Limited access to child and adolescent, adult, and geriatric psychiatry, as well as other mental health providers, has a large impact on the capacity of our health care system to address mental health needs, particularly in underserved urban and rural areas. A major determinant of this limited access is an under-supply of mental health providers. The recently developed Teaching Health Center Graduate Medical Education (THCGME) program provides a promising resource to address this problem because of its unique educational setting, which could facilitate integration of behavioral medicine into primary care graduate medical education (GME).
In this post we describe the workforce crisis limiting access to mental health providers, and we outline a new primary care GME paradigm addressing this crisis through integration of behavioral medicine into primary care GME. We explain the multiple advantages of this integration and how it could be implemented in conjunction with the recently established THCGME program. We specifically describe how this integration could be accomplished by its inclusion in the three-year THCGME program of the three medical primary care disciplines.
Finally, we describe how the proposed THC “whole person” approach represents a continuation of the curricular emphasis of colleges of osteopathic medicine and makes THCs an ideal GME setting for the high percentage of their graduates who pursue primary care.
The Mental Health Workforce Crisis
The mental health workforce shortage in the US has long been considered a significant problem. It is growing worse as more patients are being encouraged to seek treatment, or find that they can afford treatment for the first time as a result of new federal requirements for guaranteed mental health coverage by insurance plans. This increase in people presenting for care corresponds with a growing awareness of the extensive degree of co-morbid physical and psychiatric disorders. Enhanced implementation of the mental health parity law will further increase demand for mental health services.
As of late 2014, some 96.5 million Americans were living in areas with shortages of mental health providers, according to a new assessment by the Health Resources and Services Administration (HRSA). The shortage of psychiatrists results from the long training pipeline, as well as their relatively low pay and the high turnover for some positions. There has been no increase in federally funded residency positions to train psychiatrists, other than a recent VA initiative, despite provider groups advocating for psychiatry GME expansion for more than fifteen years. Of particular concern is the shortage of child and adolescent psychiatrists, which is especially severe in rural areas. The shortage of geriatric psychiatrists is also becoming increasingly severe with current aging demographics.
Advantages Integrating Behavioral Health Medicine And Primary Care GME
Treatment of mental health disorders in primary care has been proposed for many years. (Unutzer J. Integrated Mental Health Care; Mental Health is Part of Overall Health. Personal communication.) Advantages may include 1) an established provider-patient relationship; 2) less stigma; 3) better coordination with medical care; 4) most depression is treated in primary care (approximately 70 percent of anti-depressant therapy); and 5) primary care providers can focus on common mental disorders, allowing our limited number of mental health clinicians to focus on the most challenging patients. There is increasing evidence that persons with significant psychiatric challenges carry a heavy burden of physical morbidity and early mortality, which requires extensive coordination with primary medical care.
Key components of successful training programs should include medication management and brief, evidence-based counseling/psychotherapy, with psychiatric consultation as needed. The previous success of a limited number of programs integrating behavioral medicine with primary care provides a model for including substantial behavioral medicine GME in a modified THCGME curriculum.
To sustain the innovation and value of patient-centered medicine, it is critical that primary care GME include integrated care delivered by health care teams. Nowhere is this more crucial than in the recognition and treatment of psychiatric and substance abuse illnesses that co-occur with medical illnesses. Primary care physicians in training need to develop skills and innovative methods to address the psychiatric and behavioral health needs of their patients; one of the best ways to do this is to work side by side with psychiatrists during training in THCs. Experience demonstrates that interprofessional education involving psychologists and medical social workers within the PCMH, supplemented by consultation with affiliated psychiatrists, provides a strong behavioral health component in primary care settings.
Unfortunately as currently structured, THCs are not a practical training setting for psychiatric residents and not even available for child and adolescent psychiatry trainees. This disconnect between needed access to services and federal support policies is the type of issue addressed in the mental health reform legislation, “Helping Families in Mental Health Crisis Act” (House Bill #3717) sponsored by Congressman Tim Murphy. This bill proposes some organizational and policy changes to support initiatives such as integrated and coordinated training of primary care and psychiatry in THCs, for which our specific proposals are as follows:
Administration And Implementation Of New Integrated Programs
The administration of the TCHGME program should remain within the HRSA Bureau of Health Workforce, where considerable experience has been gained in program administration and oversight. These training programs would require both primary care and qualified behavioral medicine health faculty members, with academic appointments in their respective departments. The primary care residency program directors would maintain responsibility for direction of the program. Residents would continue to be recruited through the residency match of the primary care department, as is true now.
THCGME funding must be continued at or near current levels to sustain the added curricular activities and potentially multiple faculty members (including psychiatric consultants, psychologists, and medical social workers) requiring support for teaching time. Future growth of the program would be dependent upon outcome analysis, with its success facilitated by availability of National Health Service Corps educational debt repayment opportunities to incentivize applicants. The inclusion of child and adolescent psychiatry residents and developmental/behavioral pediatric fellowship residents in this debt repayment program would be a step forward in addressing the mental health provider shortage.
Proposals Regarding THC Curriculum, Accreditation, And Required Faculty For Each Primary Care Specialty
Trainees in each specialty receive their ambulatory training and some didactic sessions in the THC setting. They receive substantial inpatient training during the first two years of residency.
Training of ambulatory pediatricians in behavioral medicine and social determinants of health is particularly needed in view of the critical shortage of child psychiatrists and the significant impact of adversity in the first thousand days of life on developing brains. Since primary-care pediatricians are a large part of the universal point of access for young children (namely, routine health supervision visits), having these practitioners aware of, screening for, diagnosing, treating, and preventing or mitigating early mental health concerns is essential. This is not a major change, since much of the substance of a pediatric health supervision visit is already centered on issues of behavior, relational dynamics, and cognitive growth.
In addition to training in behavioral medicine, residents would receive substantial training via THCs in population health, child development, and social determinants of mental health. Curriculum time for this training could be derived by decreasing time devoted to inpatient ward and intensive care rotations. These concepts have already been piloted in a number of programs and have been conceptually integrated into health supervision visits as well. By incorporating this approach into a training model, residents would internalize this broader view of health care into their own skill set; they could adapt to existing models of practice following this approach or (more likely) spearhead an evolution toward this model as an enhancement to more traditional systems of care.
Additional innovations that would support this role and which have, to varying extents, been piloted, include: 1) embedded mental health providers (psychologists) who work within the medical home to provide evaluation services, act as a bridge to ongoing care, and provide support for minor-to-moderate problems; 2) strongly-linked home visiting services which extend, enhance, and augment the reach of the anticipatory guidance and other advice provided in the clinic; and 3) consulting psychiatry models, involving psychiatrists who provide expert evaluation, diagnostic clarification, and medication recommendations to be implemented by the primary-care provider.
General Internal Medicine (GIM)
In addition to increasing the teaching of behavioral medicine, the aging of the population demonstrates the need for integrating geriatric training—including psychiatry—into GIM ambulatory training. There are a limited number of geriatricians and geriatric psychiatrists in the U.S. Most are affiliated with academic departments and would be needed as faculty in these programs. Eventually, graduates from these programs could serve as faculty providing instruction in both behavioral health and geriatrics, with a strong emphasis on geriatric psychiatry.
Other additions to the curriculum should include public health, preventive medicine, and palliative medicine. Expertise in these areas would allow primary care physicians to maintain their relationship with patients, reduce the cost of care, and minimize the burden upon other specialties. Extra time for the foregoing in the curriculum could be obtained by decreasing intensive care unit (ICU) and coronary care unit (CCU) rotations time, since these primary care physicians would likely be managing their hospitalized patients through hospitalists. As with the other primary care specialties, curricular changes would need to be approved by the Residency Review Committee (RRC) and board exams would need to be structured differently. Fortunately, current RRC requirements are flexible and require just one year of inpatient rotations.
Leaders in the field of family medicine have long supported and advocated integration of behavioral health and family systems training as key components of continuous coordinated primary care. This model, referred to as the biopsychosocial and relationship-centered approach to care, includes mental health and substance abuse care as part of primary care services. According to family medicine program accreditation requirements as stipulated by the family medicine RRC, residencies much have faculty members dedicated to the integration of behavioral health in the educational program, a resource that may be underutilized and limited if not aggressively implemented. A number of fellowship and certificate programs have been developed to provide additional training and could be expanded to improve the faculty pipeline as well as train physicians and mental health providers with the skills the population needs to improve overall health and well-being.
The THC As A GME Continuation Of The Osteopathic “Whole Person” Approach
The THC is an ideal setting for teaching the many graduates of our colleges of osteopathic medicine who pursue GME in primary care. The osteopathic profession fully supports the THCGME initiative. From its roots in the rural hills of Missouri to the current 30 colleges of osteopathic medicine in 40 locations, with nearly half in rural areas, the osteopathic profession has emphasized providing health care in underserved regions. Some 60 percent of the more than 85,000 Doctors of Osteopathic Medicine (DO’s) practice in one of the primary care specialties. The emphasis of the osteopathic profession is and always has been the “whole person” approach. This was well described in a recent report, which includes the following personal attributes desired of a graduate osteopathic physician (first three of thirteen attributes):
- Capacity to be a “team player.”
- Advanced proficiency in working with people: ….empathy, compassion….
- Appreciation for and capacity to employ social and behavioral science in medical practice.
Today one of every five students in medical school in the United States is enrolled in a college of osteopathic medicine. Additionally, the osteopathic profession has made a strong commitment to creating new GME programs focused on previously untapped hospitals in rural and urban areas, through the Osteopathic Graduate Medical Education Development Initiative. The THCGME program has been fully embraced by the osteopathic profession as it aligns with the focus of training fully qualified osteopathic physicians who can meet the needs, both medical and behavioral, of all regions in the United States.
We have described the need for and major advantages of integrating behavioral medicine into primary care GME in THCs. We propose logistics of program administration, as well as accreditation and funding, with specific descriptions of proposed programs in the primary care disciplines.
Integrating behavioral medicine with the primary care curriculum is a paradigm for incorporation of several disciplines into primary care GME in the THC environment, where the PCMH is the prevalent care model. Training in behavioral medicine, geriatrics, preventive medicine, palliative medicine, and public health provides primary care physicians with the expertise to be effective and knowledgeable leaders of PCMH teams.
Twenty-first century primary care practice is rapidly evolving. As hospitalists increasingly assume inpatient care, curriculum for primary care physicians working in the ambulatory domain must stretch to meet the demands of an evolving health care system, changing demographics, and population needs.
Authors’ note: The authors’ recommendations do not necessarily represent the position of their present or past affiliations.