October 6, 2000

education & training

Primary Care Residents Not Getting Sufficient Training in Psychiatry

Two-thirds of primary care residency training directors believe that their residents are not receiving sufficient training in psychiatry. However, a San Francisco residency training program strives to remedy this problem.

Studies show that primary care physicians provide as much as three-quarters of psychiatric care in the country. With many questions and few data about the extent of psychiatric training of primary care residents in their residency programs, a research team at the University of California at San Francisco (UCSF) sought answers. Not knowing what to expect, they found that "real-time" supervision is most commonly used to train primary care residents in psychiatry and that psychiatrists are not the only ones doing the training.

The survey aimed to determine, among other issues, whether there was didactic training, who led the training, and the format in which it was taught. H. Paul Chin, M.D., and colleagues sent a one-page questionnaire with seven questions to the residency training directors of the 101 primary care–internal medicine residencies in the U.S., and the results were published in the September-October issue of Psychosomatics.

Fifty-four of the residency training programs responded, and data showed an average of 65 hours of the three-year residency was spent in clinical psychiatric training. Most of this time was spent in outpatient psychiatry. In addition, 83 percent of the residency programs offered lectures in psychiatry, while 23 percent offered seminars and 19 percent offered interviewing courses. The training programs used more than one training format. Training techniques were centered mostly on real-time supervision, at 74 percent, and the next most popular technique was videotaping. Other techniques included case conferences and written tests.

Courses may have been taught by more than one discipline, so of all the residency programs, psychiatrists taught in most of the didactic courses, but primary care physicians taught in 70 percent of the courses, psychologists taught in 28 percent, and social workers in 21 percent.

Commented Chin, a staff psychiatrist at California Pacific Medical Center in San Francisco, "We didn’t know what to expect in regard to the study findings, but we did get a sense that psychiatric training is not a top priority in these residency programs."

Are the primary care physicians prepared to diagnose and treat these patients adequately? No, according to residency training directors. When questioned by the researchers, 63 percent of the respondents believed that more psychiatry training was needed in their programs.

James Thompson, M.D., M.P.H., director of APA’s Division of Education, Minority, and National Programs agreed, adding, "Another area of concern is that often primary care physicians are not well informed about when they should make a referral to a psychiatrist. We have been working with the American Academy of Family Physicians to help develop materials that will help their members in the diagnosis, treatment, and timely referral of patients with psychiatric disorders."

UCSF Program Sets Standard

What these training directors might hope for is already a part of the University of California, San Francisco–Mount Zion primary care–internal medicine residency program. Residents in this model program are required to complete a two-month rotation through the psychiatry outpatient consultation clinics, perform psychiatric evaluations, provide medication management, and plan treatment under the direct supervision of a PGY-4 resident or attending in psychiatry.

Chin, who trained the primary care residents at the UCSF program in 1998 and 1999, emphasized that the residents in the program were very enthusiastic about the psychiatry training. "They appreciated the extra time they had to think about a patient, formulate a treatment, and have the opportunity to see beyond the medical problems—to see the patient as a whole person."

The residents are also prepared to depend on their psychiatric counterterparts for necessary help. Stated Chin, "One of the things we conveyed to the primary care doctors was not just the limitations of what we can do as consulting psychiatrists, but the limitations of what they can do in their offices." He believes that the residents entered the training program with that understanding, given their limited knowledge base and the time they would have to address any complicated psychosocial issues. "Another thing we wanted to instill was a collegiality between ourselves [the psychiatrists] and the primary care residents, so that they would be comfortable referring these patients to us," he added.

Challenges Faced

There were some challenges that Chin and C-L psychiatrist Steve Prakken, M.D., another investigator on the study, faced in training the primary care residents. "The main challenge at first was figuring out what their needs were," stated Chin. "We found that they wanted more psychopharmacology training, and we actually changed the residency training program to focus more on that area."

The residency program turned out to be a mutually beneficial relationship, according to Chin. "We learned from the residents as well in terms of treating patients with more complex medical problems."

The researchers highlighted some of the obstacles to proper diagnosis and treatment of primary care patients with psychiatric illnesses. For one, there is a thin line between psychiatric and medical symptoms in many primary care patients. Symptoms may range from chronic fatigue to acute cardiac problems, which could either indicate a general medical or a psychiatric disorder. There is also the ever-present shadow of stigma.

"Nonpsychiatric physicians may not want to deal with the emotional pain in their patients because of what it might bring up in them—thoughts they don’t feel comfortable with," Prakken speculated.

The survey results may be biased in at least one respect: those programs that returned the survey may have been more likely to have psychiatry training in their program or view the training as a high priority, noted the authors. In addition, the study was limited because the survey was not sent to all primary care residencies, such as family practice.

"To a certain extent, changing the way people view psychiatry will always be an uphill battle," commented Chin, who entered medical school with a resolve to become a primary care physician. After he completed his rotations, however, he decided to become a psychiatrist. "That was one of the things that led me to pursue this training and be a consultation-liaison psychiatrist."