Teaching Family Physicians About Mood Disorders: A Procedure Suite for Behavioral Medicine

BACKGROUND AND OBJECTIVES: One of the skills required of family physicians is the ability to recognize and treat individuals suffering from mood disorders. This study represents an interdisciplinary residency training approach that (1) is unique in family practice residencies; (2) trains faculty, residents, and students in mood disorder recognition and treatment; (3) has been evaluated by the Residency Review Committee and found compatible with psychiatry training guidelines; and (4) is adaptable to varied settings. METHOD: Existing psychiatric education at an urban family practice residency program was evaluated. A new curriculum was developed to emphasize clinical interactions that would allow residents to model the behavior of family physicians who demonstrate interest and expertise in psychiatry. The centerpiece of this curriculum is a family-physician-led, multidisciplinary, in-house consultation service known as a mood disorders clinic (MDC). Educational effectiveness was evaluated by comparing resident identification rates of mood disorders before and after training. Educational utility was evaluated by implementation in a variety of settings. RESULTS: Fifty-one residents rotated through 1 or more of 3 practice sites during a 60-month period. Psychiatric diagnoses for the 187 patients who remained in treatment for complete clinical assessment included all major mood and anxiety disorders outlined in the DSM-IV. A wide variety of associated psychosocial problems were also identified. A significant difference (p <.05) was seen between the number of continuity patients diagnosed with psychiatric conditions by resident physicians before and after the training experience. CONCLUSION: Implementation of this intensive training experience resulted in subjective as well as objective enhancement of resident education by providing an intensive, focused educational experience in primary care psychiatry. This concept is adaptable to a variety of practice sites and educational levels. The MDC could become the hub of an integrated delivery system for mental health services in an ambulatory primary care setting.     

Training child psychiatrists in rural public mental health

Lack of appropriate training in both public mental health service and rural mental health service is a major factor in the critical shortage of child psychiatrists in rural settings. The authors describe a residency training program in rural public mental health designed to help alleviate that shortage. The program familiarizes fourth-year residents in child psychiatry with the clinical, political, and social aspects of rural public mental health services through didactic and supervisory sessions as well as an eight-month practicum experience involving provision of inservice training and administrative and case-related consultation to staff of mental health agencies. An assessment of the program indicated that participants felt it was beneficial, but the program was only partly successful in increasing the number of child psychiatrists entering practice in rural areas. The authors urge that residency programs in child psychiatry give priority to training child psychiatrists for work in rural settings.     

Training family practice residents in psychiatry: an ambulatory care training model

OBJECTIVE: To demonstrate the importance of providing psychiatric training to primary care practitioners in ambulatory care settings. Additionally, to describe the model used for this purpose in the Department of Psychiatry and Behavioral Sciences of the University of Texas Medical School at Houston in order to further stimulate educational opportunities on this topic. METHOD: A review of the psychiatric curriculum offered to family practice residents during their PGY-2 year one-month rotation in psychiatry at the University of Texas Mental Sciences Institute is provided. Emphasis is given to key areas of the curriculum such as: knowledge, skills, and attitude development. Special focus on the clinical and educational experiences is also offered for the purpose of providing unique perspectives about the curriculum methodology. RESULTS: The careful assessment of the feedback obtained from the family practice residents who were exposed to this ambulatory training model demonstrates that this type of setting was satisfactory for the teaching of psychiatry to primary care residents. CONCLUSIONS: Primary care residents have always treated a large number of psychiatric patients. Given the current status of our health care system, primary care practitioners should have even a greater role in the future delivery of psychiatric services. In this article, we offer a model of training for primary care residents in psychiatry, which emphasize cost-effectiveness, high quality of care, and ambulatory care settings.     

Global Mental Health as a Component of Psychiatric Residency Training

This study seeks to assess the educational value of an international psychiatry elective using a cross section of psychiatric residents. In 2010, a 10-item semi-structured questionnaire was administered to Mount Sinai psychiatric residents who have participated in the Global Health Residency Track of the Mount Sinai School of Medicine. Authors reviewed the qualitative data and arrived at a consensus regarding trends and deviations regarding residents’ experiences of their international field work. Six residents participated in this study. Common themes included exposure to sicker, treatment-naïve patients in resource scarce conditions, enhancement of cross-cultural communications skills, renewed appreciation for psychiatry, empowerment as teachers, and greater awareness of health-care systems. Knowing that an international elective existed would be a significant factor in their choice of residency. Respondents had concerns for the sustainability. Participants felt that the elective was a place to consolidate skills already learned during residency and resulted in increased professional confidence although it did not necessarily alter career paths. International electives can enrich psychiatric residency training in terms of understanding of mental health care systems, cross cultural psychiatry, sharpening diagnostic skills, building professional confidence and communication skills, and reaffirming motivation to practice psychiatry.     

Outpatient consultation-liaison psychiatry: A valuable addition to the training of advanced psychiatry residents

With current health care reimbursement conditions and recent research denoting the important relationship between mental health status and poor functioning, especially in medically ill patients, one would think that consultation-liaison (C-L) psychiatry would have an increasingly viable role in the outpatient health care sector. However, only a small number of outpatient C-L clinics are reported and recently several of these have folded. These outpatient C-L clinics can follow different clinical models and have the potential, especially at the residency and fellowship training levels, for interesting and useful educational opportunities. This paper describes a recently founded outpatient C-L clinic—the Medical Illness Clinic—in a university medical center's department of Psychiatry. We highlight the structure of the clinic, the kinds of patients seen, and focus on the unique educational residency training opportunities this setting presents. The results of clinic rotation evaluations by residents are also presented. We conclude with recommendations for more exploration of this clinical model and evaluation of its utility in psychiatric residency education.     

The aftercare clinic as a residency training site. 'Community neuropsychiatry'.

Refocusing service and research priorities in psychiatry toward problems of major mental illness and its long-term management requires that more specific attention be paid to this area by residency training programs. A "community neuropsychiatry" residency training experience based in a state hospital aftercare clinic is described as one model for achieving this objective. Supplemented by didactic course work in mental health administration, the history and theory of community psychiatry, and experiences in other, varied service settings, this program has proved to be valuable for learning and teaching skills basic to community psychiatry practice.     

Putting "rural" into psychiatry residency training programs.

OBJECTIVE: Evidence indicates disparities in the number of psychiatrists practicing in rural America compared to urban areas suggesting the need for a greater emphasis on rural psychiatry in residency training programs. The authors offer suggestions for integrating a rural focus in psychiatry residency training to foster greater competency and interest in rural psychiatry. METHODS: The authors surveyed the limited rural psychiatry training and the more extensive family medicine rural residency literature to review efforts to develop rural focused training curricula. RESULTS: Many factors in the rural environment influence mental health care, including overlapping professional-patient relationships, caregiver isolation and stress, limited availability and access to mental health resources, disease stigma, and economic and health status. To enhance both an interest in and the quality of the training for a rural practice, the authors suggest three levels of training for integrating rural factors into psychiatry programs from a basic didactic understanding of the contextual issues affecting rural psychiatry, to creating rural clinical experiences and preceptors, to developing a rural psychiatry fellowship. CONCLUSIONS: Providing trainees with an understanding of the rural mental health issues and experiences might contribute to trainees' selecting rural practices and enhance the rural competency of psychiatrists.     

Community Psychiatry Tracks for Residents: A Review of Four Programs

Many psychiatry residency graduates end up practicing at least in part in community settings. However, declining funding and other issues prevent many residency programs from offering robust community psychiatry training to all of their residents. Accordingly, some residency programs have developed Community Psychiatry Tracks, with the goal of developing future leaders in public sector psychiatry. We cataloged US psychiatry residency programs offering Community Psychiatry Tracks by reviewing the literature and surveying training directors and members of the American Association of Community Psychiatrists. Authors from each of the four programs found to be actively offering such tracks describe their track curricula, from which we elucidated common and variable elements as well as strengths and weaknesses and then make recommendations for other programs wishing to start a track. A Community Psychiatry Track preliminarily appears to be a well-received way to offer enhanced Community Psychiatry training to interested residents, to recruit medical students to residency programs, to offer opportunities for collaboration between residents and faculty members, and to expand opportunities for scholarly work by residents.     

Psychiatry Resident and Medical Student Perspectives on ECT: Influence of Exposure and Education

We surveyed medical students doing the required psychiatry clerkship at our hospital and first-year psychiatry residents in our residency training program for their attitudes, knowledge, and opinions about electroconvulsive therapy (ECT) before and after their inpatient rotations. The students' knowledge was lower and their attitudes more negative toward ECT than those of residents at baseline. Upon completion of the rotation, students and residents had more knowledge and highly positive attitudes about ECT and stated that they would undergo ECT if it were recommended. Willingness to undergo ECT if it were recommended correlated with the knowledge measures of ECT.     

The influence of the curriculum in psychiatry residency education

Extraordinary economic forces are influencing graduate medical education in this country. Federal, state, and third party cost containment efforts, managed care, medical student loan indebtedness, and decreasing governmental and industry enthusiasm to support residency training are producing significant external pressures on academic health centers, recruitment into psychiatry, and on the practice of psychiatry. Other pressures on the psychiatry residency curriculum are being generated from the rapid expansion in our scientific knowledge base in clinical psychiatry and the influence of subspecialization. The future psychiatrist will be trained for a life long career in continuing education to accommodate for the explosive scientific contributions to our field. The residency training program will promote the ability to think scientifically, to teach others, to administrate and lead, and to achieve clinical competence in a more rigorous fashion. Regardless of the number and forms of emerging practice settings, it is best to train our residents for flexibility through emphasizing fundamental clinical and scientific excellence.     

When psychiatric residents treat medical students: Passage through idealization and overidentification

The author describes a survey of psychiatric residents and faculty supervisors inquiring as to problematic aspects of the psychotherapy of medical students when treated by residents. Medical students' idealization of and identification with their resident-therapist were found to produce a significant amount of discomfort for the trainee. Difficulties in the psychotherapies were also attributed to the numerous possibilities of identification by the residents with their medical student patients. The varied forms of identification are detailed through the use of clinical vignettes submitted by respondents. It is the author's contention that psychotherapies involving these “special patients” provide a window for examining many issues in the development of the resident's professional self. Given the increasing number of medical students electing some form of personal psychotherapy and the declining number entering psychiatry residency training, the timeliness of this issue is noted.     

A curriculum for the psychiatric training of family physicians

Recognizing the important role of family physicians in mental health care, psychiatry and family medicine faculty developed a psychiatric curriculum for family medicine residents. The collaborative effort utilized graduate interviews, literature review, and specialized group techniques to develop a competency-based curriculum that begins early in the residency, is integrated longitudinally into the remainder of the curriculum, and utilizes seminars, clinical experience, and liaison with a mental health team in the training design.     

Attitudes of U.S. Psychiatry Residents and Fellows towards Mental Illness and its Causes: a Comparison Study with Medical Students

Stigma towards people with mental illness remains a burden for patients and healthcare providers. This study at a large US university examined the attitudes of psychiatry residents and fellows towards mental illness and its causes, and whether their attitudes differed from the medical student attitudes previously studied utilizing the same survey method. An electronic questionnaire examining attitudes toward people with mental illness, causes of mental Illness, and treatment efficacy was used to survey the attitudes of psychiatry residents and fellows. Exploratory factor analysis derived from the authors’ medical student survey was used to examine attitudinal factors. The study response rate was 54.2% (n =?94). Factor analysis employed three factors previously identified reflecting social acceptance of mental illness, belief in supernatural causes, and belief in biopsychosocial causes. Residents and fellows reporting more personal experiences with mental illness, both as a group and when compared with medical students, were significantly more willing to socialize with the mentally ill. Respondents who had more professional (work) experience other than medical school or post-graduate training were less likely to believe in supernatural causes of mental illness. Female residents and fellows were more willing to socialize with the mentally ill, and were less likely to believe in supernatural causes for mental illness than their male counterparts. In our study, increased social acceptance of the mentally ill relates to having personal experiences, advanced training in psychiatry, and female gender. Both professional experiences outside of training and female gender reduced the belief in supernatural causes.     

When a psychiatry resident's patient commits suicide: transference trials and tribulations

It is an unfortunate reality that a substantial proportion of psychiatry residents will experience the suicide death of one or more of their patients during the course of their training. The psychological impact of such deaths may result in marked repercussions on the treating resident; but, in addition, many other individuals and entities--resident peers, supervisors, other mental health professionals and staff, training directors, training programs, psychiatry departments--may be affected as well to a greater or lesser extent. This paper explores one manifestation of the impact on a psychiatry resident of a patient's suicide death: the activation of transference reactions and transference enactments on the part of both a resident and a residency training director. The author argues that the very breadth and depth of such transference responses offer invaluable opportunities for self-observation, psychological introspection, and personal growth if involved individuals have sufficient courage and supportive mechanisms for processing of the patient suicide and its aftermath. The failure of many current psychiatric trainees to undergo personal intensive psychotherapy is identified as a major obstacle to turning such potentially destructive experiences into learning and growth opportunities.     

A reexamination of the psychiatric resident's experience in the general hospital

The authors discuss three phases of psychiatric residency training: the beginning psychiatry training syndrome, the professional and psychologic changes associated with the second year, and the senior resident year, characterized by transition to practice issues. Since most residency training experiences occur in general hospital settings, it is imperative that general hospital psychiatrists be aware of the professional and emotional changes that residents experience as they move from inpatient to outpatient settings and assume more administrative responsibilities in departments of psychiatry. The authors recommend preventive steps that residency training directors in general hospitals might take to reduce residents' adverse emotional responses to stresses associated with each training period in the general hospital.     

A review of mental health services for refugees between 1975 and 1985 and a proposal for future services

A lack of federal planning and foresight and an uneven and poorly coordinated network of state services have resulted in fragmented mental health care for the large number of Southeast Asian and other refugees who have entered the United States since 1975. The author reviews the history of mental health services for refugees between 1975 and 1985 and proposes the development of separate mental health and health services for refugees that are responsive to their political, social, economic, and cultural needs. Ideally the services would be provided within existing medical institutions and staffed by medical, psychiatric, and social services personnel assisted by culturally sensitive translators. The author outlines the role of government and organized psychiatry in shaping new programs for refugees and promoting their mental health.     

A survey of psychiatric residency directors on current priorities and preparation for public-sector care

OBJECTIVE: This study assessed how resident psychiatrists are being prepared to deliver effective public-sector care. METHODS: Ten leaders in psychiatric education and practice were interviewed about which tasks they consider to be essential for effective public-sector care. The leaders identified 16 tasks. Directors of all general psychiatry residency programs in the United States were then surveyed to determine how they rate the importance of these tasks for delivery of care and how their training program prepares residents to perform each task. RESULTS: A total of 114 of 150 residency directors (76 percent) responded to the survey. Factor analysis divided 14 of the tasks into three categories characterized by the extent to which their performance requires integration of services: within the mental health system (for example, lead a multidisciplinary team), across social service systems (for example, interact with staff of supportive housing programs), and across institutions with different missions (for example, distinguish behavioral problems from underlying psychiatric disorders among prisoners). Preparation for tasks that involved integration of services across institutions was rated as least important, was least likely to be required, and was covered by less intensive teaching modalities. Tasks entailing integration within the mental health system were rated as most important, preparation was most likely to be required, and they were covered most intensively. Midway between these two categories, but significantly different from each, were tasks relying on integration across social service systems. CONCLUSIONS: Tasks that involved integrating services across institutions with different missions were consistently downplayed in training. Yet the importance of such tasks is underscored by the assessments of the psychiatric leaders who were interviewed, the high valuation placed on this type of integration by a substantial subset of training directors, and the extent of mental illness among populations who are institutionalized in nonpsychiatric settings.