Acad Psychiatry (2015) 39:461–465 DOI 10.1007/s40596-015-0348-3
COLUMN: EDUCATIONAL CASE REPORT
Integrated Medicine and Psychiatry Curriculum for Psychiatry Residency Training: a Model Designed to Meet Growing Mental Health Workforce Needs Robert M. McCarron 1 & James A. Bourgeois 2 & Lydia A. Chwastiak 3 & David Folsom 4 & Robert E. Hales 1 & Jaesu Han 1 & Jeffrey Rado 5 & Sarah Rivelli 6 & Lorin Scher 1 & Angie Yu 1
Received: 19 September 2014 / Accepted: 16 April 2015 / Published online: 27 May 2015 # Academic Psychiatry 2015
Patients with chronic mental illness have significantly higher rates of medical comorbidity and resultant lower life expectancies when compared to the general population [1–3]. This survival discrepancy is not fully accounted for by the higher rate of suicide completion in these patients but, rather, is often attributable to mortality from cardiovascular, metabolic, and other systemic illness. Many such individuals are seen in community mental health settings and have poor access to primary health care. In some cases, the psychiatrist may become the “de facto primary care physician,” while providing some preventive health screening and treatment of general medical conditions. For those patients who are cared for by a primary care provider, the psychiatrist may support preventive medical recommendations with psychopharmacological interventions and the use of psychotherapies such as cognitive behavioral therapy, problem solving therapy, supportive psychotherapy, and motivational interviewing. Strong evidence calls for improved general medical care for people with severe mental illnesses. In a 17-year followup study of over 80,000 people in the USA, those with mental illness died an average of 8.2 years earlier than those without mental illness, with excess mortality primarily due to socioeconomic factors, poor access to effective primary and
preventative care, and the burden of chronic health conditions [1]. Moreover, individuals with schizophrenia tend to die 20– 30 years earlier than the population average, even after excluding deaths by suicide [2]. Similarly, those with bipolar disorder have a twofold higher mortality rate than the general population [3]. Patients with major depression are also at higher risk of medical illness, such as diabetes mellitus and ischemic heart disease [4, 5]. The increased risk of diabetes mellitus, metabolic syndrome, cardiovascular disease, and stroke associated with atypical antipsychotics further underscores the need for the psychiatrist to engage in risk factor monitoring, risk reduction, and recognition and management of comorbid medical conditions in their patients [6–8]. Given the significantly increased mortality among psychiatric patients as a result of non-psychiatric medical conditions, it is essential we provide psychiatric training that mirrors significant changes to our mental health delivery system by way of the Patient Protection and Affordable Care Act. Psychiatry residents should receive training about collaborative and targeted preventive medical care, which better approximates current and real-world clinical practice guidelines found in patient-centered medical homes. We suggest one approach to accomplishing this is to provide residents with an Integrated Medicine and Psychiatry (IMAP) curriculum.
* Robert M. McCarron [email protected] 1
University of California, Davis School of Medicine, Sacramento, CA, USA
2
University of California, San Francisco, San Francisco, CA, USA
3
University of Washington, Seattle, WA, USA
4
University of California, San Diego, San Diego, CA, USA
5
Rush University, Chicago, IL, USA
6
Duke University, Durham, NC, USA
Integrated Medicine and Psychiatry Curriculum for Residency Training Integrated behavioral health care most often refers to coordinated primary care and mental health delivery at a co-located clinical site or some model of consultation services by a psychiatrist at a primary care clinical site. Reverse integrated care generally refers to the practice of bringing primary and preventive medical care to the psychiatric clinical setting.
462
Acad Psychiatry (2015) 39:461–465
Although this type of integrated care is recognized as important, there is currently a paucity of evidenced-based, bestpractice recommendations on how to provide integrated preventive medical training to psychiatric trainees [9]. IMAP is a clinically based curriculum that includes a broad-based overview on various types of integrated clinical care and a targeted approach to preventive medical care for those with comorbid mental health conditions. This curriculum includes milestone-based learning with didactics temporally mirroring clinical experiences, when possible. We strongly suggest this pedagogical approach to be longitudinal in nature, ideally beginning in postgraduate year one (PGY-1) and extending through PGY-4. The following is an overview of the IMAP clinical and lecture components, as developed by the University of California, Davis, and the University of Washington. Clinical Rotations Although most are in very early stages, approximately three fourths of general psychiatry residencies (including child and adolescent programs) have started to incorporate an integrated psychiatry curriculum for residents [10]. Many programs have developed this curriculum while mindful of fulfilling the Accreditation Council for Graduate Medical Education (ACGME) rotational requirements, the competency-based development outcomes or Milestones for psychiatry residency training, and the availability of appropriate educational resources. Potential integrated residency education partners include the Veterans Administration (VA) system, Federally Qualified Health Centers (FQHC), along with academic primary care and specialty clinics. Collaborative care, telemedicine, and traditional outpatient primary care consultation models generally only require a supervising psychiatrist. Inpatient or outpatient medicine/psychiatry clinical experiences, where psychiatry residents manage both general medical and psychiatric conditions, require both a supervising psychiatrist and family physician or internist (or a combined-trained physician). This dual supervision model is comprehensive but Table 1
may present a greater challenge for psychiatry residency programs, as it calls for greater clinical and administrative coordination (Table 1). Regardless of the clinical model used, we believe the key component of developing and supporting an integrated site is to identify “champion” faculty members who oversee the clinical service. These champions are often psychiatry or psychosomatic faculty members who are already embedded within a general medical setting, either in a general hospital setting or in an outpatient clinic. It is paramount to develop a trusting and mutually beneficial working relationship with clinical staff, faculty, and administrators. The IMAP clinical curriculum ideally should begin in the PGY-1. The vast majority of residency programs fulfill the ACGME 4-month medicine requirement with rotations on inpatient medical units (sometimes intensive care medical units) or emergency medical settings. Under the IMAP curriculum, residents would gain exposure to the practice of preventive care and management of common primary care conditions by moving to outpatient primary care or integrated clinical sites during the intern year [11]. This would be much more relevant to the majority of residents who may practice in the outpatient setting after graduation. During PGY-3 to PGY-4, residents can be introduced to models of integrated clinical care. Residency programs with inpatient medicine/psychiatry units (sometimes called “complexity evaluation units”) allow resident exposure to the management of acute psychiatric and medical illness, while fulfilling the requirement to complete inpatient psychiatry rotations. Collaborative care, telepsychiatry, and traditional outpatient psychiatry consultation models would also prepare trainees in the area of integrated care. Additionally, specialty clinics with significant overlap with psychiatry such as pediatrics, neurology, oncology, palliative care, and pain medicine represent unique learning opportunities. These experiences, though not strictly fulfilling ACGME rotational requirements, map well on several other ACGME Milestones for systems-based practice, interpersonal communication, medical knowledge, and providing psychiatric consultation [12].
Examples of current behavioral health and primary care models of integration [18]
Models of integration
Brief description
Telepsychiatry
Consultation and education model that uses video connections to communicate with primary care providers and psychiatric patients Psychiatric care for patients in a non-psychiatric setting
Collocation and psychiatric consultation in the primary care or medical specialty setting Medicine/psychiatric or dual-trained care Mid-level behavioral health provider care Collaborative care
General medical and behavioral health conditions are addressed by providers who are dual-trained in medicine and psychiatry Assess need for psychiatric care and provide recommendations accordingly A behavioral health care manager (non-physician) works as a liaison among the psychiatrist, the primary care provider, and the patient. Diagnostic and treatment protocols are often utilized
Acad Psychiatry (2015) 39:461–465
Longitudinal Lecture Series IMAP lectures are clinically based and co-led by nonpsychiatry medical colleagues. Each 60- to 90-min learning session focuses on models of integrated care or a targeted and system-based approach to preventive medical care for those with mental illness. The following is a list of core IMAP curriculum objectives. &
& & &
Learn practical preventive medicine strategies so that psychiatrists can advocate for the physical health of their patients. Trainees will learn the essentials of preventive medicine with a focus on primary and secondary prevention of cardiovascular/pulmonary, endocrine, oncologic, infectious, pediatric, geriatric, and pain-related disorders. Understand how to effectively stay current over the course of a career on important changes to preventive medicine guidelines. Incorporate brief psychotherapies in order to optimize understanding and adherence to medical treatment plans. Understand how different models of integrated care can complement existing models of psychiatric practice.
Existing curricula can be easily used to teach psychiatric residents [13–15]. The Advancing Integrated Mental Health Solutions (AIMS) Center at the University of Washington has Table 2
463
developed a set of six online learning modules to support a clinical rotation in collaborative care. These modules cover the fundamentals of the role of a psychiatric consultant on a collaborative care team. This user-friendly introduction to teambased and collaborative care can be used to train psychiatrists to function in any role at the interface of primary care and mental health and may be useful in programs even where a collaborative care setting is not available [14]. A recommended curriculum, titled Preventive Medical Care in Psychiatry: A Practical Guide for Health Care Providers, covers common, potentially lethal, and treatable conditions found in the psychiatric patient population [15]. Psychiatry residents can review primary and secondary prevention measures related to nicotine dependence, obesity, immunization, cancer screening, cardiac risk assessment, prevention and treatment of sexually transmitted infections, and age-appropriate health screening (Table 2). These curricula will provide a framework for learners as they complete integrated rotations during residency training and prepare to enter a workforce with expanding integrated care opportunities.
IMAP Faculty Development and Combined-Trained Physicians Many psychiatry residency programs may not have an established curriculum on integrated care. We suggest an in-
Suggested IMAP learning topics and timeline for a longitudinal lecture series
PGY-2 Overview of preventive medicine aspects of psychiatric care Cardiopulmonary disordersa Endocrine/metabolic disordersa Infectious disordersa Oncologic disordersa Geriatricsa Pain medicinea PGY-3 Overview of mental health disparities and increased morbidity Learn how to provide patient-centered care Introduction to integrated and collaborative mental health care (1 of 2) Introduction to integrated and collaborative mental health care (2 of 2) Motivational interviewing in a collaborative setting (1 of 2) Motivational interviewing in a collaborative setting (2 of 2) Brief psychotherapies: cognitive behavioral therapy, problem solving therapy, and supportive psychotherapy PGY-4 Longitudinal learning in preventive medicine Teaching and providing consultation to colleagues Team-based learning (case-based) Fundamentals of health behavioral change Learning skills in advocacy for those with mental illness and comorbid health conditions
PGY postgraduate year a
Content is focused on primary and secondary preventive care strategies and not on primary care treatment of medical disorders
464
cremental or stepwise approach when considering how best to implement, while recruiting internal medicine, family medicine, pediatric, and OB/GYN faculty to co-lead with psychiatry faculty champions of integrated care. We recommend including primary care-based senior or chief residents to “cross teach” their respective discipline to psychiatry residents (e.g., internal medicine chief resident co-teaching a session on prevention of common infectious diseases in the psychiatric patient population). Conversely, senior psychiatry residents may consider co-teaching “primary care psychiatry” to primary care-based residents. Developing faculty to teach the IMAP curriculum can be challenging because of the overlap between general medicine and psychiatry. Combined-trained, double-board, or tripleboard certified physicians in family medicine-psychiatry, internal medicine-psychiatry, neurology-psychiatry, or pediatrics-psychiatry-child psychiatry represent a unique and highly trained physician force in integrated behavioral health and medical care and may be well positioned to provide and oversee this training [16, 17]. Unfortunately, there is a limited number of combined-training programs and graduates to meet this workforce need. We propose the following recommendations for IMAP faculty development when combined-trained faculty members are not available. 1. Encourage the incorporation of brief psychotherapies and motivational interviewing with most of the didactics (particularly when discussing preventive guidelines). 2. Consider inviting non-psychiatry faculty members from internal medicine, family medicine, pediatrics, and obstetrics-gynecology to discuss general medical topics. When possible, co-presenting with non-psychiatry faculty is ideal. 3. Choose course organizer(s) with a high level of familiarity about the IMAP curriculum, and mentor other faculty who wish to learn this content. 4. Use existing curriculum, as outlined in this article, as an educational supplement.
Acad Psychiatry (2015) 39:461–465
introduction to integrated systems of care as well as a comprehensive overview on preventive medical care for those with mental illness. This curriculum is designed to address the inherent vulnerability, increased morbidity, and premature death found in the psychiatric patient population. Partnership with non-psychiatry physician colleagues and crossdisciplinary learning is essential for this type of curriculum to be effectively delivered. Our specialty is in the early stages of integrated curricular development, and the next steps include further development and standardization, as well as measurement of practice pattern outcomes and patient satisfaction. Implications for Educators • Patients with mental illness are at increased risk for early death and morbidity. Psychiatric educators can address this by teaching trainees how to work collaboratively with other providers to address and potentially prevent common and treatable medical conditions. • Psychiatry residents may benefit from understanding different models of integrated care and how to incorporate the use of evidence-based brief psychotherapies into these types of practices. • Learners may benefit from exposure to a combination of didactics and clinical experiences in integrated and preventive medical care, which span over a 3–4-year period.
Acknowledgments The authors acknowledge Mehrbanoo Lashai. Disclosures Dr. Robert McCarron is an editor for the American Psychiatric Publishing textbook Preventive Medical Care in Psychiatry: a Clinical Guide for Health Care Providers, which is cited in the references.
References 1.
2.
3.
Discussion For myriad reasons, including the implementation of the Affordable Care Act, the practice of medicine and psychiatry is being transformed. Integrated systems of care such as collaborative and team-based care are increasing in number, particularly at VA and FQHC sites. Psychiatry residency training directors may consider revising their curricula to prepare future graduates better for a workforce that is increasingly integrated with general medicine. IMAP curriculum is both clinically and didactically based. We propose an established curriculum that covers both an
4. 5.
6.
7. 8.
Druss BG, Zhao L, von Esenwein S, et al. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care. 2011;49:599–604. Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry. 2007;64:1123–31. Crump C, Sundquist K, Winkleby MA, et al. Comorbidities and mortality in bipolar disorder: a Swedish national cohort study. JAMA Psychiatry. 2013;70:931–9. Mezuk B, Eaton W, Albrecht S, et al. Depression and type 2 diabetes over the lifespan. Diabetes Care. 2008;31:2383–90. Van der Kooy K, van Hout H, Marwijk H, et al. Depression and the risk for cardiovascular diseases: systematic review and meta-analysis. Int J Geriatr Psychiatry. 2007;22:613–26. American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity and Diabetes: Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care. 2004; 27:596–601. Jin H, Meyer JM, Jeste DV. Atypical antipsychotics and glucose dysregulation: a systematic review. Schizophr Res. 2004;71:195–212. Folsom DP, Okereke OI. Medical comorbidity in geriatric psychiatry. Am J Geriatric Psychiatry. 2005;13(3):177–9.
Acad Psychiatry (2015) 39:461–465 9.
Cowley D, Dunaway K, Forstein M, et al. Teaching psychiatry residents to work at the interface of mental health and primary care. Academic Psychiatry. 2014;38(4):398–404. 10. Reardon CL, et al. General and child and adolescent psychiatry resident training in integrated care: a survey of training directors. Academic Psychiatry. (In press) 11. Onate J, Hales R, McCarron R, et al. A novel approach to medicine training for psychiatry residents. Acad Psychiatry. 2008;32:518–20. 12. Accreditation Council for Graduate Medical Education: The psychiatry milestone project. November 2013. http://acgme.org/ acgmeweb/Portals/0/PDFs/Milestones/PsychiatryMilestones.pdf. Accessed September 9, 2014. 13. Raney LE. Integrated care: working at the interface of primary and behavioral health care. Arlington: American Psychiatric Publishing; 2015.
465 14.
Advanced Integrated Mental Health Solutions Center. http://aims. uw.edu. Accessed September 9, 2014. 15. McCarron RM, Xiong G, Keenan CR, et al. Preventive medical care in psychiatry: a clinical guide for health care providers. Arlington: American Psychiatric Publishing; 2015. 16. Jain G, Dzara K, Gagliardi JP, et al. Assessing the practices and perceptions of dually-trained physicians: a pilot study. Academic Psychiatry. 2012;36:1. 17. Summergrad P, Silberman E, Price L. Practice and career outcomes of double boarded psychiatrists. Psychosomatics. 2011;52:537–43. 18. Kathol RG, Summergrad P. Training the next generation of psychiatrists in integrated medical-psychiatric care. In: Integrated care in psychiatry: redefining the role of mental health. New York: Springer; 2014. p. 197–210.
COLUMN: EDUCATIONAL CASE REPORT
Integrated Medicine and Psychiatry Curriculum for Psychiatry Residency Training: a Model Designed to Meet Growing Mental Health Workforce Needs Robert M. McCarron 1 & James A. Bourgeois 2 & Lydia A. Chwastiak 3 & David Folsom 4 & Robert E. Hales 1 & Jaesu Han 1 & Jeffrey Rado 5 & Sarah Rivelli 6 & Lorin Scher 1 & Angie Yu 1
Received: 19 September 2014 / Accepted: 16 April 2015 / Published online: 27 May 2015 # Academic Psychiatry 2015
Patients with chronic mental illness have significantly higher rates of medical comorbidity and resultant lower life expectancies when compared to the general population [1–3]. This survival discrepancy is not fully accounted for by the higher rate of suicide completion in these patients but, rather, is often attributable to mortality from cardiovascular, metabolic, and other systemic illness. Many such individuals are seen in community mental health settings and have poor access to primary health care. In some cases, the psychiatrist may become the “de facto primary care physician,” while providing some preventive health screening and treatment of general medical conditions. For those patients who are cared for by a primary care provider, the psychiatrist may support preventive medical recommendations with psychopharmacological interventions and the use of psychotherapies such as cognitive behavioral therapy, problem solving therapy, supportive psychotherapy, and motivational interviewing. Strong evidence calls for improved general medical care for people with severe mental illnesses. In a 17-year followup study of over 80,000 people in the USA, those with mental illness died an average of 8.2 years earlier than those without mental illness, with excess mortality primarily due to socioeconomic factors, poor access to effective primary and
preventative care, and the burden of chronic health conditions [1]. Moreover, individuals with schizophrenia tend to die 20– 30 years earlier than the population average, even after excluding deaths by suicide [2]. Similarly, those with bipolar disorder have a twofold higher mortality rate than the general population [3]. Patients with major depression are also at higher risk of medical illness, such as diabetes mellitus and ischemic heart disease [4, 5]. The increased risk of diabetes mellitus, metabolic syndrome, cardiovascular disease, and stroke associated with atypical antipsychotics further underscores the need for the psychiatrist to engage in risk factor monitoring, risk reduction, and recognition and management of comorbid medical conditions in their patients [6–8]. Given the significantly increased mortality among psychiatric patients as a result of non-psychiatric medical conditions, it is essential we provide psychiatric training that mirrors significant changes to our mental health delivery system by way of the Patient Protection and Affordable Care Act. Psychiatry residents should receive training about collaborative and targeted preventive medical care, which better approximates current and real-world clinical practice guidelines found in patient-centered medical homes. We suggest one approach to accomplishing this is to provide residents with an Integrated Medicine and Psychiatry (IMAP) curriculum.
* Robert M. McCarron [email protected] 1
University of California, Davis School of Medicine, Sacramento, CA, USA
2
University of California, San Francisco, San Francisco, CA, USA
3
University of Washington, Seattle, WA, USA
4
University of California, San Diego, San Diego, CA, USA
5
Rush University, Chicago, IL, USA
6
Duke University, Durham, NC, USA
Integrated Medicine and Psychiatry Curriculum for Residency Training Integrated behavioral health care most often refers to coordinated primary care and mental health delivery at a co-located clinical site or some model of consultation services by a psychiatrist at a primary care clinical site. Reverse integrated care generally refers to the practice of bringing primary and preventive medical care to the psychiatric clinical setting.
462
Acad Psychiatry (2015) 39:461–465
Although this type of integrated care is recognized as important, there is currently a paucity of evidenced-based, bestpractice recommendations on how to provide integrated preventive medical training to psychiatric trainees [9]. IMAP is a clinically based curriculum that includes a broad-based overview on various types of integrated clinical care and a targeted approach to preventive medical care for those with comorbid mental health conditions. This curriculum includes milestone-based learning with didactics temporally mirroring clinical experiences, when possible. We strongly suggest this pedagogical approach to be longitudinal in nature, ideally beginning in postgraduate year one (PGY-1) and extending through PGY-4. The following is an overview of the IMAP clinical and lecture components, as developed by the University of California, Davis, and the University of Washington. Clinical Rotations Although most are in very early stages, approximately three fourths of general psychiatry residencies (including child and adolescent programs) have started to incorporate an integrated psychiatry curriculum for residents [10]. Many programs have developed this curriculum while mindful of fulfilling the Accreditation Council for Graduate Medical Education (ACGME) rotational requirements, the competency-based development outcomes or Milestones for psychiatry residency training, and the availability of appropriate educational resources. Potential integrated residency education partners include the Veterans Administration (VA) system, Federally Qualified Health Centers (FQHC), along with academic primary care and specialty clinics. Collaborative care, telemedicine, and traditional outpatient primary care consultation models generally only require a supervising psychiatrist. Inpatient or outpatient medicine/psychiatry clinical experiences, where psychiatry residents manage both general medical and psychiatric conditions, require both a supervising psychiatrist and family physician or internist (or a combined-trained physician). This dual supervision model is comprehensive but Table 1
may present a greater challenge for psychiatry residency programs, as it calls for greater clinical and administrative coordination (Table 1). Regardless of the clinical model used, we believe the key component of developing and supporting an integrated site is to identify “champion” faculty members who oversee the clinical service. These champions are often psychiatry or psychosomatic faculty members who are already embedded within a general medical setting, either in a general hospital setting or in an outpatient clinic. It is paramount to develop a trusting and mutually beneficial working relationship with clinical staff, faculty, and administrators. The IMAP clinical curriculum ideally should begin in the PGY-1. The vast majority of residency programs fulfill the ACGME 4-month medicine requirement with rotations on inpatient medical units (sometimes intensive care medical units) or emergency medical settings. Under the IMAP curriculum, residents would gain exposure to the practice of preventive care and management of common primary care conditions by moving to outpatient primary care or integrated clinical sites during the intern year [11]. This would be much more relevant to the majority of residents who may practice in the outpatient setting after graduation. During PGY-3 to PGY-4, residents can be introduced to models of integrated clinical care. Residency programs with inpatient medicine/psychiatry units (sometimes called “complexity evaluation units”) allow resident exposure to the management of acute psychiatric and medical illness, while fulfilling the requirement to complete inpatient psychiatry rotations. Collaborative care, telepsychiatry, and traditional outpatient psychiatry consultation models would also prepare trainees in the area of integrated care. Additionally, specialty clinics with significant overlap with psychiatry such as pediatrics, neurology, oncology, palliative care, and pain medicine represent unique learning opportunities. These experiences, though not strictly fulfilling ACGME rotational requirements, map well on several other ACGME Milestones for systems-based practice, interpersonal communication, medical knowledge, and providing psychiatric consultation [12].
Examples of current behavioral health and primary care models of integration [18]
Models of integration
Brief description
Telepsychiatry
Consultation and education model that uses video connections to communicate with primary care providers and psychiatric patients Psychiatric care for patients in a non-psychiatric setting
Collocation and psychiatric consultation in the primary care or medical specialty setting Medicine/psychiatric or dual-trained care Mid-level behavioral health provider care Collaborative care
General medical and behavioral health conditions are addressed by providers who are dual-trained in medicine and psychiatry Assess need for psychiatric care and provide recommendations accordingly A behavioral health care manager (non-physician) works as a liaison among the psychiatrist, the primary care provider, and the patient. Diagnostic and treatment protocols are often utilized
Acad Psychiatry (2015) 39:461–465
Longitudinal Lecture Series IMAP lectures are clinically based and co-led by nonpsychiatry medical colleagues. Each 60- to 90-min learning session focuses on models of integrated care or a targeted and system-based approach to preventive medical care for those with mental illness. The following is a list of core IMAP curriculum objectives. &
& & &
Learn practical preventive medicine strategies so that psychiatrists can advocate for the physical health of their patients. Trainees will learn the essentials of preventive medicine with a focus on primary and secondary prevention of cardiovascular/pulmonary, endocrine, oncologic, infectious, pediatric, geriatric, and pain-related disorders. Understand how to effectively stay current over the course of a career on important changes to preventive medicine guidelines. Incorporate brief psychotherapies in order to optimize understanding and adherence to medical treatment plans. Understand how different models of integrated care can complement existing models of psychiatric practice.
Existing curricula can be easily used to teach psychiatric residents [13–15]. The Advancing Integrated Mental Health Solutions (AIMS) Center at the University of Washington has Table 2
463
developed a set of six online learning modules to support a clinical rotation in collaborative care. These modules cover the fundamentals of the role of a psychiatric consultant on a collaborative care team. This user-friendly introduction to teambased and collaborative care can be used to train psychiatrists to function in any role at the interface of primary care and mental health and may be useful in programs even where a collaborative care setting is not available [14]. A recommended curriculum, titled Preventive Medical Care in Psychiatry: A Practical Guide for Health Care Providers, covers common, potentially lethal, and treatable conditions found in the psychiatric patient population [15]. Psychiatry residents can review primary and secondary prevention measures related to nicotine dependence, obesity, immunization, cancer screening, cardiac risk assessment, prevention and treatment of sexually transmitted infections, and age-appropriate health screening (Table 2). These curricula will provide a framework for learners as they complete integrated rotations during residency training and prepare to enter a workforce with expanding integrated care opportunities.
IMAP Faculty Development and Combined-Trained Physicians Many psychiatry residency programs may not have an established curriculum on integrated care. We suggest an in-
Suggested IMAP learning topics and timeline for a longitudinal lecture series
PGY-2 Overview of preventive medicine aspects of psychiatric care Cardiopulmonary disordersa Endocrine/metabolic disordersa Infectious disordersa Oncologic disordersa Geriatricsa Pain medicinea PGY-3 Overview of mental health disparities and increased morbidity Learn how to provide patient-centered care Introduction to integrated and collaborative mental health care (1 of 2) Introduction to integrated and collaborative mental health care (2 of 2) Motivational interviewing in a collaborative setting (1 of 2) Motivational interviewing in a collaborative setting (2 of 2) Brief psychotherapies: cognitive behavioral therapy, problem solving therapy, and supportive psychotherapy PGY-4 Longitudinal learning in preventive medicine Teaching and providing consultation to colleagues Team-based learning (case-based) Fundamentals of health behavioral change Learning skills in advocacy for those with mental illness and comorbid health conditions
PGY postgraduate year a
Content is focused on primary and secondary preventive care strategies and not on primary care treatment of medical disorders
464
cremental or stepwise approach when considering how best to implement, while recruiting internal medicine, family medicine, pediatric, and OB/GYN faculty to co-lead with psychiatry faculty champions of integrated care. We recommend including primary care-based senior or chief residents to “cross teach” their respective discipline to psychiatry residents (e.g., internal medicine chief resident co-teaching a session on prevention of common infectious diseases in the psychiatric patient population). Conversely, senior psychiatry residents may consider co-teaching “primary care psychiatry” to primary care-based residents. Developing faculty to teach the IMAP curriculum can be challenging because of the overlap between general medicine and psychiatry. Combined-trained, double-board, or tripleboard certified physicians in family medicine-psychiatry, internal medicine-psychiatry, neurology-psychiatry, or pediatrics-psychiatry-child psychiatry represent a unique and highly trained physician force in integrated behavioral health and medical care and may be well positioned to provide and oversee this training [16, 17]. Unfortunately, there is a limited number of combined-training programs and graduates to meet this workforce need. We propose the following recommendations for IMAP faculty development when combined-trained faculty members are not available. 1. Encourage the incorporation of brief psychotherapies and motivational interviewing with most of the didactics (particularly when discussing preventive guidelines). 2. Consider inviting non-psychiatry faculty members from internal medicine, family medicine, pediatrics, and obstetrics-gynecology to discuss general medical topics. When possible, co-presenting with non-psychiatry faculty is ideal. 3. Choose course organizer(s) with a high level of familiarity about the IMAP curriculum, and mentor other faculty who wish to learn this content. 4. Use existing curriculum, as outlined in this article, as an educational supplement.
Acad Psychiatry (2015) 39:461–465
introduction to integrated systems of care as well as a comprehensive overview on preventive medical care for those with mental illness. This curriculum is designed to address the inherent vulnerability, increased morbidity, and premature death found in the psychiatric patient population. Partnership with non-psychiatry physician colleagues and crossdisciplinary learning is essential for this type of curriculum to be effectively delivered. Our specialty is in the early stages of integrated curricular development, and the next steps include further development and standardization, as well as measurement of practice pattern outcomes and patient satisfaction. Implications for Educators • Patients with mental illness are at increased risk for early death and morbidity. Psychiatric educators can address this by teaching trainees how to work collaboratively with other providers to address and potentially prevent common and treatable medical conditions. • Psychiatry residents may benefit from understanding different models of integrated care and how to incorporate the use of evidence-based brief psychotherapies into these types of practices. • Learners may benefit from exposure to a combination of didactics and clinical experiences in integrated and preventive medical care, which span over a 3–4-year period.
Acknowledgments The authors acknowledge Mehrbanoo Lashai. Disclosures Dr. Robert McCarron is an editor for the American Psychiatric Publishing textbook Preventive Medical Care in Psychiatry: a Clinical Guide for Health Care Providers, which is cited in the references.
References 1.
2.
3.
Discussion For myriad reasons, including the implementation of the Affordable Care Act, the practice of medicine and psychiatry is being transformed. Integrated systems of care such as collaborative and team-based care are increasing in number, particularly at VA and FQHC sites. Psychiatry residency training directors may consider revising their curricula to prepare future graduates better for a workforce that is increasingly integrated with general medicine. IMAP curriculum is both clinically and didactically based. We propose an established curriculum that covers both an
4. 5.
6.
7. 8.
Druss BG, Zhao L, von Esenwein S, et al. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care. 2011;49:599–604. Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry. 2007;64:1123–31. Crump C, Sundquist K, Winkleby MA, et al. Comorbidities and mortality in bipolar disorder: a Swedish national cohort study. JAMA Psychiatry. 2013;70:931–9. Mezuk B, Eaton W, Albrecht S, et al. Depression and type 2 diabetes over the lifespan. Diabetes Care. 2008;31:2383–90. Van der Kooy K, van Hout H, Marwijk H, et al. Depression and the risk for cardiovascular diseases: systematic review and meta-analysis. Int J Geriatr Psychiatry. 2007;22:613–26. American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity and Diabetes: Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care. 2004; 27:596–601. Jin H, Meyer JM, Jeste DV. Atypical antipsychotics and glucose dysregulation: a systematic review. Schizophr Res. 2004;71:195–212. Folsom DP, Okereke OI. Medical comorbidity in geriatric psychiatry. Am J Geriatric Psychiatry. 2005;13(3):177–9.
Acad Psychiatry (2015) 39:461–465 9.
Cowley D, Dunaway K, Forstein M, et al. Teaching psychiatry residents to work at the interface of mental health and primary care. Academic Psychiatry. 2014;38(4):398–404. 10. Reardon CL, et al. General and child and adolescent psychiatry resident training in integrated care: a survey of training directors. Academic Psychiatry. (In press) 11. Onate J, Hales R, McCarron R, et al. A novel approach to medicine training for psychiatry residents. Acad Psychiatry. 2008;32:518–20. 12. Accreditation Council for Graduate Medical Education: The psychiatry milestone project. November 2013. http://acgme.org/ acgmeweb/Portals/0/PDFs/Milestones/PsychiatryMilestones.pdf. Accessed September 9, 2014. 13. Raney LE. Integrated care: working at the interface of primary and behavioral health care. Arlington: American Psychiatric Publishing; 2015.
465 14.
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