Acad Psychiatry DOI 10.1007/s40596-014-0106-y
IN BRIEF REPORT
Status of General Medicine Training and Education in Psychiatry Residency Aniyizhai Annamalai & Robert M. Rohrbaugh & Michael J. Sernyak
Received: 16 July 2013 / Accepted: 11 October 2013 # Academic Psychiatry 2014
Abstract Objective With the current emphasis on integrated care, the role of psychiatrists is expanding to either directly provide medical care or coordinate its delivery. The purpose of this study was to survey general psychiatry programs on the extent of general medicine training provided during residency. Methods A short web-based survey was sent to 173 residency program directors to recruit participants for a larger survey. Thirty-seven participants were recruited and surveyed, and of these, 12 (32.4 %) responded. The survey assessed the extent of general medicine training and didactics during and after the first postgraduate year and attitudes towards enhancing this training in residency. This study was approved by the local institutional review board. Results Seventy-five percent of programs require only the minimum 4 months of primary care in the first postgraduate year, and didactics during these months is often not relevant to psychiatry residents. Some programs offer elective didactics on chronic medical conditions in the fourth postgraduate year. Respondents are in favor of enhancing general medicine training in psychiatry but indicate some resistance from their institutions. Conclusions These results suggest that very few programs require additional clinical training in relevant medical illnesses after the first postgraduate year. Respondents indicated favorable institutional support for enhancing training, but also expected resistance. The reasons for resistance should be an area of future research. Also important is to determine if enhancing medical didactics improves patient care and outcomes. The changing role of psychiatrists entails a closer look at resident curricula.
A. Annamalai (*) : R. M. Rohrbaugh : M. J. Sernyak Yale University, New Haven, CT, USA e-mail: [email protected]
Keywords Psychiatry . Education . Curriculum . Standards
People with serious mental illness have been demonstrated to have shortened life spans mainly due to chronic medical illnesses [1]. Given that for many people with serious mental illness (SMI), psychiatrists and mental health providers are their only point of contact with medical care [2], there has been an emphasis on integrating medical care into psychiatric care. In this model, psychiatrists can either provide the medical care directly or coordinate its delivery. This study focuses on the degree to which psychiatry residents (in residencies not leading to board certification in both general psychiatry AND internal medicine or family practice) receive training in medical issues. The current standard of the Accreditation Council for Graduate Medical Education (ACGME) states that psychiatry graduates should have a “sound clinical judgment” and “a high order of knowledge” of “all psychiatric disorders, together with other common medical and neurological disorders that relate to the practice of psychiatry” [3]. Residency training in psychiatry currently includes a mandatory minimum of 4 months of primary care in the first year. However, this allotted time in the first year is not necessarily tailored to the specific needs of psychiatry residents, and there is no requirement that these primary care skills be augmented, or even maintained, during the remainder of the residency. While the general impression among many leaders in psychiatric education is that there is a need for enhanced general medicine training in psychiatric residency with some models already implemented [4–7], to our knowledge, there is no systematic review of the status of general medicine training in psychiatry residencies or the attitudes of faculty and trainees towards this training. We initially sent a web-based survey of four questions to 173 residency directors; 37 (21 %) responded. Out of the 37
Acad Psychiatry
respondents, 12 completed a more detailed survey. The survey assessed the following features of programs: presence of dually board certified physicians, required and elective clinical time spent on general medicine during and after postgraduate year 1 (PGY1), extent and nature of curricular training on general medicine during and after PGY1, and attitudes towards enhancing general medical training in residency. This study was approved by the local institutional review board. Respondents were primarily from training programs educating 21–40 residents (58.3 %), with at least one dually board certified faculty member (66.6 %). Eight (75 %) programs reported offering only the minimum required 4 months of general medical training in postgraduate year 1 (PGY1). Only two reported required medical training after PGY1, but eight offered medical electives after PGY1. During medical rotations, mean of 4.45 h weekly (SD=2.5) were spent on didactics, but the proportion of time spent on medical issues specific to psychiatry ranged from 0 to 100 %. Five programs offered some didactics after PGY1, most commonly in postgraduate year 4 (PGY4). Various issues were addressed during didactic sessions: smoking cessation, 91 %; diabetes screening, 75 %; screening for hypertension and hyperlipidemia, 66.6 %; evaluating sexual dysfunction, 66.6 %; non-pharmacologic treatment of obesity, 66.6 %; and treatment of diabetes, hypertension, hyperlipidemia, and sexual dysfunction, 58.3 %. Only one program reported any formal instruction in other medical conditions such as human immunodeficiency virus, hepatitis, or urinary tract infections. Respondents were in favor of enhancing medical training in psychiatry; they also indicated a favorable attitude from their programs, but to a slightly lesser degree (see Table 1). Seven of 12 (58 %) respondents expected resistance by faculty to enhancing medical training during residency, and 5 of 12 (41 %) expected resistance from residents. These results suggest that very few programs require additional clinical training in the screening, diagnosis, or treatment of even the most common medical illnesses after PGY1, although many do offer electives in PGY4. Few programs offer didactics on medicine after PGY1, and the emphasis on topics specific to psychiatry was variable and even zero in some programs. Very few programs provide didactics in actual treatment of medical conditions though many do include didactics in preventive health care and screening for chronic medical conditions. Respondents endorsed educating residents about preventive care and screening for chronic medical conditions; they were equally interested in including training on actual treatment of medical issues resulting from psychiatric treatment. In addition, some innovative clinical programs were described— one program has PGY1 residents providing primary care to a panel of seriously mentally ill patients and another is building
Table 1 Enhanced medical training in psychiatry residency (n=11)
Internal medicine training after PGY1 Respondenta Programb Counseling in preventive care Respondent Program Screening for chronic medical conditions Respondent Program Treatment of medical adverse effects from psychiatric treatment Respondent Program Initial treatment of chronic medical conditions Respondent Program a
Mean
SD
Median
3.6 3.4
0.9 1.3
4 4
4.6 4.4
0.5 0.5
5 4
4.5 4.2
0.5 0.7
5 4
4.6 4.2
0.6 0.7
5 4
3.9 3.6
0.9 1.2
4 4
Refers to level of respondent agreement in including these curricular topics
b
Refers to level of perceived program support in including these curricular topics Numbers based on Likert scale: 1=strongly disagree; 2=disagree; 3= neutral; 4=agree; 5=strongly agree
an inpatient medical home for psychiatry patients (ref-private communication). While there is clearly an awareness of the importance of education in physical health issues for psychiatry residents, in almost all cases, required educational elements are limited to PGY1. In addition, while respondents indicated favorable institutional support, they also thought there would be resistance to any increase in the clinical time spent addressing medical issues. It would be useful to survey residents as they often drive curricular changes. The reasons for resistance were not addressed in the survey, but should be addressed in future research. Future research might also help determine if enhancing medical didactics and clinical experience improves patient care and outcomes. Limitations of this study are that the sample size is very small and respondents who answered this survey are more likely to be favorably inclined towards improved medical training. Estimates of didactic hours on medical issues described by the respondents may be higher than most programs as this group likely represents psychiatrists particularly committed to resident education on this subject and may be in a position to influence curriculum choices. Data presented here illustrate why trainee’s level of comfort with medical issues likely decreases after their internship with the current emphasis on integrating medical and psychiatric care; psychiatric educators should
Acad Psychiatry
consider methods which allow residents to maintain the competence in treating medical illness that they gained during internship. Our data suggests that there are already innovative programs being pursued throughout the country and that one of the first tasks would be to establish what these current “best practices” entail. Implications for Educators & The changing role of psychiatrists in the current health care system entails a shift in existing residency curricula. & Psychiatrists are increasingly responsible for ensuring medical care for mentally ill patients but results of this study indicate only minimal training in general medicine during residency. & Educators should consider innovative activities or programs to allow residents to maintain competence in general medicine.
Disclosure The authors have no conflicts of interest.
References 1. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis. 2006;3:A42. 2. Druss BG, Rosenheck RA. Locus of mental health treatment in an integrated health care setting. Psychiatr Serv. 2000;51:890–2. 3. ACGME http://www.acgme.org/acgmeweb/ProgramandInstitu tionalGuidelines/MedicalAccreditation//Psychiatry.aspx. 4. Kick SD, Morrison M, Kathol RG. Medical training in psychiatry residency. A proposed curriculum. Gen Hosp Psychiatry. 1997;19(4): 259–66. 5. Dobscha SK, Ganzini L. A program for teaching psychiatric residents to provide integrated psychiatric and primary medical care. Psychiatr Serv. 2001;52:1651–3. 6. Rohrbaugh RM, Felker B, Kosten T. The VA psychiatry-primary care education initiative. Acad Psychiatry. 2009;33(1):31–6. 7. Onate J, Hales R, McCarron R, Han J, Pitman D. A novel approach to medicine training for psychiatry residents. Acad Psychiatry. 2008;32(6):518–20.
IN BRIEF REPORT
Status of General Medicine Training and Education in Psychiatry Residency Aniyizhai Annamalai & Robert M. Rohrbaugh & Michael J. Sernyak
Received: 16 July 2013 / Accepted: 11 October 2013 # Academic Psychiatry 2014
Abstract Objective With the current emphasis on integrated care, the role of psychiatrists is expanding to either directly provide medical care or coordinate its delivery. The purpose of this study was to survey general psychiatry programs on the extent of general medicine training provided during residency. Methods A short web-based survey was sent to 173 residency program directors to recruit participants for a larger survey. Thirty-seven participants were recruited and surveyed, and of these, 12 (32.4 %) responded. The survey assessed the extent of general medicine training and didactics during and after the first postgraduate year and attitudes towards enhancing this training in residency. This study was approved by the local institutional review board. Results Seventy-five percent of programs require only the minimum 4 months of primary care in the first postgraduate year, and didactics during these months is often not relevant to psychiatry residents. Some programs offer elective didactics on chronic medical conditions in the fourth postgraduate year. Respondents are in favor of enhancing general medicine training in psychiatry but indicate some resistance from their institutions. Conclusions These results suggest that very few programs require additional clinical training in relevant medical illnesses after the first postgraduate year. Respondents indicated favorable institutional support for enhancing training, but also expected resistance. The reasons for resistance should be an area of future research. Also important is to determine if enhancing medical didactics improves patient care and outcomes. The changing role of psychiatrists entails a closer look at resident curricula.
A. Annamalai (*) : R. M. Rohrbaugh : M. J. Sernyak Yale University, New Haven, CT, USA e-mail: [email protected]
Keywords Psychiatry . Education . Curriculum . Standards
People with serious mental illness have been demonstrated to have shortened life spans mainly due to chronic medical illnesses [1]. Given that for many people with serious mental illness (SMI), psychiatrists and mental health providers are their only point of contact with medical care [2], there has been an emphasis on integrating medical care into psychiatric care. In this model, psychiatrists can either provide the medical care directly or coordinate its delivery. This study focuses on the degree to which psychiatry residents (in residencies not leading to board certification in both general psychiatry AND internal medicine or family practice) receive training in medical issues. The current standard of the Accreditation Council for Graduate Medical Education (ACGME) states that psychiatry graduates should have a “sound clinical judgment” and “a high order of knowledge” of “all psychiatric disorders, together with other common medical and neurological disorders that relate to the practice of psychiatry” [3]. Residency training in psychiatry currently includes a mandatory minimum of 4 months of primary care in the first year. However, this allotted time in the first year is not necessarily tailored to the specific needs of psychiatry residents, and there is no requirement that these primary care skills be augmented, or even maintained, during the remainder of the residency. While the general impression among many leaders in psychiatric education is that there is a need for enhanced general medicine training in psychiatric residency with some models already implemented [4–7], to our knowledge, there is no systematic review of the status of general medicine training in psychiatry residencies or the attitudes of faculty and trainees towards this training. We initially sent a web-based survey of four questions to 173 residency directors; 37 (21 %) responded. Out of the 37
Acad Psychiatry
respondents, 12 completed a more detailed survey. The survey assessed the following features of programs: presence of dually board certified physicians, required and elective clinical time spent on general medicine during and after postgraduate year 1 (PGY1), extent and nature of curricular training on general medicine during and after PGY1, and attitudes towards enhancing general medical training in residency. This study was approved by the local institutional review board. Respondents were primarily from training programs educating 21–40 residents (58.3 %), with at least one dually board certified faculty member (66.6 %). Eight (75 %) programs reported offering only the minimum required 4 months of general medical training in postgraduate year 1 (PGY1). Only two reported required medical training after PGY1, but eight offered medical electives after PGY1. During medical rotations, mean of 4.45 h weekly (SD=2.5) were spent on didactics, but the proportion of time spent on medical issues specific to psychiatry ranged from 0 to 100 %. Five programs offered some didactics after PGY1, most commonly in postgraduate year 4 (PGY4). Various issues were addressed during didactic sessions: smoking cessation, 91 %; diabetes screening, 75 %; screening for hypertension and hyperlipidemia, 66.6 %; evaluating sexual dysfunction, 66.6 %; non-pharmacologic treatment of obesity, 66.6 %; and treatment of diabetes, hypertension, hyperlipidemia, and sexual dysfunction, 58.3 %. Only one program reported any formal instruction in other medical conditions such as human immunodeficiency virus, hepatitis, or urinary tract infections. Respondents were in favor of enhancing medical training in psychiatry; they also indicated a favorable attitude from their programs, but to a slightly lesser degree (see Table 1). Seven of 12 (58 %) respondents expected resistance by faculty to enhancing medical training during residency, and 5 of 12 (41 %) expected resistance from residents. These results suggest that very few programs require additional clinical training in the screening, diagnosis, or treatment of even the most common medical illnesses after PGY1, although many do offer electives in PGY4. Few programs offer didactics on medicine after PGY1, and the emphasis on topics specific to psychiatry was variable and even zero in some programs. Very few programs provide didactics in actual treatment of medical conditions though many do include didactics in preventive health care and screening for chronic medical conditions. Respondents endorsed educating residents about preventive care and screening for chronic medical conditions; they were equally interested in including training on actual treatment of medical issues resulting from psychiatric treatment. In addition, some innovative clinical programs were described— one program has PGY1 residents providing primary care to a panel of seriously mentally ill patients and another is building
Table 1 Enhanced medical training in psychiatry residency (n=11)
Internal medicine training after PGY1 Respondenta Programb Counseling in preventive care Respondent Program Screening for chronic medical conditions Respondent Program Treatment of medical adverse effects from psychiatric treatment Respondent Program Initial treatment of chronic medical conditions Respondent Program a
Mean
SD
Median
3.6 3.4
0.9 1.3
4 4
4.6 4.4
0.5 0.5
5 4
4.5 4.2
0.5 0.7
5 4
4.6 4.2
0.6 0.7
5 4
3.9 3.6
0.9 1.2
4 4
Refers to level of respondent agreement in including these curricular topics
b
Refers to level of perceived program support in including these curricular topics Numbers based on Likert scale: 1=strongly disagree; 2=disagree; 3= neutral; 4=agree; 5=strongly agree
an inpatient medical home for psychiatry patients (ref-private communication). While there is clearly an awareness of the importance of education in physical health issues for psychiatry residents, in almost all cases, required educational elements are limited to PGY1. In addition, while respondents indicated favorable institutional support, they also thought there would be resistance to any increase in the clinical time spent addressing medical issues. It would be useful to survey residents as they often drive curricular changes. The reasons for resistance were not addressed in the survey, but should be addressed in future research. Future research might also help determine if enhancing medical didactics and clinical experience improves patient care and outcomes. Limitations of this study are that the sample size is very small and respondents who answered this survey are more likely to be favorably inclined towards improved medical training. Estimates of didactic hours on medical issues described by the respondents may be higher than most programs as this group likely represents psychiatrists particularly committed to resident education on this subject and may be in a position to influence curriculum choices. Data presented here illustrate why trainee’s level of comfort with medical issues likely decreases after their internship with the current emphasis on integrating medical and psychiatric care; psychiatric educators should
Acad Psychiatry
consider methods which allow residents to maintain the competence in treating medical illness that they gained during internship. Our data suggests that there are already innovative programs being pursued throughout the country and that one of the first tasks would be to establish what these current “best practices” entail. Implications for Educators & The changing role of psychiatrists in the current health care system entails a shift in existing residency curricula. & Psychiatrists are increasingly responsible for ensuring medical care for mentally ill patients but results of this study indicate only minimal training in general medicine during residency. & Educators should consider innovative activities or programs to allow residents to maintain competence in general medicine.
Disclosure The authors have no conflicts of interest.
References 1. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis. 2006;3:A42. 2. Druss BG, Rosenheck RA. Locus of mental health treatment in an integrated health care setting. Psychiatr Serv. 2000;51:890–2. 3. ACGME http://www.acgme.org/acgmeweb/ProgramandInstitu tionalGuidelines/MedicalAccreditation//Psychiatry.aspx. 4. Kick SD, Morrison M, Kathol RG. Medical training in psychiatry residency. A proposed curriculum. Gen Hosp Psychiatry. 1997;19(4): 259–66. 5. Dobscha SK, Ganzini L. A program for teaching psychiatric residents to provide integrated psychiatric and primary medical care. Psychiatr Serv. 2001;52:1651–3. 6. Rohrbaugh RM, Felker B, Kosten T. The VA psychiatry-primary care education initiative. Acad Psychiatry. 2009;33(1):31–6. 7. Onate J, Hales R, McCarron R, Han J, Pitman D. A novel approach to medicine training for psychiatry residents. Acad Psychiatry. 2008;32(6):518–20.
