In 1995, the American Board of Family Practice (ABFP) and the American Board of Psychiatry and Neurology (ABPN) issued a white paper setting forth board requirements for residency training programs combining the specialties of family practice and psychiatry. The paper was never published, but it was circulated among training directors in both specialties. Since that time, a number of combined family medicine/psychiatry (CFMP) training programs have been created. One physician graduated from a CFMP program last year, and this year several programs are graduating a handful of doctors who are eligible to sit for boards in both specialties.Rationale
It has long been recognized that a large percentage of visits to primary care physicians are motivated more by psychosocial concerns than by gross physical pathology. Indeed, primary care physicians prescribe more selective serotonin reuptake inhibitor antidepressants than do psychiatrists. Yet most primary care physicians have limited training in recognizing and treating psychiatric illnesses.
Though many patients would benefit from referral to a mental health care specialist, there are many barriers to receiving appropriate care. Often third-party payers place significant restrictions on mental health care. There remains a social stigma to receiving care from a psychiatrist that is not present in the primary care office. In many areas, adequate numbers of psychiatrists simply are not available to handle the increased demand that would be generated by frequent referrals by primary care physicians.
Though psychiatrists receive the same medical and first-year postgraduate training as all other licensed physicians, their practices do not expose them to as much peripheral pathology as their counterparts in primary care clinics. They are often self-selected for an interest more in behavioral pathology than in gross peripheral pathology, and the bulk of their postgraduate education is focused entirely on psychopathology.
Many patients who present to primary care settings with significant underlying psychopathology are not "pure somatosizers." Indeed, in my personal experience, the most common presentation seems to be the patient with a chronic illness who experiences greater distress than would be expected given the medical findings. Bifurcating the care of such patients between a psychiatrist and a primary care provider is fraught with difficulties, particularly if the patients' underlying personality organization makes them prone to primitive defenses such as splitting.
Unless communication between the psychiatrist and the primary care doctor is especially strong, neither will be able to feel confident in differentiating between psychiatric and medical illness. Such a differentiation might not even be possible; as more is learned about the biological bases of mental illness, it appears that the tentorium is not the dividing line we once believed it to be.
By training a single practitioner with expertise in both specialties, the disorders that have traditionally defied easy categorization as medical or mental (e.g., fibromyalgia and other pain syndromes, recurrent atypical chest pain, irritable bowel syndrome, and many others) can be more easily and effectively treated.Program Structure
The boards' white paper described the basic characteristics of CFMP programs. They must be five years in length, and graduating residents must meet the training requirements for both the ABFP and ABPN. Outpatient continuity clinic requirements are retained for both specialties.
Beyond the basic requirements, programs are largely free to structure trainees' experiences in whatever way best addresses educational and institutional needs. Most existing programs use a model where residents change from one department's training site to the other every few months except during the board-required 12-month outpatient psychiatric clinic experience. Two fundamental variations concern the intern year.
Some programs focus the intern year on meeting family practice board requirements. This approach has the advantage of allowing trainees to complete their intern requirements in the first year of training but the disadvantage of isolating the CFMP residents from their colleagues in psychiatry during that year.
The other model stresses combined training from the outset, switching residents every few months from one department to the other. While this insures that residents will have exposure to colleagues in both programs from the beginning, in many cases it means that they will still be following a more demanding intern-year rotation and call schedule well into their second year.
Growth of CFMP programs was very rapid during the first few years. There are currently nine civilian and two military programs listed by the Fellowship and Residency Electronic Interactive Database (FREIDA), the American Medical Association's index of residency training programs. They include:
- University of California (UC), Davis Program
- UC San Diego Program
- Tripler Army Medical Center Program
- University of Iowa Hospitals and Clinics Program
- National Capital Consortium Program
- University of Minnesota Program
- Case Western Reserve University/University Hospitals of Cleveland Program
- University of Cincinnati Hospital Group Program
- University of Oklahoma College of Medicine, Tulsa Program
- Medical College of Wisconsin Program
- West Virginia University Program
(More information on FREIDA and the residency programs can be found at
Margaret E. McCahill, M.D., training director for the CFMP program at UC San Diego, is boarded in psychiatry and family practice, although she completed two separate residency programs. In 1997, she identified a number of similarly dual-boarded physicians and interviewed them to determine their practice patterns (McCahill and Palinkas, 1997). Although the majority of the respondents still practice in both disciplines, the results showed -- not surprisingly -- that many physicians concentrate in the specialty in which they most recently trained. McCahill speculated that the practice patterns of those who chose from the outset to train in both specialties are likely to be much different.
Experience with actual CFMP graduates is quite limited. As of this writing, there is only one such graduate. According to Lawson Wulsin, M.D., residency director of the combined training program at University of Cincinnati, Lisa Cantor, M.D., took three part-time positions when she graduated, including faculty positions with University of Cincinnati's psychiatry and family medicine departments.
This year's crop of graduates seems to be following a similar pattern. I will be taking a position with the department of psychiatry at UC Davis, but my duties will be manifold. I will be heading up two clinics for the county of Sacramento, one providing integrated primary care, substance use and psychiatric services to the county's homeless population and the other providing integrated medical and psychiatric care on a consultation basis for patients currently seen at the county's mental health clinics. Both of these clinics will also serve as training sites for CFMP residents. I will also provide psychiatric consultation for UC Davis' Center of Excellence for the Treatment of Huntington's Disease and will continue a small psychotherapy practice.
According to Wulsin, one of University of Cincinnati's new graduates, Jennie Hahn, M.D., will be staffing a rural family practice clinic where she will also be able to provide psychiatric care. Nichole Brandts, M.D., University of Cincinnati's other new graduate, will be working as a family doctor and a psychiatrist in two separate clinical practices in the same building. She will also be spending one day each week in an urban free clinic.Pitfalls
In the family practice clinic at UC Davis, there has been a distinct trend toward CFMP residents acquiring a panel of patients considered difficult by our categorical family practice colleagues. These are patients for whom traditional diagnostic and therapeutic modalities have failed.
The problem with loading CFMP residents' clinics with these patients is twofold. First, it deprives CFMP residents of the chance to see a diverse patient population. For example, I was able to follow only one obstetrical patient from prenatal visit to delivery in my entire five years of residency. Second, categorical family practice trainees will encounter these challenging patients frequently in their practices after residency. Experience gained with them during training is essential.
As the UC Davis program matures, a better balance is being achieved whereby CFMP residents serve more in a consulting role to categorical residents. Still, any programs that mix categorical and CFMP residents must have mechanisms in place to insure balance in patient populations. If patients or clerical personnel are allowed to decide which providers patients are assigned to, overall training will continue to suffer.
There is impressive demand for CFMP graduates in the community, in spite of our small numbers. My personal experience in this strong managed care environment was pretty sobering, however. Although many HMOs and physicians' groups eagerly offered positions, none were willing to modify their "productivity" expectations for such a unique and challenging patient panel. In other words, while they readily acknowledged that this was a particularly time-consuming group of patients who were not well served by their existing systems, these groups were largely unwilling to allocate any additional resources to their care.
One of the special challenges facing CFMP graduates will be defining their position in a health care system that has a centuries-long tradition of enforcing the Cartesian fallacy that the mind and body are separate.Future Directions
There are certainly a number of places where CFMP graduates can fit in right now, especially in public-sector positions where patient care remains a focus and the population often defies stereotypes of medical versus psychiatric illness.
There is also an emerging opportunity for CFMP-trained physicians to define a new subspecialty devoted to treating patients where complex interactions between their psychosocial situations and their biology have stymied traditional practices.