Original Research

A Curriculum for Training Medical Faculty to Teach Mental Health Care—and Their Responses to the Learning

Journal of Clinical Outcomes Management. 2020 July;27(4):166-173 | 10.12788/jcom.0016

References

1. Smith R, Gardiner J, Luo Z, et al. Primary care physicians treat somatization. J Gen Int Med. 2009;24:829-832.

2. Smith RC, Lyles JS, Gardiner JC, et al. Primary care clinicians treat patients with medically unexplained symptoms—a randomized controlled trial. J Gen Intern Med. 2006;21:671-677.

3. Smith RC, Lein C, Collins C, et al. Treating patients with medically unexplained symptoms in primary care. J Gen Intern Med. 2003;18:478-489.

4. Smith RC, Lyles JS, Mettler J, et al. The effectiveness of intensive training for residents in interviewing. A randomized, controlled study. Ann Intern Med. 1998;128:118-126.

5. Smith R, Laird-Fick H, D’Mello D, et al. Addressing mental health issues in primary care: an initial curriculum for medical residents. Patient Educ Couns. 2014;94:33-42.

6. Smith R, Laird-Fick H, Dwamena F, et al. Teaching residents mental health care. Patient Educ Couns. 2018;101:2145-2155.

7. Cunningham PJ. Beyond parity: primary care physicians’ perspectives on access to mental health care. Health Aff (Millwood). 2009;28:w490-501.

8. US Department of Health and Human Services: Healthy People 2020: The Road Ahead. Washington, DC: US Governmant Printing Office; 2011.

9. US Department of Health and Human Services. Facing Addiction in America—The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: US Dept of Health and Human Services; 2016.

10. US Department of Health and Human Services. Mental Health and Mental Disorders. Washington, DC: US Government Printing Office; 2000.

11. Hogan MF. The President’s New Freedom Commission: recommendations to transform mental health care in America. Psychiatr Serv. 2003;54:1467-1474.

12. Morrisey J, Thomas K, Ellis A, et al. Development of a New Method for Designation of Mental Health Professional Shortage Areas. Chapel Hill, NC: University of North Carolina at Chapel Hill; 2007.

13. US Department of Health and Human Services. Mental Health: a Report of the Surgeon General. Rockville, MD: Dept. of Health and Human Services; 1999.

14. Wang PS, Lane M, Olfson M, et al. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:629-640.

15. Kern DE, Thomas PA, Hughes MT. Curriculum Development for Medical Education: A Six-Step Approach. Baltimore, MD: The Johns Hopkins University Press; 2009.

16. Fortin 6th AH, Dwamena F, Frankel R, et al. Smith’s Patient-Centered Interviewing: An Evidence-Based Method. 4th ed. New York, NY: McGraw-Hill; 2018.

17. Smith R, D’Mello D, Osborn G, et al. Essentials of Psychiatry in Primary Care: Behavioral Health in the Medical Setting. New York, NY: McGraw Hill; 2019 .

18. Smith R, Fortin AH 6th, Dwamena F, et al. An evidence-based patient-centered method makes the biopsychosocial model scientific. Patient Educ Couns. 2013;90:265-270.

19. Smith R, Dwamena F, Grover M, et al. Behaviorally-defined patient-centered communication—a narrative review of the literature. J Gen Intern Med. 2010;26:185-191.

20. Smith RC, Dwamena FC. Classification and diagnosis of patients with medically unexplained symptoms. J Gen Intern Med. 2007;22:685-691.

21. Schneider RK, Levenson JL. Psychiatry Essentials for Primary Care. Philadelphia, PA: American College of Physicians; 2008.

22. Dwamena F, Laird-Fick H, Freilich L, et al. Behavioral health problems in medical patients. J Clin Outcomes Manage. 2014;21:497-505.

23. Vidyo (Hackensack, NJ). http://www.vidyo.com/products/use/. 2014.

24. Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177:195-205.

25. Huffman JC, Niazi SK, Rundell JR, et al. Essential articles on collaborative care models for the treatment of psychiatric disorders in medical settings: a publication by the Academy of Psychosomatic Medicine Research and Evidence-Based Practice Committee. Psychosomatics. 2014;55:109-122.

26. Smith RC, Dwamena FC, Fortin AH 6th. Teaching personal awareness. J Gen Intern Med. 2005;20:201-207.

Skills Practice

The patient-centered interviewing skills practice, which occurred in the second 2-hour period during the first 6 months, was lauded by the faculty trainees. It was considered the “most immediately relevant component” of this period of training. Because the trainees were experienced physicians when they began this project, they felt this part of training made the “…material more accessible to myself, more germane to what I do day in and day out.” The insight of modifying the interviewing techniques to connect with different patient personality types was particularly helpful. One trainee described an “aha moment” of “getting patients to open up in a way I had not been able to do before.” As time went on, the trainees felt empowered to adapt “the interviewing script” modestly to fit their already developed “rhythm and style with their patients.”

Wellness/Mentoring

The 2 trainees were at different stages of their careers, 1 early-career faculty and 1 mid-career faculty. This academic diversity within the small training group provided varied perspectives not only on the concepts presented and discussed, but also on a more personal level. In an otherwise hectic academic medicine environment, this group had a weekly chance to stop, “check in” with each other, and truly connect on a personal level. To be asked “about your week and actually mean it and want to hear the answer” is an unusual opportunity, one noted. It also offered time and support for purposeful self-reflection, which “often brought some emotions to the surface…at different times.” These connections were perhaps one of the most valuable parts of the experience. With burnout among physicians rampant,²⁴ establishing these networks is invaluable. In addition to introspection and personal connections, there was a strong element of mentoring during these weekly meetings. The opportunity to meet in a small group with senior faculty was highly valued by the trainees.

Mental Health Care: Complex Patient Clinic

The faculty were eager, but very apprehensive, in beginning the second segment of training, where work shifted from lectures and practicing skills to mental health care training in the CPC. The trainees expressed anxiety about several areas. These included additional clinical workload, patient referral/selection, and transition of patient care back to the primary care provider. Of note, they did not particularly express worries about the care they would be providing, because a psychiatrist would be available to them on site. In reflection, after spending 4 months in the clinic, trainees noted “how important observing live interviews for evaluation/feedback was to their learning.” The CPC provided “learning in the moment on specific patients [which] was without question the most powerful teaching tool.” The support of the training faculty who were present at each clinic was invaluable. Whereas the earlier didactics given by psychiatrists were received by trainees with lukewarm enthusiasm, the point-of-care, case-by-case learning and feedback truly advanced the trainees’ knowledge, as well as skills, and improved their confidence in providing mental health care.

One of the tenets of the mental health care models is collaborative care.²⁵ Recognizing this critical component of patient care, the CPC experience integrated a clinical social worker. The faculty noted the critical role she played in the patient care experience. They described her as “fabulous and awesome.” Her grasp of the health care system and community resources (particularly for an underserved population) was indispensable. Additionally, she was able to serve as a steady contact to follow patients through multiple visits and improve their feelings of continuity.

Teaching: Psychosocial Rotation

The first psychosocial teaching occurred after the interviewing skills and didactic experiences in the first 6 months. The trainees expressed great doubt about tackling this initial teaching experience. From residents challenging the need for interviewing and other aspects of “touchy-feely” teaching, to patients expressing raw emotions, the trainees lacked confidence in their ability to handle these moments. At this early stage of their training, one trainee said, “I feel like I am becoming a better interrogator, but I haven’t learned the skills to be a better healer yet.” Over time, this concern disappeared. As training evolved, the trainees began to thrive in their role as educator. At the final focus group, it was noted that “teaching has enhanced [my] confidence in the framework and in turn has made it easier to teach.”