Psychosocial training in U.S. internal medicine and family practice residency programs

Identifying core curricular components for behavioral health training in internal medicine residency: Qualitative interviews with residents, faculty, and behavioral health clinicians

OBJECTIVE

Behavioral health services frequently delivered by primary care providers include care for mental health and substance abuse disorders and assistance with behavioral risk factor reduction. Internal medicine residencies in the United States lack formal expectations regarding training in behavioral health for residents. This qualitative study aimed to determine learners' and teachers' perceptions about appropriate behavioral health curricular components for internal medicine residents.

METHOD

Focus groups and interviews were conducted with the following individuals from the Duke Outpatient Clinic: residents with continuity practice (n = 27), advanced practice providers (n = 2), internal medicine attending physicians (n = 4), internal medicine/psychiatry attending physicians (n = 2), and behavioral health clinicians (n = 4). A focus group leader asked regarding residents' successes and challenges in managing behavioral health issues and about specific learning components considered necessary to understand and manage these behavioral health conditions. Transcripts were coded using an editing analysis style to identify central themes and concordance/discordance between groups.

RESULTS

Regarding mental health management (Theme 1), residents emphasized a need for better care coordination with specialty mental health, while attendings and behavioral health clinicians gave priority to residents' skills in primary management of mental health. Residents, attendings, and behavioral health clinicians all emphasized advanced interviewing skills (Theme 2) with subthemes: eliciting the patient's perspective, managing time in encounters, improving patients' understanding, and patient counseling.

CONCLUSIONS

Internal medicine residents, attendings, and behavioral health clinicians may differ significantly in their perceptions of primary care's role in mental health care. Future internal medicine behavioral health curricula should specifically address these attitudinal differences. Curricula should also emphasize interview skills training as an essential component of behavioral health learning.

"Conversational Advice": A mixed-methods analysis of medical residents' experiences co-managing primary care patients with behavioral health providers

OBJECTIVE

When integrated behavioral health clinicians (IBHCs) and residents co-manage patients, residents may learn new approaches. We aimed to understand the effect of co-management on residents' behavioral health (BH) management learning.

METHODS

Residents completed a web-based survey enquiring: whether co-management included a shared visit and/or face-to-face meeting with an IBHC, whether residents received feedback from the IBHC, and what they learned. Qualitative responses were coded thematically using a constant comparative method.

RESULTS

Among 117 respondents (overall response rate 72%, 117/163), from five residencies recruited from 40 residencies with BH integration, residents were significantly more likely to receive feedback if they had a shared visit with the patient and an IBHC (yes 69% vs. no 33%; adjusted OR 3.0, 95% CI 1.2-7.6). Residents reported three major learning themes: interpersonal communication skills awareness, BH skills awareness, and newly adopted attitudes toward BH. Residents who received feedback were more likely to report themes of interpersonal communication skills awareness (yes 26.6% vs. no 9.4%).

CONCLUSION

BH integration promotes increased feedback for residents practicing face-to-face co-management with IBHCs, and a positive influence regarding residents' attitudes and perceived skills.

PRACTICAL IMPLICATIONS

Residency programs can meaningfully improve residents' learning by promoting face-to-face co-management with IBHCs.

Differences in prescribing patterns for anxiety and depression between General Internal Medicine and Family Medicine

INTRODUCTION

Depression and anxiety are routinely managed by physicians in Family Medicine (FM) or General Internal Medicine (GIM). Because FM requires more behavioral health training than GIM, we sought to determine if prescribing patterns for patients with anxiety, depression, or both differed between FM vs. GIM providers.

METHODS

In a cross-sectional design, patient data and provider type were obtained from 2008 to 2013 electronic medical record patient data registry (n=27,225 (FM=10,994, GIM=16,231)) Prescription orders were modeled for specific benzodiazepines and antidepressants and by drug class. Covariates included gender, age, race, marital status and comorbidity index. Separate logistic regression models were computed, before and after adjusting for covariates, to estimate the odds of FM vs. GIM providers prescribing benzodiazepine or antidepressant medication to patients with anxiety, depression, and both disorders.

RESULTS

After adjusting for covariates, patients with anxiety alone, depression alone, and both had significantly greater odds of receiving an antidepressant (OR=2.08;95%CI:1.46-2.96, OR=2.13;95%CI:1.48-3.06, and OR=2.26;95%CI:1.09-4.66, respectively) if treated by FM vs. GIM. Benzodiazepine prescription did not differ by physician type.

LIMITATIONS

It is not known if results will generalize to other regions of the United States.

CONCLUSIONS

Patients with anxiety, depression, and both seen by FM providers, as compared to GIM providers, are more likely to receive antidepressant medications. Further investigation into the determinants of these differences is warranted. Under-treatment in GIM may result in less advantageous outcomes.

Differences between internists and family practitioners in the diagnosis and management of the same patient with coronary heart disease

It has been suggested that internists and family practitioners have somewhat different "disease" perspectives, which may be generated by use of different explanatory models during medical training (pathophysiological vs. biopsychosocial, respectively). This article explores differences between internists and family practitioners in their suggested diagnoses, level of diagnostic certainty, test and prescription ordering, when encountering exactly the same "patient" with coronary heart disease (CHD). Internists were more certain of a CHD diagnosis than family practitioners and were more likely to act on this diagnosis. Family practitioners were more likely to diagnose (and were more certain of) a mental health condition. While many physicians simultaneously entertain several alternate diagnoses, diagnostic certainty has shown to have an important influence on subsequent clinical actions, such as stress testing and prescription of beta blockers. These results may inform future educational strategies designed to reduce diagnostic uncertainty in the face of life-threatening conditions, such as CHD.

Jeopardy!: an innovative approach to teach psychosocial aspects of pediatrics

OBJECTIVE

Medical educators have used Jeopardy! game to teach medical knowledge. None has reported using it to teach psychosocial aspects of medicine.

METHODS

As part of a cross-cultural communication curriculum for residents in an urban, medically underserved area, we piloted "Bronx Jeopardy!to teach psychosocial aspects of the surrounding community. We applied the same rules used in the popular game show. Participants were asked to complete a survey to rate the content and format of the training.

RESULTS

Thirty-four residents participated; 30 (88%) completed the survey. Most reported that the information was new. Almost all reported increased understanding of community diversity, desire to learn more about it, and raised awareness of its challenges and resources. All believed that the session helped dispel negative stereotypes. Regarding format, all participants reported that it built collegiality, stimulated interest, was a fun and effective way to learn, and helped retain information.

CONCLUSION

Bronx Jeopardy! was a fun and effective way to learn about psychosocial aspects of pediatrics.

PRACTICE IMPLICATIONS

Using a gaming format, Bronx Jeopardy! demonstrated an application of Adult Learning Theory. With an expanding questions bank, the tool can be adapted for teaching this topic in other residency programs.

Primary care providers' views of challenges and rewards of dementia care relative to other conditions

OBJECTIVES

To compare primary care providers' (PCPs') perceptions about dementia and its care within their healthcare organization with perceptions of other common chronic conditions and to explore factors associated with differences.

DESIGN

Cross-sectional survey.

SETTING

Three California healthcare organizations.

PARTICIPANTS

One hundred sixty-four PCPs.

MEASUREMENTS

PCPs' views about primary care for dementia were analyzed and compared with views about care for heart disease, diabetes mellitus, and selected other conditions. Differences in views about conditions according to PCP type (internists, family physicians) were assessed. Multivariate analysis examined relationships between provider and practice characteristics and views about dementia care.

RESULTS

More PCPs strongly agreed that older patients with dementia are difficult to manage (23.8%) than for heart disease (5.0%) or diabetes mellitus (6.3%); PCPs can improve quality of life for heart disease (58.9%) and diabetes mellitus (61.6%) than for dementia (30.9%); older patients should be routinely screened for heart disease (63.8%) and diabetes mellitus (67.7%) than dementia (55.5%); and their organizations have expertise/referral resources to manage diabetes mellitus (49.4%) and heart disease (51.8%) than dementia (21.1%). More PCPs reported almost effortless organizational care coordination for heart disease (13.0%) or diabetes mellitus (13.7%) than for dementia (5.6%), and a great deal or many opportunities for improvement in their ability to manage dementia (50.6%) than incontinence, depression, or hypertension (7.4-34.0%; all P<.05). Internists' views regarding dementia care were less optimistic than those of family physicians, but PCP type was unrelated to views on diabetes mellitus or heart disease.

CONCLUSION

Improving primary care management of dementia should directly address PCP concerns about expertise and referral resources, difficulty of care provision, and PCP views about prospects for patient improvement.

Contextualizing cultural competence training of residents: results of a formative research study in Geneva, Switzerland

Medical training programs need to prepare physicians to provide care to increasingly diverse patient populations. While the general concepts and approaches of clinical cultural competence are broadly relevant across contexts, the content of cultural competence training should reflect and respond to the specific needs and challenges of clinicians in their local reality. In order to better understand and respond to the needs and challenges of residents working with diverse patients in Geneva, Switzerland, depth interviews with physicians and professional medical interpreters and direct observations of consultations were combined. Cross-cultural communication difficulties were intertwined with more general difficulties related to primary care in an outpatient context, and physicians' frustrations reflected the expectations and image of medicine that they developed during their hospital-centered training. Study results point to the need to understand how cross-cultural communication challenges articulate with other aspects of the clinical context.

Mental health and psychiatry training in primary care residency programs. Part II. What skills and diagnoses are taught, how adequate, and what affects training directors' satisfaction?

OBJECTIVE

The purpose of this study is to describe the psychiatric skills and diagnostic categories taught in primary care training programs, their adequacy, the perceived needs and desires for curriculum enhancement and the factors affecting training directors' satisfaction.

METHOD

All 1365 directors of accredited residency training programs in Internal Medicine (IM), Family Practice (FP), Obstetrics and Gynecology (Ob/Gyn), Pediatrics (Peds) and psychiatry received a 16-item anonymous questionnaire about psychiatry training in their program. Responses to the questionnaire to items concerning the skills and diagnostic categories taught, assessment of adequacy of teaching and desires for curriculum enhancement for specific skills and diagnostic categories were analyzed. The factors affecting training directors' satisfaction were explored.

RESULTS

Interviewing skills were taught by a majority of all training programs and were considered adequate by 81% of FP and 54% of IM programs, in contrast to less than a majority of Ob/Gyn and Peds programs (P<.001). A majority provided diagnostic interviewing and counseling training, but only FP considered it adequate. A majority taught psychopharmacology and various psychiatric diagnoses, but only in FP did a majority consider them adequate. Both Peds and FP programs teach child psychiatry; significantly, more Peds compared to FP consider their training to be adequate. A vast majority of IM, Ob/Gyn and Peds programs, and 50% of FP programs desired more training in interviewing techniques and diagnostic interview. A majority of all programs desired more counseling and psychopharmacology training and more training in disorders of childhood and adolescence. The overall satisfaction rate for psychiatric training across specialties was 46% (n=657). Sixty-four percent of FP programs were satisfied compared to 31% of non-FP programs. Satisfaction was associated with increased amount of psychiatric training, diversity of training formats, venues, faculty and settings, the amount of contribution to teaching by psychiatry departments and the presence of current teaching in interviewing skills. There were specialty-specific differences in factors associated with satisfaction. In general, a smaller size of residency program was associated with satisfaction except in IM, where larger size was associated with satisfaction. Satisfaction was associated with the opinion that primary care physician should be ready and willing to treat more psychiatric conditions.

CONCLUSION

Most primary care training programs currently offer training in most psychiatric skills and disorders, but a majority of training directors are dissatisfied with their psychiatry training. There is a difference in the estimation of adequacy concerning training between FP, which consistently rates their teaching to be adequate, and all other primary care programs, which consider their teaching inadequate. This difference may be partly due to actual differences in amount and diversity of training as well as differences in the threshold for satisfaction. A vast majority of primary care training programs desire more training in almost all aspects of psychiatry, and there may be specialty-specific needs and areas of curriculum enhancement. To enhance satisfaction, we should improve the quality as well as the quantity of training, as well as the diversity in training formats, venues and faculty.

Mental health and psychiatry training in primary care residency programs. Part I. Who teaches, where, when and how satisfied?

OBJECTIVE

Some 40% of patients treated by primary care physicians have significant mental health problems. Only about half eventually receive mental health care, usually by the primary care physicians, often inadequately. Recently, there has been an increased attempt to incorporate psychiatry in primary care training programs. The authors sought to assess the current status of psychiatry training in Internal Medicine (IM), Family Practice (FP), Pediatrics (Peds) and Obstetrics and Gynecology (Ob/Gyn) residency programs.

METHOD

All 1365 directors of accredited residency training programs in IM, FP, Ob/Gyn and Peds received a 16-item anonymous questionnaire in 2001-2002, collecting descriptive data concerning their psychiatry training.

RESULTS

A great majority of IM (71%), Ob/Gyn (92%) and Peds (85%) training directors felt that the training was minimal or suboptimal, as compared to 41% of FP training directors (P<.001). Sixty-four percent of FP program directors were satisfied with their training (P<.001). In contrast, 54% of other PC program directors were dissatisfied with their psychiatry training. All programs utilized ambulatory care setting extensively. Family Practice programs had more types of mental health teachers, teaching formats and teaching settings (P<.001). A majority of IM (57%) and Peds (70%) residencies desired more psychiatry training in their programs compared to only a third of FP and 40% of Ob/Gyn programs (P<.001). Teaching in clinical settings was preferred by all except Ob/Gyn programs (P<.001). Psychiatry departments contributed more to IM and Peds programs than others.

CONCLUSION

A majority of primary care training programs are dissatisfied with the current status of their psychiatric training except for FP programs. Family Practice programs have the most variety in training formats, venues and teachers. There are some specialty-specific differences in perceived needs and desires in psychiatric training.

Changing habits of practice. Transforming internal medicine residency education in ambulatory settings

PURPOSE

The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change.

METHODS

The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance.

RESULTS

Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education.

CONCLUSION

This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident's level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia.

Family physicians' involvement and self-reported comfort and skill in care of children with behavioral and emotional problems: a population-based survey

Background

Little is known about general and family practitioners' (GP/FPs') involvement and confidence in dealing with children with common psychosocial problems and mental health conditions. The aims of this study were to ascertain GP/FPs' preferred level of involvement with, and perceived comfort and skill in dealing with children with behavioral problems, social-emotional difficulties, attention-deficit/hyperactivity disorder (ADHD), and mood disorders; and to identify factors associated with GP/FPs' involvement, comfort and skill.

Methods

Postal survey of a representative sample of 801 GP/FPs in British Columbia, Canada, which enquired about level of involvement (from primarily refer out to deal with case oneself); ratings of comfort/skill with assessment/diagnosis and management; beliefs regarding psychosocial problems in children; basic demographics; and practice information.

Results

Surveys were completed by 405 of 629 eligible GP/FPs (64.4%). Over 80% of respondents reported collaborative arrangements with specialists across problem and condition types, although for children with behavior problems or ADHD, more physicians primarily refer (χ² (1) = 9.0; P < 0.005; and χ² (1) = 103.9; P < 0.001, respectively). Comfort/skill levels (mean ± s.d) were higher for mood disorders (4.4 ± 1.3) than behavior problems (3.6 ± 1.1; F [3, 1155] = 84.0, P < .0001; effect size = 0.67), but not different from social-emotional difficulties (3.8 ± 1.1) or ADHD (3.9 ± 1.3). Taking primary responsibility for a case was consistently related to self-reported comfort/skill with each condition type (34% to 61% of variance across condition types), while comfort/skill ratings for each condition were related to exposure to relevant continuing medical education (all P ≤ 0.001), and beliefs that these problems are significant and that GP/FPs have a role to play in dealing with them (P values ranged from 0.01 to <0.001).

Conclusion

Supporting GP/FPs in their care for children with common psychosocial and mental health problems should include efforts to bolster their confidence and modify attitudes in relation towards these problems, especially behavior problems and ADHD, possibly within innovative continuing education programs.

More training needed in chronic care: a survey of US physicians

PURPOSE

Although more than 125 million North Americans have one or more chronic conditions, medical training may not adequately prepare physicians to care for them. The authors evaluated physicians' perceptions of the adequacy of their chronic illness care training to and the effects of training on their attitudes toward care of persons with chronic conditions.

METHOD

In November 2000 through June 2001, the authors surveyed by telephone a random sample of U.S. physicians who had > or =20 hours of patient contact per week. The interview instrument examined demographics, career satisfaction, practice characteristics, perceived adequacy of chronic illness care training in ten competencies (geriatric syndromes, chronic pain, nutrition, developmental milestones, end-of-life care, psychosocial issues, patient education, assessment of caregiver needs, coordination of services, and interdisciplinary teamwork), and effect of training on attitudes toward chronic illness care.

RESULTS

Of 1,905 eligible physicians, 1,236 (65%) responded (270 family or general practitioners, 231 internists, 129 pediatricians, 335 nonsurgical specialists, and 271 surgeons). Most physicians reported their chronic disease training was less than adequate for all ten competencies. Family practitioners were more likely (p <.05) to report adequate training in seven competencies compared with internists, and in two to four competencies when compared with pediatricians, nonsurgical specialists, or surgeons. Most physicians reported that training had a positive effect on attitudes toward care of people with chronic conditions, including the ability to make a difference in their lives (74-84%).

CONCLUSIONS

Physicians perceived their medical training for chronic illness care was inadequate. Medical schools and residencies may need to modify curricula to better prepare physicians to treat the growing number of people with chronic conditions.