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References and Abstracts
Burns T, MacDonald L, Sibbald B, Gask L, Roberts G. Educational assessment of general practice experience for psychiatric trainees. Med Educ 1995;29(2):159-64.
Eighteen psychiatric trainees spent 6 months each as general practice trainees. The educational impact of the experience was assessed by a self-assessment questionnaire, a semi-structured interview and a videotaped interview with a psychiatric patient. Each assessment was conducted at a baseline and after 12 months. A control group of 14 trainees was recruited from the same rotation. On the self-assessment questionnaire, the study registrars rated their abilities to solve general medical problems significantly improved compared to controls. They had also acquired greater understanding of the limitation of their knowledge and their legal responsibilities towards their patients. The semi-structured interview failed to distinguish between the two groups. Videotapes for rating at baseline and follow-up were available for only 17 of the trainees. Assessment of the tapes used the Maguire Scale and the Interview Behaviour Scale. Neither scale demonstrated any intervention effect. The interviews were all characterized by a preponderance of closed psychological and checking-out questions. It appears that psychiatric trainees’ interviewing styles had not been influenced by the experience. This study suggests that psychiatric trainees gain greater confidence in their role as a doctor and greater understanding of the scope and nature of general practice by such an attachment. It is unclear whether or not supplementary interviewing skills had been acquired which were not utilized in the taped interview, which conforms very much to traditional psychiatric examination behaviour. Trainees were reassured that they had increased their knowledge without losing any of their specific professional skills.
Carr VJ, Hazell PL, Williamson M. Teaching psychiatry in an integrated medical curriculum. Aust N Z J Psychiatry 1996;30(2):210-9.
Objective: Efforts to improve the psychiatric competence of the general medical workforce must include an appraisal of how psychiatry is taught in medical schools. As a contribution to this appraisal a description is given of psychiatric education in the innovative undergraduate medical curriculum at the University of Newcastle. Method: An outline of the features which characterize medical education at Newcastle is provided and the way in which the teaching of psychiatry is organized within this framework is presented. Results: The characteristics of the Newcastle undergraduate program in psychiatry include its integration with teaching in other clinical and basic science disciplines, continuity throughout the entire five years of the course, and the emphasis on skills acquisition and their assessment. Conclusions: The relative merits and disadvantages of the Newcastle approach to undergraduate psychiatry education are presented and the problem of assessing the effectiveness of this approach by outcomes measurement, particularly of integrated competencies and their application in general medical settings, is discussed.
Carr VJ, Faehrmann C, Lewin TJ, Walton JM, Reid AA. Determining the effect that consultation-liaison psychiatry in primary care has on family physicians psychiatric knowledge and practice. Psychosomatics 1997;38(3):217-29.
The impact of a community-based consultation-liaison (C-L) psychiatry service on family physicians’ levels of psychiatric knowledge, diagnostic and treatment confidence, and patterns of referral to mental health care agencies was evaluated over a 12-month period. The physicians with long-term access to the C-L service had higher levels of psychiatric knowledge than those with short-term or no access. However, there was no evidence that the C-L service produced changes in the physicians’ levels of clinical confidence, referral likelihood, or psychiatric knowledge during the evaluation period. Significant predictors of psychiatric knowledge were age (younger) and gender (women). The participating physicians were highly satisfied with the service and preferred it over other possible referral agencies. However, community C-L services in family practice appear to have a limited role in the provision of psychiatric care and are not an efficient way for improving family physicians levels of psychiatric knowledge or altering their practices. The appropriate role of community C-L psychiatry may be as one component of a comprehensive service-delivery strategy integrated within ongoing, formal family- physician educational programs.
Cohen-Cole SA, Boker J, Bird J, and others Psychiatric education improves internists knowledge: a three-year randomised, controlled evaluation. Psychosom Med 1993;55(2):212-8.
SA, Sullivan M, Kathol R, Warshaw C. A model curriculum for mental disorders
and behavioral problems in primary care. Gen Hosp Psychiatry 1995;17(1):13-8.
Changes in the health care delivery system will increasingly emphasize the role of the primary care physician in diagnosing and treating mental disorders and behavioral problems. This increasing emphasis points to the need for more systematic definition of the knowledge and skills that future primary care physicians will need for effective delivery of mental health services. The model curriculum described in this paper represents the efforts of a multidisciplinary Task Force to describe basic training objectives for the psychiatric education of future primary care physicians.
Covington EC, Rodenhauser P, Gottlieb ME, Houston A. Psychiatric training for primary care residents: proposed standards. Int J Psychiatry Med 1987;17(4):327-40.
Most of the nation’s psychiatric care is provided by primary care physicians, and this trend is expected to continue. Primary care physicians see themselves as poorly trained in psychiatry, and evidence supports a high incidence of missed diagnosis and inadequate or inappropriate treatment. In addition, poor training may underlie the indifference to psychiatric problems often demonstrated by primary physicians. The Ohio Psychiatric Association Foundation has designated an annual award to be given to the primary care program which provides the best psychiatric training in the state, and the psychiatric training directors met to develop criteria for selecting the recipients. The resulting standards emphasize the importance of training which is relevant to a medical care setting, provided by psychiatrists, and supportive of the integration of psychiatric methods into medical care.
Cowley DS, Katon W, Veith RC. Training psychiatry residents as consultants in primary care. Academic Psychiatry 2000;24(3):124-132.
Davies JW, Ward WK, Groom GL, Wild AJ, Wild S. The case-conferencing project: a first step towards shared care between general practitioners and a mental health service. Aust N Z J Psychiatry 1997;31(5):751-5.
Objectives: The objectives of this study were: (i) to improve general practitioners’ knowledge of the mental disorders they commonly treat, and to increase their confidence in managing people with these disorders; and (ii) to increase general practitioners’ familiarity with the Logan-Beaudesert Mental Health Service. Method: Eleven general practitioners met with psychiatrists from the Logan-Beaudesert Mental Health Service in six 2-hour sessions held at monthly intervals. Each session comprised a teaching component, a consumer interview and a case-conference. Outcomes were measured using an objective test of general practitioners’ knowledge, a subjective test of their confidence in dealing with mental health problems, and satisfaction surveys for participating consumers, general practitioners and psychiatrists. Results: On the objective test, the scores of 10 out of the 11 general practitioners improved (P < 0.05). On the subjective test, the ranked scores improved in nine out of the 11 cases (P < 0.05). Consumers, general practitioners and psychiatrists expressed their satisfaction with the format and content of the course. Conclusions: Having improved the knowledge of a group of general practitioners who are familiar with the functioning of the Logan-Beaudesert Mental Health Service, the stage is now set to proceed to the next step: the shared-care project.
Davis DA, Thomson MA, Oxman AD, Haynes RB. Evidence for the effectiveness of CME. A review of 50 randomised controlled trials. JAMA 1992;268(9):1111-7.
Objective: To assess the impact of diverse continuing medical education (CME) interventions on physician performance and health care outcomes. Data Sources: Using continuing medical education and related phrases, we performed regular searches of the indexed literature (MEDLINE, Social Science Index, the National Technical Information Service, and Educational Research Information Clearinghouse) from 1975 through 1991. In addition, for these years, we used manual searches, key informants, and requests to authors to locate other indexed articles and the nonindexed literature of adult and continuing professional education. Study Selection: From the resulting database we selected studies that met the following criteria: randomised controlled trials; educational programs, activities, or other interventions; studies that included 50% or more physicians; follow-up assessments of at least 75% of study subjects; and objective assessments of either physician performance or health care outcomes. Data Extraction: Studies were reviewed for data related to physician specialty and setting. Continuing medical education interventions were classified by their mode(s) of activity as being predisposing, enabling, or facilitating. Using the statistical tests supplied by the original investigators, physician performance outcomes and patient outcomes were classified as positive, negative, or inconclusive. Data Synthesis: We located 777 CME studies, of which 50 met all criteria. Thirty-two of these analyzed physician performance; seven evaluated patient outcomes; 11 examined both measures. The majority of the 43 studies of physician performance showed positive results in some important measures of resource utilization, counseling strategies, and preventive medicine. Of the 18 studies of health care outcomes, eight demonstrated positive changes in patients’ health care outcomes. Conclusion: Broadly defined CME interventions using practice-enabling or reinforcing strategies consistently improve physician performance and, in some instances, health care outcomes.
Fisman S, Sangster J, Steele MM, Stewart MA, Rae-Grant N. Teaching child and adolescent psychiatry to family medicine trainees: a pilot experience. Can J Psychiatry 1996;41(10):623-8.
Objective: To develop learning objectives for teaching child psychiatry to family medicine trainees and to evaluate the best method of teaching these objectives. Method: For this descriptive study, knowledge, attitude, and skill objectives were presented to trainees at the start of a 6-month rotation, and an evaluation mechanism was developed based on the learning objectives. The method of instruction in each of the training locations was described independently by the child psychiatry consultant and attending family physician. The trainees evaluations were presented according to training locations. Results: Family medicine trainees perceived the teaching-consultation method, with live interviews, to be the most helpful and the didactic lecture format to be least helpful. Conclusion: The importance of teaching family medicine residents to recognize mental health problems in children and adolescents, preferably by using live interviews, and the implications for postresidency practice are emphasized.
Former internal medicine (N = 24, 88.9%) and psychiatry residents (N = 13, 100%) who shared time on a consultation-liaison service responded to a survey assessing their educational expectations and the ability of the rotation to meet these. Internists rated the time spent with patients (54.2%) as most valuable and requested more psychiatric training (70.8%) to enhance supportive therapy. All psychiatrists reported they most benefited from exposure to the medically ill patient (100%) and learning about organic brain disorders (92%). A comparison of psychotropic prescribing practices indicated that internists were comfortable prescribing anxiolytics and antidepressants more frequently than the psychiatrists advised they should be. The internists remained positive about the value of psychiatric consultation and recommendations. Both psychiatrists and internists felt they benefited from the experience and urged continuation of the joint rotation. Recommendations to increase rounding time and resident-to-resident presentations might further enhance the mutuality both groups highly valued.
Goldberg D, Gater R. Implications of the World Health Organization study of mental illness in general health care for training primary care staff. Br J Gen Pract 1996;46(409):483-5.
A substantial international study of mental disorders seen in primary care settings has shown that there are marked differences in prevalence between centres. Detection of mental disorders is better in centres using a personal style of clinical service, and where there has been close collaboration between psychiatrists and general practitioners. However, even in the better centres, substantial numbers of mental disorders are missed and treatment often appears to be given regardless of diagnosis. It is argued that changes need to be made to the way in which both undergraduates and vocational trainees are taught about mental disorders, so that teaching emphasizes the psychological syndromes that general practitioners are likely to meet in their everyday work. Training packages need to be developed for primary care staff in the detection and management of mental disorders.
Kates N, Lesser A, Dawson D, Devine J, Wakefield J. Psychiatry and family medicine: the McMaster approach. Can J Psychiatry 1987;32(3):170-4.
Family physicians may spend up to 50% of their time dealing with emotional problems but will refer less than 10% of these cases for psychiatric treatment. This paper describes an approach developed at McMaster University which emphasizes the importance of understanding the needs of family physicians and helping them make optimum use of available psychiatric services. Such an approach aims at increasing the comfort and expertise of family physicians in handling the problems they see on a regular basis, involving them actively in their patients’ care after a referral, and offering relevant services that supplement those of the family physician, while monitoring and correcting problems that can arise when the two specialties work together. The implications that this has on the training of family medicine and psychiatry residents are discussed as well as ways in which continuing education can be provided for family physicians in community practice.
Klamen D, Miller NS. Undergraduate medical education in psychiatry and primary care. Psychiatric Annals 1997;26:436-39.
Lang FH, Johnstone EC, Murray GD. Service provision for people with schizophrenia. II. Role of the general practitioner. Br J Psychiatry 1997;171:165-8.
Background: This second report of a study of service provision for patients with schizophrenia describes patients’ contact with general practice and general practitioners’ (GPs’) views of the mental health services. Method: A postal questionnaire was sent to the GPs, and patients’ primary care records were examined. Results: Data were collected on 131 subjects. The majority of patients (96) (73%) were in regular contact with their GP and were consulting for many different reasons; 27 (21%) were posing particular difficulties for the primary care team. GPs reported that 27 (21%) patients required additional support and that the care arrangements for 50 (38%) patients could be improved if alterations were made to the roles of the professionals already involved. Conclusions: GPs are central to service provision for patients with schizophrenia. Both additional resources and changes in working practices are required to improve patient care. The service implications of these findings are discussed.
Leverette J, Massabki A. Training residents for rural child psychiatry: defining the objectives. Can J Psychiatry 1995;40(6):342-7.
Objective: To discuss the contribution of consultative skills to the practice of child psychiatry and to develop curriculum which enhances the ability of residents to participate in community-based care. Method: The development of a training site for residents and fourth year medical students in a weekly half-day traveling child psychiatry clinic to a rural children’s aid society is described. A method of designing educational objectives for community-based training is reviewed and expanded to provide a template for constructing a comprehensive curriculum. Results: The educational objectives specific to the rural training site chosen are provided and their contribution as a subset of the curriculum is defined. Conclusion: The authors suggest that a more fulsome discussion of curriculum design and content in the Canadian literature will aid in the development of emerging practice patterns in child psychiatry.
Phongsavan P, Ward JE, Oldenburg BF, Gordon JJ. Mental health care practices and educational needs of general practitioners. Med J Aust 1995;162(3):139-42.
Objectives: To describe current mental health care practices of general practitioners and to identify their educational priorities and training preferences. Method: Self-administered questionnaire to a stratified random sample of New South Wales general practitioners. Subjects: 721 full-time general practitioners, of whom 534 (74%) responded. Results: Mental health problems recognized by general practitioners at least once per week were psychosomatic (93%), emotional (89%), addiction (79%), social/economic (71%) and family (69%). At least two-thirds recognized sexual problems, sexual abuse and major psychiatric problems less frequently than once per week. Sixty-four percent of general practitioners reported that patients felt uncomfortable about being referred to psychiatrists; 53% that referral service waiting lists were too long; 51% that there were insufficient local mental health services; and 25% that communication difficulties between referring general practitioners and mental health specialists obstructed optimal care. Educational priorities were diagnostic and counselling skills, with particular emphasis on crisis, family, individual and marital counselling and strategies to prevent general practitioner burn-out. Conclusions: General practitioners are interested in improving their mental health counselling and diagnostic skills but barriers remain. Both structural and educational initiatives are essential to enhance the quality of mental health care in general practice.
Shore JH. A psychiatry primary care training track: overdue, but not too late. Harv Rev Psychiatry 1996;4(2):105-6.
Sriram TG, Chandrashekar CR, Isaac MK, Srinivasa Murthy R, Shanmugham V. Training primary care medical officers in mental health care: an evaluation using a multiple-choice questionnaire. Acta Psychiatr Scand 1990;81(5):414-7.
This report aimed to evaluate the mental health knowledge of primary care medical officers following short-term training in mental health care using a multiple-choice questionnaire. Seventy-eight medical officers who underwent 2 weeks’ training in mental health care were assessed using parallel forms of a standardized multiple-choice questionnaire administered before and soon after the training. Young doctors scored significantly higher in the pretraining assessment. The medical officers demonstrated a significant gain in knowledge, although the amount of gain varied. Doctors who had relatively lower pretraining scores showed a higher gain. Six doctors (8%) showed less than acceptable posttraining scores. These doctors were older than the rest of the group. The doctors’ pretraining knowledge was best with respect to epilepsy and poorest with respect to manic-depressive psychosis. Items pertaining to epidemiology and aetiology elicited relatively less gain than other clinical dimensions.
Stoudemire A. Psychiatry in medical practice. Implications for the education of primary care physicians in the era of managed care: Part 1. Psychosomatics 1996;37(6):502-8.
In an effort to control the costs of mental health care, many medical care systems have emphasized the management of psychiatric illness by primary care physicians and curtailed specialty mental health referrals. While this trend mandates that primary care physicians have expertise in the diagnosis and treatment of psychiatric disorders, evidence indicates that not only are psychiatric disorders underrecognized in primary care settings, but also that treatment is often inadequate and accompanied by less than optimal outcomes. In Part 1 of this 2-part series, representative studies of the epidemiology of psychiatric disorders in primary care are reviewed in addition to data that has documented low rates of recognition and suboptimal management of psychiatric illness. In Part 2, to be published in the January-February 1997 issue of Psychosomatics, a core psychiatric curriculum for primary care physicians will be presented that emphasizes the use of competency-based training modules. Strategies for the development and implementation of these educational training modules will also be discussed.
Stoudemire A. Psychiatry in medical practice. Implications for the education of primary care physicians in the era of managed care: Part 2. Psychosomatics 1997;38(1):1-9.
In Part 1 of this 2-part series, the epidemiology of psychiatric disorders in primary care settings was reviewed as well as evidence that indicates that these conditions often go underrecognized and undertreated by primary care physicians. Educational studies to improve the psychiatric skills of primary care physicians were also reviewed. In Part 2 of this series, a core curriculum for primary care physicians in the diagnosis and treatment of psychiatric disorders that emphasizes competency-based learning is presented. Recommendations for the development and implementation of these competency-based training modules are offered in the conclusion.
Strain JJ, Pincus HA, Houpt JL, Gise LH, Taintor Z. Models of mental health training for primary care physicians. Psychosom Med 1985;47(2):95-110.
Of the 15% of the population with DSM III diagnosable disorders, 54% are seen exclusively by their primary care physician or by other health professionals. To understand how primary care physicians are prepared for this task the authors attempted to develop a taxonomy of mental health training programs for primary care physicians by: review of the literature, interviews with program sponsors, review of NIMH training grants, and site visits to teaching programs. From this process six program types were defined: consultation, liaison, bridge, hybrid, autonomous, and postgraduate specialization. The characteristics and emphasis of these model types are described as well as program needs for future training. Competence in psychosomatic medicine, psychophysiologic reactions, and the interactions of biologic, psychologic, and social factors in health and disease can be imparted to primary care physicians by such mental health training program designs.
Strain JJ, Pincus HA, Gise LH, Houpt J. Mental health education in three primary care specialties. J Med Educ 1986;61(12):958-66.
JJ, Pincus HA, Gise LH, Houpt JL. The role of psychiatry in the training
of primary care physicians. Gen Hosp Psychiatry 1986;8(5):372-85.
The question of psychiatry’s role in medicine, and in particular its role in the training of primary care physicians (PCPs), is heightened by the knowledge that 60% of the 15% of patients who have DSM-III diagnosable alcohol, drug abuse, and mental health (ADM) disorders are seen exclusively in the general health sector. In addition, although PCPs have a low recognition rate of ADM disorders and are pessimistic about their outcome even with treatment, they prescribe the majority of tricyclic and anxiolytic medications. Models of mental health training for PC residents in training are examined, with particular emphasis on competencies taught, pedagogic vehicles, disciplines of the mental health teacher, and the relationship to departments of psychiatry. A computerized approach to assist the mental health training of primary care physicians developed at the Mount Sinai School of Medicine and Northwestern is presented. Finally, critical policy issues with regard to psychiatry’s future role in training is described.
Thompson C, Kinmonth AL, Stevens L, and others. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Lancet 2000;355(9199):185-91.
Background: Depression is a major individual and public-health burden throughout the world and is managed mainly in primary care. The most effective strategy to reduce this burden has been believed to be education of primary-care practitioners. We tested this assumption by assessing the effectiveness of an educational programme based on a clinical-practice guideline in improving the recognition and outcome of primary-care depression. Methods: We carried out a randomised controlled trial in a representative sample of 60 primary-care practices (26% of the total) in an English health district. Education was delivered to practice teams and quality tested by feedback from participants and expert raters. The primary endpoints were recognition of depression, defined by the hospital anxiety and depression (HAD) scale, and clinical improvement. Analysis was by intention to treat. Findings: The education was well received by participants, 80% of whom thought it would change their management of patients with depression. 21409 patients were screened, of whom 4192 were classified as depressed by the HAD scale. The sensitivity of physicians to depressive symptoms was 39% in the intervention group and 36% in the control group after education (odds ratio 1.2 [95%CI, 0.88 to 1.61]). The outcome of depressed patients as a whole at 6 weeks or 6 months after the assessment did not significantly improve. Interpretation: Although well received, this in-practice programme, which was designed to convey the current consensus on best practice for the care of depression, did not deliver improvements in recognition of or recovery from depression.
Toews J, Lockyer J, Addington D, McDougall G, Ward R, Simpson E. Improving the management of patients with schizophrenia in primary care: assessing learning needs as a first step. Can J Psychiatry 1996;41(10):617-22.
Objective: To assess family physician learning needs related to the care of patients with schizophrenia. Methods: Questionnaires were mailed to all family physicians and general practitioners practising in southern Alberta. Physicians were asked to indicate the number of patients with schizophrenia cared for, their interest in improving the care the provided, their preferred learning methods, and the content they wished to learn. Results: A total of 539 surveys were returned for a return rate of 43.8%. Over half of the physicians (53.5%) indicated that they saw 1 to 2 patients with schizophrenia each month. Almost half (48.5%) indicated they were somewhat or very interested in increasing the care provided. Primary learning needs included increasing their knowledge of psychopharmacologic agents and monitoring and adjusting medications. Lectures and half-day workshops were the preferred learning methods. Conclusion: Our study was helpful in identifying the types of education that physicians wanted as well as the duration of the programming prior to the development of teaching interventions.
Wulsin L, Cantor L. The current status of combined family practice and psychiatry residency programs. Fam Med 1999;31(9):606.
Wulsin LR. An agenda for primary care psychiatry. Psychosomatics 1996;37(2):93-9.
With the advent of managed care and the primary care gatekeeper, psychiatry’s relationship to primary care is shifting. Four recent surveys suggest that, in general, departments of psychiatry have done little to restructure their relationships with primary care. This article proposes an agenda for developing primary care psychiatry programs in departments of psychiatry. The rationale for shifting resources toward primary care psychiatry is followed by a discussion of the goals of primary care psychiatry programs. The agenda presents specific high-priority projects in the areas of research, education, and clinical care, citing examples of existing initiatives and discussing the resources needed for funding primary care psychiatry programs.
Yudkowsky YR. So you train psychiatry residents in ambulatory care settings: a primer and guide for program directors. Academic Psychiatry 2000;24(3):133-138.
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