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Primary care physicians are not properly trained to recognize, diagnose, and treat psychiatric disorders, according to former APA president Jerry Wiener, M.D.
"Is it possible that a modern-day emperor without clothes now rides the horse of cost containment through the streets of the health care community, especially the mental health community?" asked Wiener at APA’s annual Institute on Psychiatric Services in Washington, D.C., in October.
There is no reason that primary care residency programs cannot be revised to provide better psychiatric training, said Wiener. Doing so is critical because the primary care doctor—not the psychologist or psychiatric social worker—is trained in the biomedical model necessary to understand and prescribe medication for those patients who will not or cannot see a psychiatrist.
Primary care providers fail to recognize 50 percent of patients with a diagnosable mental disorder. Those diagnosed are treated almost entirely by prescribed medication, he added. In fact, a majority of psychiatric drugs are prescribed by nonpsychiatrists.
Over the last two decades, the diagnosis of psychiatric disorders has become more reliable and more accessible to clinicians, said Wiener. The development of a DSM aimed at primary care doctors has contributed to this accessibility. Treatments, especially but not exclusively psychopharmacological, have become more effective, more sophisticated, and more available.
If primary care physicians are to meet their own stated mission as frontline providers of care for psychiatric disorders, they must enhance their knowledge, develop appropriate psychiatric diagnostic and clinical skills, and cultivate a positive attitude toward the recognition and treatment of psychiatric disorders.
At present, none of these essential prerequisites is being met, said Wiener. Doing so will require "a significant change in attitude toward psychiatry and mental illness on the part of many, if not most, primary care training programs," he asserted. Further, departments of psychiatry must undergo a change in "attitude and responsiveness" toward primary care training.
"This change in attitude will require an understanding and acceptance on the part of primary care that psychologists and social workers may well be participants in the educational program, but cannot substitute for psychiatry and cannot provide training in the medical model toward diagnosis and treatment of mental illness," Wiener stressed. "There should be no question about the opportunity for effective and efficient training programs, since primary care residents and practitioners already are grounded in the biomedical knowledge and the medical model" needed to recognize, diagnose, and treat mental illness.
If the requisite changes occur, a "genuine partnership can be forged between psychiatry and primary care, each respecting the roles and boundaries of the other," Wiener added. But absent such changes, the claim that primary care physicians can act as frontline providers of psychiatric care is misleading and "leaves them in the role of the emperor who rides naked through the streets while managed care and cost-cutting health-policy gurus ask that we admire the emperor’s new clothes."
Wiener based his thesis on a survey he completed earlier this year. He received replies from 72 (of 129 surveyed) departments of psychiatry reporting the extent to which they were involved in training in any of four categories of primary care programs: family practice, internal medicine, pediatrics, and obstetrics-gynecology.
The survey assumed that if there was 100 percent involvement of departments of psychiatry in training primary care physicians, there would be 288 primary care programs collaborating with departments of psychiatry in any given academic institution, that is, 72 times 4. (The survey assumed that within the same academic institution as the psychiatry department, there would be the four primary care specialties, and did not consider involvement of psychiatry departments from one academic institution at another, which would be extremely unusual, according to Wiener). The survey found, however, only 130 primary care programs collaborating with departments of psychiatry, that is, a 45 percent collaboration rate. Of the 130, 70 percent were in family practice or internal medicine, and 30 percent in pediatrics or obstetrics-gynecology.
The survey also looked at the details of training collaboration. It found that didactic lectures were the most common form of collaboration (68 percent), but that a majority (60 percent) of the participating programs provided fewer than five lectures a year. Only 26 percent of the participating primary care programs provided up to 10 lectures a year. None of the internal medicine or pediatric programs provided more than 10 lectures a year, while 10 of the family practice programs provided more than 10 lectures a year.
Other forms of psychiatric training included case conferences, employed by 53 percent of the 130 participating primary care programs, direct presence of a psychiatrist in the ambulatory care setting (50 percent), and rotation onto a psychiatric service (25 percent). Forty percent of the psychiatry programs reported that some psychiatric training was provided by primary care programs independent of the psychiatry program, and this was almost invariably by psychologists or social workers.
Family practice programs provided the most extensive psychiatric training.
The survey also asked the psychiatry department heads whether the training for primary care residents was adequate for frontline diagnosis and treatment of mental disorders. The responses were negative for 77 percent of family practice programs, 90 percent of internal medicine programs, 98 percent of pediatric programs, and 97 percent of obstetrics-gynecology programs.