ORANGE, CALIF. – When Shannon Suo, MD, reached her family medicine rotation as a medical student at the University of Cincinnati, she recalls that the faculty “seemed a little lost” when they encountered patients who presented with psychiatric issues.
Dr. Shannon Suo
“If it were diabetes, high blood pressure, or back pain, they knew what to do; they had a plan,” said Dr. Suo, who is now training director for the combined family medicine/psychiatry residency at the University of California, Davis. “But when it came to depression, anxiety, maybe even some psychosis, they kind of looked a little nervous. Maybe they prescribed an antidepressant, but then they were like, ‘I don’t know what else to do for you.’ I felt uncomfortable with that.”
Eric Eschweiler, DNP, can identify with that sentiment. After he assumed the medical directorship of a federally qualified health center that opened 4 years ago in San Bernardino, Calif., nearly every person who presented for treatment had an underlying psychiatric disorder, from depression and anxiety to bipolar disorder and substance abuse stemming from childhood trauma.
Dr. Eric Eschweiler
“I really felt unprepared to take care of that population because with those mental health disorders, we would get a lot of concomitant chronic medical conditions,” Dr. Eschweiler said. “But they were not adherent, not compliant because they couldn’t control the mental health aspects, or we couldn’t get a handle on those issues.
“In [nurse practitioner] training, we really don’t get a whole lot of education related to the psychiatric component of health care,” he said. “I have a doctorate, but even with that, we didn’t get very much.”
When Dr. Eschweiler learned about a yearlong clinical fellowship designed for primary care–oriented trainees and clinicians who wish to receive advanced training in primary care psychiatry, he applied, “hoping I’d be first in line,” he said. He earned a spot in the 2018 class.
The program, known as the UC Irvine/UC Davis Train New Trainers (TNT) Primary Care Psychiatry (PCP) Fellowship, launched in 2016 as a way to train primary care clinicians to diagnose and treat the most common psychiatric conditions found in the primary care setting. The fellowship is aimed at educating not only MDs and DOs, but physician assistants, nurse practitioners, and pharmacists as well.
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Dr. Robert M. McCarron
“We want to give high-quality training to as many people as we can in order to optimize and expand the psychiatric workforce,” said Robert M. McCarron, DO, founding codirector of the fellowship program, and professor and vice chair of education and integrated care at the University of California, Irvine. “That’s really what we’re trying to do here.”
According to Dr. McCarron, who founded the fellowship with seed money during his tenure as a faculty member at UC Davis, up to 60% of all behavioral health care is provided in the busy primary setting, and as many as 80% of antidepressants are prescribed by nonpsychiatrists. Couple that with the current psychiatric workforce shortage “and you have a perfect storm,” he said.
“The toughest part is the volume of patients primary care providers have to see, comingled with a high frequency of comorbid mental illness. Added on to that, they didn’t get the training for much of the conditions they’re trying to address or treat. A primary care provider can refer to a psychiatrist, but there is not a large referral base. In addition, plenty of studies show that about half of those patients don’t end up seeing a mental health provider. Resources are limited in many areas of the country.”
TNT PCP fellows participate in the year-long program during nonclinic hours and accrue more than 45 CME units. Much of the training involves online courses framed around the textbook Primary Care Psychiatry (Wolters Kluwer, 2019), but fellows also are required to attend two intensive weekend sessions where they drill down on core topics, such as how to conduct an effective psychiatric interview, techniques, and how to screen and treat for psychiatric disorders.
“It’s not just about medicine options,” said Jaesu Han, MD, a fellowship faculty member who is board certified in psychiatry and family medicine. “For example, we try to focus on basic principles of cognitive-behavioral therapy, the role of psychotherapy, and the role of motivational interviewing. We try to help the providers recognize that there are other tools available [besides medication]. Those principles are going to help them engage with their patients more and have a larger impact.”
Dr. Jaesu Han
During one of the intensive weekend sessions, fellows are required to give a PowerPoint lecture on a topic of their choosing, with the idea of getting them comfortable with training their primary care colleagues on principles they learn.
“Some fellows are training their staff on their lunch breaks, or they’re implementing different tools they learned in our program to their organization,” said Wendy Cant, MBA, who is TNT PCP’s administrative director.
Wendy Cant, MBA
During a PowerPoint presentation a few years ago, one fellow chose to lecture about how to administer long-term antipsychotic medication in the primary care setting, a topic that the TNT PCP faculty had not thought to recommend. “We thought that was something a primary care provider would punt on,” said Dr. Suo, who is codirector of the fellowship program. “The fellow said, ‘No. This makes absolute sense. Our offices are equipped to do IM injections; our medical staff are trained to do that. It’s something that improves adherence and outcomes. It stabilizes people, and it makes us better able to take care of that population and not have to punt.’ That was unexpected and gratifying to know that we increased his comfort level to that point.”
Fellows also participate in two interactive learning sessions per month with faculty members, and each is paired with a faculty mentor, with whom they meet monthly in person or by video call or phone call.
“One of my fellows is feeling overwhelmed because she’s been tasked with taking care of the general psychiatric population, to do initial triage before she refers off to one of very few psychiatrists,” said Matthew Reed, MD, MSPH, one of the faculty mentors who serves as director of education for TNT PCP. “Her biggest concern is, ‘How do I not hate what I’m doing with my job because it’s so stressful and all patients want are opioid analgesics, or all they want are some benzodiazepines? They always want something, and I can’t get them to do what I want them to do.’ ” Together, they discuss various tools that might help her situation, such as using motivational interviewing to foster a sense of collaboration with patients.
Dr. Matthew Reed
Dr. Reed used the analogy of skeet shooting to illustrate the point that, without inviting patients to share in decision making, they are more likely to “shoot down” interventions that clinicians suggest to them.
Currently, about 80% of the program’s 118 fellows practice in California, there is a similar proportion of men and women, and their experience levels range from trainees to seasoned clinicians.
“They have 10, 15, and in some cases 25 years of experience, and they’re saying, ‘I‘ve been practicing for years and have been struggling when it comes to psychiatric issues. I want to do better,’ ” Dr. Suo noted.
Tuition is $15,500, and it usually is covered by outside funding sources. Last year, the program received a $1 million grant from California’s Office of Statewide Health Planning and Development, which was enough to fund tuition for 62 fellows. TNT PCP administrators and faculty also formed sponsor partnerships with several health plans and counties, including Inland Empire Health Plan, LA Care, Alameda Health Consortium, and Fresno County.
Employers also have stepped up. Cedars-Sinai Medical Center recently supplied a grant to fund tuition for 30 affiliated clinicians from different service planning areas. Other organizations that support funding for the fellowship include the American Academy of Pediatrics, the California Academy of Family Physicians, the California Behavioral Health Directors Association, and the California Psychiatric Association.
Meanwhile, word about the TNT PCP program is spreading to clinicians in other states. “By far, the hardest part is helping fellows from out of state find funding in their area,” Ms. Cant said. “That’s new territory we are starting to look into, but typically it’s not out of pocket. We only had three people pay out of pocket last year.”
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Program faculty hope to not only improve the fellows’ knowledge in psychiatry and better treatment for depression, anxiety, and substance abuse, but also decrease prescription of opioids and decrease the stigma that some clinicians might perceive in mental illness. “People come to our fellowship feeling like there’s a void in their training,” Dr. Suo said. “We’re able to fill that void. In the first year, we had a fellow who said that, after completing the program, she felt physically less tired at the end of the day, because she had been so anxious about what to do for her patients who came in with mental health complaints.
“Now she knows what to do, so she can relax and listen to them – and be more connected.”
In the spirit of paying his TNT PCP education forward, last year Dr. Eschweiler secured a Song Brown grant to implement a 2-day psychiatric course for family medicine NP students at Western University of Health Sciences in Pomona, Calif., where he holds a faculty post. After they completed the course, students spent 80 hours with Dr. Eschweiler or with a designated clinician in the clinic, where they applied what they learned.
“By the time we shared information with students who I received in the TNT PCP fellowship, their comfort level went up by 80%-90%,” he said.
Such stories are heartening to TNT PCP faculty. “We simply do not have enough psychiatrists in the country to provide mental health care for everybody who needs it,” Dr. Suo said. “Unfortunately, that means primary care will have to take up the slack. We want to prepare people to be able to do that.”
For information about the 2020 TNT PCP Fellowship, visit www.psychiatry.uci.edu/tnt.