Teamwork Helps Family Medicine, Psychiatry Break Down Walls

Of the strategies for stretching psychiatry's resources further in a time of growing need, cooperation with primary care providers may hold the most promise because it builds on a model familiar to both sides.

The departments of family medicine and psychiatry at the University of Tennessee medical school in Memphis tested that hypothesis in June with their first joint continuing medical education (CME) program. The program was an outgrowth of the annual family medicine CME program, which marked its 40th year.

The two specialties each contributed 11 speakers to the three-day event, which covered typical family medicine subjects such as cardiology, vaccines, and type 2 diabetes, but also included updates on suicide risk, bipolar disorder, ADHD, and depression in special populations (see Family Medicine Docs Learn Psychiatry).

The program originated through a fortunate set of circumstances. Both departments hired new chairs from outside the university in recent years. David Maness, D.O., spent 27 years as a U.S. Army physician in clinical, administrative, and academic positions before taking over as head of family medicine at Tennessee in 2007. Psychiatry chair James Greene, M.D., had worked closely with geriatricians to set up a teaching nursing home at the medical school at Eastern Tennessee State university in Johnson City. After moving across the state to Memphis, he decided the department of psychiatry needed to build relationships with other departments such as pediatrics, internal medicine, and family medicine.

Because both Greene and Maness were new to their jobs, neither was wedded to previous ways of doing things, and both were ready to work together.

Maness said he and Greene meet regularly for conversations exploring avenues for cooperation on education at all levels—for medical school students, residents, and practicing doctors. Already, the family medicine residency program at Tennessee includes psychiatric topics throughout the residency as well as during specific blocks.

The two decided to add a major psychiatry component to the annual family medicine update for the first time.

“Through teamwork, you can accomplish a lot across specialties by working on joint endeavors to improve patient care, teaching, and research,” said Maness in an interview. “Ultimately, that benefits the patient, and that's what it's all about.”

That is certainly what it's about in Tennessee. As in other states, the medical school's mission is to prepare doctors to serve the state residents who support the school, and most medical graduates do remain in the state to practice.

On some level, collaboration between primary care physicians and psychiatrists is inevitable, said Greene. Family doctors provide a lot of psychiatric care anyway, he pointed out.

That collaboration could take place on any number of levels aside from the straightforward referral, said both Maness and Greene. Psychiatrists might extend their traditional role as consultants in evaluating and stabilizing patients, then send them back to the family doctor for longer care, interspersed with occasional visits to the psychiatrist. Psychiatrists might be fully responsible for procedures—like ECT—that only they can handle. Or psychiatrists might work with primary care providers (or designated staff members) using telepsychiatry to evaluate and treat patients in rural areas.

One delicate question has to do with finances, said Najiba Battaile, M.D., an assistant professor of psychiatry, during a conference session. Some primary care physicians may be skittish about referring patients to specialists, fearing that they will never see them again.

The fear is not entirely unfounded, said Battaile. She recalled the case of one mental health center that did not send patients back to their family doctor, claiming that the reasons were continuity of care and also its patient census.

“Now I regulate psychotropic medications—even those prescribed by the primary physician—but send the patients back to the primary for lab tests before changing medications,” Battaile said. “Primaries are better able to respond to abnormal lab results.”

Understanding the clinical and professional needs of the physician at the other end of the line would work to the advantage of both, she said.

Greene believes that opening the borders between the two specialties can only help.

“We must make sure that they have good current knowledge about psychiatry and that [psychiatrists] are aware of what our role is,” he said.

Greene also sees telepsychiatry as an emerging field for psychiatry and an opportunity to expand the specialty's geographic reach. “It's like bringing the university to a small town,” he said.

Telehealth is no longer the stepchild of medicine, said Michael Caudle, M.D., vice chancellor of health system affairs at the University of Tennessee, Knoxville, in a conference session.

“It is also the part of psychiatry that is growing fastest,” said Caudle. “My advice is to embrace this technology and use it for specialist care, patient education, and videoconferencing to train medical professionals.”

Part of Greene's broader outreach plan for psychiatry is connecting with other parts of the medical school and the greater medical community in Memphis. After a series of meetings with the CEOs of area hospitals, Greene helped arrange for two residents to do part of their training at St. Francis Hospital. Then he was surprised to discover that St. Jude Children's Hospital, perhaps the best-known medical facility in the city, had “phenomenal brain power, but no psychiatry.” He's hoping to develop a palliative medicine fellowship at St. Jude's within the University of Tennessee child psychiatry residency program. ▪