Michele S. Smith, PhD, Atlanta Medical Center Family Medicine Residency Program, Atlanta, GA

Research demonstrates that patients have many unmet mental health needs and are more likely to address these with their primary care physicians than to seek out mental health services.¹ A study on the treatment of depression in primary care determined that current physician education is inadequate to prepare them to achieve guideline level care. Changes in service delivery, particularly collaboration with mental health professionals, was key to improving training and patient care.² It was also shown that physicians’ perspectives of collaboration and use of psychotherapy improve significantly when incorporated into their training.³

It is critical for patient care and physician competence that residents be well trained in mental health management. Joint training of family medicine residents and mental health professionals is a creative way to enhance behavioral health training and increase integrated psychosocial care for patients. Mental health trainees from different modalities, eg, marriage and family therapy or health psychology, and at different training levels (Masters, doctoral), can be utilized.

The goals of co-training family medicine residents and mental health trainees are to (1) demonstrate co-treatment and co-success of collaboration, (2) create opportunity and offer modeling to learners for putting into practice the skills taught in the behavioral science curriculum, (3) educate about behavioral medicine topics and related treatments, and (4) demonstrate practical skills related to both disciplines. This improves interviewing and assessment skills and increases medical knowledge as both sets of learners receive instruction and supervision from medicine and mental health faculty.

A key component of co-training involves learners interviewing patients in a live setting; each provider is responsible for recruiting her/his own patients. The process is explained to the patient by the provider ahead of time, and the patient signs a consent form at the time of the interview. Each interview lasts 45-50 minutes, with a brief presentation of the case preceding the interview. Faculty and other learners observe the interview in the same room, via closed circuit television, or through a one-way mirror, depending on the facility and the patient preference (some patients prefer for everyone to be in the same room; others only want to see the provider). The interviewer consults with the team mid-way through the interview, allowing for immediate feedback and provider implementation regarding patient care. A review of the process from a strengths-based approach and other relevant teaching points occurs at the conclusion of the interview. Assessment and motivational interviewing skills are emphasized. This allows for residents to address ongoing issues, eg, weight loss or smoking, more effectively in their continuity patients during regular clinic visits.

Feedback from residents, trainees, and faculty has been positive. There is noticeable improvement in physician-patient communication and shared decision making, as well as increased collaboration with mental health providers. There are, however, some challenges. Blocking time from clinic schedules for several providers (family medicine attending, behavioral science attending, residents, mental health trainees) will impact the number of patients who can be seen. We have chosen days in the middle of the week, when there is less demand for appointment slots. Establishing affiliations with mental health training programs and screening for trainees who are a good fit for the setting are also important. In our case, the behavioral science faculty is an instructor in a family therapy training program and is able to assess interest and ability prior to application.

The ACGME core competencies of patient care, medical knowledge (social-behavioral), practice-based learning and improvement, interpersonal and communication skills, and professionalism are all addressed within this framework. Through the use of the techniques described, a foundation for a stronger fiduciary patient-physician relationship is developed from the onset.

References
1. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med 2006;166:2314-21.
2. Lin EH, Katon WJ, Simon GE, et al. Achieving guidelines for the treatment of depression in primary care: is physician education enough? Med Care 2000;35(8):831-42.
3. Chand MSP, Templeton GB, Hayes MS, Livingston SE, Mowery RL, Hardee JF. Training MFTs and medical students in a family therapy clinic. Presented at the AAMFT Annual Conference, September 2010, Atlanta, GA.