Setting and Problem
Primary care physicians often are the first providers to encounter patients with undiagnosed or undertreated psychiatric illness, but they are rarely trained to competently evaluate and treat these patients. In addition, mental health resources are difficult for patients to access. Providing internal medicine (IM) residents with education and training in ambulatory mental health will better equip them with the competencies to address the needs of this complex patient population.
We adopted a “2 + 4” immersion schedule for our primary care IM residency at Cambridge Health Alliance to provide more meaningful ambulatory training experiences. Residents rotate for 2 weeks in the ambulatory setting, alternating with 4 weeks in other inpatient settings and electives for all 3 years of training. This structure emphasizes longitudinal relationships with patients, a meaningful participation in our transformation to a patient-centered medical home and our focus on teamwork and community health.
Residents participate in a primary care continuity clinic at 1 of 3 busy, urban community health centers affiliated with our institution. Psychiatric comorbidity is common in our patient population. In an integrated model of care, staff psychiatrists, psychologists, and counselors work with primary care providers at each site to care for patients with comorbid psychiatric illness and addictions.
We developed a novel longitudinal mental health rotation for our first-year primary care residents which addresses the gap in mental health knowledge and skills for primary care IM residents. We worked closely with psychiatry leaders to align faculty resources and goals for the rotation. This work was facilitated by an existing structure of psychiatry providers who already practiced in the ambulatory sites where IM residents see their patients. Core goals and objectives for the rotation were developed collaboratively by IM and psychiatry faculty.
Outcomes to Date
For a full year, first-year residents work with a staff psychiatrist once a week at the resident's continuity clinic site. During this 4-hour session, IM residents participate in the care of patients referred to a consult liaison psychiatrist, and comanage each patient with the consultant. Time is set aside for case-based teaching that builds longitudinally throughout the year. The rotation enables trainees to refer their own patients to sessions with the psychiatrist. Importantly, IM residents are present for the mental health evaluation and contribute the medical perspective, as diagnostic and treatment strategies for each patient are evolving. Rather than seeing patients once in an acute phase of mental illness, as is the case in inpatient psychiatry rotations for IM residents, this rotation allows residents to longitudinally observe treatment, patient response, and the course of illness. The longitudinal nature of the rotation makes it a more meaningful experience for trainees who aim to practice primary care.
Our second cohort of 8 first-year primary care residents is currently participating in this mental health rotation. Residents who completed the first rotation of this type evaluated its overall quality as excellent (mean score 5.17 on a 6-point Likert scale), and believed the rotation was of high educational value and utility.
The supervised rotation provides a robust educational experience for residents, facilitates integrated care for patients, and promotes ongoing primary care-mental health collaboration.
We found our program's immersion schedule provides a facilitating framework for innovative, longitudinal care experiences with patients and for more meaningful educational engagement in outpatient medicine. We expect it also will reinforce resident development of humanistic practice toward patients with psychiatric comorbidity.
Plans are underway to document the program's effectiveness and to demonstrate feasibility for adoption by other residency programs.