Preparing Psychiatry Residents as 21st Century Psychiatrists

—Jürgen Unützer, M.D., M.P.H.

These days, collaborative care or integrated care is increasingly being talked about at national meetings. Collaborative care—in which primary care providers, care managers, and psychiatrists work as a team and take a population-based approach—is a rapidly growing field of behavioral health care. More than 70 randomized, controlled studies have demonstrated the efficacy as well as cost-effectiveness of this approach. Collaborative care interventions are based on population group information: systematic screening, active case-identification, and patient registries. Care is delivered by a primary care provider and a behavioral care manager, using evidence-based algorithms and weekly systematic case reviews by a psychiatric consultant and the care manager for patients who do not improve on specified behavioral health outcomes (for example, on the PHQ-9) using treatment-to-target.

This model of care delivery has the potential to provide more patients with increased access to the expertise of psychiatrists, specialists who currently are in short supply. Despite its strong evidence base, the collaborative care model has not been widely adopted, yet this is likely to change with the implementation of accountable care organizations (ACOs), in accordance with the Patient Protection and Affordable Care Act.

For most psychiatry trainees, collaborative care is exciting, yet unfamiliar territory. Collaborative care is not just about the way care is organized; it requires a dramatic change in the way psychiatrists think about their role in the evolving health care system. Current clinical psychiatric training is largely focused on the direct provision of patient care in tertiary settings, working with complicated cases on inpatient units, with some responsibility as consultants (for example, on psychosomatic medicine rotations) and occasionally in outpatient clinics. This training scheme may suit the needs of the hospital systems in which they train, but it leaves trainees largely unprepared for jobs as psychiatric consultants in the emerging “real world” of accountable care organizations. As APA President Jeffrey Lieberman wrote in the December 6, 2013, Psychiatric News, “We do know that this role, which will expand in the coming years, involves increased knowledge and comfort with primary care medicine, understanding of chronic illness and how people adapt, a population-based approach, as well as strong skills in interpersonal communication and collaboration and knowledge about systems of care.”

But how do we systematically prepare psychiatry residents as 21st century psychiatrists to work in collaborative care systems? ACGME has recognized the need for such training. For instance, in the new milestones (which will take effect in July 2014), there is an emphasis on learning how to consult to primary care providers and how to effectively integrate behavioral health care in primary care settings. The Advancing Integrated Mental Health Solutions (AIMS) Center at the University of Washington recently developed a curriculum to help psychiatry residency programs teach residents about Collaborative Care both didactically and through a Collaborative Care rotation. But even if a training program does not have access to a Collaborative Care rotation, there are essential skills residents can learn as their health care systems move from traditional care models to integrated models. The skills include: use of validated instruments (e.g. PHQ-9 and GAD-7) to track clinical outcomes, provision of stepped care, close collaboration with a primary care team member (for example, care manager or primary care provider), and being a caseload consultant. The authors are developing a curriculum that helps training programs teach these collaborative-care skills even if they are not practicing in such a setting. The curriculum is designed according to a “flipped classroom” model approach where residents will utilize both AIMS Center (http://uwaims.org) and APA (http://www.psychiatry.org/integratedcare) learning resources. Psychiatry residents will watch videos and read articles on integrated care from these sites prior to coming to class and use class time to revisit the concepts and practice their skills under the supervision of a faculty member. The advantage of this curriculum is that it is composed of just two sessions, covers several milestones (SBP4 and ICS1), and helps residents apply their collaborative care skills while still in training.

Job descriptions for psychiatrists in outpatient settings will change significantly over the next few years. Specifically, psychiatrists will be called on to work effectively as caseload consultants to the primary care team. If psychiatry training programs do not keep pace with these changes, residents graduating will face a steep learning curve and will have to do a lot of on-the-job training with little opportunity for mentorship. Given the structural changes in the system, we need to prepare our trainees for the new challenges that lie ahead so that they may thrive as essential care team members in Patient-Centered Medical Homes and ACOs to better help our patients, expand our impact on a population level, and increase the value of behavioral health services. ■