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Education and Training
This section describes the literature on resident training and family physician continuing medical education (CME) relevant to mental health care in the primary care setting. It should be noted that most of the papers which deal with the mental health care training of primary care physicians, either as residents or later through CME, are concerned with improving detection, diagnostic, and treatment skills. Few directly address the knowledge and skills necessary to work effectively in shared care models. Similarly, few articles describe training programs designed to enhance the consultation or collaborative skills of psychiatrists or psychiatry residents.
The training of family medicine residents in psychiatry has received considerable attention in the literature. It is generally accepted that mental health problems may present differently in primary care, with different frequencies and different comorbidities. This has implications for the classification of mental disorders in primary care and also for the kinds of skills needed to care for patients with mental health problems in the primary care setting. A paper by Goldberg and Gater (1996) uses data from the World Health Organization study of mental illness in general health care to highlight the need for trainees to be taught about mental health problems that GPs are likely to meet in their everyday work.
Stoudemire (1997) discusses the implications of the emergence of the US managed care system for the education of primary care physicians. He sets out a simplified curriculum for the training of primary care physicians in psychiatric and behavioural disorders. This includes basic communication and interviewing skills, psychosocial data and mental status examination, differential diagnosis and case formulation, basic psychotherapeutic skills and management of emotional reactions to various stressors, recognition and basic treatment of uncomplicated presentations of psychiatric disorders, and guidelines for psychiatric referral. He recommends that basic modules be developed in each of these areas for teaching purposes.
Other writers (Cole and others 1995; Stoudemire 1997) have also produced needs assessments and curricula for training family medicine residents in psychiatry. Covington and others (1987) proposed setting standards for psychiatric training for residents and introduced their use in Ohio. Fisman and others (1996) discuss the development of learning objectives for teaching child psychiatry to family medicine trainees and the evaluation of these objectives. This latter paper will be of assistance to those seeking to develop child psychiatry training within a family medicine program. Strain and others (1985) provide a questionnaire that they administered to mental health training program directors to assess the nature and content of behavioural-science mental health training as a basis for program assessment. Unfortunately, none of these curricula appear to address residents needs for skill development in collaborative care.
Four articles describe training programs that provided psychiatry and family medicine residents with opportunities to train in nontraditional settings or to share training experiences. Franco (1993) describes a consultation-liaison rotation shared by family medicine and internal medicine residents. Both groups of residents felt they had benefited from the experience and urged continuation of the program. Burns and others (1995) describe a project in the UK wherein 18 psychiatric trainees spent 6 months each as general practice trainees. This was a randomized controlled trial with 14 trainees in the control group. Several forms of assessment were undertaken, including rating of videotapes and assessments of the trainees abilities to solve clinical problems, understand legal responsibilities, and understand some of their own limitations. At the end of the intervention period, there were relatively small differences between the experimental and the control group in terms of improving the participants interviewing style or skills. However, they did demonstrate more confidence as practising physicians. This study is notable for the detail and care of the evaluation and for its use of a randomized controlled trial methodology. Leverette and Massabki (1995) describe the development of a training site for residents and 4th-year medical students designed to provide some experience and training for child psychiatry in a rural setting. The training-program priorities, training-site characteristics, and definition of the objectives are all provided in their paper.
Phongsavan and others (1995) surveyed GPs in New South Wales to identify their educational priorities and training preferences with regard to mental health care. Clinical problems presenting at least once weekly for most practitioners included psychosomatic, emotional, addiction, socioeconomic, and family problems. The educational priorities identified included diagnostic and counselling skills, with particular emphasis on crisis, family, individual, and marital counselling, as well as strategies to prevent GP burnout.
Davis and others (1992) reported on evidence for the effectiveness of CME after reviewing 50 randomized controlled trials of CME. Their general conclusion was that CME can effectively improve the knowledge base, skills, and outcomes of practising physicians but that educational programs differ in their effectiveness. Those that use practice-enabling or reinforcing strategies improve physician performance and, in some trials, health care outcomes.
Thompson and others (2000) conducted a randomized controlled trial of CME for family physicians using a clinical practice guideline for the recognition and treatment of depression. Compared with a control group, family physicians who had received the practice-based education program did not increase their recognition of depression or improve the clinical outcomes of patients diagnosed with depression. The authors questioned whether the negative findings may have been attributed to high levels of knowledge and expertise in both groups prior to the intervention.
Sriram and others (1990) describe a program of short-term training in mental health care for primary care medical officers that was evaluated using a pre- and posttraining questionnaire. They demonstrated improved knowledge among the physicians, particularly among those who were younger and those who had low pretraining scores.
Carr and others (1997a) attempted to determine the impact of a community-based consultation-liaison psychiatry service on family physician levels of psychiatric knowledge and practice in Australia. Those physicians with long-term access to the consultation-liaison service had slightly better psychiatric knowledge than those with little or no access. However, there was no evidence that the consultation-liaison service produced changes in levels of confidence or psychiatric knowledge during the 12-month evaluation period. Despite the participating physicians high degree of satisfaction with the service, the authors concluded that community consultation-liaison services in family practice are not an efficient method of improving the level of psychiatric knowledge of family physicians.
Davies and others (1997) described a successful educational program that included conferencing between mental health staff and GPs, a didactic component, and case discussions as a preparation phase prior to introducing a shared care program in Australia. The success of this program deserves greater attention, because it suggests that preparation for participation in shared care initiatives may improve their effectiveness.
Wulsin (1996 ) describes a change in the relation between psychiatry and primary care in the US, primarily because of a greater emphasis on the primary care physician as the gatekeeper to other services. Recent surveys suggest that departments of psychiatry have done little to restructure their relations with primary care services. This article proposes an agenda for developing primary care psychiatry programs in departments of psychiatry and suggests high-priority projects in research, education, and clinical care.
A limited number of papers address the training of psychiatry residents to work effectively in the primary care setting. Kates and others (1987) describe a psychiatry residency training program at McMaster University in Ontario; it includes a brief curriculum for training psychiatry residents to work with primary care physicians. Burns and others (1995) describe a training program for psychiatric residents that includes time spent as general practice trainees. This was not a program to train psychiatry residents to work effectively as psychiatrists with GPs but to give psychiatry residents a training opportunity in general practice. Cowley and others (2000) state that it is important that psychiatry residents be trained in the specific skills necessary to work as consultants in primary care settings. They describe a consultation-liaison rotation experience for 4th-year psychiatry residents (this can be done as one-half day weekly for 1 year or 1 day weekly for 6 months). When a supervising psychiatrist worked in the same clinic, higher satisfaction and effectiveness ratings were noted. Yudkowsky (2000) proposes guidelines for consultation-liaison rotations for psychiatry residents in ambulatory primary care settings. She recommends that program directors planning new rotations evaluate and publish their efforts to increase the evidence base in this field.
It is apparent that, if psychiatrists are to work effectively in primary care settings, much more needs to be done in determining what training is required, the type of rotation most likely to meet these training needs, and what didactic teaching is necessary.
There are several papers outlining the problems of caring for those with
severe mental illness in the primary care sector and suggesting changes
in service-delivery methods. While some authors report successful programs
integrating psychiatry with primary care for this group of patients, there
are few papers dealing with the educational requirements needed to support
collaborative care for SMI patients. Toews and others (1996) conducted
a survey of family physicians to assess their learning needs related to
the care of patients with schizophrenia. Almost one-half the physicians
stated that they saw 1 or 2 patients with schizophrenia each month, and
about one-half indicated that they were interested in improving the care
they provided. They indicated a need to increase their knowledge of psychopharmacological
agents and monitoring and adjusting medication. Lectures and short workshops
were the preferred learning methods. Lang and others (1997) examined the
role of the GP in providing services for people with schizophrenia. Seventy-three
percent of the patients studied were in regular contact with their GP
for many different reasons. Twenty-one percent required additional support,
and a similar number were posing special difficulties for the primary
care team, particularly where there was a history of drug misuse. For
38% of the patients, services could have been improved if alterations
were made to the roles of the professionals already involved. Perhaps
the most outstanding finding is the importance of the role of the GP in
the ongoing care of these patients.
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