental health teaching [131, and the different staffing and curricular patterns among primary care specialties [141. The present survey adds to this information through its focus on internal medicine residencies and its contrast of primary care and categorical programs. Training differences between these programs were found almost exclusively in the resident didactic and ambulatory precepting formats. These are the areas of residency education most likely to have been affected by ambulatory and general internal medicine training grants. Training differences generally were not found in ward rounds or grand rounds where the traditional biomedical culture of internal medicine is more dominant. New data concerning the importance of psychiatric disorders in ambulatory medical settings appear to have shaped medicine residencies only where special efforts have been made. If psychiatric consultants are present in medical clinics or on wards, this is almost always the result of training grants [15]. Psychiatrists accustomed to practicing in specialty
settings may not be prepared to teach in a way appropriate to the primary care setting. In order to increase the time available for consultation psychiatrists to train residents in internal medicine, departments of medicine would have to contribute salary support for these individuals. Clinical psychologists and other behavioral scientists have been hired to train residents in many family medicine residencies. This has been a valuable resource for family medicine. There are limitations, however, because these individuaIs generally have not been socialized into medical modes of diagnosis, treatment, and responsibility for patients. Moreover, these individuals often have limited knowledge of the interaction of medical and psychiatric illness, as well as the use of medications and other somatic treatments for psychiatric problems. In addition to educating internal medicine residents directly, consultation psychiatrists could develop a training experience for internal medicine faculty to allow them to perform some or all of the necessary teaching. There is already a model for this in the program of the American Academy on the Physician and Patient to train internists in tnterviewing skills. Despite their prevalence, specific psychiatric disorders are not usually included in an internist’s initial differential diagnosis for common symptoms presented in the primary care setting. Psychiatric disorders are generally considered only secondarily after organic disease has been “ruled out.” Recent attention by internists to the psychosocial aspects of medical practice has been focused on the medical interview [16-181. Though interviewing skills help build rapport, gather data, and promote compliance, alone they may not improve management of psychiatric problems in medical patients. Psychiatric disorders offer a focus for psychosocial teaching that offers clear and effective avenues for action by primary care physicians. Psychiatry education programs involving brief didactics 8191, a consultationliaison experience [20], or more extensive training [21] have been shown to improve medicine residents’ skills at recognizing and treating common psychiatric problems like anxiety and depression. Curricula in psychiatric disorders have been developed for use in primary care [22,23] and internal medicine [24] residencies. What remains to be done is to convince internal medicine training directors and residen.ts that it is worth spending precious curricular time on psychiatric disorders. The epidemiologic evidence con-
99
M. D. Sullivan et al. cerning the importance of psychiatric disorders in primary care is already strong. But training directors and residents will continue to minimize psychiatric training unless they are convinced that it will allow them to practice better and more efficient medicine. Psychiatric co-morbidity frustrates physicians [25], increases the time necessary to diagnose and treat affected patients [261, contributes to patients’ dissatisfaction with care [271, and ultimately increases the cost of medical care to patients and society [28]. Current shifts toward training in ambulatory settings and capitated funding for patient care will likely accentuate the importance of psychiatric disorders and their treatment in the primary care setting. by a grant from the Upjohn Company to the Workgroup on Psychiatric Disorders in Internal Medicine of fhe Society for General Internal Medicine (SGIM).
This research was supported
References 1. Barrett JE, Barrett JA, Oxman TE, Gerber PD: The
prevalence of psychiatric disorder in a primary care practice. Arch Gen Psychiatry 45:1100-1106,1988 2. VonKorff M, Shapiro S, Burke JD, et al: Anxiety and depressionin a primary care clinic: comparison of DiagnosticInterview Schedule,General Health Questionnaire, and practitioner assessments.Arch Gen Psychiatry 44:152-156,1987 3. Katon W, Schulberg H: Epidemiology of depression in primary care. Gen Hosp Psychiatry 14:237-247, 1992 4. Wells KB, Stewart A, Hays RD, et al: The functioning and well-being of depressedpatients. JAMA 262:914919, 1989 5. Regier DA, Hirschfield MA, Goodwin FK, et al: The NIMH depressionawareness,recognition and treatment program: structure, aim, and scientific basis. Am J Psychiatry 145:1351-1357,1988 6. Shapiro S,Skinner EA, KesslerLG, et al: Utilization of health and mental health services: three epidemiologic catchment sites. Arch Gen Psychiatry 41:971978, 1984 7. BridgesK, Goldberg D: Somaticpresentation of DSMIII psychiatric disordersin the primary care setting. J PsychosomRes29:563-569,1985 8. Coulehan J, Schulberg H, Block M, et al: Medical comorbidity of major depressivedisorder in a primary medical practice. Arch Intern Med 150:2363-2367, 1990 9. Ormel J, VanDenBrink W, Koeter MW, et al: Recognition, management, and outcome of psychological disorders in primary care: a naturalistic follow-up study. Psycho1Med 20:909-923,199O 10. Strain J, George LK, Pincus HA, et al: Models of men-
tal health training for primary care physicians. PsychosomMed 49:88-98,1987 11. EisenbergL: Treating depressionand anxiety in primary care: closing the gap between knowledge and practice. N Engl J Med 326:1080-1084,1992 12. Meredith LS, Wells KB, Camp P: Clinician specialty and treatment style for depressedoutpatients with and without medical comorbidities. Arch Fam Med 3:10651072, 1994 13. Goldberg RJ,Novack DH, Fulton JP,Wartmann SA: A survey of psychiatry and behavior sciencecurricula in primary care residency training. J Psychiatr Educ 9:3-11, 1985 14. Strain JJ,PincusHA, Gise LH, Houpt J: Mental health education in three primary care specialties.J Med Educ 61:958-966,1986 15. Dolinar LJ: A historical review of outpatient consultation-liaison psychiatry. Gen Hosp Psychiatry 15: 363-368,1993 16. Williamson PR, Smith RC, Kern DE, et al: The medical interview and psychosocial aspectsof medicine: block curricula for residents.J Gen Intern Med 7:235242, 1992 17. Kern DE, Grayson M, Barker LR, et al: Residency training in interviewing skills and the psychosocial domain of medical practice. J Gen Intern Med 4:421431, 1989 18. Novack DH, Volk G, DrossmanDA, Lipkin M: The teaching of medical interviewing and interpersonal skills: a survey of U.S. medical schools.JAMA 269: 2101-2105,1992 19. Anderson SM, Harthorn BH: Changing the psychiatric knowledge of primary care physicians:the effects of a brief intervention on clinical diagnosisand treatment. Gen Hosp Psychiatry 12:177-190,199O 20. Cohen-ColeSA, Boker J, Folks D, Raczynski J, et al: Psychiatric education improves internists’ knowledge:a three-year randomized, controlled evaluation. PsychosomMed 55:212-218,1993 21. Smith R, Cohen-Cole SA: Psychiatric education for internal medicine residents. J Gen Intern Med (in press) 22. Novack DH, Goldberg RJ, Rowland-Morin P, et al: Toward a comprehensivepsychiatry/behavioral sciencescurriculum for primary care residents.Psychosomatics30:213-222,1989 23. Cohen-Cole SA, Bird J: Teaching psychiatry to nonpsychiatrist: a model curriculum. Gen Hosp Psychiatry 6:1-11, 1984 24. Cohen-ColeSA, Sullivan MD, Kathol R, Warshaw C: A model curriculum for mental disordersand behavioral problemsin primary care. Gen Hosp Psychiatry (in press) 25. Lin EH, Katon W, VonKorff M, et al: Frustrating patients: physician and patient perspectivesamong distressed high utilizers of medical services.J Gen Int Med 6:241-246,1991 26. Gerrard TJ, Riddell JD: Difficult patients: black holes and secrets.Br Med J 197:53&532,1980
.
Psychiatric Training in Medicine Kesidencies 27. Schwenk TL, Marquez JT, Lefever D, Cohen M: Physician and patient determinants of difficult physician-patient relationships. J Fam Pratt 11:933-938, 1989
28. McFarland BH, Freeborn DK, Mulloky JP, Pope CR: Utilization patterns among long-tern1 enrollees in a prepaid group practice health maintenance organization. Med Care 23:1221-1233, 1985
Psychiatric
Training
in Medicintz
Current Needs, Practices, and Satisfaction Mark D. Sullivan, M.D., Ph.D., Steven A. Cole, M.D., Geoff Gordon, M.D., Steven R. Hahn, M.D., and Roger G. Kathol, M.D.
Abstract:
Introduction
Department of Psychiatry and Behavioral Sciences, RP-10, Universitv of Washinrrton, Srattle, Washinaton (M.D.% Deuartment of &ychiatry, tong Island’Jewish I%spital, Long Island, New York (S.A.C.), Department of Medicine, Oregon Health Sciences University, (G.G.), Department of Medicine, Albert Einstem College of Medicine, Bronx, New York (S.R.H.1, Departments of Medicine and Psychiatry, University of Iowa, Iowa City, Iowa (R.K.) Presented at the American Psvchiatric Association 1994 An, nual Meeting. Address reprint requests to: Mark D. Sullivan, M.D., Department of Psychiatry and Behavioral Sciences, RP-10, University of Washington, Seattle, WA 98195.
The recognition of psychiatric disorders as an important factor in primary care medical practice is now well established. Approximately 25% of primary care patients meet diagnostic criteria for a psychiatric disorder on structured interview [1,2J. Depressive disorders are most commun, with major depression seen in 5%-10% of primary care patients [3]. These depressed patients demonstrate functional impairment equivalent to or greater than the associated chronic medical illness such as diabetes and arthritis [41 and utihze health care at three times the rate of nondepressed controls [51. Most depressed patients are never seen by mental health practitioners [61. Many of these psychiatric disorders are not recognized in the primary care setting because the patients present with physical symptoms PI or have a concurrent chronic medical illness [SJ. These unrecognized disorders show a protracted course with respect to both symptoms and social disability [91. Despite these facts, primary care physicians, especially internists, receive little training in the diagnosis and management of common psychiatric problems [lo]. Recently, a calf has been issued to “close the gap between knowledge and practice” with respect to the treatment of commun psychiatric disorders in primary care [ll]. The advent of health care reform, with its proposed role for primary care physicians as gatekeepers for all forms of health care, makes improved recognition of mental disorders by these physicians even more important. Among primary care specialties, training in psychiatric disorders is more developed in family prac-
Thepurposeof this study wasto determinethe CUYrent level of psychiatrictraining in internal medicine residencies,satisfactionwith this training, and perceivedneed,if any, for more training. Surveysweremailedto all training directors of accredited prima y care(N = 178)andcategorical(N = 410) internalmedicineresidencies in the UnitedStates;110primary care (62%) and 238 categorical(58%) training directorsreturned the surveys, Seventy-five percentof categoricaland 66% of primary caretraining directorsthought their program shouldspendmoretime on psychiatricdisorders.For all categoriesof psychiatricdisorder,training intensity wasgreater and satisfactionwith training higherin the primary carePYOgrams,but lessthan half of the directorsweresatisfiedwith their current levelof training, e.g.,33% of categorkaland47% of primary care directorswere satisfiedwith their residents training concerningdepression. Trainingin somatofinm disorders,psychotropicdrugs,and officepsychotherapyweremost frequently identifiedasdeficient.Themostfavoredadditionsto thecurriculum werepsychiatricconsultantsin medicalclinics and on medicalwards.Although mostoutpatientcarefor psychiatricdisordersisgiven by primary carephysicians,internal medicinetraining directorsperceivecurrent levelsof training in their residencies as inadequate.Innovative collaborations betweenmedicineand psychiatry deparfmentswill be necessay if treatmentof psychiatricdisordersin primay careis to beimproved.
General Hospital Psychiatry 18,95-101, 1996 0 1996 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
95 ISSN Ol63-8%3/96/$15.00 SSDI 0163-H943(95)00129-8
M. D. Sullivan et al. tice residencies than in internal medicine residencies, due in part to board requirements for a behavioral scientist in the residency curriculum. Family physicians have been demonstrated to employ more counseling and antidepressants for depression than internists [121. The general pattern of depression care by family physicians more closely parallels that of psychiatrists than does that of internists. The extent of training offered to internal medicine residents in psychiatry is not well known. To assess the preparation of internal medicine residents to recognize and manage the psychiatric disorders most commonly encountered in primary care practice, we surveyed all internal medicine residency program directors. We report here their perceived needs, current practices, and degree of satisfaction with psychiatric training in their residency programs. We consider these training directors conservative but well-informed judges of the need for psychiatric training for internists. Members of the Working Group on Psychiatric Disorders in Primary Care of the American Academy on the Physician and Patient (formerly the Task Force on the Doctor and Patient of the Society for General Internal Medicine (SGIM)) conducted this survey as the first step in the development of a model curriculum in psychiatric disorders for internal medicine residencies.
Method Subjects Survey forms were mailed to all training directors of accredited primary care (178) and categorical (410) internal medicine residencies in the United States. Each training director received a copy of the survey, a letter explaining the purpose of the survey, and a promise to send the results of the survey and model curriculum eventually developed. No other incentives for reply were offered. If a training director directed both primary care and categorical residencies, he or she received a survey for each residency. One follow-up letter was sent to those directors who had not responded after 3 months.
survey The survey contained frequency of teaching
five questions assessing 1) concerning nine psychiatric
topics in grand rounds, ward rounds, clinic precepting, and resident didactics; 2) perceived general need for more or less psychiatry curriculum time; 3) satisfaction with teaching in each of the nine topic areas; 4) favored additions to psychiatry curriculum; and 5) barriers encountered in implementing a psychiatry curriculum. The nine topics were chosen as those most common in primary care: depression, anxiety, substance abuse, somatoform disorders, organic mental disorders, psychiatric emergencies, psychotropic drugs, office psychotherapy (counseling during a regular clinic visit), and geriatric psychiatry.
Analysis Teaching frequency was grouped into dichotomous categories using cutoff frequencies closest to the median response for that group of items. For lecture settings, i.e., grand rounds and resident didactics, those programs reporting at least one session per year were compared with those who reported no sessions. For clinical settings, i.e., attending ward rounds and clinic precepting, those programs reporting more than three sessions per yeur were compared with those with less than three sessions. Primary care programs were compared with categorical programs using unpaired t-tests on the percentage of respondents endorsing a given item. Significance is reported at the p < 0.05 level in order to highlight those areas where primary care and categorical programs appear to diverge. A more conservative criterion of p < 0.01 would be more appropriate, given the multiple comparisons made, if this survey were to be used to prove the existence of specific disparities between programs.
Results Training directors from categorical programs returned 238 surveys (58% response); those from primary care programs returned 110 surveys (62% response). Less than 5% of questions were left unanswered in surveys returned except for the questions concerning training frequency for specific psychiatric topics, where 15%-25% of responses were missing. Table 1 shows the general need for psychiatric training in medicine residencies as perceived by the training directors. Two-thirds of primary care and
Psychiatric Training in Medic YW Residencies Table 1. Perceived need for psychiatric training Time for psychiatry
Primary care (%)
Traditional (o/o)
Much more time More time
6 60
9 66
Sametime asnow
34
23
,DD % of training /
directors
reporting at least _______---_-._-
1 sessiQrVyr. .--.--.--
_-
t = 2.13, p 5 0.03 Psychiatric
three-fourths of categorical training directors think their program should devote more time to psychiatric training. The difference in perceived needs between program types is significant at p s 0.03. Figure 1 shows the frequency with which psychiatric topics are addressed at medical grand rounds (estimated time 60-90 minutes). Depression and substance abuse are the only topics addressed by more than half of the programs in an average year. Somatoform disorders, psychiatric emergencies, and office psychotherapy received the least attention, each being addressed in less than 30% of programs. Though all psychiatric topics were more frequently addressed in the primary care programs, the difference was significant (p < 0.05) only for anxiety. Figure 2 shows the frequency with which psychiatric topics are addressed in didactic sessions directed at residents (estimated time 60 minutes). Most programs have at least one session on each topic, with the exception of office psychotherapy. Training frequency is again higher in the primary care programs, with all except depression and substance abuse reaching statistical significance (p < 0.05).
% of training 70 r-----p 60
directors
reporting
at least
m
Primary
care
Disorders m
Traditioval
2. Intensity of psychiatric trainiq:---resident didactics. “p i 0.05. Figure
Figure 3 shows the frequency with which psychiatric topics are addressed in attending ward rounds (estimated time 5-10 minutes). Less than half of programs have more than three sessionsper year. Differences between primary care and categorical programs are less dramatic in this inpatient setting and none achieved statistical significance, Figure 4 represents the frequency with which psychiatric topics are addressed through precepting in ambulatory clinic settings (estimated time 5-10 minutes). There is considerable variability in those reporting more than three sessionsper year by both program and topic. Significant differences (p =c0.05) between primary care and categorical programs are noted for those topics taught at a high frequency in primary care programs, e.g., depression and substance abuse, and those taught at a very low frequency in categorical programs, e,g , psychiatric emergencies.
1 session/yr.
60 40
30
30
20
20 10
10 0
Dapr
Anx
SubAbu
Somat
Organlo
Psychiatric m
Primary
1. Intensity rounds. *p 4 0.05. Figure
oare
Emerg
PsydrugPsyther
G&at
0
Depr
Anx
SubAbu
Disorders @
Traditional
of psychiatric training-grand
Soe~tt
m&e
Psychiatric m
Primary
care
Ellraf#
Pefltur&YtfWr
Gerfat
Disorders m
Traditiona!
3. Intensity of psychiatric training-attending ward rounds. Figure
97
M. D. Sullivan et al. Figure 5 displays percent of training directors who are satisfied with their current psychiatric teaching by topic. Over half of directors in each type of program thought there should be more teaching on every psychiatric topic assessed. Categorical program directors more often saw a need for increased psychiatric teaching than primary care directors, with depression (p < O.Ol), anxiety (p < O.Ol>,and geriatric psychiatry (p < 0.05) differences reaching statistical significance. Figure 6 shows the psychiatric curriculum additions favored by medicine training directors. Most popular were psychiatric consultants in medical clinics or wards. Significantly more categorical programs desired more lectures in psychiatry. Barriers identified to the implementation of an expanded psychiatry curriculum were the familiar issues of time, money, and resident interest. Significantly more categorical program directors identified time (55% vs 42%, p < 0.05) and internal medicine faculty interest (16% vs 6%, p < 0.01) as barriers.
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in internal medicine training. For example, it appears that less curriculum time is spent on depression than on other disorders of equal prevalence, such as hypertension. The results of this survey help specify the intensity of current psychiatric training and the areas thought to be deficient by medicine training directors. Current program directors value training during the residency experience in depression, anxiety, substance abuse, organic mental disorders, and psychotropic medications, for 60%-80% of programs include lectures on these topics. These topics should be included in a basic psychiatric curriculum for internal medicine residents to insure their inclusion in residency training. Information about unexplained somatic symptoms, emergency psychiatry, and geriatric psychiatry is provided less frequently (40%-60% of existing programs). Psycho-
Two-thirds to three-fourths of training directors think that there should be more curriculum time devoted to psychiatric topics. Psychiatric training occurs at a lower level in categorical than in primary care residencies and these training directors more often think that it should be increased. There is evidence of a gap between the epidemiologic importance of psychiatric problems in medical practice and the time accorded to psychiatric problems
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6. Favored additions to curriculum in psychiatry.
Psychiatric Training in Medicine Residencies therapy is given little attention (5%40%). The low level of attention that these topics receive is likely related to a variety of factors including time constraints, perceived seriousness or treatability of psychiatric illness, or seeing these problems as outside the scope of the internist’s practice. When considering the results of this survey, certain limitations of the method utilized should be kept in mind. First, only 60% of those surveyed responded to the survey It is not known how responders compare to nonresponders, so there is the possibility of response bias in our sample. Those responding to this survey may be more interested in psychiatry than those who did not. This could produce an inaccurate estimate of both the frequency of psychiatric teaching and the desire for more teaching. Second, there was a high rate of missing responses concerning teaching of specific psychiatric topics in specific settings. These have been treated as not having teaching in these areas, but this may have produced a low estimate of the teaching that is occurring. Third, residency program directors have detailed knowledge of the state of training programs but their views may not reflect the opinions of most of internists, or even academic internists, concerning the proper role of psychiatric training in medicine residencies. Previous surveys concerning mental health education in primary care specialties have focused upon the determinants of time spent on mental health teaching [131, and the different staffing and curricular patterns among primary care specialties [141. The present survey adds to this information through its focus on internal medicine residencies and its contrast of primary care and categorical programs. Training differences between these programs were found almost exclusively in the resident didactic and ambulatory precepting formats. These are the areas of residency education most likely to have been affected by ambulatory and general internal medicine training grants. Training differences generally were not found in ward rounds or grand rounds where the traditional biomedical culture of internal medicine is more dominant. New data concerning the importance of psychiatric disorders in ambulatory medical settings appear to have shaped medicine residencies only where special efforts have been made. If psychiatric consultants are present in medical clinics or on wards, this is almost always the result of training grants [15]. Psychiatrists accustomed to practicing in specialty
settings may not be prepared to teach in a way appropriate to the primary care setting. In order to increase the time available for consultation psychiatrists to train residents in internal medicine, departments of medicine would have to contribute salary support for these individuals. Clinical psychologists and other behavioral scientists have been hired to train residents in many family medicine residencies. This has been a valuable resource for family medicine. There are limitations, however, because these individuaIs generally have not been socialized into medical modes of diagnosis, treatment, and responsibility for patients. Moreover, these individuals often have limited knowledge of the interaction of medical and psychiatric illness, as well as the use of medications and other somatic treatments for psychiatric problems. In addition to educating internal medicine residents directly, consultation psychiatrists could develop a training experience for internal medicine faculty to allow them to perform some or all of the necessary teaching. There is already a model for this in the program of the American Academy on the Physician and Patient to train internists in tnterviewing skills. Despite their prevalence, specific psychiatric disorders are not usually included in an internist’s initial differential diagnosis for common symptoms presented in the primary care setting. Psychiatric disorders are generally considered only secondarily after organic disease has been “ruled out.” Recent attention by internists to the psychosocial aspects of medical practice has been focused on the medical interview [16-181. Though interviewing skills help build rapport, gather data, and promote compliance, alone they may not improve management of psychiatric problems in medical patients. Psychiatric disorders offer a focus for psychosocial teaching that offers clear and effective avenues for action by primary care physicians. Psychiatry education programs involving brief didactics 8191, a consultationliaison experience [20], or more extensive training [21] have been shown to improve medicine residents’ skills at recognizing and treating common psychiatric problems like anxiety and depression. Curricula in psychiatric disorders have been developed for use in primary care [22,23] and internal medicine [24] residencies. What remains to be done is to convince internal medicine training directors and residen.ts that it is worth spending precious curricular time on psychiatric disorders. The epidemiologic evidence con-
99
M. D. Sullivan et al. cerning the importance of psychiatric disorders in primary care is already strong. But training directors and residents will continue to minimize psychiatric training unless they are convinced that it will allow them to practice better and more efficient medicine. Psychiatric co-morbidity frustrates physicians [25], increases the time necessary to diagnose and treat affected patients [261, contributes to patients’ dissatisfaction with care [271, and ultimately increases the cost of medical care to patients and society [28]. Current shifts toward training in ambulatory settings and capitated funding for patient care will likely accentuate the importance of psychiatric disorders and their treatment in the primary care setting. by a grant from the Upjohn Company to the Workgroup on Psychiatric Disorders in Internal Medicine of fhe Society for General Internal Medicine (SGIM).
This research was supported
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