- Email: [email protected]
Teaching psychiatry to primary care internists
Teaching Psychiatry to Primary Care Internists Troy L. Thompson
II, M.D.
Associate Professor of Psychiatry and Medicine and Acting Director, Psychiatric Liaison Division
Marshall
R. Thomas,
M.D.
Chief Resident in Psychiatry, University of Colorado School of Medicine, Denver Colorado
Abstract: Many patients who seek the care of primary care physicians are sufferingfrom a wide variety of psychiatric disorders. Primary care physicians should become skilled in interviewing techniques and basic psychiatric differential diagnosis, management, and treatment approaches for some types of psychiatric disorders and learn to regularly consult with and make referrals to psychiatrists when appropriate. Psychiatrists should play a very active role in the education of primary care specialists. This should include observation of the physician interviewing patients with different types of psychiatric disorders in addition to didactic teaching and supervision on topics such as psychopharmacology. With mutual collaboration between primay care interests and psychiatrists the patients of both groups of physicians should receive better care and continuing education of both may occur through an ongoing dialogue.
Primary care medicine and the important role of psychiatry in primary care have gained much needed recognition in the past decade [l-3]. In the face of increasing technology and growing subspecialization, both patients and the medical community have turned to primary care physicians with the expectation that they should provide and coordinate comprehensive health care programs [4]. Gone are the days of the old family physician who had relatively little in the way of biomedical knowledge but who knew and cared for each of his patients and their families personally. Today’s primary care physician is being asked to respond to the simultaneous demands for compassion and technologic expertise. It is ironic that as technical and biomedical advances have allowed for the more effective treatment of many disorders, they have also contributed
to new stresses in the doctor-patient relationship. New technology vigorously competes for the physician’s time and energy by demanding that he be involved in continuing education constantly to broaden and maintain his base of technical knowledge. The very successes of medical research have brought about higher expectations in patients who often expect not just good care, but a cure of any condition. The ever-increasing bulk of scientific data encourages many physicians to subspecialize in order to keep pace with advances and to provide a sense of protection from the malpractice threat. In addition, the involvement of numerous third parties (e.g., government agencies, insurance companies, other regulatory agencies) may ultimately improve health care standards, but also add to the stress of, and at times intrude upon, the doctorpatient relationship. The primary care specialties have come to be known by a number of titles, including general internal medicine, family practice, family medicine, and general pediatrics. Sometimes obstetriciangynecologists and psychiatrists function as the primary care givers to certain patients [5]. The primary care physician is usually the physician of first contact and is expected to use a biopsychosocial approach to evaluate and treat all of the patients biomedical and psychosocial problems [6]. Where he or she cannot provide specific treatment, he or she is expected to integrate and coordinate the other care that is needed and to provide follow-up and continuity of care. Though the expectations placed on the primary care physician are perhaps the most taxing in medicine, he or she is among the poorest in terms of reimbursement. General Hospital
210 ISSN 0163-8343/65/$3.30
Psychiatry 7, 21C-213, 1985 0 Elsevier Science Publishing Co., Inc. 1985 52 Vanderbilt Avenue, New York, NY 10017
Teaching Psychiatry to Internists
Most patients, however, expect to have a general physician treat their emotional needs. Eighty-eight percent of patients who feared they were having a “nervous breakdown” first sought help from a primary care physician [7]. Eighty-four percent of primary care physicians feel strongly that they should care for the emotional problems of their patients. Only 10% of those patients diagnosed as having a psychiatric disorder are referred by their primary physician for psychiatric consultation. It has been estimated that about 60% of mental health care in the United States is provided by general physicians and only 20% by mental health professionals [8]. Since patients with psychiatric symptoms tend initially to seek out primary care physicians, such a physician will see a number of patients with a wide range of psychiatric disorders. Studies of the prevalence of significant psychiatric disorders in the patient populations of primary care physicians have had results ranging from 2% to 90%, with most studies estimating 4%-20% [9]. Lipowski reported that as many as 30-60% of medical and surgical inpatients and 50%~80% of outpatients have some psychiatric disorder severe enough to interfere with optimal medical care [lo]. Primary care physicians estimate spending between 20% and 50% of their time treating psychiatric problems [ 10,111. These estimates may reflect not only the prevalence of such problems, but the perceived burden that caring for patients with psychiatric problems imposes on many physicians. Depression is generally considered to be the most frequent psychiatric problem in primary care. Other frequent problems include multiple functional somatic complaints, anxiety, noncompliance, conflicts in the doctor-patient relationship, alcoholism, dementia, and maintenance treatment of chronic psychoses. Life-style habits that significantly effect health, such as excessive use of alcohol or smoking, are estimated to be present in 20-40% of medical patients [ll]. Despite the frequency of psychiatric problems, it has been estimated that general physicians correctly identify only about 10% of the psychiatric problems in their patients [12]. Major knowledge deficits exist in such important areas as the recognition and treatment of depression, delirium, dementia, and psychogenic pain [13]. A recent study found that general internists in a university hospital outpatient clinic recognized only 3 of 17 areas of major psychiatric distress in their patients [14]. Among the areas of which the physicians were unaware were the misuse of prescription medica-
tions, sexual difficulties (which may be secondary to medical illness or medication), and suicidal ideation. A significant finding in this study was that primary care physicians were unaware of when they were unaware in certain areas. In general the primary care physicians overestimated their ability to accurately recognize the majority of psychiatric problems. Until recently, most primary care physicians received little or no psychiatric training beyond a psychiatry rotation in medical school. Few (10%) primary care physicians have received any form of continuing medical education in psychiatry [3]. Even today many medical and surgical training programs behave as though psychiatric problems are relatively unimportant and spend little or no time discussing those aspects of their patients on rounds or with nursing staff. Even where psychiatry is emphasized, many trainees may have entered their primary care specialty despite the prevalence of psychiatric problems rather than out of an interest in evaluating and treating psychiatric disorders. Nevertheless, beyond the humanistic concerns about patient discomfort, there are several objective advantages to paying careful attention to psychiatric disorders and to improving physician-patient relationships [15,16]. Effective psychiatric consultation-liaison may increase patient compliance and decrease overuse of high technology. Decreases in the utilization of emergency, outpatient, and inpatient services, of course, reduce overall health care costs. Patient morbidity may be positively effected as in the coronary care units where careful evaluation and appropriate treatment of patients with psychiatric disorders has been found to decrease mortality rates [17]. Despite its importance, there are several reasons why the primary care physician may find treating patients with psychiatric problems difficult and frustrating. To start with, the inhumane time pressures of most training programs do not create an atmosphere where the house officer is likely to feel able to put a premium on humane care. In addition, patients with psychiatric problems can stir up painful and disorganizing affects that in order to deal with appropriately will require adequate time and support on the part of the physician. If the physician has difficulty understanding his patient’s problems or feels that they are beyond his capacity to treat, he will often become frustrated. Physicians may use a number of common rationalizations to try to avoid responsibility for and guilt over not being able to care for psychiatric 211
T. L. Thompson II and M. R. Thomas
patients adequately [NJ. They may assume the attitude that most psychiatric problems are “incurable” and therefore believe that attempting to deal with them is a waste of time. They may revert to dualistic thinking by defining their own role as “purely medical” in an attempt to put patients with psychiatric problems outside the domain of “real medicine. ” Physicians may project their own discomfort onto the patient and make the excuse that talking about such issues with the patient will be “too upsetting for the patient.” Another disincentive for attention to psychiatric etiologies and consultation is the current pattern of remuneration. Income generated from time spent in the operating room or from performing a biomedical procedure is generally five to ten times greater than that generated from the same amount of time spent doing psychotherapy, educating, or counseling a patient [19]. Physicians may be reluctant to charge an extra fee for the additional time they spend using these nonsurgical means of managing their patients, though few would hesitate to charge for a repeat biomedical procedure. Although it is not their responsibility to treat all psychiatric problems, it is certainly the primary care physician who has the opportunity and responsibility to consider and screen for psychiatric disorders [20-251. Reluctance to charge for psychiatric care may create another resistance to providing such care and may convey the message to patients, third-party payers, and others that it is not as important as the other uses of the physician’s time. Most primary care programs now have some type of psychiatric education. The approaches vary widely from periodic lectures by psychiatrists to combined internal medicine and psychiatric residency programs. Many programs have psychiatrists available for consultation and some make rounds with house staff in order to enhance the psychiatric care of the patients and the psychiatric education of the physicians [26]. Regardless of the specific model employed, most programs tend to emphasize increasing the sensitivity of the physician to psychiatric symptoms and enhancing the physician’s introspective capacities to monitor emotional reactions to patients. In teaching psychiatry to primary care physicians it is easy to become overly ambitious and necessary to decide on what is important to teach. It is important that the physicians develop a high index of suspicion, become aware of the prevalence of psychiatric disorders, and learn to routinely consider and screen for them in their patients. The 212
physician should also learn how to generate a comprehensive psychosocial and psychiatric data base and how to arrange for psychiatric consultation. Once this is accomplished, when and how to use several basic psychiatric therapeutic approaches may also be appropriately taught. However, educational efforts should focus initially on the recognition of psychiatric symptoms and appropriate consultation and referral. To emphasize complex psychiatric theories or treatments is to put the cart before the horse. It is unrealistic to believe that other specialties can be taught in a few hours per week to perform complex diagnostic and therapeutic psychiatric activities as effectively as a well-trained psychiatrist. Additionally, encouraging such beliefs only reinforces the relatively low reimbursement that psychiatrists tend to receive. Although a certain amount of factual knowledge is important, the cornerstone of psychiatric primary care education is learning to develop and maintain effective physician-patient relationships. Such relationships are based upon open communication and physician self-awareness in diagnosing and treating disruptions in the doctor-patient relationship [18]. The doctor should learn that his or her interactions with the patient symbolically represent a “drug” that may have either a therapeutic or an adverse effect on the patient. It is also important for the physician to learn the usefulness of educating patients about the risks associated with their illness and how to teach patients to accept appropriate degrees of responsibility for their health care. It is our experience that effective psychiatric skills and attitudes are best taught to primary care physicians individually or in small groups, with one of the physician’s patients present for at least part of the meeting. It is in this setting that effective interviewing techniques and methods of eliciting covert psychiatric symptoms can most effectively be taught. Through interviewing the patient the psychiatrist serves as a role model and can enhance the physician’s appreciation of the complexities and potential usefulness of effective psychiatric treatment. Interviewing skills can then be seen as a bridge to the successful and ongoing doctor-patient relationship. Although a variety of approaches may be necessary to “open the door” and develop an alliance for teaching, liaison teaching ultimately best follows direct patient consultation and patientcentered education.
References 1. Byyny RL, Thompson TL II: The evolution of primary
Teaching
2.
3.
4.
5. 6. 7.
8.
9.
10.
11.
12.
13.
care medicine. In Thompson TL II, Byyny RL (eds), Primary and Team Health Care Education. New York, Praeger, 1983, p 5 Smarr EP, Berkow R: Teaching psychological medicine to family practice residents. Am J Psychiatry 134:984, 1977 Fink PJ: Psychiatry and the primary care physician. In Kaplan HI, Freedman AM, Sadock BJ (eds), Comprehensive Textbook of Psychiatry-III, Baltimore, Williams and Wilkins, 1980, p 2077 Alpert JL, Charney E: The Education of Physicians for Primary Care, DHEW Pub HRA74-3113. Washington, DC, US Department of Health, Education, and Welfare, 1973 Fink PJ, Oken D: The role of psychiatry as a primary care specialty. Arch Gen Psychiatry 33:998, 1976 Engel GL: The need for a new medical model: A challenge for biomedicine. Science 196:129, 1977 Enslow A: Prevention of medical disorder: The role of the general practitioner. California Medicine 104:16, 1966 Regier DA, Goldberg ID, Taube CA: The defacto US mental health services system-A public health perspective. Arch Gen Psychiatry 35:685, 1978 Houpt JL, Orleans CS, George LK, et al: The role of psychiatric and behavioral factors in the practice of medicine. Am J Psychiatry 137:137, 1980 Lipowski ZJ: Review of consultation psychiatry and psychosocial medicine. II: Clinical aspects. Psychosom Med 29:201, 1967 Stoudemire A, Thompson TL II, Mitchell WD, Grant RL: Family physicians’ perceptions of psychosocial disorders: Pilot survey report and educational implications. Int J Psychiatry Med 12281, 1982-83 Hoeper EW, Nycz, GR, Cleary I’D, Regier DA, Goldberg ID: Estimated prevalence of RDC mental disorder in primary medical care. Int J Ment Health 8:6, 1979 Cohen-Cole SA, Bird J, Freeman A, Boker J, Hain J, Shugerman A: An oral examination of the psychiatric knowledge of medical housestaff: Assessment of needs and evaluation baseline. Gen Hosp Psychiatry 4:103, 1982
Psychiatry
to Internists
14. Thompson TL II, Stoudemire A, Mitchell WD, Grant RL: Underrecognition of patients’ psychosocial distress in a university hospital medical clinic. Am J Psychiatry 140:158, 1983 15. Levitan SJ, Kornfeld DS: Clinical and cost benefits of liaison psychiatry. Am J Psychiatry 138:790, 1981 16. Mumford E, Schlesinger HJ, Glass GV: The effects of psychological intervention on recovery from surgery and heart attacks: An analysis of the literature. Am J Public Health 72:141, 1982 17. Dubovsky S, Getto C, Gross S, Paley J: Psychiatrists on the coronary care unit. Psychosomatics 18:18,1977 18. Duffy DL, Hamerman D, Cohen MA: Communication skills of house officers: A study in a medical clinic. Ann Intern Med 93:354, 1980 19. Almy TP: The role of the primary physician in the health-care “industry.” N Engl J Med 304:225, 1981 20. Goldberg RL, Haas MR, Eaton JS, Grubbs JH: Psychiatry and the primary care physician. JAMA 236:944, 1976 21. Barsky AJ, Brown HN: Psychiatric teaching and consultation in a primary care clinic. Psychosomatics 23:908, 1982 22. Fauman MA: Psychiatric components of medical and surgical practice, II: Referral and treatment of psychiatric disorders. Am J Psychiatry 140:760, 1983 23. Balint M: The Doctor, His Patient, and the Illness. New York, International Universities Press, 1973 24. Hales RE: Primary care in psychiatry residency training. Gen Hosp Psychiatry 2:148, 1980 25. Borus JF, Casserly MK: Psychiatrists and primary physicians: Collaborative learning experiences in delivering primary care. Hosp Community Psychiatry 30:686, 1979 26. Strain J, Hamerman D: Ombudsman-medical-psychiatric teaching rounds (ombudsman rounds). Ann Intern Med 80:550, 1977 Direct reprint requests to:
Troy L. Thompson II, M.D. 4200 East Ninth Avenue, C268 Denver, CO 80262
213
II, M.D.
Associate Professor of Psychiatry and Medicine and Acting Director, Psychiatric Liaison Division
Marshall
R. Thomas,
M.D.
Chief Resident in Psychiatry, University of Colorado School of Medicine, Denver Colorado
Abstract: Many patients who seek the care of primary care physicians are sufferingfrom a wide variety of psychiatric disorders. Primary care physicians should become skilled in interviewing techniques and basic psychiatric differential diagnosis, management, and treatment approaches for some types of psychiatric disorders and learn to regularly consult with and make referrals to psychiatrists when appropriate. Psychiatrists should play a very active role in the education of primary care specialists. This should include observation of the physician interviewing patients with different types of psychiatric disorders in addition to didactic teaching and supervision on topics such as psychopharmacology. With mutual collaboration between primay care interests and psychiatrists the patients of both groups of physicians should receive better care and continuing education of both may occur through an ongoing dialogue.
Primary care medicine and the important role of psychiatry in primary care have gained much needed recognition in the past decade [l-3]. In the face of increasing technology and growing subspecialization, both patients and the medical community have turned to primary care physicians with the expectation that they should provide and coordinate comprehensive health care programs [4]. Gone are the days of the old family physician who had relatively little in the way of biomedical knowledge but who knew and cared for each of his patients and their families personally. Today’s primary care physician is being asked to respond to the simultaneous demands for compassion and technologic expertise. It is ironic that as technical and biomedical advances have allowed for the more effective treatment of many disorders, they have also contributed
to new stresses in the doctor-patient relationship. New technology vigorously competes for the physician’s time and energy by demanding that he be involved in continuing education constantly to broaden and maintain his base of technical knowledge. The very successes of medical research have brought about higher expectations in patients who often expect not just good care, but a cure of any condition. The ever-increasing bulk of scientific data encourages many physicians to subspecialize in order to keep pace with advances and to provide a sense of protection from the malpractice threat. In addition, the involvement of numerous third parties (e.g., government agencies, insurance companies, other regulatory agencies) may ultimately improve health care standards, but also add to the stress of, and at times intrude upon, the doctorpatient relationship. The primary care specialties have come to be known by a number of titles, including general internal medicine, family practice, family medicine, and general pediatrics. Sometimes obstetriciangynecologists and psychiatrists function as the primary care givers to certain patients [5]. The primary care physician is usually the physician of first contact and is expected to use a biopsychosocial approach to evaluate and treat all of the patients biomedical and psychosocial problems [6]. Where he or she cannot provide specific treatment, he or she is expected to integrate and coordinate the other care that is needed and to provide follow-up and continuity of care. Though the expectations placed on the primary care physician are perhaps the most taxing in medicine, he or she is among the poorest in terms of reimbursement. General Hospital
210 ISSN 0163-8343/65/$3.30
Psychiatry 7, 21C-213, 1985 0 Elsevier Science Publishing Co., Inc. 1985 52 Vanderbilt Avenue, New York, NY 10017
Teaching Psychiatry to Internists
Most patients, however, expect to have a general physician treat their emotional needs. Eighty-eight percent of patients who feared they were having a “nervous breakdown” first sought help from a primary care physician [7]. Eighty-four percent of primary care physicians feel strongly that they should care for the emotional problems of their patients. Only 10% of those patients diagnosed as having a psychiatric disorder are referred by their primary physician for psychiatric consultation. It has been estimated that about 60% of mental health care in the United States is provided by general physicians and only 20% by mental health professionals [8]. Since patients with psychiatric symptoms tend initially to seek out primary care physicians, such a physician will see a number of patients with a wide range of psychiatric disorders. Studies of the prevalence of significant psychiatric disorders in the patient populations of primary care physicians have had results ranging from 2% to 90%, with most studies estimating 4%-20% [9]. Lipowski reported that as many as 30-60% of medical and surgical inpatients and 50%~80% of outpatients have some psychiatric disorder severe enough to interfere with optimal medical care [lo]. Primary care physicians estimate spending between 20% and 50% of their time treating psychiatric problems [ 10,111. These estimates may reflect not only the prevalence of such problems, but the perceived burden that caring for patients with psychiatric problems imposes on many physicians. Depression is generally considered to be the most frequent psychiatric problem in primary care. Other frequent problems include multiple functional somatic complaints, anxiety, noncompliance, conflicts in the doctor-patient relationship, alcoholism, dementia, and maintenance treatment of chronic psychoses. Life-style habits that significantly effect health, such as excessive use of alcohol or smoking, are estimated to be present in 20-40% of medical patients [ll]. Despite the frequency of psychiatric problems, it has been estimated that general physicians correctly identify only about 10% of the psychiatric problems in their patients [12]. Major knowledge deficits exist in such important areas as the recognition and treatment of depression, delirium, dementia, and psychogenic pain [13]. A recent study found that general internists in a university hospital outpatient clinic recognized only 3 of 17 areas of major psychiatric distress in their patients [14]. Among the areas of which the physicians were unaware were the misuse of prescription medica-
tions, sexual difficulties (which may be secondary to medical illness or medication), and suicidal ideation. A significant finding in this study was that primary care physicians were unaware of when they were unaware in certain areas. In general the primary care physicians overestimated their ability to accurately recognize the majority of psychiatric problems. Until recently, most primary care physicians received little or no psychiatric training beyond a psychiatry rotation in medical school. Few (10%) primary care physicians have received any form of continuing medical education in psychiatry [3]. Even today many medical and surgical training programs behave as though psychiatric problems are relatively unimportant and spend little or no time discussing those aspects of their patients on rounds or with nursing staff. Even where psychiatry is emphasized, many trainees may have entered their primary care specialty despite the prevalence of psychiatric problems rather than out of an interest in evaluating and treating psychiatric disorders. Nevertheless, beyond the humanistic concerns about patient discomfort, there are several objective advantages to paying careful attention to psychiatric disorders and to improving physician-patient relationships [15,16]. Effective psychiatric consultation-liaison may increase patient compliance and decrease overuse of high technology. Decreases in the utilization of emergency, outpatient, and inpatient services, of course, reduce overall health care costs. Patient morbidity may be positively effected as in the coronary care units where careful evaluation and appropriate treatment of patients with psychiatric disorders has been found to decrease mortality rates [17]. Despite its importance, there are several reasons why the primary care physician may find treating patients with psychiatric problems difficult and frustrating. To start with, the inhumane time pressures of most training programs do not create an atmosphere where the house officer is likely to feel able to put a premium on humane care. In addition, patients with psychiatric problems can stir up painful and disorganizing affects that in order to deal with appropriately will require adequate time and support on the part of the physician. If the physician has difficulty understanding his patient’s problems or feels that they are beyond his capacity to treat, he will often become frustrated. Physicians may use a number of common rationalizations to try to avoid responsibility for and guilt over not being able to care for psychiatric 211
T. L. Thompson II and M. R. Thomas
patients adequately [NJ. They may assume the attitude that most psychiatric problems are “incurable” and therefore believe that attempting to deal with them is a waste of time. They may revert to dualistic thinking by defining their own role as “purely medical” in an attempt to put patients with psychiatric problems outside the domain of “real medicine. ” Physicians may project their own discomfort onto the patient and make the excuse that talking about such issues with the patient will be “too upsetting for the patient.” Another disincentive for attention to psychiatric etiologies and consultation is the current pattern of remuneration. Income generated from time spent in the operating room or from performing a biomedical procedure is generally five to ten times greater than that generated from the same amount of time spent doing psychotherapy, educating, or counseling a patient [19]. Physicians may be reluctant to charge an extra fee for the additional time they spend using these nonsurgical means of managing their patients, though few would hesitate to charge for a repeat biomedical procedure. Although it is not their responsibility to treat all psychiatric problems, it is certainly the primary care physician who has the opportunity and responsibility to consider and screen for psychiatric disorders [20-251. Reluctance to charge for psychiatric care may create another resistance to providing such care and may convey the message to patients, third-party payers, and others that it is not as important as the other uses of the physician’s time. Most primary care programs now have some type of psychiatric education. The approaches vary widely from periodic lectures by psychiatrists to combined internal medicine and psychiatric residency programs. Many programs have psychiatrists available for consultation and some make rounds with house staff in order to enhance the psychiatric care of the patients and the psychiatric education of the physicians [26]. Regardless of the specific model employed, most programs tend to emphasize increasing the sensitivity of the physician to psychiatric symptoms and enhancing the physician’s introspective capacities to monitor emotional reactions to patients. In teaching psychiatry to primary care physicians it is easy to become overly ambitious and necessary to decide on what is important to teach. It is important that the physicians develop a high index of suspicion, become aware of the prevalence of psychiatric disorders, and learn to routinely consider and screen for them in their patients. The 212
physician should also learn how to generate a comprehensive psychosocial and psychiatric data base and how to arrange for psychiatric consultation. Once this is accomplished, when and how to use several basic psychiatric therapeutic approaches may also be appropriately taught. However, educational efforts should focus initially on the recognition of psychiatric symptoms and appropriate consultation and referral. To emphasize complex psychiatric theories or treatments is to put the cart before the horse. It is unrealistic to believe that other specialties can be taught in a few hours per week to perform complex diagnostic and therapeutic psychiatric activities as effectively as a well-trained psychiatrist. Additionally, encouraging such beliefs only reinforces the relatively low reimbursement that psychiatrists tend to receive. Although a certain amount of factual knowledge is important, the cornerstone of psychiatric primary care education is learning to develop and maintain effective physician-patient relationships. Such relationships are based upon open communication and physician self-awareness in diagnosing and treating disruptions in the doctor-patient relationship [18]. The doctor should learn that his or her interactions with the patient symbolically represent a “drug” that may have either a therapeutic or an adverse effect on the patient. It is also important for the physician to learn the usefulness of educating patients about the risks associated with their illness and how to teach patients to accept appropriate degrees of responsibility for their health care. It is our experience that effective psychiatric skills and attitudes are best taught to primary care physicians individually or in small groups, with one of the physician’s patients present for at least part of the meeting. It is in this setting that effective interviewing techniques and methods of eliciting covert psychiatric symptoms can most effectively be taught. Through interviewing the patient the psychiatrist serves as a role model and can enhance the physician’s appreciation of the complexities and potential usefulness of effective psychiatric treatment. Interviewing skills can then be seen as a bridge to the successful and ongoing doctor-patient relationship. Although a variety of approaches may be necessary to “open the door” and develop an alliance for teaching, liaison teaching ultimately best follows direct patient consultation and patientcentered education.
References 1. Byyny RL, Thompson TL II: The evolution of primary
Teaching
2.
3.
4.
5. 6. 7.
8.
9.
10.
11.
12.
13.
care medicine. In Thompson TL II, Byyny RL (eds), Primary and Team Health Care Education. New York, Praeger, 1983, p 5 Smarr EP, Berkow R: Teaching psychological medicine to family practice residents. Am J Psychiatry 134:984, 1977 Fink PJ: Psychiatry and the primary care physician. In Kaplan HI, Freedman AM, Sadock BJ (eds), Comprehensive Textbook of Psychiatry-III, Baltimore, Williams and Wilkins, 1980, p 2077 Alpert JL, Charney E: The Education of Physicians for Primary Care, DHEW Pub HRA74-3113. Washington, DC, US Department of Health, Education, and Welfare, 1973 Fink PJ, Oken D: The role of psychiatry as a primary care specialty. Arch Gen Psychiatry 33:998, 1976 Engel GL: The need for a new medical model: A challenge for biomedicine. Science 196:129, 1977 Enslow A: Prevention of medical disorder: The role of the general practitioner. California Medicine 104:16, 1966 Regier DA, Goldberg ID, Taube CA: The defacto US mental health services system-A public health perspective. Arch Gen Psychiatry 35:685, 1978 Houpt JL, Orleans CS, George LK, et al: The role of psychiatric and behavioral factors in the practice of medicine. Am J Psychiatry 137:137, 1980 Lipowski ZJ: Review of consultation psychiatry and psychosocial medicine. II: Clinical aspects. Psychosom Med 29:201, 1967 Stoudemire A, Thompson TL II, Mitchell WD, Grant RL: Family physicians’ perceptions of psychosocial disorders: Pilot survey report and educational implications. Int J Psychiatry Med 12281, 1982-83 Hoeper EW, Nycz, GR, Cleary I’D, Regier DA, Goldberg ID: Estimated prevalence of RDC mental disorder in primary medical care. Int J Ment Health 8:6, 1979 Cohen-Cole SA, Bird J, Freeman A, Boker J, Hain J, Shugerman A: An oral examination of the psychiatric knowledge of medical housestaff: Assessment of needs and evaluation baseline. Gen Hosp Psychiatry 4:103, 1982
Psychiatry
to Internists
14. Thompson TL II, Stoudemire A, Mitchell WD, Grant RL: Underrecognition of patients’ psychosocial distress in a university hospital medical clinic. Am J Psychiatry 140:158, 1983 15. Levitan SJ, Kornfeld DS: Clinical and cost benefits of liaison psychiatry. Am J Psychiatry 138:790, 1981 16. Mumford E, Schlesinger HJ, Glass GV: The effects of psychological intervention on recovery from surgery and heart attacks: An analysis of the literature. Am J Public Health 72:141, 1982 17. Dubovsky S, Getto C, Gross S, Paley J: Psychiatrists on the coronary care unit. Psychosomatics 18:18,1977 18. Duffy DL, Hamerman D, Cohen MA: Communication skills of house officers: A study in a medical clinic. Ann Intern Med 93:354, 1980 19. Almy TP: The role of the primary physician in the health-care “industry.” N Engl J Med 304:225, 1981 20. Goldberg RL, Haas MR, Eaton JS, Grubbs JH: Psychiatry and the primary care physician. JAMA 236:944, 1976 21. Barsky AJ, Brown HN: Psychiatric teaching and consultation in a primary care clinic. Psychosomatics 23:908, 1982 22. Fauman MA: Psychiatric components of medical and surgical practice, II: Referral and treatment of psychiatric disorders. Am J Psychiatry 140:760, 1983 23. Balint M: The Doctor, His Patient, and the Illness. New York, International Universities Press, 1973 24. Hales RE: Primary care in psychiatry residency training. Gen Hosp Psychiatry 2:148, 1980 25. Borus JF, Casserly MK: Psychiatrists and primary physicians: Collaborative learning experiences in delivering primary care. Hosp Community Psychiatry 30:686, 1979 26. Strain J, Hamerman D: Ombudsman-medical-psychiatric teaching rounds (ombudsman rounds). Ann Intern Med 80:550, 1977 Direct reprint requests to:
Troy L. Thompson II, M.D. 4200 East Ninth Avenue, C268 Denver, CO 80262
213