Laura Freilich, MD

From Michigan State University, East Lansing, MI.

Abstract

• Objective: We previously reported that training medical faculty to teach mental health care to residents was effective. We here describe the faculty’s training curriculum and their responses to learning and teaching mental health care, a unique focus in the educational literature.
• Design: Qualitative researchers assessed the experiences of medical faculty trainees in learning and teaching mental health care.
• Setting: Internal medicine residency training program at Michigan State University.
• Participants: One early career medicine faculty learner and another faculty learner at mid-career, 4 faculty trainers, and 2 qualitative researchers.
• Measurements: Typed qualitative research reports were evaluated by the authors from 4 time periods: (1) following didactic and interviewing training; (2) following training in a mental health clinic; (3) following training to teach residents mental health care; and (4) 8 months after training.
• Results: Faculty expressed anxiety and low confidence at each of 3 levels of training, but progressively developed confidence and satisfaction during training at each level. They rated didactic experiences as least valuable, seeing these experiences as lacking practical application. Experiential training in interviewing and mental health care were positively viewed, as was the benefit from mentoring. Teaching mental health skills to residents was initially difficult, but faculty became comfortable with experience, which solidified the faculty’s confidence in their own skills.
• Conclusion: A new curriculum for training medical faculty to teach mental health care was demonstrated to be acceptable to the faculty, based on findings from multiple focus groups.

Keywords: psychiatry; primary care mental health; medical education; curriculum; formative evaluation.

We previously trained general medicine faculty intensively in 3 evidence-based models essential for mental health care.^1-4 They, in turn, trained medical residents in the models over all 3 years of residency training.⁵ The results of this quasi-experimental trial demonstrated highly significant learning by residents on all 3 models.⁶ To address the mental health care crisis caused by the severe shortage of psychiatrists in the United States,^7-14 we propose this train-the-trainer intervention as a model for widescale training of medical faculty in mental health care, thus enabling them to then train their own residents and students indefinitely.⁶

This brief report details the faculty training curriculum in mental health care and its teaching, along with the responses of medical faculty to the training; no similar training experiences have been reported in the medical or psychiatric literature. While the residency training curriculum has been published,⁵ the faculty training curriculum has not. Additionally, faculty responses to the training are important because they can provide key information about what did and did not work. Even though demonstrated to be effective for teaching mental health care to residents,⁶ the training must also be acceptable to its new teachers.¹⁵

Methods

Design, Setting, and Participants

This descriptive study was conducted by 2 experienced qualitative researchers in the setting of a 5-year quantitative study of residents’ learning of mental health care.^5,6 They interviewed 2 general medicine faculty undergoing training in mental health care on 4 occasions: 3 times during training and once following training. Learners were taught by 4 faculty trainers (2 general medicine, 2 psychiatry). The setting was the internal medicine residency program at Michigan State University. The project was approved by the local Institutional Review Board.

Faculty Training Intervention

The 2 training faculty evaluated in this study were taught in a predominantly experiential way.⁵ Learning objectives were behaviorally defined (see Table 1, which also presents the teaching methods). Teaching occurred in 3 segments over 15 months, with a 10% weekly commitment to training supported by a research grant.

First 6 Months. For 1 half-day (4 hours) every week, teaching sessions were divided into 2 parts:

1. Experiential learning of the objectives, particularly patient-centered interviewing (Table 2)¹⁶ and mental health care models (Table 3).^3,17 This initially involved role playing and was followed by using the models with hospital and clinic patients, sometimes directly observed, other times evaluated via audiotaped recordings.

2. Lecture and reading series, which occurred in 2 parts: (a) For the first 3 months, a biopsychosocial and patient-centered medicine seminar was guided by readings from a patient-centered interviewing textbook and 4 articles.^3,16,18-20 These readings were supplemented by a large collection of material on our website that was utilized in a learner-centered fashion, depending on learners’ interests (these are available from the authors, along with a detailed outline we followed for each teaching session). (b) For the last 3 months, a psychiatry lecture series addressed the material needed for primary care mental health. The lectures were guided by a psychiatry textbook (the schedule and content of presentations is available from the authors).²¹

Beginning in the first 6 months, faculty also participated as co-teachers with their trainers in a long-standing psychosocial rotation, a 1-month full-time rotation for PGY-1 residents that occurred twice yearly during training. This initially helped them learn the models, and they later received experience in how to teach the models.

Middle 4 Months. During this period, faculty learners were supervised by trainers as they transitioned to learn mental health care in a Complex Patient Clinic (CPC). Training was guided by a syllabus now contained in a textbook.¹⁷ The CPC is a unique mental health care clinic located in the clinic area where faculty and residents observe other patients. Rooms resemble other exam rooms, except they have a computer attached to an audio-video camera that delivers the physician-patient interaction live to another room, where faculty observe it via a software program (Vidyo, Hackensack, NJ)^22,23; no recordings are made of the live interactions. The details of patient recruitment and the CPC are described elsewhere.²² CPC patients had an average of 2.3 DSM-V diagnoses and 3.3 major medical diagnoses. Faculty trainees evaluated 2 or 3 patients each day.

Final 5 Months. Supervision continued for faculty learners as they taught mental health care to postgraduate year (PGY) 2 and 3 residents in the CPC. Residents had between 6 and 8 sessions in each of their last 2 years of training; 2 residents were assigned for each half-day CPC session and each evaluated 2 or 3 patients under faculty-learner supervision.

The qualitative interviewers were independent of the study. The research team members did not see the transcripts until preparing this report in conjunction with the interviewers. Data were collected from faculty at 4 points: following the initial 6 months of training in the models; following training in mental health care in the CPC; following supervision of faculty training of residents; and 8 months following completion of training, during which time they independently taught residents.

Data were collected in a systematic way over 1 hour, beginning and continuing open-endedly for about 30 minutes and concluding with closed-ended inquiry to pin down details and to ask any pre-planned questions that had not been answered. The protocol that guided focus group interviews is available from the authors.

Audio recordings were made from each group, and a 500- to 1000-word report was written by the interviewers, which served as the basis of the present descriptive evaluation. The authors independently analyzed the data at each collection point and then came to the consensus that follows.

Results

Lectures/Didactic Training

The training sessions involved 2 parts: lectures and didactic material around interviewing, general system theory, and psychiatry diagnoses; and skills practice in interviewing and the mental health care models. The trainers and faculty met weekly for 4 hours, and the first 2 hours of these sessions were spent reviewing the background of what would become the mainstay of the teaching, the models for interviewing and mental health care (Table 2 and Table 3). These readings differed in content and style from the typical clinical readings that physicians use, and they required considerable outside time and preparation, beyond that anticipated by the trainees. Digging into these theoretical concepts was described as interesting and “refreshing,” but the trainees at first found the readings disconnected from their clinical work. Faculty trainees later recognized the importance of understanding the models as they prepared for their roles as teachers. All told, however, the trainees believed there was too much didactic material.

Receiving education on diagnosis and management of common psychiatric disorders from academic psychiatrists was appreciated, but the trainees also expressed the greatest frustrations about this part of the curriculum. They felt that the level of these sessions was not always appropriately gauged—ranging from too simplistic, as in medical school, to too detailed, especially around neurochemical and neurobiological mechanisms. Although they appreciated learning about advanced psychiatric illness and treatments (eg, electroconvulsive treatment, especially), they did not believe the information was necessary in primary care. Trainees were experienced primary care providers and were more interested in case-based education that could highlight the types of patients seen in their office every day. One trainee indicated that these sessions were lacking “the patient voice.” Abstract discussion of diagnoses and treatments made it challenging to apply this new knowledge to the trainees’ practices. Trainees also suggested trying to integrate this section of the training with the interviewing skills training to better highlight that interplay. The trainees believed that their understanding and familiarity with the diagnosis and management of mental disorders occurred primarily in later CPC training. The trainees recommended that all didactic material be reduced by half or more in future teaching.

The patient-centered interviewing skills practice, which occurred in the second 2-hour period during the first 6 months, was lauded by the faculty trainees. It was considered the “most immediately relevant component” of this period of training. Because the trainees were experienced physicians when they began this project, they felt this part of training made the “…material more accessible to myself, more germane to what I do day in and day out.” The insight of modifying the interviewing techniques to connect with different patient personality types was particularly helpful. One trainee described an “aha moment” of “getting patients to open up in a way I had not been able to do before.” As time went on, the trainees felt empowered to adapt “the interviewing script” modestly to fit their already developed “rhythm and style with their patients.”

Wellness/Mentoring

The 2 trainees were at different stages of their careers, 1 early-career faculty and 1 mid-career faculty. This academic diversity within the small training group provided varied perspectives not only on the concepts presented and discussed, but also on a more personal level. In an otherwise hectic academic medicine environment, this group had a weekly chance to stop, “check in” with each other, and truly connect on a personal level. To be asked “about your week and actually mean it and want to hear the answer” is an unusual opportunity, one noted. It also offered time and support for purposeful self-reflection, which “often brought some emotions to the surface…at different times.” These connections were perhaps one of the most valuable parts of the experience. With burnout among physicians rampant,²⁴ establishing these networks is invaluable. In addition to introspection and personal connections, there was a strong element of mentoring during these weekly meetings. The opportunity to meet in a small group with senior faculty was highly valued by the trainees.

Mental Health Care: Complex Patient Clinic

The faculty were eager, but very apprehensive, in beginning the second segment of training, where work shifted from lectures and practicing skills to mental health care training in the CPC. The trainees expressed anxiety about several areas. These included additional clinical workload, patient referral/selection, and transition of patient care back to the primary care provider. Of note, they did not particularly express worries about the care they would be providing, because a psychiatrist would be available to them on site. In reflection, after spending 4 months in the clinic, trainees noted “how important observing live interviews for evaluation/feedback was to their learning.” The CPC provided “learning in the moment on specific patients [which] was without question the most powerful teaching tool.” The support of the training faculty who were present at each clinic was invaluable. Whereas the earlier didactics given by psychiatrists were received by trainees with lukewarm enthusiasm, the point-of-care, case-by-case learning and feedback truly advanced the trainees’ knowledge, as well as skills, and improved their confidence in providing mental health care.

One of the tenets of the mental health care models is collaborative care.²⁵ Recognizing this critical component of patient care, the CPC experience integrated a clinical social worker. The faculty noted the critical role she played in the patient care experience. They described her as “fabulous and awesome.” Her grasp of the health care system and community resources (particularly for an underserved population) was indispensable. Additionally, she was able to serve as a steady contact to follow patients through multiple visits and improve their feelings of continuity.

Teaching: Psychosocial Rotation

The first psychosocial teaching occurred after the interviewing skills and didactic experiences in the first 6 months. The trainees expressed great doubt about tackling this initial teaching experience. From residents challenging the need for interviewing and other aspects of “touchy-feely” teaching, to patients expressing raw emotions, the trainees lacked confidence in their ability to handle these moments. At this early stage of their training, one trainee said, “I feel like I am becoming a better interrogator, but I haven’t learned the skills to be a better healer yet.” Over time, this concern disappeared. As training evolved, the trainees began to thrive in their role as educator. At the final focus group, it was noted that “teaching has enhanced [my] confidence in the framework and in turn has made it easier to teach.”

Teaching: Complex Patient Clinic

This powerful teaching tool to train residents was the centerpiece of training. The faculty trainees had some hesitation about their role as teacher before it began. The faculty trainees were at different stages of their careers, and their confidence in their own teaching skills was not uniform. Importantly, the initial structure of the CPC, which included psychiatrists and senior faculty supervision, provided strong and continued support for the faculty trainees. Later work in the CPC as teacher, rather than trainee, further bolstered the faculty’s confidence in the treatment models. As confidence with their own skills grew, faculty noted that it became “easier to teach” as well. Faculty also recognized the unique opportunity that the CPC provided in directly observing a resident’s patient interaction. This allows them to “monitor progress, provide specific feedback, and address issues.” The time spent debriefing after each patient encounter was noted to be particularly important. When they became too busy to adequately provide this debriefing, changes to the schedule were made to accommodate it (follow-up visits were lengthened from 30 to 60 minutes). In addition to giving an opportunity to provide feedback, this extra time available for residents to interact with a patient—to utilize and practice the interviewing skills, for example—was quite valuable, independent of actual mental health care training. Finally, the faculty were able to create a “relaxed and comfortable” space in the CPC. Indeed, the faculty felt comfortable sharing some of their struggles and reflections on caring for a mental health patient population, and residents were able, in turn, to engage in some self-reflection and debriefing as well.

Discussion

Faculty trainees demonstrated a striking evolution as they progressed through this curriculum. At each of the 3 stages of training, they endorsed a broad range of feelings, from anxiety and uncertainty initially, to confidence and growth and appreciation later. They felt satisfied with having participated in the project and are engaged in exploring next steps.

Of note, these faculty members had some exposure to the skills models prior to starting the program because the residency program has integrated patient-centered interviewing into its program for many years. The faculty were supportive of the models prior to engaging in the curriculum, and they volunteered to participate. Similarly, the residents were familiar with the expectations as they went through the psychosocial rotation and the CPC. It is conceivable that the interviewing and mental health material may not be received as easily at an institution where the culture has had less exposure to such teaching.

While describing a faculty curriculum for mental health training is unique⁵ and the primary intent of this paper, we wanted to present its formative evaluation even though only 2 faculty trainees were involved. Simply put, the grant for this project supported only 2 trainees, and no more were required. Nevertheless, we propose that this only reported experience of medical faculty with mental health training is an important addition to the literature in mental health education. It will be a critical guide for others who choose the new direction of training medical faculty to teach mental health care.

As the research team looks to foster dissemination of the curriculum, it continues to be streamlined to highlight the components most useful and germane to learners. The early didactic readings on subjects such as general system theory were less engaging. (In later training of new medical faculty learners, the focus on theory and other didactics was reduced.) In contrast, the trainees clearly valued the interviewing skills experience (both learning and teaching). While the mental health curriculum and the CPC were associated with much greater anxiety in the trainees, with practical, respectful, and supervised teaching, they became confident and satisfied—as well as effective.⁶ Future teachers will benefit from slowly and understandingly addressing trainees’ personal issues, particularly during the initial phases of training.²⁶ It appeared to us to be the key factor enabling the faculty to successfully learn and teach mental health care. Once they overcame their personal reactions to mental health material, they learned mental health skills just as they learn the more familiar physical disease material.

Conclusion

In a new direction in medical education, a curriculum for training medical faculty to teach mental health care is presented. Not only did prior research demonstrate that the faculty effectively trained residents, but we also demonstrated here that the training was acceptable to and valued by faculty. With mental health often an alien dimension of medicine, acceptability is especially important when we recommend disseminating the curriculum as a way to offset the national mental health care crisis.

Corresponding author: Robert C. Smith, 788 Service Road, B314 Clinical Center, East Lansing, MI 48824; smithrr@msu.edu.

Financial disclosures: None.

Funding support: The authors are grateful for the generous support from the Health Resources and Services Administration (D58HP23259).

From Michigan State University, East Lansing, MI.

Abstract

• Objective: We previously reported that training medical faculty to teach mental health care to residents was effective. We here describe the faculty’s training curriculum and their responses to learning and teaching mental health care, a unique focus in the educational literature.
• Design: Qualitative researchers assessed the experiences of medical faculty trainees in learning and teaching mental health care.
• Setting: Internal medicine residency training program at Michigan State University.
• Participants: One early career medicine faculty learner and another faculty learner at mid-career, 4 faculty trainers, and 2 qualitative researchers.
• Measurements: Typed qualitative research reports were evaluated by the authors from 4 time periods: (1) following didactic and interviewing training; (2) following training in a mental health clinic; (3) following training to teach residents mental health care; and (4) 8 months after training.
• Results: Faculty expressed anxiety and low confidence at each of 3 levels of training, but progressively developed confidence and satisfaction during training at each level. They rated didactic experiences as least valuable, seeing these experiences as lacking practical application. Experiential training in interviewing and mental health care were positively viewed, as was the benefit from mentoring. Teaching mental health skills to residents was initially difficult, but faculty became comfortable with experience, which solidified the faculty’s confidence in their own skills.
• Conclusion: A new curriculum for training medical faculty to teach mental health care was demonstrated to be acceptable to the faculty, based on findings from multiple focus groups.

Keywords: psychiatry; primary care mental health; medical education; curriculum; formative evaluation.

We previously trained general medicine faculty intensively in 3 evidence-based models essential for mental health care.^1-4 They, in turn, trained medical residents in the models over all 3 years of residency training.⁵ The results of this quasi-experimental trial demonstrated highly significant learning by residents on all 3 models.⁶ To address the mental health care crisis caused by the severe shortage of psychiatrists in the United States,^7-14 we propose this train-the-trainer intervention as a model for widescale training of medical faculty in mental health care, thus enabling them to then train their own residents and students indefinitely.⁶

This brief report details the faculty training curriculum in mental health care and its teaching, along with the responses of medical faculty to the training; no similar training experiences have been reported in the medical or psychiatric literature. While the residency training curriculum has been published,⁵ the faculty training curriculum has not. Additionally, faculty responses to the training are important because they can provide key information about what did and did not work. Even though demonstrated to be effective for teaching mental health care to residents,⁶ the training must also be acceptable to its new teachers.¹⁵

Methods

Design, Setting, and Participants

This descriptive study was conducted by 2 experienced qualitative researchers in the setting of a 5-year quantitative study of residents’ learning of mental health care.^5,6 They interviewed 2 general medicine faculty undergoing training in mental health care on 4 occasions: 3 times during training and once following training. Learners were taught by 4 faculty trainers (2 general medicine, 2 psychiatry). The setting was the internal medicine residency program at Michigan State University. The project was approved by the local Institutional Review Board.

Faculty Training Intervention

The 2 training faculty evaluated in this study were taught in a predominantly experiential way.⁵ Learning objectives were behaviorally defined (see Table 1, which also presents the teaching methods). Teaching occurred in 3 segments over 15 months, with a 10% weekly commitment to training supported by a research grant.

First 6 Months. For 1 half-day (4 hours) every week, teaching sessions were divided into 2 parts:

1. Experiential learning of the objectives, particularly patient-centered interviewing (Table 2)¹⁶ and mental health care models (Table 3).^3,17 This initially involved role playing and was followed by using the models with hospital and clinic patients, sometimes directly observed, other times evaluated via audiotaped recordings.

2. Lecture and reading series, which occurred in 2 parts: (a) For the first 3 months, a biopsychosocial and patient-centered medicine seminar was guided by readings from a patient-centered interviewing textbook and 4 articles.^3,16,18-20 These readings were supplemented by a large collection of material on our website that was utilized in a learner-centered fashion, depending on learners’ interests (these are available from the authors, along with a detailed outline we followed for each teaching session). (b) For the last 3 months, a psychiatry lecture series addressed the material needed for primary care mental health. The lectures were guided by a psychiatry textbook (the schedule and content of presentations is available from the authors).²¹

Beginning in the first 6 months, faculty also participated as co-teachers with their trainers in a long-standing psychosocial rotation, a 1-month full-time rotation for PGY-1 residents that occurred twice yearly during training. This initially helped them learn the models, and they later received experience in how to teach the models.

Middle 4 Months. During this period, faculty learners were supervised by trainers as they transitioned to learn mental health care in a Complex Patient Clinic (CPC). Training was guided by a syllabus now contained in a textbook.¹⁷ The CPC is a unique mental health care clinic located in the clinic area where faculty and residents observe other patients. Rooms resemble other exam rooms, except they have a computer attached to an audio-video camera that delivers the physician-patient interaction live to another room, where faculty observe it via a software program (Vidyo, Hackensack, NJ)^22,23; no recordings are made of the live interactions. The details of patient recruitment and the CPC are described elsewhere.²² CPC patients had an average of 2.3 DSM-V diagnoses and 3.3 major medical diagnoses. Faculty trainees evaluated 2 or 3 patients each day.

Final 5 Months. Supervision continued for faculty learners as they taught mental health care to postgraduate year (PGY) 2 and 3 residents in the CPC. Residents had between 6 and 8 sessions in each of their last 2 years of training; 2 residents were assigned for each half-day CPC session and each evaluated 2 or 3 patients under faculty-learner supervision.

The qualitative interviewers were independent of the study. The research team members did not see the transcripts until preparing this report in conjunction with the interviewers. Data were collected from faculty at 4 points: following the initial 6 months of training in the models; following training in mental health care in the CPC; following supervision of faculty training of residents; and 8 months following completion of training, during which time they independently taught residents.

Data were collected in a systematic way over 1 hour, beginning and continuing open-endedly for about 30 minutes and concluding with closed-ended inquiry to pin down details and to ask any pre-planned questions that had not been answered. The protocol that guided focus group interviews is available from the authors.

Audio recordings were made from each group, and a 500- to 1000-word report was written by the interviewers, which served as the basis of the present descriptive evaluation. The authors independently analyzed the data at each collection point and then came to the consensus that follows.

Results

Lectures/Didactic Training

The training sessions involved 2 parts: lectures and didactic material around interviewing, general system theory, and psychiatry diagnoses; and skills practice in interviewing and the mental health care models. The trainers and faculty met weekly for 4 hours, and the first 2 hours of these sessions were spent reviewing the background of what would become the mainstay of the teaching, the models for interviewing and mental health care (Table 2 and Table 3). These readings differed in content and style from the typical clinical readings that physicians use, and they required considerable outside time and preparation, beyond that anticipated by the trainees. Digging into these theoretical concepts was described as interesting and “refreshing,” but the trainees at first found the readings disconnected from their clinical work. Faculty trainees later recognized the importance of understanding the models as they prepared for their roles as teachers. All told, however, the trainees believed there was too much didactic material.

Receiving education on diagnosis and management of common psychiatric disorders from academic psychiatrists was appreciated, but the trainees also expressed the greatest frustrations about this part of the curriculum. They felt that the level of these sessions was not always appropriately gauged—ranging from too simplistic, as in medical school, to too detailed, especially around neurochemical and neurobiological mechanisms. Although they appreciated learning about advanced psychiatric illness and treatments (eg, electroconvulsive treatment, especially), they did not believe the information was necessary in primary care. Trainees were experienced primary care providers and were more interested in case-based education that could highlight the types of patients seen in their office every day. One trainee indicated that these sessions were lacking “the patient voice.” Abstract discussion of diagnoses and treatments made it challenging to apply this new knowledge to the trainees’ practices. Trainees also suggested trying to integrate this section of the training with the interviewing skills training to better highlight that interplay. The trainees believed that their understanding and familiarity with the diagnosis and management of mental disorders occurred primarily in later CPC training. The trainees recommended that all didactic material be reduced by half or more in future teaching.

The patient-centered interviewing skills practice, which occurred in the second 2-hour period during the first 6 months, was lauded by the faculty trainees. It was considered the “most immediately relevant component” of this period of training. Because the trainees were experienced physicians when they began this project, they felt this part of training made the “…material more accessible to myself, more germane to what I do day in and day out.” The insight of modifying the interviewing techniques to connect with different patient personality types was particularly helpful. One trainee described an “aha moment” of “getting patients to open up in a way I had not been able to do before.” As time went on, the trainees felt empowered to adapt “the interviewing script” modestly to fit their already developed “rhythm and style with their patients.”

Wellness/Mentoring

The 2 trainees were at different stages of their careers, 1 early-career faculty and 1 mid-career faculty. This academic diversity within the small training group provided varied perspectives not only on the concepts presented and discussed, but also on a more personal level. In an otherwise hectic academic medicine environment, this group had a weekly chance to stop, “check in” with each other, and truly connect on a personal level. To be asked “about your week and actually mean it and want to hear the answer” is an unusual opportunity, one noted. It also offered time and support for purposeful self-reflection, which “often brought some emotions to the surface…at different times.” These connections were perhaps one of the most valuable parts of the experience. With burnout among physicians rampant,²⁴ establishing these networks is invaluable. In addition to introspection and personal connections, there was a strong element of mentoring during these weekly meetings. The opportunity to meet in a small group with senior faculty was highly valued by the trainees.

Mental Health Care: Complex Patient Clinic

The faculty were eager, but very apprehensive, in beginning the second segment of training, where work shifted from lectures and practicing skills to mental health care training in the CPC. The trainees expressed anxiety about several areas. These included additional clinical workload, patient referral/selection, and transition of patient care back to the primary care provider. Of note, they did not particularly express worries about the care they would be providing, because a psychiatrist would be available to them on site. In reflection, after spending 4 months in the clinic, trainees noted “how important observing live interviews for evaluation/feedback was to their learning.” The CPC provided “learning in the moment on specific patients [which] was without question the most powerful teaching tool.” The support of the training faculty who were present at each clinic was invaluable. Whereas the earlier didactics given by psychiatrists were received by trainees with lukewarm enthusiasm, the point-of-care, case-by-case learning and feedback truly advanced the trainees’ knowledge, as well as skills, and improved their confidence in providing mental health care.

One of the tenets of the mental health care models is collaborative care.²⁵ Recognizing this critical component of patient care, the CPC experience integrated a clinical social worker. The faculty noted the critical role she played in the patient care experience. They described her as “fabulous and awesome.” Her grasp of the health care system and community resources (particularly for an underserved population) was indispensable. Additionally, she was able to serve as a steady contact to follow patients through multiple visits and improve their feelings of continuity.

Teaching: Psychosocial Rotation

The first psychosocial teaching occurred after the interviewing skills and didactic experiences in the first 6 months. The trainees expressed great doubt about tackling this initial teaching experience. From residents challenging the need for interviewing and other aspects of “touchy-feely” teaching, to patients expressing raw emotions, the trainees lacked confidence in their ability to handle these moments. At this early stage of their training, one trainee said, “I feel like I am becoming a better interrogator, but I haven’t learned the skills to be a better healer yet.” Over time, this concern disappeared. As training evolved, the trainees began to thrive in their role as educator. At the final focus group, it was noted that “teaching has enhanced [my] confidence in the framework and in turn has made it easier to teach.”

Teaching: Complex Patient Clinic

This powerful teaching tool to train residents was the centerpiece of training. The faculty trainees had some hesitation about their role as teacher before it began. The faculty trainees were at different stages of their careers, and their confidence in their own teaching skills was not uniform. Importantly, the initial structure of the CPC, which included psychiatrists and senior faculty supervision, provided strong and continued support for the faculty trainees. Later work in the CPC as teacher, rather than trainee, further bolstered the faculty’s confidence in the treatment models. As confidence with their own skills grew, faculty noted that it became “easier to teach” as well. Faculty also recognized the unique opportunity that the CPC provided in directly observing a resident’s patient interaction. This allows them to “monitor progress, provide specific feedback, and address issues.” The time spent debriefing after each patient encounter was noted to be particularly important. When they became too busy to adequately provide this debriefing, changes to the schedule were made to accommodate it (follow-up visits were lengthened from 30 to 60 minutes). In addition to giving an opportunity to provide feedback, this extra time available for residents to interact with a patient—to utilize and practice the interviewing skills, for example—was quite valuable, independent of actual mental health care training. Finally, the faculty were able to create a “relaxed and comfortable” space in the CPC. Indeed, the faculty felt comfortable sharing some of their struggles and reflections on caring for a mental health patient population, and residents were able, in turn, to engage in some self-reflection and debriefing as well.

Discussion

Faculty trainees demonstrated a striking evolution as they progressed through this curriculum. At each of the 3 stages of training, they endorsed a broad range of feelings, from anxiety and uncertainty initially, to confidence and growth and appreciation later. They felt satisfied with having participated in the project and are engaged in exploring next steps.

Of note, these faculty members had some exposure to the skills models prior to starting the program because the residency program has integrated patient-centered interviewing into its program for many years. The faculty were supportive of the models prior to engaging in the curriculum, and they volunteered to participate. Similarly, the residents were familiar with the expectations as they went through the psychosocial rotation and the CPC. It is conceivable that the interviewing and mental health material may not be received as easily at an institution where the culture has had less exposure to such teaching.

While describing a faculty curriculum for mental health training is unique⁵ and the primary intent of this paper, we wanted to present its formative evaluation even though only 2 faculty trainees were involved. Simply put, the grant for this project supported only 2 trainees, and no more were required. Nevertheless, we propose that this only reported experience of medical faculty with mental health training is an important addition to the literature in mental health education. It will be a critical guide for others who choose the new direction of training medical faculty to teach mental health care.

As the research team looks to foster dissemination of the curriculum, it continues to be streamlined to highlight the components most useful and germane to learners. The early didactic readings on subjects such as general system theory were less engaging. (In later training of new medical faculty learners, the focus on theory and other didactics was reduced.) In contrast, the trainees clearly valued the interviewing skills experience (both learning and teaching). While the mental health curriculum and the CPC were associated with much greater anxiety in the trainees, with practical, respectful, and supervised teaching, they became confident and satisfied—as well as effective.⁶ Future teachers will benefit from slowly and understandingly addressing trainees’ personal issues, particularly during the initial phases of training.²⁶ It appeared to us to be the key factor enabling the faculty to successfully learn and teach mental health care. Once they overcame their personal reactions to mental health material, they learned mental health skills just as they learn the more familiar physical disease material.

Conclusion

In a new direction in medical education, a curriculum for training medical faculty to teach mental health care is presented. Not only did prior research demonstrate that the faculty effectively trained residents, but we also demonstrated here that the training was acceptable to and valued by faculty. With mental health often an alien dimension of medicine, acceptability is especially important when we recommend disseminating the curriculum as a way to offset the national mental health care crisis.

Corresponding author: Robert C. Smith, 788 Service Road, B314 Clinical Center, East Lansing, MI 48824; smithrr@msu.edu.

Financial disclosures: None.

Funding support: The authors are grateful for the generous support from the Health Resources and Services Administration (D58HP23259).

From Michigan State University, East Lansing, MI.

Abstract

• Objective: We previously reported that training medical faculty to teach mental health care to residents was effective. We here describe the faculty’s training curriculum and their responses to learning and teaching mental health care, a unique focus in the educational literature.
• Design: Qualitative researchers assessed the experiences of medical faculty trainees in learning and teaching mental health care.
• Setting: Internal medicine residency training program at Michigan State University.
• Participants: One early career medicine faculty learner and another faculty learner at mid-career, 4 faculty trainers, and 2 qualitative researchers.
• Measurements: Typed qualitative research reports were evaluated by the authors from 4 time periods: (1) following didactic and interviewing training; (2) following training in a mental health clinic; (3) following training to teach residents mental health care; and (4) 8 months after training.
• Results: Faculty expressed anxiety and low confidence at each of 3 levels of training, but progressively developed confidence and satisfaction during training at each level. They rated didactic experiences as least valuable, seeing these experiences as lacking practical application. Experiential training in interviewing and mental health care were positively viewed, as was the benefit from mentoring. Teaching mental health skills to residents was initially difficult, but faculty became comfortable with experience, which solidified the faculty’s confidence in their own skills.
• Conclusion: A new curriculum for training medical faculty to teach mental health care was demonstrated to be acceptable to the faculty, based on findings from multiple focus groups.

Keywords: psychiatry; primary care mental health; medical education; curriculum; formative evaluation.

We previously trained general medicine faculty intensively in 3 evidence-based models essential for mental health care.^1-4 They, in turn, trained medical residents in the models over all 3 years of residency training.⁵ The results of this quasi-experimental trial demonstrated highly significant learning by residents on all 3 models.⁶ To address the mental health care crisis caused by the severe shortage of psychiatrists in the United States,^7-14 we propose this train-the-trainer intervention as a model for widescale training of medical faculty in mental health care, thus enabling them to then train their own residents and students indefinitely.⁶

This brief report details the faculty training curriculum in mental health care and its teaching, along with the responses of medical faculty to the training; no similar training experiences have been reported in the medical or psychiatric literature. While the residency training curriculum has been published,⁵ the faculty training curriculum has not. Additionally, faculty responses to the training are important because they can provide key information about what did and did not work. Even though demonstrated to be effective for teaching mental health care to residents,⁶ the training must also be acceptable to its new teachers.¹⁵

Methods

Design, Setting, and Participants

This descriptive study was conducted by 2 experienced qualitative researchers in the setting of a 5-year quantitative study of residents’ learning of mental health care.^5,6 They interviewed 2 general medicine faculty undergoing training in mental health care on 4 occasions: 3 times during training and once following training. Learners were taught by 4 faculty trainers (2 general medicine, 2 psychiatry). The setting was the internal medicine residency program at Michigan State University. The project was approved by the local Institutional Review Board.

Faculty Training Intervention

The 2 training faculty evaluated in this study were taught in a predominantly experiential way.⁵ Learning objectives were behaviorally defined (see Table 1, which also presents the teaching methods). Teaching occurred in 3 segments over 15 months, with a 10% weekly commitment to training supported by a research grant.

First 6 Months. For 1 half-day (4 hours) every week, teaching sessions were divided into 2 parts:

1. Experiential learning of the objectives, particularly patient-centered interviewing (Table 2)¹⁶ and mental health care models (Table 3).^3,17 This initially involved role playing and was followed by using the models with hospital and clinic patients, sometimes directly observed, other times evaluated via audiotaped recordings.

2. Lecture and reading series, which occurred in 2 parts: (a) For the first 3 months, a biopsychosocial and patient-centered medicine seminar was guided by readings from a patient-centered interviewing textbook and 4 articles.^3,16,18-20 These readings were supplemented by a large collection of material on our website that was utilized in a learner-centered fashion, depending on learners’ interests (these are available from the authors, along with a detailed outline we followed for each teaching session). (b) For the last 3 months, a psychiatry lecture series addressed the material needed for primary care mental health. The lectures were guided by a psychiatry textbook (the schedule and content of presentations is available from the authors).²¹

Beginning in the first 6 months, faculty also participated as co-teachers with their trainers in a long-standing psychosocial rotation, a 1-month full-time rotation for PGY-1 residents that occurred twice yearly during training. This initially helped them learn the models, and they later received experience in how to teach the models.

Middle 4 Months. During this period, faculty learners were supervised by trainers as they transitioned to learn mental health care in a Complex Patient Clinic (CPC). Training was guided by a syllabus now contained in a textbook.¹⁷ The CPC is a unique mental health care clinic located in the clinic area where faculty and residents observe other patients. Rooms resemble other exam rooms, except they have a computer attached to an audio-video camera that delivers the physician-patient interaction live to another room, where faculty observe it via a software program (Vidyo, Hackensack, NJ)^22,23; no recordings are made of the live interactions. The details of patient recruitment and the CPC are described elsewhere.²² CPC patients had an average of 2.3 DSM-V diagnoses and 3.3 major medical diagnoses. Faculty trainees evaluated 2 or 3 patients each day.

Final 5 Months. Supervision continued for faculty learners as they taught mental health care to postgraduate year (PGY) 2 and 3 residents in the CPC. Residents had between 6 and 8 sessions in each of their last 2 years of training; 2 residents were assigned for each half-day CPC session and each evaluated 2 or 3 patients under faculty-learner supervision.

The qualitative interviewers were independent of the study. The research team members did not see the transcripts until preparing this report in conjunction with the interviewers. Data were collected from faculty at 4 points: following the initial 6 months of training in the models; following training in mental health care in the CPC; following supervision of faculty training of residents; and 8 months following completion of training, during which time they independently taught residents.

Data were collected in a systematic way over 1 hour, beginning and continuing open-endedly for about 30 minutes and concluding with closed-ended inquiry to pin down details and to ask any pre-planned questions that had not been answered. The protocol that guided focus group interviews is available from the authors.

Audio recordings were made from each group, and a 500- to 1000-word report was written by the interviewers, which served as the basis of the present descriptive evaluation. The authors independently analyzed the data at each collection point and then came to the consensus that follows.

Results

Lectures/Didactic Training

The training sessions involved 2 parts: lectures and didactic material around interviewing, general system theory, and psychiatry diagnoses; and skills practice in interviewing and the mental health care models. The trainers and faculty met weekly for 4 hours, and the first 2 hours of these sessions were spent reviewing the background of what would become the mainstay of the teaching, the models for interviewing and mental health care (Table 2 and Table 3). These readings differed in content and style from the typical clinical readings that physicians use, and they required considerable outside time and preparation, beyond that anticipated by the trainees. Digging into these theoretical concepts was described as interesting and “refreshing,” but the trainees at first found the readings disconnected from their clinical work. Faculty trainees later recognized the importance of understanding the models as they prepared for their roles as teachers. All told, however, the trainees believed there was too much didactic material.

Receiving education on diagnosis and management of common psychiatric disorders from academic psychiatrists was appreciated, but the trainees also expressed the greatest frustrations about this part of the curriculum. They felt that the level of these sessions was not always appropriately gauged—ranging from too simplistic, as in medical school, to too detailed, especially around neurochemical and neurobiological mechanisms. Although they appreciated learning about advanced psychiatric illness and treatments (eg, electroconvulsive treatment, especially), they did not believe the information was necessary in primary care. Trainees were experienced primary care providers and were more interested in case-based education that could highlight the types of patients seen in their office every day. One trainee indicated that these sessions were lacking “the patient voice.” Abstract discussion of diagnoses and treatments made it challenging to apply this new knowledge to the trainees’ practices. Trainees also suggested trying to integrate this section of the training with the interviewing skills training to better highlight that interplay. The trainees believed that their understanding and familiarity with the diagnosis and management of mental disorders occurred primarily in later CPC training. The trainees recommended that all didactic material be reduced by half or more in future teaching.

The patient-centered interviewing skills practice, which occurred in the second 2-hour period during the first 6 months, was lauded by the faculty trainees. It was considered the “most immediately relevant component” of this period of training. Because the trainees were experienced physicians when they began this project, they felt this part of training made the “…material more accessible to myself, more germane to what I do day in and day out.” The insight of modifying the interviewing techniques to connect with different patient personality types was particularly helpful. One trainee described an “aha moment” of “getting patients to open up in a way I had not been able to do before.” As time went on, the trainees felt empowered to adapt “the interviewing script” modestly to fit their already developed “rhythm and style with their patients.”

Wellness/Mentoring

The 2 trainees were at different stages of their careers, 1 early-career faculty and 1 mid-career faculty. This academic diversity within the small training group provided varied perspectives not only on the concepts presented and discussed, but also on a more personal level. In an otherwise hectic academic medicine environment, this group had a weekly chance to stop, “check in” with each other, and truly connect on a personal level. To be asked “about your week and actually mean it and want to hear the answer” is an unusual opportunity, one noted. It also offered time and support for purposeful self-reflection, which “often brought some emotions to the surface…at different times.” These connections were perhaps one of the most valuable parts of the experience. With burnout among physicians rampant,²⁴ establishing these networks is invaluable. In addition to introspection and personal connections, there was a strong element of mentoring during these weekly meetings. The opportunity to meet in a small group with senior faculty was highly valued by the trainees.

Mental Health Care: Complex Patient Clinic

The faculty were eager, but very apprehensive, in beginning the second segment of training, where work shifted from lectures and practicing skills to mental health care training in the CPC. The trainees expressed anxiety about several areas. These included additional clinical workload, patient referral/selection, and transition of patient care back to the primary care provider. Of note, they did not particularly express worries about the care they would be providing, because a psychiatrist would be available to them on site. In reflection, after spending 4 months in the clinic, trainees noted “how important observing live interviews for evaluation/feedback was to their learning.” The CPC provided “learning in the moment on specific patients [which] was without question the most powerful teaching tool.” The support of the training faculty who were present at each clinic was invaluable. Whereas the earlier didactics given by psychiatrists were received by trainees with lukewarm enthusiasm, the point-of-care, case-by-case learning and feedback truly advanced the trainees’ knowledge, as well as skills, and improved their confidence in providing mental health care.

One of the tenets of the mental health care models is collaborative care.²⁵ Recognizing this critical component of patient care, the CPC experience integrated a clinical social worker. The faculty noted the critical role she played in the patient care experience. They described her as “fabulous and awesome.” Her grasp of the health care system and community resources (particularly for an underserved population) was indispensable. Additionally, she was able to serve as a steady contact to follow patients through multiple visits and improve their feelings of continuity.

Teaching: Psychosocial Rotation

The first psychosocial teaching occurred after the interviewing skills and didactic experiences in the first 6 months. The trainees expressed great doubt about tackling this initial teaching experience. From residents challenging the need for interviewing and other aspects of “touchy-feely” teaching, to patients expressing raw emotions, the trainees lacked confidence in their ability to handle these moments. At this early stage of their training, one trainee said, “I feel like I am becoming a better interrogator, but I haven’t learned the skills to be a better healer yet.” Over time, this concern disappeared. As training evolved, the trainees began to thrive in their role as educator. At the final focus group, it was noted that “teaching has enhanced [my] confidence in the framework and in turn has made it easier to teach.”

Teaching: Complex Patient Clinic

This powerful teaching tool to train residents was the centerpiece of training. The faculty trainees had some hesitation about their role as teacher before it began. The faculty trainees were at different stages of their careers, and their confidence in their own teaching skills was not uniform. Importantly, the initial structure of the CPC, which included psychiatrists and senior faculty supervision, provided strong and continued support for the faculty trainees. Later work in the CPC as teacher, rather than trainee, further bolstered the faculty’s confidence in the treatment models. As confidence with their own skills grew, faculty noted that it became “easier to teach” as well. Faculty also recognized the unique opportunity that the CPC provided in directly observing a resident’s patient interaction. This allows them to “monitor progress, provide specific feedback, and address issues.” The time spent debriefing after each patient encounter was noted to be particularly important. When they became too busy to adequately provide this debriefing, changes to the schedule were made to accommodate it (follow-up visits were lengthened from 30 to 60 minutes). In addition to giving an opportunity to provide feedback, this extra time available for residents to interact with a patient—to utilize and practice the interviewing skills, for example—was quite valuable, independent of actual mental health care training. Finally, the faculty were able to create a “relaxed and comfortable” space in the CPC. Indeed, the faculty felt comfortable sharing some of their struggles and reflections on caring for a mental health patient population, and residents were able, in turn, to engage in some self-reflection and debriefing as well.

Discussion

Faculty trainees demonstrated a striking evolution as they progressed through this curriculum. At each of the 3 stages of training, they endorsed a broad range of feelings, from anxiety and uncertainty initially, to confidence and growth and appreciation later. They felt satisfied with having participated in the project and are engaged in exploring next steps.

Of note, these faculty members had some exposure to the skills models prior to starting the program because the residency program has integrated patient-centered interviewing into its program for many years. The faculty were supportive of the models prior to engaging in the curriculum, and they volunteered to participate. Similarly, the residents were familiar with the expectations as they went through the psychosocial rotation and the CPC. It is conceivable that the interviewing and mental health material may not be received as easily at an institution where the culture has had less exposure to such teaching.

While describing a faculty curriculum for mental health training is unique⁵ and the primary intent of this paper, we wanted to present its formative evaluation even though only 2 faculty trainees were involved. Simply put, the grant for this project supported only 2 trainees, and no more were required. Nevertheless, we propose that this only reported experience of medical faculty with mental health training is an important addition to the literature in mental health education. It will be a critical guide for others who choose the new direction of training medical faculty to teach mental health care.

As the research team looks to foster dissemination of the curriculum, it continues to be streamlined to highlight the components most useful and germane to learners. The early didactic readings on subjects such as general system theory were less engaging. (In later training of new medical faculty learners, the focus on theory and other didactics was reduced.) In contrast, the trainees clearly valued the interviewing skills experience (both learning and teaching). While the mental health curriculum and the CPC were associated with much greater anxiety in the trainees, with practical, respectful, and supervised teaching, they became confident and satisfied—as well as effective.⁶ Future teachers will benefit from slowly and understandingly addressing trainees’ personal issues, particularly during the initial phases of training.²⁶ It appeared to us to be the key factor enabling the faculty to successfully learn and teach mental health care. Once they overcame their personal reactions to mental health material, they learned mental health skills just as they learn the more familiar physical disease material.

Conclusion

In a new direction in medical education, a curriculum for training medical faculty to teach mental health care is presented. Not only did prior research demonstrate that the faculty effectively trained residents, but we also demonstrated here that the training was acceptable to and valued by faculty. With mental health often an alien dimension of medicine, acceptability is especially important when we recommend disseminating the curriculum as a way to offset the national mental health care crisis.

Corresponding author: Robert C. Smith, 788 Service Road, B314 Clinical Center, East Lansing, MI 48824; smithrr@msu.edu.

Financial disclosures: None.

Funding support: The authors are grateful for the generous support from the Health Resources and Services Administration (D58HP23259).

From Michigan State University, East Lansing, MI.

Abstract

• Objective: To describe the clinical presentations of medical patients attending a behavioral health clinic staffed by medical residents and faculty in the patients’ usual medical setting.
• Methods: We extracted the following clinical data from the patients’ electronic medical records: duration of problem; symptom presentation; symptom types; use of narcotics, antidepressants, benzodiazepines, antipsychotics, and mood stabilizers; impairment/disability; PHQ-9 scores and DSM-V diagnoses; and prior care from behavioral health professionals.
• Results: There were 64 patients, with an average age of 48.6 years. 68.8% were female, and 81.3% had had the presenting problem > 5 years. Presentation was psychological in 21/64 (32.8%), physical in 16/64 (25%), and both in 27/64 (42.2%). Patients averaged 3.3 common comorbid medical disease diagnoses. DSM-V diagnoses averaged 2.3 per patient; 30/64 (46.9%) had somatic symptom disorder, 27/64 (42.2%) had major depressive disorder, and 24/64 (37.5%) had generalized anxiety disorder. Social and economic impairment was present in > 70%. Some narcotic use occurred in 35/64 (54.7%) but only 7/35 (20.0%) were on unsafe doses; 46/64 (71.9%) took antidepressants but only 6/46 (13.0%) were on subtherapeutic doses. Averaging 71.9 months in the same clinic, only 18/64 (28.1%) had received behavioral health care for the presenting problem, and only 10.9% from psychiatrists.
• Conclusion: We described the chronic behavioral health problems of medical patients receiving behavioral care in their own medical setting from medical residents and faculty. These data can guide educators interested in training residents to manage common but now unattended behavioral health problems.

Patients with “any DSM behavioral health disorder” (mental health and substance use problems) account for 25% of patients seen in medical clinics [1]. These patients frequently present with poorly explained and sometimes confusing physical symptoms, and less often with psychological symptoms [2,3]. Common complaints in this population include chronic pain in almost any location, bowel complaints, insomnia, and fatigue [4]. Multiple somatic symptoms and increasing severity of symptoms correlate with the likelihood of an underlying depressive or anxiety disorder [3]. Unfortunately, medical physicians often do not recognize behavioral health problems and provide inadequate treatment for those they do [5].

As part of a Health Resources and Services Administration (HRSA) grant to develop behavioral health training guidelines for medical residents [6], we developed a special clinic for these patients. The clinic was located in their regular clinic area, and care was provided by medical residents and faculty. The objective of this paper is to describe the clinical presentation of patients attending the behavioral health care clinic, thus highlighting the common problems for which medical physicians are increasingly called upon to diagnose and treat.

Methods

We are in the third year of a 5-year HRSA grant to develop a method for teaching residents a primary care behavioral health care treatment model based on patient-centered, cognitive-behavioral, pharmacologic, and teamwork principles [6]. It is derived from consultation-liaison psychiatry, multidisciplinary pain management, and primary care research [7–10] and adapted for medical physicians. Described in detail elsewhere [6], we intensively train PGY-2 and PGY-3 residents in the Complex Patient Clinic (CPC), the name we applied to a behavioral health care clinic and the focus of this report.

Theoretical Base

The theoretical basis for this approach is general system theory and its medical derivative, the biopsychosocial (BPS) model [11]. In describing prevalent but overlooked behavioral health problems of patients attending our CPC, we underscore the importance of the BPS model relative to the prevailing biomedical, disease-only model. The latter does not include behavioral or psychosocial dimensions, the result being that they are largely excluded from medical education and, hence, overlooked in practice. The BPS model provides the theoretical basis for including these behavioral health patients in teaching and care.

Patients

Observations

The CPC uses 3 examination rooms for one half-day a week in the usual resident and faculty area of the Clinical Center of Michigan State University Department of Medicine. Rooms are similar to other clinic examination rooms except that a second computer attached to small audio video recorder is placed on the physician’s desk. Visible to the patient, it broadcasts live the patient-resident interaction to a nearby room where teaching faculty observe the interaction on a computer linked by a special software program (Vidyo, Hackensack, NJ) [12]. Access and control of Vidyo virtual rooms is restricted and rooms can only be entered by participating faculty using pre-assigned usernames and passwords. No recordings of the interactions are made.

Training faculty and the resident reviewed the patient’s EMR before each interaction and faculty continued to review it while observing the interaction. Both faculty and trainee documented information in the EMR in the fashion used with other patients.

Data

Two authors, RCS and AD, independently reviewed the EMR records of CPC visits, including follow-up visits and free text sources, and recorded results on an Excel spreadsheet; records of visits prior to CPC consultation were not reviewed nor were later non-CPC visits. They abstracted chart information on the first 5 patients and then updated and refined criteria. This was repeated again for the next 5 patients and near 100% agreement was obtained on all items except disability where > 90% agreement was achieved. All subsequent ratings were independently obtained and any differences were then jointly resolved in this extraction of mostly straightforward descriptive data. RCS is a senior faculty active in teaching and AD is a senior medical resident rated as superior by her faculty.

Results

Of 77 patients referred between 19 February 2013 and 10 December 2013, 13 (16.9%) did not complete the first scheduled or any subsequently scheduled appointments, while the remaining 64 patients (83.1%) completed referral to the CPC. Of the 64 attending the CPC, 6 (9.4%) missed the first appointment but made their first visit an average of 36.2 days later. The mean age was 48.6 years (range 25–75), 44/64 (68.8%) were women, 55/64 (85.9%) were Caucasian, 60/64 (93.8%) were non-Hispanic/Latino, and 63/64 (98.4%) were English speaking. All had insurance of some type, and 25/64 (39.1%) were Medicaid patients. Of 3583 total patients seen in the referring clinics during the same period, we found a mean age of 57 years (range, 17–97), 53% women, 75% Caucasian, 95% non-Hispanic/Latino, 97% English-speaking, and 9% Medicaid.

Current cigarette smokers were 22/64 (34.4%) of the population, higher than in national databases but similar to many behavioral health populations [23]. The BMI was 25 or less in 21/64 (32.8%), similar to the national distribution demonstrating that approximately 2/3 of patients are overweight or obese; 12/64 (18.8%) had a BMI of 25–30 (overweight), lower than national data, and 33/64 (48.5%) had a BMI >30 (obesity), higher than national data [24]. Similar increased rates of obesity are found in other behavioral health populations [25].

Mode of Symptom Presentation

Psychological symptoms were the sole mode of presentation in 21/64 (32.8%), while physical symptoms were the sole presenting complaint in 16/64 (25.0%). Combined psychological and physical symptoms were the predominant pattern at 27/64 (42.2%). Thus, 43/64 (67.2%) had physical symptoms and 48/64 (75.0%) had psychological symptoms at presentation. The mean duration of presenting symptoms was > 5 years in 52/64 (81.3%); only 5/64 (7.8%) had symptoms < 12 months in duration.

Presenting Symptoms

Pain symptoms were present in 53/64 (82.8%) and averaged 1.9 per patient. The details presented in Table 3 demonstrate a high frequency of musculoskeletal problems.

Non-pain physical symptoms were present in 45/64 (70.3%) and averaged 1.5 per patient. There was a very high frequency of insomnia (Table 3).

Comorbid Physical Diseases

Medications

Narcotic use was found in 35/64 (54.7%) patients; of these, 23/35 (65.7%) were using 80 or fewer morphine equivalents and 12/35 (34.3%) were using > 80 morphine equivalents, only 7/35 (20.0%) at > 120 morphine equivalents. Thus, only the latter took unsafe doses. There was no narcotic use in 29/64 (45.3%).

Antidepressant use was found in 46/64 (71.9%); only 6/46 (13.0%) were on subtherapeutic doses while 40/46 (87.0%) were on “usual therapeutic” doses. There was no antidepressant use in 18/64 (28.1%).

Benzodiazepine use was found in 31/64 (48.4%), antipsychotic use in 8/64 (12.5%), and mood stabilizer use in 10/64 (15.6%).

Impairment/Disability

Major physical impairment was present in 27/64 (42.2%), major economic impairment was present in 45/64 (70.3%), and major social impairment occurred in 49/64 (76.6%).

Diagnoses

The PHQ-9 was available in 41/64 (64.1%) of cases. Of these, it was < 5 (normal) in 3/41 (7.3%), from 5–10 (mild depression) in 11/41 (26.8%), from 10–15 (moderate depression) in 13/41 (31.7%), from 15–20 (severe depression) in 3/41 (7.3%), and > 20 (very severe depression) in 11/41 (26.8%).

Prior Care History

Behavioral health care for problems prior to the presentation problem had been received by 27/64 (42.2%): 11/27 (40.7%) from non-psychiatrists, 10/27 (37.0%) from psychiatrists, and 6/27 (22.2%) from both. Behavioral care for the presentation problem had been received by only 18/64 (28.1%): 11/18 (61.1%) from non-psychiatrists, 3/18 (16.7%) from psychiatrists, and 4/18 (22.2%) from both. Thus, of all 64 CPC patients, only 7 (10.9%) had received psychiatric care. Patients had received care in the same medical clinic for an average of 71.9 months.

Discussion

We identified the clinical profile of medical patients referred to a behavioral health care clinic. Located in the patients’ usual clinic area, care in the CPC was provided by medical residents and faculty. CPC patients were predominantly middle-aged, female, white, and non-Hispanic/Latino. Obesity and tobacco use were greater than in the general population but at levels often found in psychiatric populations [23,25]. Presenting symptoms of most patients were of > 5 years’ duration. The most common presentation was a combination of psychological and physical symptoms rather than either alone. Psychological symptoms were mainly depression and anxiety, while physical presentations primarily involved insomnia and many types of pain. These findings parallel the literature, except that psychological symptoms were more prominent than often reported [2,3]. This may indicate better recognition by referring physicians (and thus referral) of patients having a psychological presentation [26].

On average, there were 3.3 common comorbid physical disease diagnoses and 2.3 DSM-V diagnoses in each patient. The most common DSM-V diagnoses were somatic symptom disorder (46.9%), major depressive disorder (42.2%), and generalized anxiety disorder (37.5%) [22]. Representing diagnoses with which residents likely would have less recognition, several other disorders were in the 5% to 15% range: bipolar disorder, PTSD, various types of substance abuse, ADHD, psychological factors affecting medical conditions, and dysthymia.

Based on the literature and frequent comments from faculty and residents, we had expected greater narcotic use, especially at unsafe levels [27]. But, nearly half were taking none. Of those taking narcotics, only 20% received unsafe doses (more than 120 morphine equivalents). At odds with the literature citing frequent subtherapeutic antidepressant use by physicians [16], only 13.0% of the 71.9% taking antidepressants were at subtherapeutic levels. This suggests that referring physicians were not remiss when prescribing a single drug and that multiple drugs may be necessary [28]. Referring physicians may not be comfortable initiating and managing these more complex regimens. The narcotic and antidepressant practices by referring physicians suggested that the patients referred were more complex than can be addressed by good general medical care (low-dose narcotics and full-dose antidepressants). The complexity of these patients is further suggested by the PHQ-9 data, which indicated that more than one-third were in the severe to very severe range for depression [21]. The extent of economic and social impairment was striking (> 70%).

Even though these patients had been in the same medical clinic for nearly 6 years, only 28.1% had received behavioral health care for the presenting problem, and only 10.9% by a psychiatrist [5]. This suggests failure to recognize the problem [5] and/or the inability to access increasingly unavailable psychiatric consultation [29]. The latter is consistent with the literature that psychiatrists care for < 15% of all mental health patients [30], are of insufficient numbers in 96% of U.S. counties [31], and that most medical physicians find it nearly impossible to obtain a psychiatric consultation [29]. We also demonstrated behavioral health patients’ ready acceptance of behavioral health consultation in a medical setting by medical physicians. The 16.9% no-show rate for referrals to the CPC compares favorably to completion of psychiatry referrals where 50% to 60% no-show rates are not uncommon [32]. While our results may be due to decreased stigma in a medical setting [33], they likely also reflect that direct appointments were made by the referring physician at the time of the appointment (rather than the frequent psychiatry practice of having the patient make the appointment later by telephone), and that there was no more than a 1- to 2-week waiting period [34].

There were important limitations. The patient population from this small academic medical center may vary from that seen in different clinic types, and its physicians may differ in their referral practices. Although it is possible that our results are unique to the CPC and not generalizable, the similarity of our patients to those reported in the survey literature of primary care strongly suggests that these are indeed the types of patients who would be referred to and attend such clinics elsewhere. Patients also were mostly white, so the results may not apply in other populations. Further, some reports indicate using unstructured records from the EMR alone for diagnosing depression has significant limitations [35]. We did not have structured data, and the quality of documentation cannot be assured. A further limitation is that we did not verify our findings by talking with the physicians or with the patients, nor did we use formal diagnostic tools administered to patients, such as the World Health Organization Composite International Diagnostic Interview [36], to establish independently our DSM-V diagnoses [22]. Nevertheless, CPC diagnoses were made by experienced clinicians familiar with DSM-V.

Conclusion

This descriptive research demonstrated the clinical presentation of behavioral health patients when consultation was provided by medical physicians in their usual clinic. We have identified the types of patients for which educators may want to prepare their residents (and students) and for which practitioners can seek continuing education. Specifically, we demonstrated that learners will need to know how to diagnose and manage patients presenting with many different physical symptoms, often difficult to explain on a disease basis. Further, they will need to recognize that the usual mode of presentation of a primary care behavioral health problem, typically underlying depression and anxiety, is with multiple physical symptoms [37]. Learners will, in turn, need to be taught the relational, cognitive behavioral, pharmacologic, and teamwork principles that must be used in treatment [37].

Nevertheless, practically speaking, training practitioners has been ineffective [38], and training residents and students would not yield results for many years, Thus, these data also highlight the need for increased training of consultation-liaison and other psychiatrists. The well-established success of collaborative care [39] warrants increased support, as do related team efforts such as the patient-centered medical home. As well, more support for services and implementation research is badly needed to facilitate behavioral care in the medical setting.

The well-trained physician of the future can greatly complement these current efforts. If we can address all the multiple factors involved, we can look ahead to a much changed behavioral health care scene in 10 to 15 years [40].

Acknowledgements: The authors would like to acknowledge key advisory roles played by the following parts of our team in developing this project. Heather Spotts, MSW, advised and participated in team management. Jose Herrera, MD, was crucial in providing psychiatry continuity in the Complex Patient Clinic. Carmen Meerschaert, MD, played a key initial role in developing the structure of the Complex Patient Clinic. Geraud Plantegenest, MS, was responsible to developing and ensuring the function of our internet technology work in the Complex Patient Clinic.

Corresponding author: Robert C. Smith, B312 Clinical Center, 788 Service Rd., Michigan State Univ., East Lansing, MI 48824, robert.smith@ht.msu.edu.

Funding/support: We are grateful for the generous support from the Health Resources and Services Administration (HRSA) (D58HP23259) that provides the opportunity to develop this curriculum and produce papers from it. HRSA had no role in the study design; collection, analysis, and interpretation of data; writing the report; or in decision to submit the article for publication.

Financial disclosures: None.

Author contributions: conception and design, FCD, DD, JF, AD, DS, RCS; analysis and interpretation of data, FCD, AD, KGS, DS, RCS; drafting of article, FCD, HLF, LF, DD, JF, AD, KGS, DS, RCS; critical revision of the article, FCD, HLF, LF, DD, JF, AD, KGS, DS, RCS; provision of study materials or patients, FCD, HLF, LF, RCS; statistical expertise, AD, KGS, DS; obtaining of funding, FCD, LF, RCS; administrative or technical support, FCD, HLF, KGS, RCS; collection and assembly of data, AD, RCS.

From Michigan State University, East Lansing, MI.

Abstract

• Objective: To describe the clinical presentations of medical patients attending a behavioral health clinic staffed by medical residents and faculty in the patients’ usual medical setting.
• Methods: We extracted the following clinical data from the patients’ electronic medical records: duration of problem; symptom presentation; symptom types; use of narcotics, antidepressants, benzodiazepines, antipsychotics, and mood stabilizers; impairment/disability; PHQ-9 scores and DSM-V diagnoses; and prior care from behavioral health professionals.
• Results: There were 64 patients, with an average age of 48.6 years. 68.8% were female, and 81.3% had had the presenting problem > 5 years. Presentation was psychological in 21/64 (32.8%), physical in 16/64 (25%), and both in 27/64 (42.2%). Patients averaged 3.3 common comorbid medical disease diagnoses. DSM-V diagnoses averaged 2.3 per patient; 30/64 (46.9%) had somatic symptom disorder, 27/64 (42.2%) had major depressive disorder, and 24/64 (37.5%) had generalized anxiety disorder. Social and economic impairment was present in > 70%. Some narcotic use occurred in 35/64 (54.7%) but only 7/35 (20.0%) were on unsafe doses; 46/64 (71.9%) took antidepressants but only 6/46 (13.0%) were on subtherapeutic doses. Averaging 71.9 months in the same clinic, only 18/64 (28.1%) had received behavioral health care for the presenting problem, and only 10.9% from psychiatrists.
• Conclusion: We described the chronic behavioral health problems of medical patients receiving behavioral care in their own medical setting from medical residents and faculty. These data can guide educators interested in training residents to manage common but now unattended behavioral health problems.

Patients with “any DSM behavioral health disorder” (mental health and substance use problems) account for 25% of patients seen in medical clinics [1]. These patients frequently present with poorly explained and sometimes confusing physical symptoms, and less often with psychological symptoms [2,3]. Common complaints in this population include chronic pain in almost any location, bowel complaints, insomnia, and fatigue [4]. Multiple somatic symptoms and increasing severity of symptoms correlate with the likelihood of an underlying depressive or anxiety disorder [3]. Unfortunately, medical physicians often do not recognize behavioral health problems and provide inadequate treatment for those they do [5].

As part of a Health Resources and Services Administration (HRSA) grant to develop behavioral health training guidelines for medical residents [6], we developed a special clinic for these patients. The clinic was located in their regular clinic area, and care was provided by medical residents and faculty. The objective of this paper is to describe the clinical presentation of patients attending the behavioral health care clinic, thus highlighting the common problems for which medical physicians are increasingly called upon to diagnose and treat.

Methods

We are in the third year of a 5-year HRSA grant to develop a method for teaching residents a primary care behavioral health care treatment model based on patient-centered, cognitive-behavioral, pharmacologic, and teamwork principles [6]. It is derived from consultation-liaison psychiatry, multidisciplinary pain management, and primary care research [7–10] and adapted for medical physicians. Described in detail elsewhere [6], we intensively train PGY-2 and PGY-3 residents in the Complex Patient Clinic (CPC), the name we applied to a behavioral health care clinic and the focus of this report.

Theoretical Base

The theoretical basis for this approach is general system theory and its medical derivative, the biopsychosocial (BPS) model [11]. In describing prevalent but overlooked behavioral health problems of patients attending our CPC, we underscore the importance of the BPS model relative to the prevailing biomedical, disease-only model. The latter does not include behavioral or psychosocial dimensions, the result being that they are largely excluded from medical education and, hence, overlooked in practice. The BPS model provides the theoretical basis for including these behavioral health patients in teaching and care.

Patients

Observations

The CPC uses 3 examination rooms for one half-day a week in the usual resident and faculty area of the Clinical Center of Michigan State University Department of Medicine. Rooms are similar to other clinic examination rooms except that a second computer attached to small audio video recorder is placed on the physician’s desk. Visible to the patient, it broadcasts live the patient-resident interaction to a nearby room where teaching faculty observe the interaction on a computer linked by a special software program (Vidyo, Hackensack, NJ) [12]. Access and control of Vidyo virtual rooms is restricted and rooms can only be entered by participating faculty using pre-assigned usernames and passwords. No recordings of the interactions are made.

Training faculty and the resident reviewed the patient’s EMR before each interaction and faculty continued to review it while observing the interaction. Both faculty and trainee documented information in the EMR in the fashion used with other patients.

Data

Two authors, RCS and AD, independently reviewed the EMR records of CPC visits, including follow-up visits and free text sources, and recorded results on an Excel spreadsheet; records of visits prior to CPC consultation were not reviewed nor were later non-CPC visits. They abstracted chart information on the first 5 patients and then updated and refined criteria. This was repeated again for the next 5 patients and near 100% agreement was obtained on all items except disability where > 90% agreement was achieved. All subsequent ratings were independently obtained and any differences were then jointly resolved in this extraction of mostly straightforward descriptive data. RCS is a senior faculty active in teaching and AD is a senior medical resident rated as superior by her faculty.

Results

Of 77 patients referred between 19 February 2013 and 10 December 2013, 13 (16.9%) did not complete the first scheduled or any subsequently scheduled appointments, while the remaining 64 patients (83.1%) completed referral to the CPC. Of the 64 attending the CPC, 6 (9.4%) missed the first appointment but made their first visit an average of 36.2 days later. The mean age was 48.6 years (range 25–75), 44/64 (68.8%) were women, 55/64 (85.9%) were Caucasian, 60/64 (93.8%) were non-Hispanic/Latino, and 63/64 (98.4%) were English speaking. All had insurance of some type, and 25/64 (39.1%) were Medicaid patients. Of 3583 total patients seen in the referring clinics during the same period, we found a mean age of 57 years (range, 17–97), 53% women, 75% Caucasian, 95% non-Hispanic/Latino, 97% English-speaking, and 9% Medicaid.

Current cigarette smokers were 22/64 (34.4%) of the population, higher than in national databases but similar to many behavioral health populations [23]. The BMI was 25 or less in 21/64 (32.8%), similar to the national distribution demonstrating that approximately 2/3 of patients are overweight or obese; 12/64 (18.8%) had a BMI of 25–30 (overweight), lower than national data, and 33/64 (48.5%) had a BMI >30 (obesity), higher than national data [24]. Similar increased rates of obesity are found in other behavioral health populations [25].

Mode of Symptom Presentation

Psychological symptoms were the sole mode of presentation in 21/64 (32.8%), while physical symptoms were the sole presenting complaint in 16/64 (25.0%). Combined psychological and physical symptoms were the predominant pattern at 27/64 (42.2%). Thus, 43/64 (67.2%) had physical symptoms and 48/64 (75.0%) had psychological symptoms at presentation. The mean duration of presenting symptoms was > 5 years in 52/64 (81.3%); only 5/64 (7.8%) had symptoms < 12 months in duration.

Presenting Symptoms

Pain symptoms were present in 53/64 (82.8%) and averaged 1.9 per patient. The details presented in Table 3 demonstrate a high frequency of musculoskeletal problems.

Non-pain physical symptoms were present in 45/64 (70.3%) and averaged 1.5 per patient. There was a very high frequency of insomnia (Table 3).

Comorbid Physical Diseases

Medications

Narcotic use was found in 35/64 (54.7%) patients; of these, 23/35 (65.7%) were using 80 or fewer morphine equivalents and 12/35 (34.3%) were using > 80 morphine equivalents, only 7/35 (20.0%) at > 120 morphine equivalents. Thus, only the latter took unsafe doses. There was no narcotic use in 29/64 (45.3%).

Antidepressant use was found in 46/64 (71.9%); only 6/46 (13.0%) were on subtherapeutic doses while 40/46 (87.0%) were on “usual therapeutic” doses. There was no antidepressant use in 18/64 (28.1%).

Benzodiazepine use was found in 31/64 (48.4%), antipsychotic use in 8/64 (12.5%), and mood stabilizer use in 10/64 (15.6%).

Impairment/Disability

Major physical impairment was present in 27/64 (42.2%), major economic impairment was present in 45/64 (70.3%), and major social impairment occurred in 49/64 (76.6%).

Diagnoses

The PHQ-9 was available in 41/64 (64.1%) of cases. Of these, it was < 5 (normal) in 3/41 (7.3%), from 5–10 (mild depression) in 11/41 (26.8%), from 10–15 (moderate depression) in 13/41 (31.7%), from 15–20 (severe depression) in 3/41 (7.3%), and > 20 (very severe depression) in 11/41 (26.8%).

Prior Care History

Behavioral health care for problems prior to the presentation problem had been received by 27/64 (42.2%): 11/27 (40.7%) from non-psychiatrists, 10/27 (37.0%) from psychiatrists, and 6/27 (22.2%) from both. Behavioral care for the presentation problem had been received by only 18/64 (28.1%): 11/18 (61.1%) from non-psychiatrists, 3/18 (16.7%) from psychiatrists, and 4/18 (22.2%) from both. Thus, of all 64 CPC patients, only 7 (10.9%) had received psychiatric care. Patients had received care in the same medical clinic for an average of 71.9 months.

Discussion

We identified the clinical profile of medical patients referred to a behavioral health care clinic. Located in the patients’ usual clinic area, care in the CPC was provided by medical residents and faculty. CPC patients were predominantly middle-aged, female, white, and non-Hispanic/Latino. Obesity and tobacco use were greater than in the general population but at levels often found in psychiatric populations [23,25]. Presenting symptoms of most patients were of > 5 years’ duration. The most common presentation was a combination of psychological and physical symptoms rather than either alone. Psychological symptoms were mainly depression and anxiety, while physical presentations primarily involved insomnia and many types of pain. These findings parallel the literature, except that psychological symptoms were more prominent than often reported [2,3]. This may indicate better recognition by referring physicians (and thus referral) of patients having a psychological presentation [26].

On average, there were 3.3 common comorbid physical disease diagnoses and 2.3 DSM-V diagnoses in each patient. The most common DSM-V diagnoses were somatic symptom disorder (46.9%), major depressive disorder (42.2%), and generalized anxiety disorder (37.5%) [22]. Representing diagnoses with which residents likely would have less recognition, several other disorders were in the 5% to 15% range: bipolar disorder, PTSD, various types of substance abuse, ADHD, psychological factors affecting medical conditions, and dysthymia.

Based on the literature and frequent comments from faculty and residents, we had expected greater narcotic use, especially at unsafe levels [27]. But, nearly half were taking none. Of those taking narcotics, only 20% received unsafe doses (more than 120 morphine equivalents). At odds with the literature citing frequent subtherapeutic antidepressant use by physicians [16], only 13.0% of the 71.9% taking antidepressants were at subtherapeutic levels. This suggests that referring physicians were not remiss when prescribing a single drug and that multiple drugs may be necessary [28]. Referring physicians may not be comfortable initiating and managing these more complex regimens. The narcotic and antidepressant practices by referring physicians suggested that the patients referred were more complex than can be addressed by good general medical care (low-dose narcotics and full-dose antidepressants). The complexity of these patients is further suggested by the PHQ-9 data, which indicated that more than one-third were in the severe to very severe range for depression [21]. The extent of economic and social impairment was striking (> 70%).

Even though these patients had been in the same medical clinic for nearly 6 years, only 28.1% had received behavioral health care for the presenting problem, and only 10.9% by a psychiatrist [5]. This suggests failure to recognize the problem [5] and/or the inability to access increasingly unavailable psychiatric consultation [29]. The latter is consistent with the literature that psychiatrists care for < 15% of all mental health patients [30], are of insufficient numbers in 96% of U.S. counties [31], and that most medical physicians find it nearly impossible to obtain a psychiatric consultation [29]. We also demonstrated behavioral health patients’ ready acceptance of behavioral health consultation in a medical setting by medical physicians. The 16.9% no-show rate for referrals to the CPC compares favorably to completion of psychiatry referrals where 50% to 60% no-show rates are not uncommon [32]. While our results may be due to decreased stigma in a medical setting [33], they likely also reflect that direct appointments were made by the referring physician at the time of the appointment (rather than the frequent psychiatry practice of having the patient make the appointment later by telephone), and that there was no more than a 1- to 2-week waiting period [34].

There were important limitations. The patient population from this small academic medical center may vary from that seen in different clinic types, and its physicians may differ in their referral practices. Although it is possible that our results are unique to the CPC and not generalizable, the similarity of our patients to those reported in the survey literature of primary care strongly suggests that these are indeed the types of patients who would be referred to and attend such clinics elsewhere. Patients also were mostly white, so the results may not apply in other populations. Further, some reports indicate using unstructured records from the EMR alone for diagnosing depression has significant limitations [35]. We did not have structured data, and the quality of documentation cannot be assured. A further limitation is that we did not verify our findings by talking with the physicians or with the patients, nor did we use formal diagnostic tools administered to patients, such as the World Health Organization Composite International Diagnostic Interview [36], to establish independently our DSM-V diagnoses [22]. Nevertheless, CPC diagnoses were made by experienced clinicians familiar with DSM-V.

Conclusion

This descriptive research demonstrated the clinical presentation of behavioral health patients when consultation was provided by medical physicians in their usual clinic. We have identified the types of patients for which educators may want to prepare their residents (and students) and for which practitioners can seek continuing education. Specifically, we demonstrated that learners will need to know how to diagnose and manage patients presenting with many different physical symptoms, often difficult to explain on a disease basis. Further, they will need to recognize that the usual mode of presentation of a primary care behavioral health problem, typically underlying depression and anxiety, is with multiple physical symptoms [37]. Learners will, in turn, need to be taught the relational, cognitive behavioral, pharmacologic, and teamwork principles that must be used in treatment [37].

Nevertheless, practically speaking, training practitioners has been ineffective [38], and training residents and students would not yield results for many years, Thus, these data also highlight the need for increased training of consultation-liaison and other psychiatrists. The well-established success of collaborative care [39] warrants increased support, as do related team efforts such as the patient-centered medical home. As well, more support for services and implementation research is badly needed to facilitate behavioral care in the medical setting.

The well-trained physician of the future can greatly complement these current efforts. If we can address all the multiple factors involved, we can look ahead to a much changed behavioral health care scene in 10 to 15 years [40].

Acknowledgements: The authors would like to acknowledge key advisory roles played by the following parts of our team in developing this project. Heather Spotts, MSW, advised and participated in team management. Jose Herrera, MD, was crucial in providing psychiatry continuity in the Complex Patient Clinic. Carmen Meerschaert, MD, played a key initial role in developing the structure of the Complex Patient Clinic. Geraud Plantegenest, MS, was responsible to developing and ensuring the function of our internet technology work in the Complex Patient Clinic.

Corresponding author: Robert C. Smith, B312 Clinical Center, 788 Service Rd., Michigan State Univ., East Lansing, MI 48824, robert.smith@ht.msu.edu.

Funding/support: We are grateful for the generous support from the Health Resources and Services Administration (HRSA) (D58HP23259) that provides the opportunity to develop this curriculum and produce papers from it. HRSA had no role in the study design; collection, analysis, and interpretation of data; writing the report; or in decision to submit the article for publication.

Financial disclosures: None.

Author contributions: conception and design, FCD, DD, JF, AD, DS, RCS; analysis and interpretation of data, FCD, AD, KGS, DS, RCS; drafting of article, FCD, HLF, LF, DD, JF, AD, KGS, DS, RCS; critical revision of the article, FCD, HLF, LF, DD, JF, AD, KGS, DS, RCS; provision of study materials or patients, FCD, HLF, LF, RCS; statistical expertise, AD, KGS, DS; obtaining of funding, FCD, LF, RCS; administrative or technical support, FCD, HLF, KGS, RCS; collection and assembly of data, AD, RCS.

From Michigan State University, East Lansing, MI.

Abstract

• Objective: To describe the clinical presentations of medical patients attending a behavioral health clinic staffed by medical residents and faculty in the patients’ usual medical setting.
• Methods: We extracted the following clinical data from the patients’ electronic medical records: duration of problem; symptom presentation; symptom types; use of narcotics, antidepressants, benzodiazepines, antipsychotics, and mood stabilizers; impairment/disability; PHQ-9 scores and DSM-V diagnoses; and prior care from behavioral health professionals.
• Results: There were 64 patients, with an average age of 48.6 years. 68.8% were female, and 81.3% had had the presenting problem > 5 years. Presentation was psychological in 21/64 (32.8%), physical in 16/64 (25%), and both in 27/64 (42.2%). Patients averaged 3.3 common comorbid medical disease diagnoses. DSM-V diagnoses averaged 2.3 per patient; 30/64 (46.9%) had somatic symptom disorder, 27/64 (42.2%) had major depressive disorder, and 24/64 (37.5%) had generalized anxiety disorder. Social and economic impairment was present in > 70%. Some narcotic use occurred in 35/64 (54.7%) but only 7/35 (20.0%) were on unsafe doses; 46/64 (71.9%) took antidepressants but only 6/46 (13.0%) were on subtherapeutic doses. Averaging 71.9 months in the same clinic, only 18/64 (28.1%) had received behavioral health care for the presenting problem, and only 10.9% from psychiatrists.
• Conclusion: We described the chronic behavioral health problems of medical patients receiving behavioral care in their own medical setting from medical residents and faculty. These data can guide educators interested in training residents to manage common but now unattended behavioral health problems.

Patients with “any DSM behavioral health disorder” (mental health and substance use problems) account for 25% of patients seen in medical clinics [1]. These patients frequently present with poorly explained and sometimes confusing physical symptoms, and less often with psychological symptoms [2,3]. Common complaints in this population include chronic pain in almost any location, bowel complaints, insomnia, and fatigue [4]. Multiple somatic symptoms and increasing severity of symptoms correlate with the likelihood of an underlying depressive or anxiety disorder [3]. Unfortunately, medical physicians often do not recognize behavioral health problems and provide inadequate treatment for those they do [5].

As part of a Health Resources and Services Administration (HRSA) grant to develop behavioral health training guidelines for medical residents [6], we developed a special clinic for these patients. The clinic was located in their regular clinic area, and care was provided by medical residents and faculty. The objective of this paper is to describe the clinical presentation of patients attending the behavioral health care clinic, thus highlighting the common problems for which medical physicians are increasingly called upon to diagnose and treat.

Methods

We are in the third year of a 5-year HRSA grant to develop a method for teaching residents a primary care behavioral health care treatment model based on patient-centered, cognitive-behavioral, pharmacologic, and teamwork principles [6]. It is derived from consultation-liaison psychiatry, multidisciplinary pain management, and primary care research [7–10] and adapted for medical physicians. Described in detail elsewhere [6], we intensively train PGY-2 and PGY-3 residents in the Complex Patient Clinic (CPC), the name we applied to a behavioral health care clinic and the focus of this report.

Theoretical Base

The theoretical basis for this approach is general system theory and its medical derivative, the biopsychosocial (BPS) model [11]. In describing prevalent but overlooked behavioral health problems of patients attending our CPC, we underscore the importance of the BPS model relative to the prevailing biomedical, disease-only model. The latter does not include behavioral or psychosocial dimensions, the result being that they are largely excluded from medical education and, hence, overlooked in practice. The BPS model provides the theoretical basis for including these behavioral health patients in teaching and care.

Patients

Observations

The CPC uses 3 examination rooms for one half-day a week in the usual resident and faculty area of the Clinical Center of Michigan State University Department of Medicine. Rooms are similar to other clinic examination rooms except that a second computer attached to small audio video recorder is placed on the physician’s desk. Visible to the patient, it broadcasts live the patient-resident interaction to a nearby room where teaching faculty observe the interaction on a computer linked by a special software program (Vidyo, Hackensack, NJ) [12]. Access and control of Vidyo virtual rooms is restricted and rooms can only be entered by participating faculty using pre-assigned usernames and passwords. No recordings of the interactions are made.

Training faculty and the resident reviewed the patient’s EMR before each interaction and faculty continued to review it while observing the interaction. Both faculty and trainee documented information in the EMR in the fashion used with other patients.

Data

Two authors, RCS and AD, independently reviewed the EMR records of CPC visits, including follow-up visits and free text sources, and recorded results on an Excel spreadsheet; records of visits prior to CPC consultation were not reviewed nor were later non-CPC visits. They abstracted chart information on the first 5 patients and then updated and refined criteria. This was repeated again for the next 5 patients and near 100% agreement was obtained on all items except disability where > 90% agreement was achieved. All subsequent ratings were independently obtained and any differences were then jointly resolved in this extraction of mostly straightforward descriptive data. RCS is a senior faculty active in teaching and AD is a senior medical resident rated as superior by her faculty.

Results

Of 77 patients referred between 19 February 2013 and 10 December 2013, 13 (16.9%) did not complete the first scheduled or any subsequently scheduled appointments, while the remaining 64 patients (83.1%) completed referral to the CPC. Of the 64 attending the CPC, 6 (9.4%) missed the first appointment but made their first visit an average of 36.2 days later. The mean age was 48.6 years (range 25–75), 44/64 (68.8%) were women, 55/64 (85.9%) were Caucasian, 60/64 (93.8%) were non-Hispanic/Latino, and 63/64 (98.4%) were English speaking. All had insurance of some type, and 25/64 (39.1%) were Medicaid patients. Of 3583 total patients seen in the referring clinics during the same period, we found a mean age of 57 years (range, 17–97), 53% women, 75% Caucasian, 95% non-Hispanic/Latino, 97% English-speaking, and 9% Medicaid.

Current cigarette smokers were 22/64 (34.4%) of the population, higher than in national databases but similar to many behavioral health populations [23]. The BMI was 25 or less in 21/64 (32.8%), similar to the national distribution demonstrating that approximately 2/3 of patients are overweight or obese; 12/64 (18.8%) had a BMI of 25–30 (overweight), lower than national data, and 33/64 (48.5%) had a BMI >30 (obesity), higher than national data [24]. Similar increased rates of obesity are found in other behavioral health populations [25].

Mode of Symptom Presentation

Psychological symptoms were the sole mode of presentation in 21/64 (32.8%), while physical symptoms were the sole presenting complaint in 16/64 (25.0%). Combined psychological and physical symptoms were the predominant pattern at 27/64 (42.2%). Thus, 43/64 (67.2%) had physical symptoms and 48/64 (75.0%) had psychological symptoms at presentation. The mean duration of presenting symptoms was > 5 years in 52/64 (81.3%); only 5/64 (7.8%) had symptoms < 12 months in duration.

Presenting Symptoms

Pain symptoms were present in 53/64 (82.8%) and averaged 1.9 per patient. The details presented in Table 3 demonstrate a high frequency of musculoskeletal problems.

Non-pain physical symptoms were present in 45/64 (70.3%) and averaged 1.5 per patient. There was a very high frequency of insomnia (Table 3).

Comorbid Physical Diseases

Medications

Narcotic use was found in 35/64 (54.7%) patients; of these, 23/35 (65.7%) were using 80 or fewer morphine equivalents and 12/35 (34.3%) were using > 80 morphine equivalents, only 7/35 (20.0%) at > 120 morphine equivalents. Thus, only the latter took unsafe doses. There was no narcotic use in 29/64 (45.3%).

Antidepressant use was found in 46/64 (71.9%); only 6/46 (13.0%) were on subtherapeutic doses while 40/46 (87.0%) were on “usual therapeutic” doses. There was no antidepressant use in 18/64 (28.1%).

Benzodiazepine use was found in 31/64 (48.4%), antipsychotic use in 8/64 (12.5%), and mood stabilizer use in 10/64 (15.6%).

Impairment/Disability

Major physical impairment was present in 27/64 (42.2%), major economic impairment was present in 45/64 (70.3%), and major social impairment occurred in 49/64 (76.6%).

Diagnoses

The PHQ-9 was available in 41/64 (64.1%) of cases. Of these, it was < 5 (normal) in 3/41 (7.3%), from 5–10 (mild depression) in 11/41 (26.8%), from 10–15 (moderate depression) in 13/41 (31.7%), from 15–20 (severe depression) in 3/41 (7.3%), and > 20 (very severe depression) in 11/41 (26.8%).

Prior Care History

Behavioral health care for problems prior to the presentation problem had been received by 27/64 (42.2%): 11/27 (40.7%) from non-psychiatrists, 10/27 (37.0%) from psychiatrists, and 6/27 (22.2%) from both. Behavioral care for the presentation problem had been received by only 18/64 (28.1%): 11/18 (61.1%) from non-psychiatrists, 3/18 (16.7%) from psychiatrists, and 4/18 (22.2%) from both. Thus, of all 64 CPC patients, only 7 (10.9%) had received psychiatric care. Patients had received care in the same medical clinic for an average of 71.9 months.

Discussion

We identified the clinical profile of medical patients referred to a behavioral health care clinic. Located in the patients’ usual clinic area, care in the CPC was provided by medical residents and faculty. CPC patients were predominantly middle-aged, female, white, and non-Hispanic/Latino. Obesity and tobacco use were greater than in the general population but at levels often found in psychiatric populations [23,25]. Presenting symptoms of most patients were of > 5 years’ duration. The most common presentation was a combination of psychological and physical symptoms rather than either alone. Psychological symptoms were mainly depression and anxiety, while physical presentations primarily involved insomnia and many types of pain. These findings parallel the literature, except that psychological symptoms were more prominent than often reported [2,3]. This may indicate better recognition by referring physicians (and thus referral) of patients having a psychological presentation [26].

On average, there were 3.3 common comorbid physical disease diagnoses and 2.3 DSM-V diagnoses in each patient. The most common DSM-V diagnoses were somatic symptom disorder (46.9%), major depressive disorder (42.2%), and generalized anxiety disorder (37.5%) [22]. Representing diagnoses with which residents likely would have less recognition, several other disorders were in the 5% to 15% range: bipolar disorder, PTSD, various types of substance abuse, ADHD, psychological factors affecting medical conditions, and dysthymia.

Based on the literature and frequent comments from faculty and residents, we had expected greater narcotic use, especially at unsafe levels [27]. But, nearly half were taking none. Of those taking narcotics, only 20% received unsafe doses (more than 120 morphine equivalents). At odds with the literature citing frequent subtherapeutic antidepressant use by physicians [16], only 13.0% of the 71.9% taking antidepressants were at subtherapeutic levels. This suggests that referring physicians were not remiss when prescribing a single drug and that multiple drugs may be necessary [28]. Referring physicians may not be comfortable initiating and managing these more complex regimens. The narcotic and antidepressant practices by referring physicians suggested that the patients referred were more complex than can be addressed by good general medical care (low-dose narcotics and full-dose antidepressants). The complexity of these patients is further suggested by the PHQ-9 data, which indicated that more than one-third were in the severe to very severe range for depression [21]. The extent of economic and social impairment was striking (> 70%).

Even though these patients had been in the same medical clinic for nearly 6 years, only 28.1% had received behavioral health care for the presenting problem, and only 10.9% by a psychiatrist [5]. This suggests failure to recognize the problem [5] and/or the inability to access increasingly unavailable psychiatric consultation [29]. The latter is consistent with the literature that psychiatrists care for < 15% of all mental health patients [30], are of insufficient numbers in 96% of U.S. counties [31], and that most medical physicians find it nearly impossible to obtain a psychiatric consultation [29]. We also demonstrated behavioral health patients’ ready acceptance of behavioral health consultation in a medical setting by medical physicians. The 16.9% no-show rate for referrals to the CPC compares favorably to completion of psychiatry referrals where 50% to 60% no-show rates are not uncommon [32]. While our results may be due to decreased stigma in a medical setting [33], they likely also reflect that direct appointments were made by the referring physician at the time of the appointment (rather than the frequent psychiatry practice of having the patient make the appointment later by telephone), and that there was no more than a 1- to 2-week waiting period [34].

There were important limitations. The patient population from this small academic medical center may vary from that seen in different clinic types, and its physicians may differ in their referral practices. Although it is possible that our results are unique to the CPC and not generalizable, the similarity of our patients to those reported in the survey literature of primary care strongly suggests that these are indeed the types of patients who would be referred to and attend such clinics elsewhere. Patients also were mostly white, so the results may not apply in other populations. Further, some reports indicate using unstructured records from the EMR alone for diagnosing depression has significant limitations [35]. We did not have structured data, and the quality of documentation cannot be assured. A further limitation is that we did not verify our findings by talking with the physicians or with the patients, nor did we use formal diagnostic tools administered to patients, such as the World Health Organization Composite International Diagnostic Interview [36], to establish independently our DSM-V diagnoses [22]. Nevertheless, CPC diagnoses were made by experienced clinicians familiar with DSM-V.

Conclusion

This descriptive research demonstrated the clinical presentation of behavioral health patients when consultation was provided by medical physicians in their usual clinic. We have identified the types of patients for which educators may want to prepare their residents (and students) and for which practitioners can seek continuing education. Specifically, we demonstrated that learners will need to know how to diagnose and manage patients presenting with many different physical symptoms, often difficult to explain on a disease basis. Further, they will need to recognize that the usual mode of presentation of a primary care behavioral health problem, typically underlying depression and anxiety, is with multiple physical symptoms [37]. Learners will, in turn, need to be taught the relational, cognitive behavioral, pharmacologic, and teamwork principles that must be used in treatment [37].

Nevertheless, practically speaking, training practitioners has been ineffective [38], and training residents and students would not yield results for many years, Thus, these data also highlight the need for increased training of consultation-liaison and other psychiatrists. The well-established success of collaborative care [39] warrants increased support, as do related team efforts such as the patient-centered medical home. As well, more support for services and implementation research is badly needed to facilitate behavioral care in the medical setting.

The well-trained physician of the future can greatly complement these current efforts. If we can address all the multiple factors involved, we can look ahead to a much changed behavioral health care scene in 10 to 15 years [40].

Acknowledgements: The authors would like to acknowledge key advisory roles played by the following parts of our team in developing this project. Heather Spotts, MSW, advised and participated in team management. Jose Herrera, MD, was crucial in providing psychiatry continuity in the Complex Patient Clinic. Carmen Meerschaert, MD, played a key initial role in developing the structure of the Complex Patient Clinic. Geraud Plantegenest, MS, was responsible to developing and ensuring the function of our internet technology work in the Complex Patient Clinic.

Corresponding author: Robert C. Smith, B312 Clinical Center, 788 Service Rd., Michigan State Univ., East Lansing, MI 48824, robert.smith@ht.msu.edu.

Funding/support: We are grateful for the generous support from the Health Resources and Services Administration (HRSA) (D58HP23259) that provides the opportunity to develop this curriculum and produce papers from it. HRSA had no role in the study design; collection, analysis, and interpretation of data; writing the report; or in decision to submit the article for publication.

Financial disclosures: None.

Author contributions: conception and design, FCD, DD, JF, AD, DS, RCS; analysis and interpretation of data, FCD, AD, KGS, DS, RCS; drafting of article, FCD, HLF, LF, DD, JF, AD, KGS, DS, RCS; critical revision of the article, FCD, HLF, LF, DD, JF, AD, KGS, DS, RCS; provision of study materials or patients, FCD, HLF, LF, RCS; statistical expertise, AD, KGS, DS; obtaining of funding, FCD, LF, RCS; administrative or technical support, FCD, HLF, KGS, RCS; collection and assembly of data, AD, RCS.