By Ken Hausman

Whether as a survival strategy in a fast-changing medical arena or as a creative way to blend unique treatment skills, residency programs that combine psychiatry and family medicine training are gaining popularity at a rapid rate.

In the last year alone, the American Board of Psychiatry and Neurology and the American Board of Family Practice have approved seven such programs for dual board certification.

The first program to win endorsement from the two certifying bodies for a combined program is at the University of Cincinnati. Approval followed for the programs at Michigan State University, the University of Minnesota, the University of Oklahoma, the University of California at both Davis and San Diego, and Eisenhower Army Medical Center in Georgia.

"The shift in the health care delivery power structure" from a specialty to a primary care emphasis "means that psychiatry has to figure out a way to provide its services in primary care settings," said Lawson Wulsin, M.D., chair of the primary care psychiatry program at the University of Cincinnati medical school. To get psychiatric care into the settings in which people will increasingly be forced to receive their medical care, "we need physicians who are skilled and experienced in both areas, as well as people who can do research and teach" at the interface of family medicine and psychiatry, Wulsin said in an interview with Psychiatric News.

A secondary motivation for developing the new residency program was that "these combined training programs appeal to the most ambitious medical students," he noted, "and we were interested in attracting the cream of the crop."

The idea at Cincinnati for a residency that blends family practice and psychiatry arose from faculty discussions and from Wulsin's realization as the psychiatry department's training director that "psychiatry's recent recruitment woes and the need to find collaborative opportunities showed that it was time for psychiatrists to take the initiative in developing combined programs," Wulsin explained.

At the University of Oklahoma, medical students originated the idea for a residency that would prepare physicians for both family medicine and psychiatry, said Daniel Nelson, M.D., director of resident education in psychiatry. Several students who planned to work in primary care practices in rural areas of Oklahoma, where psychiatric expertise is difficult to obtain, wanted to be able to deliver skilled psychiatric care in tandem with their role as their patients' primary medical care provider.

"Fortunately, this request coincided with ABPN's approval of just such a program," Nelson told Psychiatric News.

Wulsin and Nelson both see the greatest patient benefit from this type of physician training in outpatient clinics, where patients will be more apt to get a comprehensive evaluation that includes questions about their and their family's mental health, followed by treatment if indicated. Wulsin added that facilities such as V.A. hospitals, in which physicians who deliver most of the care have little psychiatric training, and state psychiatric hospitals, where psychiatrists often need to act as primary care doctors but are insufficiently prepared to do so, will also reap the benefits of this type of residency training.

Wulsin suggested as well that graduates of the combined program are increasing their employment opportunities, since their training will make them more appealing to the behavioral health care branches of managed care organizations or to other delivery systems focused on primary care.

'Coherent Identity'

In ensuring that the new program had a "coherent identity," several challenges faced him as the program's chief developer, Wulsin said, including how closely the two disciplines should be woven together and in what sort of time blocks the content of the training curriculum should be packaged. Wulsin and the program advisers from both faculties decided to have the residents "switch back and forth a lot" between the two training areas rather than have them spend full years engaged in one or the other discipline.

"Even though this is more work and sometimes more frustrating for the residents, we thought it the best way to develop an identity and to work at the interface between the two," he said.

The Oklahoma program takes a different path, providing a heavy concentration of family practice experience in the first year, while fifth-year residents spent 10 months of the year focusing on psychiatry.

Another thorny issue confronting the Cincinnati program's developers was deciding on the setting in which the residents would get their outpatient psychiatry training, Wulsin noted. They agreed to concentrate most of this experience in the family practice milieu, though they retained the part of the psychiatry curriculum that requires one year of outpatient training in psychotherapy skills, which is needed to obtain board certification in psychiatry, he pointed out. This also ensures that all of the program's residents, including those who eventually decide to specialize in family medicine, will graduate from the program with extensive training in psychotherapy skills.

Elective Opportunities Reduced

Since residents in the combined program will have to meet the board requirements for both disciplines, the amount of hands-on and didactic content that must be included means that trainees have less time for electives than in traditional programs, Wulsin said.

While "both sides ended up giving up a little" in terms of program content, there have been remarkably few turf battles between faculty and administrators in the two specialties over the residents' time, he added.

Time constraints and content pressures also left Nelson's program with "a bare-bones curriculum that leaves no time to work in electives," he said. Because of requirements for board certification, the dual-residency trainees at Oklahoma must complete the same didactic and psychotherapy components as their colleagues in traditional psychiatric residencies, Nelson pointed out.

While obstacles have been few, the new program at Cincinnati has not been problem free. A serious funding-related problem arose this fall when program administrators learned that Medicare, which provides a substantial portion of residency training funds nationwide, will fund only four years of the five-year program. He and his colleagues are considering how to finance the fifth year, Wulsin said.

Nelson has been impressed with how few snags or disagreements impeded the combined program's development at Oklahoma. "There turned out to be strong support from the family practice people," he said. Collaboration was easy since "the rapport between the two groups was positive from the beginning." The program is administered jointly by him and the family practice residency training director.

The programs at both the University of Cincinnati and University of Oklahoma are designed for a maximum of two residents a year. There are two PGY-1 residents and one PGY-2 resident at Cincinnati. Oklahoma has one PGY-1 resident, and two are interviewing for the next class, Nelson said.

He added that the residents most likely to succeed in this intensive program "need to be a cut or two above the average resident," given its "higher degree of intrinsic chaos and demand for a higher degree of self-discipline."

(Psychiatric News, January 17, 1997)