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Evaluation of experiences of family medicine residents in an intensive outpatient psychiatry clinic.

Physicians can diagnose only what they are trained to recognize and treat what they have been adequately trained to treat. With many communities moving toward a patient-centered medical home model of care, primary care physicians coordinate their patients' care and therefore need effective training to recognize and treat mental disorders of all types (Croghan & Brown, 2010). Pomerantz, Corsonn, and Dexter (2009) noted that, as our health care systems move away from the current fee-for-service model to payment methodologies that focus on wellness and prevention, adequate attention must be given to mental health services. Thus, a need exists to provide more mental health services for patients (Leigh, Stewart, & Mallios, 2006a).

Primary care providers include family medicine, general internal medicine, general pediatrics, and obstetrics and gynecology. The most frequently used formats for mental health training in some primary care residencies consist of didactics sessions and case conferences, regardless of satisfaction (Butler, Holloway, & Fons, 2013). Often residents receive a relatively short psychiatry rotation. Leigh, Stewart, and Mallios (2006a) sought to evaluate the psychiatric training in the primary care training programs of internal medicine (IM), family practice (FP), pediatrics (peds), and obstetrics and gynecology (ob/gyn). Of 1,365 training directors surveyed, 733 (58%) responded to a sixteen-item questionnaire. Although the majority of all the primary care training directors (54%) were dissatisfied with the psychiatric training their residents received, nearly two-thirds of FP program training directors (64%) were satisfied with the psychiatric training of their residents. However, results showed a majority of peds, IM, and FP program directors desired increased mental health teaching in clinical settings. Thus, there is a need to ensure that residents have an opportunity to understand and engage with patients and to increase mental health training experiences for primary care residents.

The American Academy of Family Physicians (AAFP) documents curriculum guidelines for FM residents regarding human behavior and mental health and emphasizes the need to respect the relationship between the patient and the patient's family; be aware of the emotional aspects of organic illness; and acknowledge interrelated biologic, psychological, and social factors. In 1998, the Accreditation Council for Graduate Medical Education (ACGME, 2006) began the Outcome Project to improve the ability of U.S. resident physicians to provide quality patient care and work in current, as well as evolving, systems of health care. The Outcome Project includes training for residents in human behavior and mental health while increasing emphasis on educational outcomes measured in accreditation: "Attitudes, knowledge, and skills that are critical to family medicine should be attained through a longitudinal experience that promotes educational competencies defined by the ACGME" (AAFP, 2008). These competence definitions are agreed upon and encompass all-important domains of professional medical practice. Recommendations stated that the resident should demonstrate attitudes that include:

1. an awareness of and willingness to overcome personal own attitudes and stereotypes of mental illness and social diversity, as well as a recognition of how attitudes and stereotypes affect patient care

2. recognition of the complex bidirectional interaction between family and social factors and individual health

3. acceptance of the patient's right to self-determination

4. respect and compassion for the psychosocial dynamics that influence human behavior and the doctor/patient relationship

5. recognition of the prevalence of abuse in society and a willingness to help patients escape abusive situations

6. recognition of the importance of a multidisciplinary approach to the enhancement of individualized care

7. commitment to lifelong learning about the interaction of the biological, social, psychological, and psychiatric interaction of the human life cycle

These competencies build on a foundation of basic clinical skills, scientific knowledge, and moral development, including character development, maturation, and ability to work in a complex medical environment, ultimately leading to improved patient outcomes. In spite of the ACGME requirement for training in the domains of psychiatry, there is no clear mandate on which skills trainees must acquire in residency (Leigh, Stewart, & Mallios, 2006b).

Leigh and colleagues (2006a, 2006b) reviewed mental health training in primary care residencies. When compared to the training of other primary care specialties, FM programs had greater diversity of mental health teachers, formats, and settings. The authors documented the satisfaction of training directors in primary care specialties regarding psychiatric training. They proposed that providing more psychiatric training in primary care programs and increasing participation of psychiatry departments could increase the satisfaction of training directors and increase the diversity of training faculty, venues, and formats. Academic psychiatrists are in optimal positions to collaborate with other specialists in the "broader development and assessment of competence and incorporation of skills to learn and self-assess over a lifetime" (Kirch, 2011, p. 75).

An extensive review of mental health education for primary care physicians considered more than four hundred English language abstracts and articles divided into three focused categories: (1) needs and objectives, (2) methods, and (3) effectiveness (Hodges, Inch, & Silver, 2001). The most effective methods of education were noted when learning occurred close to the actual site of practice, with a psychiatrist and patients in the primary care setting. The results of the review led to ten recommendations to improve medical education:

1. to conduct a needs assessment of physicians participating in the educational activity

2. to involve primary care leaders who can help define mental health competencies that are important in the primary care context

3. to familiarize psychiatry teachers with the context of primary care

4. to create objectives for the domains of knowledge, skills, and attitudes

5. to pay particular attention to issues involving the perceptions of primary care physicians

6. to connect learning to actual clinical practice

7. to create interactive learning methods and involve the practice of new skills under observation

8. to assess the degree of learning using multiple measures of knowledge, skills, and attitudes

9. to track measures of outcome changes in actual clinical practice

10. to provide ongoing educational programs rather than single sessions

This review of primary care physicians in practice provides several themes that overlap with curriculum objectives for primary care residents.

Another review of thirty-four articles for establishing a psychiatry curriculum was divided into three categories according to focus: (1) psychiatry, (2) primary care, and (3) integrated (Huzij, Warner, Lacy, & Rachal, 2005). Psychiatry-focused curricula are often taught by mental health providers, emphasizing topics about diagnosis and treatment, including psychopharmacology, in a format conducive to lectures. Competency-based learning is often time intensive and fails to focus on issues relevant to primary care physicians. Primary-care-focused curricula are often taught by primary care physicians, emphasizing topics relevant to the clinical experience of primary care physicians. Frequently, case discussions provide a format for presentation and treatment options for topics such as frequently diagnosed psychiatric disorders, counseling skills, and managing difficult patients. This format involves significant input from primary care physicians. However, it may fail to address psychopharmacology, less frequent diagnoses, and assessment of danger. The integrated-focus curriculum emphasizes the involvement of both psychiatry and primary care physicians in primary care settings.

Curricula have been published concerning the acquisition of knowledge and skills in psychiatry. Smarr and Berkow (1977) documented development of an integrated curriculum with psychosomatic and liaison psychiatry. Dyck and Azim (1982) evaluated a program that trained interns in a psychiatric walk-in clinic. McMahon, Gallagher, and Little (1983) documented a clinical training program involving family practice educators collaboratively working with psychiatrists to train psychiatry and family practice residents, and medical students. The study by Berlin, Berenbaum, Wise, and Ahmed (1983) surveyed FM program directors to obtain information about rotations in general psychiatry and consultation-liaison psychiatry, the role of psychiatrists, and the usefulness of psychiatrists to the FM program.

Smith and colleagues (1991) assessed medicine residents, via questionnaires, to evaluate the efficacy of a one-month intensive, comprehensive psychosocial training utilizing seminars, interviewing skills, and a consultation-liaison service. The residents reported improved knowledge, self-awareness, self-assessment, and attitudes. Another residency curriculum trained IM residents to provide clinical care to patients at a detoxification center or to make house calls (Michael et al., 2011). Focus groups at the end of the rotations revealed improved confidence in serving underserved/indigent patients and greater knowledge of the effectiveness and importance of safety net systems.

An FM residency study described a four-week, skills-based, interactive curriculum that included motivational interviewing (Triana, Olson, & Trevion, 2012). Educational strategies included workshops, role play/real play exercises, standardized patient practice with feedback, and direct observation of residents by faculty in their continuity clinic. Feedback from residents revealed a positive trend in self-efficacy and confidence as they applied basic counseling skills and counseling for health behavior change.

Another FM residency established a behavioral medicine track to train residents to apply psychosocial medicine skills, abilities, and attitudes focused on communication, assessment, intervention, self-awareness, professional relationships, growth and coordinative skills, and lifelong skill development (Swing, 2007). Four to six electives were required, including psychosocial experiences, rotations in mental and behavioral health, or population-based rotations. One required rotation was consultation-liaison psychiatry. Other components included counseling skills seminars, psychopharmacology training, case supervision, and longitudinal integration. A full-time psychologist, a dual board family physician-psychiatrist, a social worker-case manager, and a nurse behavioral health interventionist provided diverse clinical exposure. Four residents' completion of the track determined the program as a success. Resident attitudes or perceptions were not assessed.

Manning, Zylstra, and Connor (1999) described an intensive, family-physician-led, multidisciplinary in-house consultation training in a mood disorders clinic for FM residents. Internal consultation requests were accepted for depressed and anxious patients who were diagnostic dilemmas, refractory to treatment, or in need of intensive interventions. The pre-test resident identification measure was the resident mood disorder identification rate one month prior to the curriculum experience. Post-test measures included identification rates at one month and at three months after completion of the first month of the curriculum and were obtained via faculty chart reviews. Evaluation of mean recognition rates indicated a positive trend that continued at least three months after training. The faculty evaluated written and verbal feedback. Evaluations provided suggestions for logistical adjustments of program implementation and content. This study was limited to training regarding mood disorders. Feedback did not include resident perceptions.

It is important that primary care trainees receive training in appropriate settings. An ambulatory care training model as opposed to training in inpatient psychiatric settings was recommended to teach psychiatry to family practice residents because the inpatient training did not cover the mental health disorders they would encounter in their clinical practice (Mantorin & Ruiz, 1999). Fisman, Sangster, Steele, Steward, and Rae-Grant (1996) studied teaching approaches for child psychiatry for FM trainees. Five locations employed different methods of instruction using informal to semi-structured didactics. The live teaching-consultation format had the highest percentage of residents reporting that the sessions were helpful in gaining knowledge, favorable attitudes, and skills. For these reasons psychiatry training for primary care residents should occur in outpatient settings.

Thus, existing literature provides information about curriculum development, program descriptions, surveys of programs and curricula, and program evaluations of mental health training for primary care residents. Themes of successful programs suggest utilizing integrated curricula, supervision, and didactics taught by psychiatrists, and outpatient consultation clinics in primary care settings. What has not been identified and documented are residents' perceptions regarding why they found psychiatrist supervision to be helpful and how training helped them to make gains in knowledge, skills, and positive attitudes regarding mental health concerns in primary care patients.

Context of the Clinic

The Psychiatric Consultation Clinic (PCC), a U.S. research institution that enrolls more than 35,000 students, trains a significant number of FM residents to practice in rural areas. At the inception of the clinic, three goals are identified: (1) to provide more psychiatric evaluation services for patients seen in the institution's FM clinics, (2) to provide an outpatient psychiatry consultation experience in a primary care setting as a part of the psychiatry rotation for second year FM residents, and (3) to provide an opportunity to improve FM residents' management skills for psychiatric problems in the primary care setting.

The psychiatry curriculum for FM residents was developed as a longitudinal curriculum that spans three years of residency. Postgraduate year 1 (PGY-1) residents videotape interviews of new patients in their FM clinics, receive feedback from FM and psychiatry faculty, and participate in a monthly biopsychosocial case formulation seminar co-led by a psychiatrist and a psychologist. The PGY-2 residents have a one-month psychiatry rotation with outpatient clinics at the Veterans Administration Medical Center and the research institution, including the PCC. The PGY-3 residents meet four times yearly with a psychiatrist or psychologist mentor to discuss mental health issues of patients seen in their primary care clinic. Each resident also presents a biopsychosocial case to fellow residents and FM and psychiatry faculty. Faculty psychologists and psychiatrists are aware of curriculum objectives, which address goals for residents in the area of knowledge, skills, and attitudes, and provide lectures to residents through the three years of residency. The FM and psychiatry departments agree upon topics.

Second year FM residents rotate through the PCC as a required component of the one-month psychiatry rotation. Twelve second year FM residents rotate through this clinic during a twelve-month period. The clinic occurs for one half day twice each month. Referred individuals are active patients in primary care clinics at the institution's medical center. The medical center exists as a multi-specialty clinic in which psychiatry and FM are two of seven specialties. No outside referrals are taken. The medical center is not a tertiary care clinic because more than 50 percent of new patients have not been previously diagnosed or treated. Physicians discuss with patients the option to be assessed during a single encounter in the PCC prior to the physicians' contacting the receptionist in the psychiatry department. Referrals are reviewed by the PCC psychiatrist for appropriateness to be seen in the PCC. Receptionists verify patients' insurance coverage. Patients consent to participate in the clinic. Residents complete the evaluation in the PCC with one-to-one supervision by a department psychiatrist.

The half-day clinic provides ample time for residents to obtain the history, use mental health assessment tools, discuss the clinical encounter, and receive feedback from the psychiatrist. Residents were provided a semi-structured interview guide, which assisted them in obtaining biopsychosocial information on seven areas of health, as would occur during an initial psychiatric assessment. The psychiatrist obtained additional information and discussed assessment and treatment recommendations in the presence of the resident and the patient. A letter summarizing the clinical encounter was provided to the patient. Residents documented encounters in the electronic medical record (EMR), which was sent to the referring physician. One psychiatrist supervised all FM residents in the PCC, providing consistent experiences for all residents. Each resident participates in two clinics during the psychiatry rotation.

The aim of the study was to understand the experience of the FM residents who participated in a PCC, their perceptions of its influence on their learning experience in psychiatry, and their subsequent feelings of preparedness to address psychiatric issues in their own primary care clinics. The authors hypothesized that the FM residents would benefit from several aspects of the clinic, including the additional time to interview patients, the opportunity to gain knowledge about specific psychiatric diagnoses, and supervision regarding the use of psychotropic medications.

Methods

This project was reviewed and received approval of the institution's institutional review board. The research protocol conformed to requirements for human studies. All participants provided informed consent. A case study design was used to answer the research questions (Creswell, 2007; Merriam, 2009). Participants in this study consisted of a convenience sample. The research questions were as follows:

1. How do FM residents describe experience gained from participating in the clinic?

2. How do FM residents develop knowledge, skills, and attitudes?

3. What educational factors did FM residents perceive to be related to their learning?

4. How do FM residents feel regarding their preparedness to address psychiatric issues in their primary care clinics?

A faculty member experienced in higher educational leadership who had no association with the PCC, the FM residency training program, or the psychiatry department facilitated the focus group for the purpose of data collection. The focus group lasted approximately sixty minutes, was audio recorded, and was transcribed verbatim. Open-ended questions probed the discussion to keep it on track. Questions were compiled based on seven aspects of health that served as a foundation for the knowledge and skills of residents who rotated through the PCC. These seven aspects of health, an expansion of a biopsychosocial approach, were educational, mental, physical, cultural, financial, social, and spiritual. Additional questions were compiled to focus on the developing attitudes of residents (see appendix). The data were evaluated and coded by the faculty member who conducted the focus group and a psychologist with no contact with the PCC. Data analysis involved standard qualitative techniques of analytic induction and constant comparison (Creswell, 2007; Merriam, 2009).

Eligible participants for this study were FM residents enrolled at the research institution who evaluated patients in the PCC. Residents received written invitations to participate in the focus group. Participation was voluntary and had no impact on residency status. The focus group occurred at a local hospital where the residents train. Residents received a $50 gift card for their participation in the focus group.

Of the twelve individuals invited, five participated in the focus group for a participation rate of 42 percent. Resident demographics were as follows: one resident aged twenty to twenty-nine (20%), three residents aged thirty to thirty-nine (60%), one resident aged forty to forty-nine (20%), one male (20%), four females (80%), five Caucasians (100%), three PGY-2 (60%), and two PGY-3 (40%).

Results

Findings suggest three main themes: time, teaching strategies, and practice. Two subthemes attended each main theme.

Time

Time was a principal theme. The additional time residents had in the PCC clinic appeared to have two primary benefits for them: additional information provided by the patient and additional structured questions they used to probe for additional information.

Working in the clinic provided residents with sufficient time to gather information from patients that they would not have had time to collect in a primary care clinic. Additional time for diagnosis provided more time to rehearse interviewing and gather clinical information. One resident said, "As far as spending time with them, there is ample time ... at least in my case ... there is plenty of time to see the patient, the patient's family, and sit down and go through a whole spectrum of questions." Another participant explained, "And just because she had the extra time and you could go through the whole history and pick up all this other stuff then we decided to add a different medication."

Residents asked questions about other aspects of patients' lives and had time to learn more about how mental health affects seven areas of health, including physical health. As residents obtained more specific information, a frequent result was a change in or an addition to the diagnosis.

After further delving, a resident said, "This was interesting to see the subtle difference, which we only really got ... with all those extra questions. But I did feel also ... when I saw that list of questions ... I thought is that relevant? But it actually turned out to be relevant." Another participant reflected, "It was interesting for me because the more you asked different questions about lifestyle and what they were all about, you kind of opened more problems or other reasons why--how their mental health has affected other aspects in their lives. It was almost like a Pandora's box."

Teaching Strategies

The experienced psychiatrist in the PCC not only assisted with evaluations and treatment recommendations but also demonstrated a systematic approach to interviewing patients. The result was an additional level of supervision. This had not occurred elsewhere in residents' psychiatry rotation and offered two specific benefits for residents: the opportunity for modeling and the opportunity for advice.

Residents expressed the value of observing an experienced psychiatrist demonstrate interview techniques. The attending physician served as a model for them. As one said, "It was helpful going in with her and watching her do the interview process because obviously she is skilled at things and having gone in before it was good to see how it was done. It was very helpful."

With regard to advice, one resident put it this way, "It was nice to get your feet wet and go in and do it without the psychiatrist and [then] get to see the psychiatrist."

Practice

A fundamental theme noted was increased opportunities to practice while supported in the PCC. Practice had two primary benefits: residents developed additional knowledge through practice and they gained increased comfort with their own abilities.

Residents described increased knowledge due to interactions with the PCC. Knowledge included information about when and how to refer patients and what psychiatry offers. Residents gained knowledge of psychiatry as they learned more about psychiatric diagnoses and appropriate treatments, and they gained skills in interviewing and use of less common treatments. They gained improved attitudes toward the field of psychiatry, which resulted in their openness to inquire about and manage patients' mental health. Finally, they felt optimistic about referring patients for psychiatric care in the future. One resident explained, "We do a month in psychiatry, so everybody's comfortable with the basic stuff (common psychiatric diagnoses). But then when you start wanting to add on certain medications, like an antipsychotic or something like that, it does help to sort of have an extra set of experienced eyes, just to say that you're doing the right thing (for treating less frequently seen psychiatric diagnoses in primary care clinics) and I think especially with kids."

Residents asserted that the opportunity to practice helped them develop knowledge. Often cited was the opportunity to learn more about medications. Others noted practice skill gains. As one resident said, "I think everybody benefits and the patient gets a great deal out of this and then you tend to hone in on your skills."

Residents believed that confidence allowed them the opportunity to advance in ways they might not have otherwise. The word comfort was recurrently used. One resident, for example, explained, "I got more comfortable as [I] did more and more ... how to ask each question. Fairly comfortable." Another echoed the sentiment, "I think you just get more comfortable after the first one."

Residents discussed communication as a challenge for this institution's clinic because the psychiatric electronic medical record (EMR) is separate from the EMR of other medical providers in the medical center. This separation led to more difficult communication between providers after completion of the consultation. Some patients had a follow-up appointment scheduled with their referring physicians before the referring physician received a copy of the PCC consultation. Referring physicians were not always informed when referred patients failed to schedule or keep an appointment in the PCC. Solutions to improve communication were discussed.

Discussion

The aim of this study was to explore experiences of FM residents who participated in an enhanced PCC and to understand their perceptions of its influence on their learning and preparedness to address psychiatric issues in their own primary care clinics. The focus group provided answers to the primary research questions as follows:

* How do FM residents describe experience gained from participating in the clinic? The residents described the experience gained from participating in the clinic positively. Residents requested additional experiences in a clinic, such as the PCC, to enhance their knowledge and skills. In the future, additional experiences beyond the one-month psychiatry rotation may be offered by increasing the number of patients scheduled in the clinic and extending the PCC to a continuity clinic (Manning et al., 1999). Expansion of the clinic may serve as a valuable component to document the progress of FM residents regarding ACGME competencies of the developmental milestones (ACGME, 2006). Significant gains in professional development for treating mental illness are necessary because individuals may choose to see a primary care provider rather than a mental health professional when they experience emotional distress (Manning et al., 1999).

* How do FM residents develop knowledge, skills, and attitudes? Residents developed knowledge, skills, and positive shifts in attitude regarding diagnosis and treatment of mental illness due to multiple factors. Residents had additional clinical time to interview primary care patients with mental health issues. They also had increased supervision from the psychiatrist. Residents in the PCC viewed the work with the psychiatrist positively because of her systematic teaching approaches and positive focus. This outcome is significant because primary care physicians frequently see psychiatrists as inaccessible and nonmedical (Hodges et al., 2001). Direct access to the psychiatrist during the PCC helped residents gain knowledge and improved attitudes. The psychiatrist provided residents with recommended questions, which increased their ability to obtain biopsychosocial information and improve their comfort level with diagnosis and psychopharmacology recommendations. Residents acknowledged that they would likely be more attentive to the presence of psychiatric problems in their primary care clinics.

* What educational factors did FM residents perceive to be related to their learning? Residents were better able to understand what psychiatry has to offer through their active use of a semi-structured interview guide. The guide was not only instrumental in gaining interviewing skills, but it also helped them to understand the importance of having knowledge of patients' lives and how it could help them treat mental and physical illness. This knowledge became central to treatment instead of superfluous information. In contrast, results of a survey of nine residency programs by Oyama, Kosch, Burg, and Spruill (2009) revealed that 60 percent of FM residents and faculty believed that behavioral medicine was a type of complementary and alternative medicine. No significant differences existed between residents and faculty responses. Authors believe the semi-structured interview contributed greatly to the positive outcome of this educational intervention.

* How do FM residents feel regarding their preparedness to address psychiatric issues in their primary care clinics? Residents expressed having improved attitudes, ability, and comfort regarding management of mental health issues. The PCC provided residents time to rehearse interviewing skills and gain confidence in their ability to address specific mental health issues. An important finding in the literature indicates that levels of self-efficacy and confidence are principal factors of change in practice behavior (Triana et al., 2012). This individualized training was specific to the needs of the resident rotating in the clinic. Individualized learning of the residents enhanced the value of the PCC experience. This positive experience led residents to believe that they would be more intentional in direct inquiry of mental health problems in the future. The outcomes of this clinic are in direct opposition to the curriculum outcomes by Jones, Badger, Parlour, and Coggins (1982), who described a competency-based curriculum in FM. A later outcome of this competency-based curriculum revealed the unexpected finding that residents did not assume an appropriately active or comprehensive mental health role with their patients following the training intervention (Jones et al., 1981). Suggested reasons for this outcome included a failure to identify with psychiatrist role models, residents' tendency to compartmentalize patient's physical and emotional complaints, and a need for more of the learning experience to occur within the context of primary care. Results from this focus group indicated that residents were able to identify with the psychiatrist role model and gained understanding of the value of knowledge of seven areas of health of their patients while evaluating patients from primary care clinics.

This study contributes to existing literature through its evaluation of an outpatient psychiatry consultation training experience, but is distinctive because of the documentation of perceptions of FM residents about their experience in the clinic. Residents gained knowledge and skills regarding psychiatric diagnosis and treatment. Attitudes of residents were positive and paralleled recommendations by training directors in primary care specialties (Leigh et al., 2006a) to increase the diversity of training faculty, venues, and formats, including individual supervision, with increased participation of psychiatry departments (ACGME, 2006).

Strengths of the PCC include continuity of the supervision each FM resident received from the same academic psychiatrist. This allowed residents to receive supervision, guidance for increasing knowledge and skills, and encouragement to reflect on their own attitudes and perceptions as they treated patients in need of mental health services. The supervision provided was intensive, with individualized training for assessment, diagnosis, and treatment of patients with a broad spectrum of psychiatric disorders seen in the institution's primary care clinics. A strength of the clinic was the use of the expanded biopsychosocial foundation as the basis of the clinical interview guide. An additional strength was the rigor of data analysis via two independent faculties. The teaching strategies in the PCC were a unique and effective part of the psychiatry curriculum. The PCC provided an enhanced and individualized outpatient psychiatry experience in a primary care setting as a part of the longitudinal psychiatry educational training for FM residents. These results are aligned with recommendations from a critical review of interventions to improve provider recognition and management of mental health disorders in a primary care setting (Kronenke, Taylor-Valsey, Dietrich, & Oxman, 2000).

Interpretation of the findings is subject to several limitations. Resident participation in the focus group was small, lacked diversity in gender and race, and included participants only from a single residency. It is possible that some information regarding knowledge, skills, and attitudes was not adequately expressed in the focus group. A limitation might have occurred if PGY-3 participants had had their PCC experience the previous year because significant time would have elapsed before they participated in the focus group, which might have altered their memory of their PCC experience.

The authors believe that saturation was not achieved. At the time of the focus group, there were thirty-six FM residents. Only twelve residents met criteria for inclusion in the sample (that is, they had completed a rotation in the PCC). Five of these residents agreed to participate in the focus group. Because of the small sample (both the total population and those who agreed to participate), efforts to achieve trustworthiness proved to be challenging. The authors relied upon triangulation of data and data analysis. In a process similar to that described by Rauf, Baig, Jeffery, and Shafi (2014), the authors ensured trustworthiness by multiple coding, audit trails, member checking, and peer evaluation of themes and findings. Residents' knowledge was not assessed via validated measures.

The focus group was scheduled only once. Residents may not have participated in the scheduled focus group due to schedule conflicts. Residents more interested in the outcomes of the PCC may have been more motivated to participate in the focus group. Some residents may have been motivated to participate by the $50 financial incentive that was offered for this focus group, as well as for another focus group that was not a part of this study. They may have reported more favorable opinions as a result.

Information obtained is primarily qualitative and the results should be interpreted accordingly. Despite these limitations, the results of this study represent experiences of some FM residents, which can add value to FM education in psychiatry and primary care specialties. This study's emerging themes are promising and can provide a basis for more qualitative analysis of perceptions of mental health curriculum of FM residents.

Conclusion

The PCC offers an intensive approach for teaching psychiatry to FM residents and improving their ability and comfort with regard to diagnosing and treating psychiatric disorders. This clinic, which provides individualized supervision of FM residents in outpatient psychiatry, offers an appropriate primary care educational environment for residents' training. Future steps in evaluation could include tracking professional developmental milestones achieved by FM residents toward meeting ACGME competencies. Future directions could include pre- and post-PCC clinic evaluation of knowledge, skills, and attitudes of FM residents regarding psychiatric assessment. Methods for long-term evaluation of progress in completing goals specified at the PCC meeting should be considered. This clinic could provide future benefits for FM residents by following the authors' recommendation to extend it past the one-month rotation in psychiatry to become a continuity clinic throughout the FM residency (Kronenke et al., 2000).

This clinic addresses some aspects of what current literature identifies as best practice for mental health with a family medicine residency. Family medicine residents need enhanced training in outpatient settings to develop skills and improve confidence in assessing and treating patients with psychiatric disorders seen in the primary care setting. This should be a focus for family medicine residencies in collaboration with psychiatry departments. An intensive, supervised outpatient psychiatry experience may help family medicine residents' obtain the training necessary to diagnose and treat psychiatric disorders in primary care clinics.

Lloyda B. Williamson, MD, is associate professor in the Department of Psychiatry and Behavioral Medicine, College of Community Health Sciences, the University of Alabama, Tuscaloosa. Claire Major, PhD, is professor in the Department of Higher Education Administration, College of Education, the University of Alabama, Tuscaloosa. Thaddeus Ulzen, MD, is chair and professor in the Department of Psychiatry and Behavioral Medicine, College of Community Health Sciences, the University of Alabama, Tuscaloosa. Nancy J. Rubin, PsyD, is professor in the Department of Psychiatry and Behavioral Medicine, College of Community Health Sciences, the University of Alabama, Tuscaloosa. Evangelia Fotopoulos, MD, MPH, is in private practice in Melbourne, FL.

The authors would like to thank Leslie Zganjar and Sandra Baldwin for assistance with proofreading and preparation of the manuscript and the family medicine residents who participated in the Psychiatry Consultation Clinic and provided feedback in the focus group. The lead psychiatrist author discloses that she is the psychiatry faculty member providing clinical and administrative direction for this clinic.

Supporting funding was provided by an internal grant from the University of Alabama.

Appendix:

Questions for Focus Group

1. Since participating in the consultation clinic, how do you rate your interviewing skills and assessment skills when evaluating for mental health issues in a patient in the following seven areas of health?

a. Educational: level of school/training completed? goals?

b. Mental: emotional stressors? coping skills?

c. Physical: medical problems? healthy habits?

d. Cultural attitudes about health: bias for or against treatment?

e. Financial: problems with money? assets?

f. Social: lack or presence of support systems?

g. Spiritual: doubt or belief in God/higher power?

2. Since the consult, has your attitude changed toward mental health assessment and treatment for your patients?

3. How have your skills in assessment and attitude toward mental health changed since the consultation clinic?

4. What resources or skills do you need to be able to assess and treat patients like the one you saw in the consultation clinic in a FM clinic instead?

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Author:Williamson, Lloyda B.; Major, Claire; Ulzen, Thaddeus; Rubin, Nancy J.; Fotopoulos, Evangelia
Publication:Best Practices in Mental Health
Article Type:Report
Geographic Code:1USA
Date:Mar 1, 2016
Words:6572
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