Because many patients receive care for their psychiatric disorders from primary care physicians, the development of appropriate ambulatory-care models of training is imperative.1 Unfortunately, the training of family medicine (FM) residents in psychiatry has for many years taken place on busy inpatient psychiatry units or in adult psychiatry clinics in academic medical centers. The problem is obvious: the patients seen by the FM resident bear little resemblance to those routinely encountered in the primary care setting.2
At the University of Florida (UF), under the auspices of the Community Psychiatry Program, training of second-year FM residents in psychiatry occurs through a unique clinical collaboration emphasizing the integration of psychiatric services with the delivery of primary care.
During their one-month psychiatry rotation, the FM residents have the opportunity to develop their knowledge and skills in psychiatric diagnostic assessment, psychotherapy, and psychopharmacologic management within a context of integrated primary care. The Clinic of Integrated Primary Care (CIPC) serves as the main training site for UF FM residents in their attempt to better recognize and treat the most common psychiatric disorders.
The CIPC was established in October 2001 through a collaboration between UF's Community Psychiatry Program and the Community Health Family Medicine (CHFM) primary care clinic. The CHFM clinic, based in urban Jacksonville, is staffed by six family physicians, two nurse practitioners, and one physician assistant. It provides primary care to over 10,000 unduplicated patients annually. As in most FM practices, many of the clinic's patients seek treatment for psychiatric disorders as well as their primary care needs.
In 2002, mental health services were integrated into the daily flow of the clinic through the presence of an attending psychiatrist from the Community Psychiatry Program, a rotating second-year FM resident, and a PhD psychotherapist. A collaborative model of care was developed whereby the primary care provider discusses those patients evidencing prominent psychiatric symptoms and/or disorders with the psychiatrist and the resident. The resident then, under the direct supervision of the psychiatrist, conducts a psychiatric assessment. Upon completion of the evaluation, with the patient present and participating, diagnosis (e.g., the name of the disorder, education regarding symptoms, information pertaining to etiology), treatment (e.g., pharmacolgic intervention, psychotherapy options, identification of social supports), and longitudinal follow-up are discussed and outlined.
This model of training attempts to achieve several objectives. First, it seeks to impart to residents the psychiatric knowledge and skills required to meet the needs of the patients they are likely to encounter in the primary care setting. Second, by providing direct supervision of the resident, the attending physician is able to highlight the emotional aspects of physical illnesses as well as draw attention to the psychosocial dimensions of patient care. Finally, this model promotes medical specialty collaboration and multidisciplinary teamwork in meeting the complex needs of the primary care patient with mental health issues.
This model has worked well at UF and could be replicated elsewhere. Evaluations completed by the FM residents this past year have been uniformly positive. The rotation has received superior ratings for relevance to practice, variety of patients, value of knowledge, and quality of supervision. We hope to develop longitudinal measures to ascertain whether the rotation has produced primary care physicians who demonstrate superior knowledge and skills in psychiatric care.
1. Matorin AA, Ruiz P. Training family practice residents in psychiatry: an ambulatory training model. Int J Psychiatry Med. 1999;29:327–36.
2. Walsh A, Davine J, Kates N: Teaching behavioral science to family medicine residents: integrating training into the family practice unit. Isr J Psychiatry Relat Sci. 1998;35:114–9.