It should come as no surprise that today’s psychiatrists and primary care physicians are struggling to “integrate” primary care and mental health care. For one thing, “mental health care” typically does not follow the medical model of disease identification and treatment, relying instead upon a social-disease perspective and orientation. While neither good nor bad, it is not compatible with the traditional medical model by which physicians are trained and paid.

Another factor is that residency training in psychiatry has evolved, in most programs, to the point of having virtually four years of intensive psychiatric training, at the expense of rigorous training in, and experience with, general medicine. Previous generations of psychiatrists who benefitted from the requirement to have their first year of postgraduate training in a rotating internship (no specialty focus) were perhaps better able to integrate mental health care with primary care and to identify with primary care physicians, ultimately adding to the benefit of their patients.

Primary care (family practice, internal medicine, pediatrics) training programs could also benefit from more dedicated requirements for inpatient and outpatient psychiatric rotations, including opportunities to maintain caseloads of patients with primary psychiatric conditions, especially since these patients frequently have coexisting “medical” problems.

Integrated care begins with an integrated educational focus, historically the best model.

JOHN H. RENNICK, M.D.
Brownsville, Texas