Meg Barbor, MPH

November 03, 2017

NEW ORLEANS ― Teaching medical students the concept of integrated care ― while simultaneously addressing and reducing the stigma associated with mental illness ― increases their interest in psychiatry and may help address a nationwide shortage of psychiatrists.

Here at the Institute of Psychiatric Services (IPS): The Mental Health Services 2017 Conference, psychiatrists and psychiatrists-in-training at the University of Maryland, Baltimore, offered various perspectives on this approach.

Integrated care is defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) as the systematic coordination of general and behavioral healthcare, integrating mental health, substance abuse, and primary care services. According to SAMHSA, this approach produces the best outcomes and is the most effective approach to caring for people with multiple healthcare needs.

"We often find our med students come in with great trepidation about working with people who are living with psychiatric illnesses," said Ann Hackman, MD, director, Division of Community Psychiatry, University of Maryland. "We think part of integrated care is familiarizing doctors-in-training with psychiatry and people with lived experience, and emphasizing why it matters."

The First Year

In their first year, all medical students at the University of Maryland take a tour of Baltimore to increase their knowledge of community resources. The tour exposes the students to the barriers many people face in accessing healthcare.

"This helps begin the discussion about the community as a place of treatment," said Curtis Adams, MD, psychiatrist at the University of Maryland and vice president of the American Association of Community Psychiatrists.

"The hospital isn't the place where treatment is delivered, by and large. My rule is that about 10% of what a patient faces can be fixed with a prescription pad. But about 90% is everything else, and it would behoove you to know something about that 90%." The tour exposes students early on to "how psychiatrists think" and introduces them to the concept that recovery is possible, and also expected.

The Second Year

In their second year, students are exposed to more integrated care in psychiatry, including a course in pathophysiology and therapeutics. The course has several components, including a lecture series. In addition, attending psychiatrists interview real patients while students observe, engage, and later discuss their observations.

Next comes interactive "virtual voices" training, during which students experience several hours of simulated auditory hallucinations. Although the simulation is optional, most students opt for the training, and according to faculty, it stimulates valuable discussion and puts students' coursework into context.

"We feel it's important during the preclinical years for students to have as much clinical exposure as possible," said Constance Lacap, DO, assistant professor of psychiatry at the University of Maryland. "Students are able to really hear the patient narrative through live interviews with seasoned faculty members, and that fits in nicely with what we're aiming for: that there's a whole story, not just a checklist of symptoms."

Students also have the opportunity to practice interviews with patients with psychotic, affective, and addictive disorders, whose psychiatric illnesses are directly embedded into those weeks' curricula. "So they're able to really solidify that information," she added.

Psychiatry resident Jamie Spitzer, MD, said that in his experience, "students walked away from the psychiatry block feeling engaged and excited, and I saw everyone applying what they learned throughout their clinical years. I didn't know I wanted to go into psychiatry during it, and I was still completely engaged."

The CAPP Program

One of the unique ways in which medical students are introduced to integrated care at the University of Maryland School of Medicine is through the Combined Accelerated Program in Psychiatry (CAPP) elective course.

The program, which was established in 1970, was prompted by a decrease in the number of University of Maryland medical school graduates who pursued psychiatry. It involves a combination of didactics, small group discussions, and practical inpatient and outpatient experiences during the students' first and second years of medical school.

Between their first and second year, students also have the opportunity to complete an 8-week psychiatric inpatient third-year-style clerkship, during which they are responsible for up to four of their own patients and are given the opportunity to present, diagnose, and develop treatment plans.

Benjamin Ehrenreich, MD, University of Maryland psychiatry resident and former CAPP student, said the program technically ends after the first 2 years, but the program's influence is still seen during the third and fourth years, because the CAPP faculty often serve as mentors to former students, regardless of their ultimate chosen specialty.

"I can't tell you how much this does for someone's confidence in the first few years of med school," he said. "I think it's very difficult to overstate CAPP's role in my development as a healthcare practitioner. When I interviewed for residency programs, all anyone wanted to talk about was CAPP."

The CAPP program continues to evolve in light of student demand, interest, and evolving research. The University of Maryland School of Medicine hopes it can serve as a model for other medical schools considering implementation of similar programs.

"My early exposure to clinical responsibilities opened my eyes to the ways medical students contribute to the treatment team," Dr Ehrenreich continued. "And as a resident, I've been able to incorporate medical students ― interested in a variety of disciplines ― as vital members of the team."

Dr Adams is a coeditor of the Community Mental Health Journal. Dr Lacap, Dr Ehrenreich, Dr Spitzer, and Dr Hackman have disclosed no relevant financial relationships.

Institute of Psychiatric Services (IPS): The Mental Health Services 2017 Conference. Presented October 22, 2017.

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