- Email: [email protected]
Behavioral Science Curriculum for Primary Care Residents
Toward a Comprehensive Psychiatry/Behavioral Science Curriculum for Primary Care Residents DENNIS H. NOVACK. M.D., RICHARD J. GOLDBERG, M.D. PAMELA ROWLAND-MORIN. PH.D., CAROL LANDAU, PH.D. STEVEN A. WARTMAN. Ph.D.
There is little argument that psychiatry and behavioral sciences should be taught to primary care residents. The reasons are compelling: approximately one-quarter of patients seen in general medical practice I and 75% of nursing home patients2 have significant behavioral or emotional components to their illnesses. In the United States, generalists see the majority of patients with psychiatric illnesses, many of whom present with somatic symptoms. 3.4 As a rule, medical house-staff and practitioners underrecognize and often inappropriately treat emotional disorders in their patients,s..? but there is a growing literature demonstrating cost offset of psychiatric and behavioral interventions in medical patients.8-'2 Recognizing these facts, primary care professional organizations have mandated competencies in psychiatry and behavioral sciences for board certification.I3-I~ There are equally compelling reasons to focus on the medical interview as a core clinical skill. The interview determines the accuracy and completeness of data elicited and the quality of the doctor-patient relationship.'6 The quality of this relationship is a major determinant of patient satisfaction and compliance. 17 Through the interview, clinicians can make biopsychosocial assessments that underlie rational therapeutic intervention. Yet medical school graduates are often deficient in basic interviewing skills,18 and advanced biotechnical diagnostic and therapeutic options count for little when physicians and patients disagree about the nature of the problem. 19.20 Physicians' attempts to heal are undermined when patients do not cooperate, do not understand. are too anxious or depressed to adhere to therapy, or are angry with their caregivers. Though traditionally one of the most neglected areas of medical-school and residency training, there has been some progress in the teaching of psychiatry/behavioral science in primary care programs. Changing patterns of health care have brought a growing realization of the need to shift more training into the outpatient setting and to make the teaching of psychiatry/behavioral science skills an integral part of that training. 21 Congress has supported funds for primary care training since 1976, with specific VOLUME 30 • NUMBER 2 • SPRING 1989
Received February 2. 1988; accepted May 18. 1988. From the Division of General Internal Medicine. Brown University; and the Communications Depanment. University of Rhode Island. Providence. Rhode Island. Address reprint requests to Dr. Novack. Rhode Island Hospital. Division ofGeneral Internal Medicine. 593 Eddy Street. Providence. RI 02903. Copyright © 1989 The Academy of Psychosomatic Medicine.
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monies often allocated to mental health training. 22 Though there have been recent reductions in these funds, their availability has encouraged innovations in teaching and educational research. National organizations, such as the Society of General Internal Medicine (SGIM) Task Force on the Medical Interview and Related Skills and the Association for Behavioral Sciences in Medical Education, have brought together faculty from diverse disciplines. Great strides have been made in educational theory and practice, as outlined in the Lipkin et al. 23 core curriculum on the medical interview for residencies in internal medicine. The current challenge is to adapt and implement the broad content areas of psychiatry and the behavioral sciences into individual training programs. Many programs are just beginning to approach this challenge, and many deficiencies exist. 24 There is scant practical guidance in the literature. Though many authors have presented segmental educational experiences, only a few family practice programs have published a working curriculum integrated over three years of residency.22.25.26 No primary care internal medicine program of which we are aware has presented their experience. In the Rhode Island Hospital General Internal Medicine Residency Program, we have been conducting a psychiatry/behavioral science program since 1981. In this article, we present the program content and discuss issues pertinent to developing and implementing psychiatry/behavioral science teaching in a primary care residency. (Space limitations
permit only an overview of curriculum content; full materials are available from Dr. Novack.)
THE RHODE ISLAND HOSPITAL PSYCHIATRY/BEHAVIORAL SCIENCE PROGRAM Our program had been training eight residents per year, for a total to date of 24 residents, and in July 1988, the program expanded to 12 residents per year. The core faculty of the psychiatry/behavioral science component of the program consists of a multidisciplinary team of an internist, psychiatrist, medical communication specialist, and clinical psychologist (the authors). The residency program director, an internist with a Ph.D. in medical sociology, is active in curricular modification, evaluation, and administration. The internist (DHN) and psychiatrist (RJG) are codirectors. Most of the psychiatry/behavioral science teaching is concentrated in the residents' ambulatory block experiences, which comprise three months in the first two years and two months in the senior year. During ambulatory block, residents spend all of their time in outpatient settings, seeing medical outpatients, rotating through outpatient specialty clinics, and spending one full afternoon each week in psychiatry/behavioral science experiences. Each class of residents is divided into two groups; teaching experiences are duplicated to maintain small groups with good faculty/resident ratios. Table I provides an overview of the curriculum.
TABLE 1. Curriculum summary
PGY-I Month
2
I
3
Experiential
communication skills
Didactic
psychiatry in medicine
1
ethics
I
PGY-III Month
3
1
2
Medical-psychological consultation clinic (problem-patient clinic) deve.lopmental ISSueS
Related Teaching
PGY·II Month 2
I
behavioral medicine
I
electives
Balint groups (meet biweekly or monthly throughout the year)
Monthly inpatient psych-liaison anending rounds weekly house staff suppon meetings
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Postgraduate Year I At the beginning of the first ambulatory block, the internist leads a three-hour introductory seminar on psychosomatic medicine. In this meeting, he seeks to learn the interns' educational backgrounds, their attitudes, and their learning needs in relation to psychosocial medicine. He addresses the history of psychosomatic medicine and discusses the biopsychosocial model 27 as the conceptual framework for the psychiatry/behavioral science curriculum. Specific points are illustrated by role-play and patient videotapes. Experiential component. The communication specialist carries the bulk of experiential teaching in the internship year. She begins the program by assessing the interns' concerns, needs, and levels of training, as well as individual speech patterns that can affect interviewing (e.g., rate of speech, hesitations, or speech impediments).28 Then, in eight weekly two-hour sessions, she reviews interviewing skills through didactic presentations, role-play, interviews with standardized patients, videotape review, group discussions, and individualized feedback. Principles derived from the communication literature are used as behavioral anchors for evaluating interviews. Communication competencies are taught and assessed in five areas: affIliation/support, social relaxation, empathy, behavioral flexibility, and interaction management. 29 In addition, six topics are highlighted: greeting patterns, the first five minutes of the interview, negotiation, taking a sexual history, talking about money, and closing the interview. Selected portions of videotapes of internal medicine faculty interviewing the same standardized patient are shown to highlight different styles of approaching the same issue. At the conclusion of the course, each intern is videotaped interviewing a standardized patient. The communication specialist and the residency program director evaluate these tapes, and the communication specialist provides feedback to each intern. During the last four weeks of the first-year curriculum, the communication module switches to sessions with the internist and clinical psychologist. Interviewing skills are fruther discussed VOLUME 30 • NUMBER 2 • SPRING 1989
using the Brown Evaluation Instrument, an interview-evaluation instrument developed for the undergraduate medical curriculum. This instrument specifies behaviors in information gathering, interview facilitation, and interpersonal skills. 3O •31 A detailed key that specifies behavioral anchors for Likert scales assists reliability of rating. Intern interviews with simulated and actual patients are assessed and discussed using this instrument. These faculty also introduce the interns to the concepts of working with "problem patients" by means of a videotape we produced, "The Problem Patient Clinic," and discussion of relevant papers. Didactic component. This portion of postgraduate year I (PGY -I) curriculum consists of 12 seminars (60- to 9O-minutes each) on key psychiatric topics in primary care led by the psychiatrist. Topics include: using antidepressants (two sessions); using antianxiety agents (two sessions); emergency psychopharmacology; delirium, dementia, and the cognitive mental status exam; overview of depression; use of neuroleptics and lithium; a structured treatment exercise on depression; the epidemiology and recognition of anxiety disorders; panic disorder; and a structured treatment exercise on anxiety. Related teaching. The communications module overlaps with the program's curriculum in medical ethics,32 which consists of 13 sessions (90 minutes each) over three years devoted to topics such as truth telling, informed consent, removal of life support, and confidentiality. Each topic is presented and discussed by a medical ethicist, using case histories to focus discussion. During the second session devoted to a topic, the interns interact with actors or role-play with each other to emphasize the importance of communication in creating and resolving ethical dilemmas and to learn specific skills in communicating ethical issues effectively and sensitively. The communication specialist and internal medicine faculty co-teach these latter sessions. Postgraduate Year II Building on the PGY-I skills of basic interviewing and psychiatric diagnosis and treatment, 215
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the PGY-II curriculum includes the Medical Psychological Consultation Clinic as the experiential component along with a seminar series. Experiential component. The Medical Psychological Consultation Clinic (MPCC) is also known to the residents as the "problem-patient clinic." Described in detail elsewhere,33 the MPCC is team-taught by the internist and the clinical psychologist. Each week the faculty and residents on ambulatory block interview and discuss a patient referred from the medical clinic who has been difficult to manage. Using the biopsychosocial model, we discuss diagnosis and management. A videotape of the session is then reviewed, with an emphasis on the interview process. Home visits are scheduled once each block, and papers presenting important psychiatric and psychosomatic concepts are discussed. 30·34-42 In a review of 56 patients referred to the clinic, over 90% had previously unrecognized DSM-III diagnoses. 36 Didactic component. The seminar series includes a six-session sequence on developmental psychology issues in health care. Topics include adolescence, marriage and divorce, midlife transition, geriatrics, death and dying, and grief and loss. Whenever possible, videotapes or interviews with patients are used. A second six-week sequence deals with behavioral techniques and approaches to common problems such as obesity, smoking, sexual difficulties, and alcoholism. The relaxation response, hypnosis, biofeedback, and other self-management techniques are also presented. These seminars are led by the psychologist, the internist, and invited faculty from the Department of Psychiatry. Postgraduate Year III During the PGY-III year, residents attend the MPCC each of their eight weeks of ambulatory block. The PGY-III residents attend MPCC at the same time as some of the PGY-II residents. Therefore, they are given more of a teaching role in reviewing relevant literature and in giving feedback with respect to interviewing skills. All of the general internal medicine residents complete a senior project, and many of the resi216
dents have chosen to work with behavioral science faculty. Topics have included family stress during residency,43 the development of a psychopharmacology evaluation instrument, depression and anxiety among Southeast Asian refugees, and family issues in the internship match process. In addition to helping the residents develop their research skills, this experience allows them to work closely with a faculty member and often leads to informal discussions about career development. Additional Teaching Activities Balint groups44 provide PGY-II and PGY-III residents with small group settings in which they present and discuss patients, with a focus on exploring and examining their own emotional reactions to patients. Residents work on improving self-awareness and discovering how their feelings and behaviors can help or hinder care. Depending on their schedules, the sessions are held biweekly at lunchtime or monthly in the evening at a faculty member's or resident's home. Interested residents have several options for additional tutorials within the psychiatrylbehavioral science curriculum. They can schedule difficult patients to be seen jointly with the internist during his outpatient-attending or patient-care slots. They can bring videotapes of patient interviews to the clinical psychologist and schedule individual supervision, or they can ask the communication specialist to attend and discuss patient interviews in the emergency room and on the wards. All of these options have been used by a number of residents on an ad hoc basis. A weekly journal club is well attended by house staff and faculty. In this forum, a faculty member and a resident are paired to present highquality critical reviews of recent articles or topics. The internist and psychiatrist are each responsible for four presentations per year. They use these opportunities to work intensively with house staff, presenting relevant psychosocial topics. and generating discussion and learning by other primary care faculty. The internist and another primary care facPSYCHOSOMATICS
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ulty internist lead weekly house staff support meetings.4s Although these meetings are open to the entire house staff, they are generally better attended by primary care house staff. In these meetings, house staff at all levels discuss a wide variety of issues, including administrative or programmatic issues. Many of the topics that arise are critical to the residents' growth as physicians: responding to angry patients and their families, responding to their own anger at patients, dealing with physician depression and burnout, responding to a dying patient who asks about prognosis or terminating treatment. Though not "billed" as an educational activity, these sessions are important educational experiences for many. Finally, the psychiatrist holds monthly medicaVpsychiatry attending rounds with all the ward teams. Patients referred for psychiatric consultation are presented, and the psychiatrist conducts a brief interview and leads a discussion about the interview, differential diagnosis, and treatment. DISCUSSION While we do not claim that this curriculum represents an ideal, it demonstrates what realistically can be developed and established over time, with continuous staff and resident feedback. We have learned much that may help others seeking to institute such a curriculum. The following discussion addresses curricular design, distribution of teaching activities, faculty development, administrative issues, evaluation, research, funding, and future initiatives. Curricular Design The general objectives for our psychiatry/behavioral science curriculum mirror those established by the primary care professional organizations22 and suggested by Lipkin et al.23 They are to develop 1) patient-centered interviewing and treatment; 2) an emphasis on the physician-patient relationship as a therapeutic tool; 3) a biopsychosocial approach to clinical reasoning and patient care; 4) a personal repertoire of humanistic values; and 5) the ability to recognize and manage psychiatric disorders and VOLUME 30 • NUMBER 2 • SPRING 1989
emotional problems. We want our residents to eventually regard the field of medical psychiatry/behavioral science with excitement and confidence, to view working with patients' difficult emotional problems as a challenge, and to feel that their practices are enriched by their enhanced skills. All primary care programs should develop a written curriculum in this area, and the process of writing a curriculum may be as important as the curriculum itself. Faculty develop stronger collaborative ties and become more invested in the program, and a written curriculum provides tangible evidence ofcommitment to this component. It also assists program planning and setting priorities for the use of resource. Programs that do not make the commitment to develop a written curriculum are much less likely to have actual teaching in this area. 24 For individual teaching modules, our faculty develop handouts for advance distribution to residents. These handouts include relevant readings, goals of the teaching session, and questions the resident should be able to answer by the end of the session. The overall goal is to make our teaching educationally sound by following established educational principles and using appropriate didactic techniques. 46 Learning takes place in a variety of settings, though we make an effort to impart most of the didactic material and skills training in a "protected" environment. In ambulatory block, residents are free from ward responsibilities and have specific, sequential, concentrated time set aside for psychosocial learning. Learning also takes place through a variety of educational techniques. Role-play, simulated patients, videotape review and feedback, educational videotapes, and the presentation of skills as specific defined behaviors that can be practiced are all educational techniques with unique advantages. 23 Much of the teaching takes place around medical interviews, which offer rich, complex, and elegant opportunities for teaching in a wide variety of areas. We use interviews for teaching process (the structure, function, and basic skills of interviewing), content (key psychosocial issues), sharpening observation (e.g., microanaly217
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sis of videotapes or conducting five-minute interviews on the wards to show how much can be gleaned from a brief interaction), psychiatric and biopsychosocial diagnosis, therapeutic skills, patient education skills, and physician self-observation. Programs initiating a psychiatry/behavioral science program should consider structuring their programs around interviews, both real and simulated. The topics chosen for didactic seminars reflect epidemiologic considerations of problem prevalence in medical practice, e.g., depression and anxiety are the fifth most common problems in primary care practice,47 and anxiolytics and antidepressants are among the most commonly prescribed drugs. 48.49 These topics match our own faculty's assessment of their importance to practice and closely approximates those in the curriculum proposed by the SGIM Task Force on the Medical Interview and Related Skills, to which over 100 faculty contributed. 23 Distribution of Teaching Responsibilities Our program accepts the premise that psychiatry should primarily teach psychopharmacology, differential diagnosis, and management of common psychiatric problems.~ In addition, we feel that the psychiatrist must teach psychiatry in medicine and not psychiatry per se. That is, the special considerations relevant to the application of psychiatric knowledge to medical populations must be addressed. A psychiatrist faculty member working with medical programs should have ongoing experience working with the medical population.51 It is becoming clearer that psychiatric disorders such as depression in medical populations may differ from depressive disorders seen in psychiatric settings. 52.53 In addition, there are many special considerations involving drug interactions and side effects which must be highlighted when teaching psychopharmacology to primary care physicians. Behavioral scientists from psychology, communication, social work, and education offer different and complementary perspectives to residents. In our program, the communication specialist offers insights gleaned from 218
communications research in other disciplines, as well as her own research in medical communication. The psychologist offers knowledge and skills in psychotherapy, psychological assessment, and developmental psychology. A group of educators with different backgrounds allows for a distribution of teaching responsibilities according to interest and skills. It also allows the residents to connect with different faculty according to their own interests, to learn from each of us in different ways, and to address the generalist/specialist division of responsibility for patients with mental disorders. 54 The majority of psychiatry/behavioral science programs for medical residents involve behavioral scientists from a variety of disciplines. 24.55.56 Many ofthese behavioral scientists express frustration at the difficulties in engaging medical residents,57 which can be reduced by co-teaching with medical faculty. We agree with Engel58 that medical faculty have critical roles in teaching psychiatry/behavioral sciences to medical residents. Medical faculty serve as role models to their residents, and their experience with medical patients informs their teaching. When medical faculty emphasize, teach, and practice a biopsychosocial approach to care, they may influence physicians-in-training to adopt this approach. Unfortunately, there is a dearth of internists, family practitioners, and pediatricians with interest and teaching expertise in this area. Often psychiatrists and behavioral scientists must energize and enlist support ofmedical faculty and assist them in their faculty development. Faculty Development Faculty development must address both behavioral science and medical faculty members. First, attention must be paid to the continued growth of core psychiatry/behavioral science faculty. We accomplish this by our biweekly curriculum committee meetings, in which we share ideas and work collaboratively on educational and research projects. Our faculty also attend and participate in workshops and national meetings, including the regional and national faculty development courses offered by the SGIM PSYCHOSOMATICS
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Task Force on the Medical Interview. 59 Other programs encourage faculty development and cohesiveness by holding faculty Balint groups, or monthly dinner meetings, in which faculty take turns presenting psychosocial topics or patient videotapes. The second key area of faculty development involves educating and motivating other primary care faculty members, so that they support the goals of the psychiatry/behavioral science curriculum and practice and teach a biopsychosocial approach to patients. Though this is often difficult to do, we feel we have made some headway by our presentation of psychosocial topics in journal clubs and divisional research conferences, and by informal and formal consultations on patients of faculty. Also, several of our young faculty are graduates of our own residency program and are very supportive of our teaching. Administrative Issues The primary care internal medicine residency at the Rhode Island Hospital is a carefully organized program facilitated by a fUll-time program coordinator. Though primary care residents are integrated into inpatient rotations, the primary care program is distinguished from the categorical program by a separate administration, curriculum, and selection process for its housestaff. This selection process emphasizes personal interviews, which helps us select residents who have an interest in psychosocial aspects of care. We feel it is important to have a primary care faculty member and psychiatrist codirect the educational program, for political as well as practical reasons. Again, a primary care medicine faculty member who believes in and teaches in this area gives credence to its importance to medical residents. Working together with a psychiatrist provides a model for collaboration. Because in our program the psychiatrist is also the psychiatrist-in-chief for the hospital, he can bring resources and faculty to bear in improving the curriculum. The core faculty and resident representatives on the Behavioral Science Committee meet biweekly to discuss curricular and related programVOLUME 30 • NUMBER 2 • SPRING 1989
matic issues. The residency program coordinator also participates in these meetings and helps set the agendas for subsequent meetings. The coordinator makes up resident schedules, and ensures that residents receive appropriate teaching materials in a timely manner. During monthly residency program meetings, the activities of the behavioral science faculty are presented and discussed. We occasionally suggest modifications or additions to the general medicine curriculum, such as a recent suggestion to add a three-hour training session on patient education. Such suggestions must be presented to and approved by the program curriculum committee, consisting of general medical faculty and residents. The most important administrative component may be the formal and informal support provided by the overall division director. His values in supporting this area are often mirrored in the residents, and his commitment of curricular time and funding support are critical for the program. Evaluation Resident evaluation of our program is accomplished in several ways. The residency program coordinator interviews residents after each ambulatory block rotation and administers a standardized evaluation instrument. These biannual evaluations ofour teaching have been valuable to improving the program. Two residents are members of our behavioral science curriculum committee to represent house staff views. A yearly off-campus residency program retreat allows faculty and residents to focus intensively on the program. Suggestions stemming from this retreat are discussed in subsequent behavioral science committee meetings. Faculty evaluation of house staff is accomplished in several ways. Behavioral science faculty contribute to annual program faculty discussions of residents and make specific suggestions, which are then conveyed to the residents in feedback sessions conducted by the program director. In addition, core faculty frequently discuss individual residents, our perception of their individual needs, and the steps we must take to meet these needs. When necessary, 219
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tutorials have been assigned. Though we are pleased with the progress of the residents and residents' evaluations and feedback suggest that their knowledge and skills have increased, we have not yet routinely administered standardized tests to prove success or to show that success has an impact on patient care. There are several reasons for this: First, there is no generally acknowledged standard evaluation tool for competency in medical interviewing. More research has been conducted on the Arizona Clinical Interviewing Rating Scale60•61 than any other tool, but this insbUment is optimally used with multiple standardized patients and is not easily adapted to the average program. A number of our residents are participating in the evaluation research of Stillman et al.,62 and we expect to see some useful data from this. Others have presented evaluation schema for various teaching experiences.6~ We are planning to institute a more formal evaluation of knowledge, attitudes, and skills for our next class of residents by developing test questions keyed to our seminars. These questions will be combined into a pretest administered at the beginning of internship and again at the conclusion of the second year. Included in this test will be an insbUment currently being field tested to assess psychopharmacology knowledge. To assess attitudes, we will administer a validated scale that measures attitudes toward psychosocial aspects of care. 69 In addition, we are currently revising the Brown Evaluation InsbUment for our residents. Though this insbUment is useful as a template for teaching certain skills, it awaits validation as an evaluation tool. Scholarly Work and Research Scholarly work and research productivity are important keys to academic success. In this regard, educational programs can often serve double duty, providing opportunities for publication. For example, on our problem-patient clinic we have published descriptions of our clinical practices and teaching methods and a patient follow-up study. 33.35.36 Our desire to assess curricular needs has led to other work, including a 220
questionnaire to assess residents' needs in terminal care.10 Of our biweekly faculty meetings, one is generally devoted to curriculum and the second to research. There are many fruitful and needed areas of research in psychiatrylbehavioral science. Some of these areas include educational research testing; innovative curricula or teaching methods; the development of validated evaluative measures of skills, attitudes, and knowledge; the effects of specific interventions on patient outcomes; the effects of teaching on resident behaviors and personal satisfaction; and cost offset of biopsychosocial interventions. In programs with a dearth of faculty committed to research, there are often opportunities across institutions or in national collaborative projects. 11 Funding Our program is fortunate to have had federal grant support. Were these monies to be discontinued, the hospital has expressed commitment to continue our program. However, there are many programs that are underfunded or that lack funding. Though these latter situations are difficult, they are not impossible. Primary care faculty who are committed to teaching require less funding than hiring separate behavioral science faculty. As long as they are granted curricular time, primary care faculty can begin their teaching program and begin to look for ways and funds to expand. When there are several education programs in the same area, sharing of resources can benefit all. There are several ways to approach raising funds to support psychiatrylbehavioral science teaching in the ambulatory setting. The frrst would be to obtain funding for joint psychiatry/medicine research that would pay for some psychiatry or behavioral scientist time. A second option would be to establish joint clinical moneygenerating programs between the psychiatry and medicine departments. For example, such a clinic might involve a "behavioral medicine" theme addressing eating disorders, risk factor reduction, etc. Third, there could be established some formal referral relationship between medical clinic PSYCHOSOMATICS
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and psychiatry which generates enough referrals to pay for psychiatry faculty time. Programs will increasingly depend on a creative and detailed analysis of reimbursement possibilities. Future Initiatives There is much to be accomplished in the future. We will continue to develop new evaluation instruments and try out existing instruments for measuring knowledge, skills, and attitudes. We will continue to develop educational videotapes. For example, we have shown our "Problem-Patient Clinic" and "Greeting Patterns" videotapes at regional and national meetings and are distributing them with educational materials to other programs. There is a wide variety of existing videotapes and other teaching materials that we need to evaluate. The Task Force Directory 0/ Educational Materials is of help in this regard.72 There are a number of innovative teaching techniques providing powerful learning experiences that we would like to try with our residents. One such technique is Frankel and Beckman's73 method of having physician and patient separately comment on their videotaped interaction and dubbing their comments on the video sound track. The program developed by Cope et aI. 74 for feeding-back patient satisfaction data to residents with specific suggestions for improvement in interviewing style is also quite promising. Medical Encounter, a quarterly newsletter for teachers of medical interviewing, offers ideas and descriptions of successful programs.7S We will soon institute formal teaching modules
in patient education, an often neglected area in psychosocial curricula.76.77 Other primary care disciplines have developed teaching methodologies that could be profitably employed. Constructing a family genogram78 is a technique used in many family practice residencies, and it could be instructive for internal medicine and ambulatory pediatric residents as well. At a time when fewer students are choosing internal medicine as a career, we believe that our psychiatry/behavioral science program makes our primary care residency program more attractive to highly qualified students. Our residents tell us that psychiatry/behavioral science teaching enhances their residency experience. Learning a biopsychosocial approach makes the practice of medicine more understandable, satisfying, and human. Therefore, we are committed to providing high-quality education to our residents throughout their three years of residency. We endeavor to ensure that this education will be intellectually rigorous and educationally sound. We owe much to the many who have contributed to the great progress in the field of psychiatry/behavioral science education in the last decade. Though we have an established and well-functioning program, we see many changes ahead. The field is young, and the many recent and expected educational innovations promise an exciting future.
This work was sponsored in part by a grant from the United States Department o/Health and Human Services no. 5D 28PEll095-08.
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resource use and cost among facilities treating alcohol. drug abuse. and mental disorders: implications for design of a prospective payment system. Am J Psychiatry 144:616-620.1987 9. Mumford E. Schlesinger HJ. Glass GV. et al: A new look at evidence about reduced cost of medical utilization following mental health treatment. Am J Psychiatry 141 :1145-1156.1984 10. Borus JF. Olendzki MC. Kessler L. et al: The 'offset effect' of mental health treatment on ambulatory medical care utilization and charges. Arch Gen Psychiatry 42:573-580.1985 II. Pincus AJ: Making the case for consultation liaison psychiatry: issues in cost effectiveness analysis. Gen Hosp Psychiatry 5:173-179.1984 12. Smith GR. Monson RA. Ray DC: Psychiatric consultation in somatization disorder: a randomized controlled study. N EnglJ Med314:1407-1413.1986 13. American Academy of Pediatrics: The future of pediatric education: a repon by the task force on pediatric education. Evanston. IL. American Academy of Pediatrics. 1978 14. American Board of Internal Medicine: Clinical competence in internal medicine. Ann Intern Med90:402-411. 1979 15. American Medical Association: Essentials ofAccredited Residencies. Chicago. American Medical Association. 1982 16. Lipkin M Jr: The medical interview and related skills. in Branch WT Jr (ed): Office Practice of Medicine. Second Edition. Philadelphia. PA. William B. Saunders Co. 1987. pp 1287-1306 17. DiMatteo MR. DiNicola DO: Achieving Patient Compliance. New York. Pergamon Press. 1982. pp 1-28 18. Plantt FW. McMath JC: Clinical hypocompetence: the interview. Ann Intern Med 91 :898-902. 1979 19. Freidin RB. Goldman L. Cecil RR: Patient-physician concordance in problem identification in the primary care setting. Ann Intern Med93:490-493. 1980 20. Starfield B. Wray C. Hess K. et al: The influence of patient-practitioner agreement on outcome of care. Am J Public Health 71:127-131. 1981 21. Shroeder SA. Showstock JA. Gerben B: Residency training in internal medicine: time for a change? Ann Intern Med 104:554-561.1986 22. Bums BJ. Scott IE. Burke JD. et al: Mental health training of primary care residents: a review of recent literature (1974-1981). Gen HospPsychiatry 5:157-169.1983 23. Lipkin Jr M. Quill TE. Napodano RJ: The medical interview: a core curriculum for residencies in internal medicine. Ann Intern Med 100:277-284. 1984 24. Goldberg RG. Novack DH. Fulton JP. et al: A survey of psychiatry and behavioral sciences curricula in primary care residency training programs. Journal ofPsychiatric Education 9:3-11. 1985 25. Aluise ]]: Human relations training for family practice residents: a four-year retrospective review. J Fam Pract 4:881-888.1977
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26. Johnson AH. Fisher N. Guy U. et al: Developing behavioral science for a family practice residency. J Fam Pract 4:319-324.1977 27. Engel GL: The need for a new medical model: a challenge for biomedicine. Science 196:129-135. 1977 28. Kasl SV. Mahl GF: The relationship of disturbances and hesitations in spontaneous speech to anxiety. J Pas Soc Psychol 1:425-433. 1965 29. Wiemann KM: Explication and test of a model of communication competence. Journal of Communication 3:195-213.1977 30. Forrow L. Arnold R: Communication in medical ethics: an innovative program. Medical Encounter 4:7. 1987 31. Cohen-Cole SA. Bird J: Interviewing the cardiac patient: II a practical guide for helping patients cope with thier emotions. Quality ofLife and Cardiovascular Care 2:5fr. 65. 1986 32. Novack DH. Landau C: The problem patient clinic: a unique teaching experience for psychiatry and medicine residents. Journal ofPsychiatric Education 12: 150-154. 1988 33. Lipkin Jr M: The medical interview and related skills. in Branch WT (ed): Office Practice of Medicine. Second Edition Philadelphia. PA. William B. Saunders Co. pp 1-38 34. Drossman DA: The problem patient: evaluation and care of medical patients with psychosocial disturbances. Ann Intern Med 88:36fr.372. 1978 35. Novack DH. Landau C: Consulting on the problem patient. Psychiatry in Medicine 6:53-63. 1988 36. Novack DH. Landau C: Psychiatric diagnoses in problem patients. Psychosomatics 26:853-858. 1985 37. Neilsen AC III. Williams TA: Depression in ambulatory medical patients. Arch Gen Psychiatry 37:999-1004. 1980 38. Engel GL: "Psychogenic" pain and the pain-prone patient. AmJ Med26:899-918.1959 39. Buchsbaum 00: Reassurance reconsidered. Soc Sci Med 23:423-427.1986 40. Barsky AJ: Patients who amplify bodily sensations. Ann Intern Med91:63-70. 1979 41. Gunderson 10. Singer MT: Defining borderline patients: an overview. Am J Psychiatry 132: 1-8. 1975 42. Novack DH: Therapeutic aspects of the clinical encounter. J Gen Intern Med 2:34fr.354. 1987 43. Landau C. Hall S. Wartman SA. et al: Stress in social and family relationships during the medical residency. J Med Educ 61 :654-660. 1986 44. Balint M: The Doctor. His Patient and the I//ness. New York. International University Press. 1972 45. Reuben DB. Novack DH. Wachtel TJ. et al: A comprehensive suppon system for reducing house staff distress. Psychosomatics 25:815-820. 1984 46. Bird J. Cohen-Cole SA. Boker J. et al: Teaching psychiatry to nonpsychiatrists: I. the application of educational methodology. Gen Hosp Psychiatry 5:247-253. 1983 47. Rosenblatt RA. Cherkin DC. Schneeweiss R. et al: The content of ambulatory medical care in the United States.
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N EnglJ Med309:892-897. 1983 48. Bawn C. Kennedy DL, Forbes MB, et al: Drug use and expenditures in 1982. JAMA 253:382-386, 1985 49. BuchsbawnOO.GrohMJ.CentorRM:Underdocumentation ofbenzodiazepine prescriptions in a general medicine clinic. J Gen Intern Med 1:305-308, 1986 50. Goldberg RJ. Wise TN: Where is psychiatry in primary care medical training? Psychosomatics 26:882-886, 1985 51. Barsky AJ. Brown HN: Psychiatric teaching and consultation in a primary care clinic. Psychosomatics 23:908921. 1982 52. Rodin G. Voshart K: Depression in the medically ill: an overview. Am J Psychiatry 143:696-705, 1986 53. Schulberg HC. Saul M. McClelland M. et al: Assessing depression in primary medical and psychiatric practices. Arch Gen Psychiatry 42: 1164-1170. 1985 54. Regier DA. Goldberg 10. Bums BJ. et al: Specialist/generalist division of responsibility for patients with mental disorders. Arch Gen Psychiatry 39:219-224. 1982 55. Hornsby JL. Kerr RM: Behavioral science and family practice: a status repon. J Fam Pract8:299-304. 1979 56. Kahn G. Cohen B. Jason H: Teaching interpersonal skills in family practice: results of a national survey. J Fam Pract 8:309--316.1979 57. Shapiro J: A revisionist theory for the integration of behavioral science into family medicine departments. J Fam Pract iO:275-282. 1980 58. Engel GL: The biopsychosocial model and medical education. Who are to be the teachers? N Engl J Med 306:802-805.1982 59. Benson J: The Ponland course. Medical Encounter 4: I. 5-7. 1987 60. Stillman PL: Arizona clinical interview medical rating scale. Medical Teacher 2:248-251. 1980 61. Stillman PL. Brown DR. Redfield DL. et al: Construct validation of the Arizona clinical interview rating scale. Educational Psychological Measurement 37: 1031-1056, 1977 62. Stillman PL. Swanson DB. Smee S. et al: Assessing clinical skills of residents with standardized patients. Ann InternMed 105:762-771,1986 63. Carroll JG. Monroe J: Teaching clinical interviewing in the health professions: a review of empirical research. Evaluation in the Health Professions 3:21--45,1980 64. Grayson M. Nugent C. Oken SL: A systematic and comprehensive approach to teaching and evaluating interpersonal skills.J Med Educ 52:906-913.1977
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65. Weinman J: A modified essay question evaluation of preclinical teaching of communication skills. Med Educ 18: 164-167,1984 66. Fein VK, Therrien ME: Empathy in the doctor-patient relationship: skill training for medical students. J Med Educ 52:752-757.1977 67. Pasco LV. Naarr, Guyettit R, et al: Training medical students in interpersonal relationship skills. J Med Educ 51:743-750.1976 68. Warner DW. Kagan N. Schneider J: The measurement of affective sensitivity: the development ofan instrument. in Proceedings ofthe 16th Annual Conference on Research in Medical Education. Washington, DC. Association of American Medical Colleges. 1977. pp 187-193 69. Ashwonh CD, Williamson P. Montano D: A scale to measure physician beliefs about psychosocial aspects of patient care. Soc Sci Med 19:1235-1238.1984 70. Goldberg RJ, Guadagnoli E. LaFarge S: A survey of house-staff attitudes towards terminal care education. Journal ofCancer Education (in press) 71. Roter D: Research and development working groups. Medical Encounter 4(suppl):3, 1987 72. Suchman A: Directory of Educational Resources. Medical Encounter4(suppl):2. 1987 73. Frankel RM. Beckman HB: Impact: an interaction-based method for preserving and analyzing clinical transactions, in Pettigrew L (ed): Explorations in Provider and Patient Interactions. Nashville, Humana Inc. 1982, pp 71-85 74. Cope DW. Linn LS. Leake BD. et al: Modification of residents' behavior by preceptor feedback of patient sat· isfaction. J Gen Intern Med I :39~398, 1986 75. Task Force on the Medical Interview and Related Skills: Medical Encounter. (Published quarterly by the Society of General Internal Medicine; contact D.H. Novack, M.D., Rhode Island Hospital, Providence. RI 02903.) 76. Green LW: Health education models, in Mattarazzo JD, Weiss SM, Herd JA, et al (eds): Behavioral Health: A Handbook for Health Enhancement. New York. John Wiley & Sons. 1984. pp 181-198 77. Grueninger U. Duffy FD, Goldstein MG: Patient educa· tion and the communication of information, in Lipkin Jr M. Lazare A, Pumam S (eds): The Medicallnten'iew (in press. manuscript available from Dr. Michael Goldstein. Miriam Hospital, Providence. RI 02906.) 78. Jolly W. From J. Rosen MG: The genogram. J Fam Pract 10:251-255.1980
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There is little argument that psychiatry and behavioral sciences should be taught to primary care residents. The reasons are compelling: approximately one-quarter of patients seen in general medical practice I and 75% of nursing home patients2 have significant behavioral or emotional components to their illnesses. In the United States, generalists see the majority of patients with psychiatric illnesses, many of whom present with somatic symptoms. 3.4 As a rule, medical house-staff and practitioners underrecognize and often inappropriately treat emotional disorders in their patients,s..? but there is a growing literature demonstrating cost offset of psychiatric and behavioral interventions in medical patients.8-'2 Recognizing these facts, primary care professional organizations have mandated competencies in psychiatry and behavioral sciences for board certification.I3-I~ There are equally compelling reasons to focus on the medical interview as a core clinical skill. The interview determines the accuracy and completeness of data elicited and the quality of the doctor-patient relationship.'6 The quality of this relationship is a major determinant of patient satisfaction and compliance. 17 Through the interview, clinicians can make biopsychosocial assessments that underlie rational therapeutic intervention. Yet medical school graduates are often deficient in basic interviewing skills,18 and advanced biotechnical diagnostic and therapeutic options count for little when physicians and patients disagree about the nature of the problem. 19.20 Physicians' attempts to heal are undermined when patients do not cooperate, do not understand. are too anxious or depressed to adhere to therapy, or are angry with their caregivers. Though traditionally one of the most neglected areas of medical-school and residency training, there has been some progress in the teaching of psychiatry/behavioral science in primary care programs. Changing patterns of health care have brought a growing realization of the need to shift more training into the outpatient setting and to make the teaching of psychiatry/behavioral science skills an integral part of that training. 21 Congress has supported funds for primary care training since 1976, with specific VOLUME 30 • NUMBER 2 • SPRING 1989
Received February 2. 1988; accepted May 18. 1988. From the Division of General Internal Medicine. Brown University; and the Communications Depanment. University of Rhode Island. Providence. Rhode Island. Address reprint requests to Dr. Novack. Rhode Island Hospital. Division ofGeneral Internal Medicine. 593 Eddy Street. Providence. RI 02903. Copyright © 1989 The Academy of Psychosomatic Medicine.
213
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monies often allocated to mental health training. 22 Though there have been recent reductions in these funds, their availability has encouraged innovations in teaching and educational research. National organizations, such as the Society of General Internal Medicine (SGIM) Task Force on the Medical Interview and Related Skills and the Association for Behavioral Sciences in Medical Education, have brought together faculty from diverse disciplines. Great strides have been made in educational theory and practice, as outlined in the Lipkin et al. 23 core curriculum on the medical interview for residencies in internal medicine. The current challenge is to adapt and implement the broad content areas of psychiatry and the behavioral sciences into individual training programs. Many programs are just beginning to approach this challenge, and many deficiencies exist. 24 There is scant practical guidance in the literature. Though many authors have presented segmental educational experiences, only a few family practice programs have published a working curriculum integrated over three years of residency.22.25.26 No primary care internal medicine program of which we are aware has presented their experience. In the Rhode Island Hospital General Internal Medicine Residency Program, we have been conducting a psychiatry/behavioral science program since 1981. In this article, we present the program content and discuss issues pertinent to developing and implementing psychiatry/behavioral science teaching in a primary care residency. (Space limitations
permit only an overview of curriculum content; full materials are available from Dr. Novack.)
THE RHODE ISLAND HOSPITAL PSYCHIATRY/BEHAVIORAL SCIENCE PROGRAM Our program had been training eight residents per year, for a total to date of 24 residents, and in July 1988, the program expanded to 12 residents per year. The core faculty of the psychiatry/behavioral science component of the program consists of a multidisciplinary team of an internist, psychiatrist, medical communication specialist, and clinical psychologist (the authors). The residency program director, an internist with a Ph.D. in medical sociology, is active in curricular modification, evaluation, and administration. The internist (DHN) and psychiatrist (RJG) are codirectors. Most of the psychiatry/behavioral science teaching is concentrated in the residents' ambulatory block experiences, which comprise three months in the first two years and two months in the senior year. During ambulatory block, residents spend all of their time in outpatient settings, seeing medical outpatients, rotating through outpatient specialty clinics, and spending one full afternoon each week in psychiatry/behavioral science experiences. Each class of residents is divided into two groups; teaching experiences are duplicated to maintain small groups with good faculty/resident ratios. Table I provides an overview of the curriculum.
TABLE 1. Curriculum summary
PGY-I Month
2
I
3
Experiential
communication skills
Didactic
psychiatry in medicine
1
ethics
I
PGY-III Month
3
1
2
Medical-psychological consultation clinic (problem-patient clinic) deve.lopmental ISSueS
Related Teaching
PGY·II Month 2
I
behavioral medicine
I
electives
Balint groups (meet biweekly or monthly throughout the year)
Monthly inpatient psych-liaison anending rounds weekly house staff suppon meetings
214
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Postgraduate Year I At the beginning of the first ambulatory block, the internist leads a three-hour introductory seminar on psychosomatic medicine. In this meeting, he seeks to learn the interns' educational backgrounds, their attitudes, and their learning needs in relation to psychosocial medicine. He addresses the history of psychosomatic medicine and discusses the biopsychosocial model 27 as the conceptual framework for the psychiatry/behavioral science curriculum. Specific points are illustrated by role-play and patient videotapes. Experiential component. The communication specialist carries the bulk of experiential teaching in the internship year. She begins the program by assessing the interns' concerns, needs, and levels of training, as well as individual speech patterns that can affect interviewing (e.g., rate of speech, hesitations, or speech impediments).28 Then, in eight weekly two-hour sessions, she reviews interviewing skills through didactic presentations, role-play, interviews with standardized patients, videotape review, group discussions, and individualized feedback. Principles derived from the communication literature are used as behavioral anchors for evaluating interviews. Communication competencies are taught and assessed in five areas: affIliation/support, social relaxation, empathy, behavioral flexibility, and interaction management. 29 In addition, six topics are highlighted: greeting patterns, the first five minutes of the interview, negotiation, taking a sexual history, talking about money, and closing the interview. Selected portions of videotapes of internal medicine faculty interviewing the same standardized patient are shown to highlight different styles of approaching the same issue. At the conclusion of the course, each intern is videotaped interviewing a standardized patient. The communication specialist and the residency program director evaluate these tapes, and the communication specialist provides feedback to each intern. During the last four weeks of the first-year curriculum, the communication module switches to sessions with the internist and clinical psychologist. Interviewing skills are fruther discussed VOLUME 30 • NUMBER 2 • SPRING 1989
using the Brown Evaluation Instrument, an interview-evaluation instrument developed for the undergraduate medical curriculum. This instrument specifies behaviors in information gathering, interview facilitation, and interpersonal skills. 3O •31 A detailed key that specifies behavioral anchors for Likert scales assists reliability of rating. Intern interviews with simulated and actual patients are assessed and discussed using this instrument. These faculty also introduce the interns to the concepts of working with "problem patients" by means of a videotape we produced, "The Problem Patient Clinic," and discussion of relevant papers. Didactic component. This portion of postgraduate year I (PGY -I) curriculum consists of 12 seminars (60- to 9O-minutes each) on key psychiatric topics in primary care led by the psychiatrist. Topics include: using antidepressants (two sessions); using antianxiety agents (two sessions); emergency psychopharmacology; delirium, dementia, and the cognitive mental status exam; overview of depression; use of neuroleptics and lithium; a structured treatment exercise on depression; the epidemiology and recognition of anxiety disorders; panic disorder; and a structured treatment exercise on anxiety. Related teaching. The communications module overlaps with the program's curriculum in medical ethics,32 which consists of 13 sessions (90 minutes each) over three years devoted to topics such as truth telling, informed consent, removal of life support, and confidentiality. Each topic is presented and discussed by a medical ethicist, using case histories to focus discussion. During the second session devoted to a topic, the interns interact with actors or role-play with each other to emphasize the importance of communication in creating and resolving ethical dilemmas and to learn specific skills in communicating ethical issues effectively and sensitively. The communication specialist and internal medicine faculty co-teach these latter sessions. Postgraduate Year II Building on the PGY-I skills of basic interviewing and psychiatric diagnosis and treatment, 215
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the PGY-II curriculum includes the Medical Psychological Consultation Clinic as the experiential component along with a seminar series. Experiential component. The Medical Psychological Consultation Clinic (MPCC) is also known to the residents as the "problem-patient clinic." Described in detail elsewhere,33 the MPCC is team-taught by the internist and the clinical psychologist. Each week the faculty and residents on ambulatory block interview and discuss a patient referred from the medical clinic who has been difficult to manage. Using the biopsychosocial model, we discuss diagnosis and management. A videotape of the session is then reviewed, with an emphasis on the interview process. Home visits are scheduled once each block, and papers presenting important psychiatric and psychosomatic concepts are discussed. 30·34-42 In a review of 56 patients referred to the clinic, over 90% had previously unrecognized DSM-III diagnoses. 36 Didactic component. The seminar series includes a six-session sequence on developmental psychology issues in health care. Topics include adolescence, marriage and divorce, midlife transition, geriatrics, death and dying, and grief and loss. Whenever possible, videotapes or interviews with patients are used. A second six-week sequence deals with behavioral techniques and approaches to common problems such as obesity, smoking, sexual difficulties, and alcoholism. The relaxation response, hypnosis, biofeedback, and other self-management techniques are also presented. These seminars are led by the psychologist, the internist, and invited faculty from the Department of Psychiatry. Postgraduate Year III During the PGY-III year, residents attend the MPCC each of their eight weeks of ambulatory block. The PGY-III residents attend MPCC at the same time as some of the PGY-II residents. Therefore, they are given more of a teaching role in reviewing relevant literature and in giving feedback with respect to interviewing skills. All of the general internal medicine residents complete a senior project, and many of the resi216
dents have chosen to work with behavioral science faculty. Topics have included family stress during residency,43 the development of a psychopharmacology evaluation instrument, depression and anxiety among Southeast Asian refugees, and family issues in the internship match process. In addition to helping the residents develop their research skills, this experience allows them to work closely with a faculty member and often leads to informal discussions about career development. Additional Teaching Activities Balint groups44 provide PGY-II and PGY-III residents with small group settings in which they present and discuss patients, with a focus on exploring and examining their own emotional reactions to patients. Residents work on improving self-awareness and discovering how their feelings and behaviors can help or hinder care. Depending on their schedules, the sessions are held biweekly at lunchtime or monthly in the evening at a faculty member's or resident's home. Interested residents have several options for additional tutorials within the psychiatrylbehavioral science curriculum. They can schedule difficult patients to be seen jointly with the internist during his outpatient-attending or patient-care slots. They can bring videotapes of patient interviews to the clinical psychologist and schedule individual supervision, or they can ask the communication specialist to attend and discuss patient interviews in the emergency room and on the wards. All of these options have been used by a number of residents on an ad hoc basis. A weekly journal club is well attended by house staff and faculty. In this forum, a faculty member and a resident are paired to present highquality critical reviews of recent articles or topics. The internist and psychiatrist are each responsible for four presentations per year. They use these opportunities to work intensively with house staff, presenting relevant psychosocial topics. and generating discussion and learning by other primary care faculty. The internist and another primary care facPSYCHOSOMATICS
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ulty internist lead weekly house staff support meetings.4s Although these meetings are open to the entire house staff, they are generally better attended by primary care house staff. In these meetings, house staff at all levels discuss a wide variety of issues, including administrative or programmatic issues. Many of the topics that arise are critical to the residents' growth as physicians: responding to angry patients and their families, responding to their own anger at patients, dealing with physician depression and burnout, responding to a dying patient who asks about prognosis or terminating treatment. Though not "billed" as an educational activity, these sessions are important educational experiences for many. Finally, the psychiatrist holds monthly medicaVpsychiatry attending rounds with all the ward teams. Patients referred for psychiatric consultation are presented, and the psychiatrist conducts a brief interview and leads a discussion about the interview, differential diagnosis, and treatment. DISCUSSION While we do not claim that this curriculum represents an ideal, it demonstrates what realistically can be developed and established over time, with continuous staff and resident feedback. We have learned much that may help others seeking to institute such a curriculum. The following discussion addresses curricular design, distribution of teaching activities, faculty development, administrative issues, evaluation, research, funding, and future initiatives. Curricular Design The general objectives for our psychiatry/behavioral science curriculum mirror those established by the primary care professional organizations22 and suggested by Lipkin et al.23 They are to develop 1) patient-centered interviewing and treatment; 2) an emphasis on the physician-patient relationship as a therapeutic tool; 3) a biopsychosocial approach to clinical reasoning and patient care; 4) a personal repertoire of humanistic values; and 5) the ability to recognize and manage psychiatric disorders and VOLUME 30 • NUMBER 2 • SPRING 1989
emotional problems. We want our residents to eventually regard the field of medical psychiatry/behavioral science with excitement and confidence, to view working with patients' difficult emotional problems as a challenge, and to feel that their practices are enriched by their enhanced skills. All primary care programs should develop a written curriculum in this area, and the process of writing a curriculum may be as important as the curriculum itself. Faculty develop stronger collaborative ties and become more invested in the program, and a written curriculum provides tangible evidence ofcommitment to this component. It also assists program planning and setting priorities for the use of resource. Programs that do not make the commitment to develop a written curriculum are much less likely to have actual teaching in this area. 24 For individual teaching modules, our faculty develop handouts for advance distribution to residents. These handouts include relevant readings, goals of the teaching session, and questions the resident should be able to answer by the end of the session. The overall goal is to make our teaching educationally sound by following established educational principles and using appropriate didactic techniques. 46 Learning takes place in a variety of settings, though we make an effort to impart most of the didactic material and skills training in a "protected" environment. In ambulatory block, residents are free from ward responsibilities and have specific, sequential, concentrated time set aside for psychosocial learning. Learning also takes place through a variety of educational techniques. Role-play, simulated patients, videotape review and feedback, educational videotapes, and the presentation of skills as specific defined behaviors that can be practiced are all educational techniques with unique advantages. 23 Much of the teaching takes place around medical interviews, which offer rich, complex, and elegant opportunities for teaching in a wide variety of areas. We use interviews for teaching process (the structure, function, and basic skills of interviewing), content (key psychosocial issues), sharpening observation (e.g., microanaly217
A Psychiatric Curriculum
sis of videotapes or conducting five-minute interviews on the wards to show how much can be gleaned from a brief interaction), psychiatric and biopsychosocial diagnosis, therapeutic skills, patient education skills, and physician self-observation. Programs initiating a psychiatry/behavioral science program should consider structuring their programs around interviews, both real and simulated. The topics chosen for didactic seminars reflect epidemiologic considerations of problem prevalence in medical practice, e.g., depression and anxiety are the fifth most common problems in primary care practice,47 and anxiolytics and antidepressants are among the most commonly prescribed drugs. 48.49 These topics match our own faculty's assessment of their importance to practice and closely approximates those in the curriculum proposed by the SGIM Task Force on the Medical Interview and Related Skills, to which over 100 faculty contributed. 23 Distribution of Teaching Responsibilities Our program accepts the premise that psychiatry should primarily teach psychopharmacology, differential diagnosis, and management of common psychiatric problems.~ In addition, we feel that the psychiatrist must teach psychiatry in medicine and not psychiatry per se. That is, the special considerations relevant to the application of psychiatric knowledge to medical populations must be addressed. A psychiatrist faculty member working with medical programs should have ongoing experience working with the medical population.51 It is becoming clearer that psychiatric disorders such as depression in medical populations may differ from depressive disorders seen in psychiatric settings. 52.53 In addition, there are many special considerations involving drug interactions and side effects which must be highlighted when teaching psychopharmacology to primary care physicians. Behavioral scientists from psychology, communication, social work, and education offer different and complementary perspectives to residents. In our program, the communication specialist offers insights gleaned from 218
communications research in other disciplines, as well as her own research in medical communication. The psychologist offers knowledge and skills in psychotherapy, psychological assessment, and developmental psychology. A group of educators with different backgrounds allows for a distribution of teaching responsibilities according to interest and skills. It also allows the residents to connect with different faculty according to their own interests, to learn from each of us in different ways, and to address the generalist/specialist division of responsibility for patients with mental disorders. 54 The majority of psychiatry/behavioral science programs for medical residents involve behavioral scientists from a variety of disciplines. 24.55.56 Many ofthese behavioral scientists express frustration at the difficulties in engaging medical residents,57 which can be reduced by co-teaching with medical faculty. We agree with Engel58 that medical faculty have critical roles in teaching psychiatry/behavioral sciences to medical residents. Medical faculty serve as role models to their residents, and their experience with medical patients informs their teaching. When medical faculty emphasize, teach, and practice a biopsychosocial approach to care, they may influence physicians-in-training to adopt this approach. Unfortunately, there is a dearth of internists, family practitioners, and pediatricians with interest and teaching expertise in this area. Often psychiatrists and behavioral scientists must energize and enlist support ofmedical faculty and assist them in their faculty development. Faculty Development Faculty development must address both behavioral science and medical faculty members. First, attention must be paid to the continued growth of core psychiatry/behavioral science faculty. We accomplish this by our biweekly curriculum committee meetings, in which we share ideas and work collaboratively on educational and research projects. Our faculty also attend and participate in workshops and national meetings, including the regional and national faculty development courses offered by the SGIM PSYCHOSOMATICS
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Task Force on the Medical Interview. 59 Other programs encourage faculty development and cohesiveness by holding faculty Balint groups, or monthly dinner meetings, in which faculty take turns presenting psychosocial topics or patient videotapes. The second key area of faculty development involves educating and motivating other primary care faculty members, so that they support the goals of the psychiatry/behavioral science curriculum and practice and teach a biopsychosocial approach to patients. Though this is often difficult to do, we feel we have made some headway by our presentation of psychosocial topics in journal clubs and divisional research conferences, and by informal and formal consultations on patients of faculty. Also, several of our young faculty are graduates of our own residency program and are very supportive of our teaching. Administrative Issues The primary care internal medicine residency at the Rhode Island Hospital is a carefully organized program facilitated by a fUll-time program coordinator. Though primary care residents are integrated into inpatient rotations, the primary care program is distinguished from the categorical program by a separate administration, curriculum, and selection process for its housestaff. This selection process emphasizes personal interviews, which helps us select residents who have an interest in psychosocial aspects of care. We feel it is important to have a primary care faculty member and psychiatrist codirect the educational program, for political as well as practical reasons. Again, a primary care medicine faculty member who believes in and teaches in this area gives credence to its importance to medical residents. Working together with a psychiatrist provides a model for collaboration. Because in our program the psychiatrist is also the psychiatrist-in-chief for the hospital, he can bring resources and faculty to bear in improving the curriculum. The core faculty and resident representatives on the Behavioral Science Committee meet biweekly to discuss curricular and related programVOLUME 30 • NUMBER 2 • SPRING 1989
matic issues. The residency program coordinator also participates in these meetings and helps set the agendas for subsequent meetings. The coordinator makes up resident schedules, and ensures that residents receive appropriate teaching materials in a timely manner. During monthly residency program meetings, the activities of the behavioral science faculty are presented and discussed. We occasionally suggest modifications or additions to the general medicine curriculum, such as a recent suggestion to add a three-hour training session on patient education. Such suggestions must be presented to and approved by the program curriculum committee, consisting of general medical faculty and residents. The most important administrative component may be the formal and informal support provided by the overall division director. His values in supporting this area are often mirrored in the residents, and his commitment of curricular time and funding support are critical for the program. Evaluation Resident evaluation of our program is accomplished in several ways. The residency program coordinator interviews residents after each ambulatory block rotation and administers a standardized evaluation instrument. These biannual evaluations ofour teaching have been valuable to improving the program. Two residents are members of our behavioral science curriculum committee to represent house staff views. A yearly off-campus residency program retreat allows faculty and residents to focus intensively on the program. Suggestions stemming from this retreat are discussed in subsequent behavioral science committee meetings. Faculty evaluation of house staff is accomplished in several ways. Behavioral science faculty contribute to annual program faculty discussions of residents and make specific suggestions, which are then conveyed to the residents in feedback sessions conducted by the program director. In addition, core faculty frequently discuss individual residents, our perception of their individual needs, and the steps we must take to meet these needs. When necessary, 219
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tutorials have been assigned. Though we are pleased with the progress of the residents and residents' evaluations and feedback suggest that their knowledge and skills have increased, we have not yet routinely administered standardized tests to prove success or to show that success has an impact on patient care. There are several reasons for this: First, there is no generally acknowledged standard evaluation tool for competency in medical interviewing. More research has been conducted on the Arizona Clinical Interviewing Rating Scale60•61 than any other tool, but this insbUment is optimally used with multiple standardized patients and is not easily adapted to the average program. A number of our residents are participating in the evaluation research of Stillman et al.,62 and we expect to see some useful data from this. Others have presented evaluation schema for various teaching experiences.6~ We are planning to institute a more formal evaluation of knowledge, attitudes, and skills for our next class of residents by developing test questions keyed to our seminars. These questions will be combined into a pretest administered at the beginning of internship and again at the conclusion of the second year. Included in this test will be an insbUment currently being field tested to assess psychopharmacology knowledge. To assess attitudes, we will administer a validated scale that measures attitudes toward psychosocial aspects of care. 69 In addition, we are currently revising the Brown Evaluation InsbUment for our residents. Though this insbUment is useful as a template for teaching certain skills, it awaits validation as an evaluation tool. Scholarly Work and Research Scholarly work and research productivity are important keys to academic success. In this regard, educational programs can often serve double duty, providing opportunities for publication. For example, on our problem-patient clinic we have published descriptions of our clinical practices and teaching methods and a patient follow-up study. 33.35.36 Our desire to assess curricular needs has led to other work, including a 220
questionnaire to assess residents' needs in terminal care.10 Of our biweekly faculty meetings, one is generally devoted to curriculum and the second to research. There are many fruitful and needed areas of research in psychiatrylbehavioral science. Some of these areas include educational research testing; innovative curricula or teaching methods; the development of validated evaluative measures of skills, attitudes, and knowledge; the effects of specific interventions on patient outcomes; the effects of teaching on resident behaviors and personal satisfaction; and cost offset of biopsychosocial interventions. In programs with a dearth of faculty committed to research, there are often opportunities across institutions or in national collaborative projects. 11 Funding Our program is fortunate to have had federal grant support. Were these monies to be discontinued, the hospital has expressed commitment to continue our program. However, there are many programs that are underfunded or that lack funding. Though these latter situations are difficult, they are not impossible. Primary care faculty who are committed to teaching require less funding than hiring separate behavioral science faculty. As long as they are granted curricular time, primary care faculty can begin their teaching program and begin to look for ways and funds to expand. When there are several education programs in the same area, sharing of resources can benefit all. There are several ways to approach raising funds to support psychiatrylbehavioral science teaching in the ambulatory setting. The frrst would be to obtain funding for joint psychiatry/medicine research that would pay for some psychiatry or behavioral scientist time. A second option would be to establish joint clinical moneygenerating programs between the psychiatry and medicine departments. For example, such a clinic might involve a "behavioral medicine" theme addressing eating disorders, risk factor reduction, etc. Third, there could be established some formal referral relationship between medical clinic PSYCHOSOMATICS
Novack et al.
and psychiatry which generates enough referrals to pay for psychiatry faculty time. Programs will increasingly depend on a creative and detailed analysis of reimbursement possibilities. Future Initiatives There is much to be accomplished in the future. We will continue to develop new evaluation instruments and try out existing instruments for measuring knowledge, skills, and attitudes. We will continue to develop educational videotapes. For example, we have shown our "Problem-Patient Clinic" and "Greeting Patterns" videotapes at regional and national meetings and are distributing them with educational materials to other programs. There is a wide variety of existing videotapes and other teaching materials that we need to evaluate. The Task Force Directory 0/ Educational Materials is of help in this regard.72 There are a number of innovative teaching techniques providing powerful learning experiences that we would like to try with our residents. One such technique is Frankel and Beckman's73 method of having physician and patient separately comment on their videotaped interaction and dubbing their comments on the video sound track. The program developed by Cope et aI. 74 for feeding-back patient satisfaction data to residents with specific suggestions for improvement in interviewing style is also quite promising. Medical Encounter, a quarterly newsletter for teachers of medical interviewing, offers ideas and descriptions of successful programs.7S We will soon institute formal teaching modules
in patient education, an often neglected area in psychosocial curricula.76.77 Other primary care disciplines have developed teaching methodologies that could be profitably employed. Constructing a family genogram78 is a technique used in many family practice residencies, and it could be instructive for internal medicine and ambulatory pediatric residents as well. At a time when fewer students are choosing internal medicine as a career, we believe that our psychiatry/behavioral science program makes our primary care residency program more attractive to highly qualified students. Our residents tell us that psychiatry/behavioral science teaching enhances their residency experience. Learning a biopsychosocial approach makes the practice of medicine more understandable, satisfying, and human. Therefore, we are committed to providing high-quality education to our residents throughout their three years of residency. We endeavor to ensure that this education will be intellectually rigorous and educationally sound. We owe much to the many who have contributed to the great progress in the field of psychiatry/behavioral science education in the last decade. Though we have an established and well-functioning program, we see many changes ahead. The field is young, and the many recent and expected educational innovations promise an exciting future.
This work was sponsored in part by a grant from the United States Department o/Health and Human Services no. 5D 28PEll095-08.
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