Psychiatry and Mental Health
I.
Rationale
Family physicians have incorporated knowledge of human behavior, mental health, and mental disorders
into their every day practice of medicine. The relationship between the patient and his or her family is
considered basic to an understanding of the subject. The family practice resident should have sensitivity
to, and develop knowledge of, the emotional aspects of organic illness. Family physicians must be able to
recognize interrelationships among biological, psychological and social factors in all patients. It is
important that the ethical dimensions of patient care be considered among these interrelationships.
Learning is facilitated if attention is paid to these principles as a continuum throughout the family practice
training program.
II.
Goals
Residents will be evaluated on the following six competencies, eventually achieving the expected level of
a board certified family physician. Achievement of satisfactory performance levels for all six competencies
will be necessary for successful completion of the rotation.
A. Understand normal and abnormal psychosocial growth and development across the life cycle and be
able to apply this knowledge to the care of the individual patient. (Medical Knowledge, Patient
Care)
B. Be able to recognize, initiate treatment for, and utilize appropriate referrals for mental health
disorders to optimize patient care. (Systems-based Practice, Practice-based Learning and
Improvement)
C. Demonstrate the ability to effectively interview and evaluate patients for mental health disorders
using appropriate techniques and skills to enhance the doctor-patient relationship. (Interpersonal
and Communication Skills, Patient Care)
D. Have sensitivity to and knowledge of the emotional aspects of organic illness. (Patient Care,
Professionalism)
E. Be able to intervene effectively and professionally in emergent psychiatric, domestic violence, child
abuse, and disaster situations. (Professionalism, Systems-based Practice)
F. Understand the impact of mental health disorders on the family unit. (Medical Knowledge,
Patient Care)
III.
Objectives
Medical Knowledge
A. Review and Discuss:
1. Normal and abnormal psychosocial growth and development across the life cycle, and
variants
2. Recognition of interrelationships among biologic, psychological and social factors in all
patients
3. Reciprocal effects of acute and chronic illnesses on patients and their families
4. Factors that influence adherence to a treatment plan
5. Family functions and common interactional patterns in coping with stress
6. Awareness of one's own attitudes and values, which influence effectiveness and
satisfaction as a physician
Last Updated March 7, 2013
7. Stressors on physicians and approaches to effective coping
8. Ethical issues in medical practice, including informed consent, patient autonomy,
confidentiality and issues quality of life
B.
Demonstrate the ability to diagnose and manage the following:
1. Disorders principally diagnosed in infancy, childhood or adolescence
a. Mental retardation
b. Learning disorders
c. Motor skills disorders
d. Communication disorders
e. Pervasive developmental disorders
f. Attention deficit and disruptive behavior disorders
g. Feeding and eating disorders of infancy or early childhood
h. Tic disorders
I. Elimination disorders
j. Other disorders of infancy, childhood or adolescence
2. Delirium, dementia, amnesic and other cognitive disorders
3. Substance-related disorders
a. Alcohol
b. Amphetamines
c. Caffeine
d. Cannabis
e. Cocaine
f. Hallucinogens
g. Inhalants
h. Nicotine
I. Opioids
j. Phencyclidine
k. Sedative-, hypnotic- or anxiolytic-related disorders
l. Polysubstance-related disorder
4. Schizophrenia and other psychotic disorders
a. Paranoid
b. Disorganized
c. Catatonic
d. Undifferentiated
e. Residual
5. Mood disorders
a. Major depressive disorder
b. Dysthymic
c. Bipolar disorders, including hypomanic, manic, mixed and depressed
6. Anxiety disorder
a. Panic attack
b. Phobias
c. Obsessive/compulsive disorder
d. Post-traumatic stress disorder
e. Acute stress disorder
f. Generalized anxiety disorder
7. Somatoform disorders
a. Somatization
Last Updated March 7, 2013
b. Conversion
c. Pain
d. Hypochondriasis
8. Factitious disorders
9. Dissociative Disorders
10. Sexual and gender identity disorders
a. Sexual desire disorder
b. Sexual aversion disorder
c. Orgasmic disorders
d. Sexual pain disorders
e. Sexual dysfunction related to a general medical condition
f. Paraphillias
g. Gender identity disorder
11. Eating disorders
a. Anorexia nervosa
b. Bulimia nervosa
c. Eating disorder
12. Sleep disorders
a. Insomnia
b. Hypersomnia
c. Narcolepsy
d. Breathing-related sleep disorder
e. Circadian-rhythm sleep disorders
f. Parasomnias
13. Impulse control disorders
14. Adjustment disorders
a. Depressed Mood
b. Anxiety
c. Mixed Anxiety and Depressed mood
d. Disturbance of conduct
15. Personality Disorder
a. Paranoid
b. Schizoid
c. Schizotypal
d. Antisocial
e. Borderline
f. Histrionic
g. Narcissistic
h. Avoidant
I. Dependent
j. Obsessive-compulsive
16. Problems related to abuse or neglect
17. Additional conditions
a. Noncompliance
b. Malingering
c. Borderline intellectual functioning
d. Age-related cognitive decline
e. Bereavement
f. Academic problem
g. Occupational problem
Last Updated March 7, 2013
h. Identity problem
I. Religious or spiritual problem
j. Acculturation problem
k. Phase-of-life problem
Learning Activities
X
Attending Rounds
Research Conference
X
Multidisciplinary Rounds
Ethics/Comm. Conference
X
Grand Rounds
X
Specialty Conference
X
Sub-Specialty Conference
X
Noon Conference
X
Morning Report
X
Faculty Supervision
X
Didactics
Procedures
Other
Evaluation Methods
X
Attending Evaluation
Program Dir.
Review
360 ᵒ evaluation
X
Other
X
Directly Supervised Procedures
In-Training Exam
Videotape Review
X
X
X
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Readings
Morning Report
Faculty Supervision
and Feedback
Quarterly Review
Patient Care
A.
Demonstrate the following evaluation skills
1. Interviewing skills, which enhance data collection in short periods of time and
optimize doctor/patient relationship
2. Performance of mental status examination
3. Indications for special procedures in psychiatric disorder diagnosis, including
psychological testing, laboratory testing and brain- imaging testing
4. Capability to elicit and recognize the common signs and symptoms of the disorders
under knowledge
5. Consultation procedures
B. Demonstrate the following therapeutic skills
1. Management of emotional aspects of no psychiatric disorders
2. Skills in enhancing compliance with medical treatment regimens
3. Initial management of psychiatric emergencies: the suicidal patient, the acutely
psychotic patient
4. Proper use of psychopharmacologic agents
a. Diagnostic indications and contraindications
b. Dosage, length of use, monitoring of response, side effects and compliance
c. Drug interactions
d. Associated medical problems
5. Family support therapy
6. Behavioral modification techniques, such as those pertinent to obesity management
and other lifestyle changes
7. Utilization of community resources
8. Crisis-counseling skills
9. Modification of patient environment
10. Ability to vary treatment based on the patient's personality, lifestyle and family
setting
Last Updated March 7, 2013
11. Identification of, intervention in and therapy for drug and alcohol dependency and
abuse
12. Appropriate care of health disorders listed under Psychopathology
13. Appropriate referral procedures to ensure continuity of care and optimal information
sharing, and to enhance patient compliance
Learning Activities
X
Attending Rounds
X
Multidisciplinary Rounds
Grand Rounds
X
Sub-Specialty Conference
X
Morning Report
X
Didactics
Other
Evaluation Methods
X
Attending Evaluation
Program Dir
Review
360 ᵒ evaluation
X
Other
X
X
X
Research Conference
Ethics/Comm. Conference
Specialty Conference
Noon Conference
Faculty Supervision
Procedures
X
Directly Supervised Procedures
In-Training Exam
X
X
X
Videotape Review
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Readings
Morning Report
Faculty Supervision
and Feedback
Quarterly Review
Professionalism
Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population. Residents are expected to:
A. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and
society that supersedes self-interest; accountability to patients, society, and the profession; and a
commitment to excellence and on-going professional development.
B. Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care,
confidentiality of patient information, informed consent, and business practices.
C. Demonstrate sensitivity and responsiveness to patients' culture, age, gender, and disabilities.
D. Arrive at the rotation in a timely fashion.
E. Work effectively as a member of a team.
F. Respect patient privacy by guarding medical records and discussion of personal information
about patients.
G. Assist patients and their families in planning for future care needs and care decisions based
on prognosis for the disease.
H. Support the patient in their healthcare decisions.
I. Demonstrate professional, respectful demeanor when addressing team members, patients,
ancillary staff, and consultants.
J. Appear professionally dressed and well groomed.
K. Completes consultation and clinic notes in a timely fashion.
L. Attends required conferences.
M. Responds to pages in a timely fashion.
Learning Activities
Attending Rounds
Last Updated March 7, 2013
Research Conference
X
Outpatient Clinics
Multidisciplinary Rounds
Grand Rounds
Sub-Specialty Conference
Morning Report
Didactics
Other
X
Evaluation Methods
X
Attending Evaluation
X
Program Director
Review
360 ᵒ evaluation
Other
Ethics/Comm Conference
Specialty Conference
Noon Conference
Faculty Supervision
Procedures
X
Direct Patient care
Resident Seminar
Journal Club
Readings
Directly Supervised Procedures
In-Training Exam
X
X
Videotape Review
X
Morning Report
Faculty Supervision
and Feedback
Quarterly Review
Practice-based Learning and Improvement
Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate
scientific evidence, and improve their patient care practices. Residents are expected to:
A. Analyze practice experience and perform practice-based improvement activities using a systematic
methodology.
B. Locate, appraise, and assimilate evidence from scientific studies related to their patients' health
problems.
C. Obtain and use information about their own population of patients and the larger population from
which their patients are drawn.
D. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and
other information on diagnostic and therapeutic effectiveness.
E. Use information technology to manage information, access on-line medical information; and support
their own education.
G. Learn to incorporate health promotion and disease prevention into patient care.
H. Use evidence-based medicine, evaluation of available evidence, and use of best-available
evidence at morning report meetings and during routine clinical care.
Learning Activities
Attending Rounds
Multidisciplinary Rounds
Grand Rounds
Sub-Specialty Conference
Morning Report
Didactics
Other
Evaluation Methods
X
Attending Evaluation
X
Program Director
Review
360 ᵒ evaluation
Other
Last Updated March 7, 2013
X
Research Conference
Ethics/Comm Conference
Specialty Conference
Noon Conference
Faculty Supervision
Procedures
X
X
Directly Supervised Procedures
In-Training Exam
X
X
Videotape Review
X
X
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Readings
Morning Report
Faculty Supervision
and Feedback
Quarterly Review
Interpersonal and Communication Skills
Residents must be able to demonstrate interpersonal and communication skills that result in effective
information exchange and teaming with patients, their patients families, and professional associates.
Residents are expected to:
A. Develop skills for interviewing patients that allow accurate, complete collection of information
regarding symptoms, and the community environment that affect the patient’s mental health.
B. Develop skills in communicating results, educating patients and their families, and dealing with
sensitive issues for patients and families, and negotiating a plan of treatment with the patient and
family.
C. Residents will understand the need for a multidisciplinary, integrated approach to mental health
disorders.
D. Develop patient sensitive skills for interviewing that allow accurate, and complete collection of
information regarding symptoms, the family and the community that affect the patient's mental
health and care.
E. Develop skills in educating patients and their families, in dealing with sensitive issues for patients and
families, and in negotiating a plan of investigation and treatment with the patient and family.
F. Develop professional relationships with co-workers, consultants, ancillary staff and other professionals
to enable assembling of health care teams and mobilization of community resources to optimize care
of the patient.
G. Develop an understanding of the role of the psychiatric consultant, and is able to
support the patient through the process of consultation, medical evaluation, treatment,
rehabilitation and long-term care.
H. Use professional language and demeanor when communicating with other residents, with
Family Medicine attending physicians, with physicians from other services, with nonphysician clinical staff, with non-physician non-clinical staff, and with patients and their
families.
I. Create and sustain a therapeutic and ethically sound relationship with patients.
J. Use effective listening skills and elicit and provide information using effective nonverbal,
explanatory, questioning, and writing skills.
K. Work effectively with others as a member or leader of a health care team or other
professional group.
Learning Activities
Attending Rounds
Multidisciplinary Rounds
Grand Rounds
Sub-Specialty Conference
Morning Report
Didactics
Other
Evaluation Methods
X
Attending Evaluation
X
Program Director
Review
360 ᵒ evaluation
Last Updated March 7, 2013
X
X
X
Research Conference
Ethics/Comm Conference
Specialty Conference
Noon Conference
Faculty Supervision
Procedures
X
X
X
Directly Supervised Procedures
In-Training Exam
X
Videotape Review
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Readings
Morning Report
Faculty Supervision
and Feedback
Quarterly Review
Other
Systems-based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
health care and the ability to effectively call on system resources to provide care that is of optimal value.
Residents are expected to:
A. Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, and the larger society and how these elements of the
system affect their own practice.
B. Know how types of medical practice and delivery systems differ from one another, including methods
of controlling health care costs and allocating resources.
C. Practice cost-effective health care and resource allocation that does not compromise quality of care.
D. Advocate for quality patient care and assist patients in dealing with system complexities.
E. Know how to partner with health care managers and health care providers to assess, coordinate, and
improve health care and know how these activities can affect system performance.
F. Learn the appropriate documentation, coding, and billing for consults, procedures, and patient
education.
G. Thoroughly document the plan for patient care management in the medical record.
H. Learn what constitutes an appropriate psychiatric consult, including the formulation of a specific
clinical question for the consultant.
I. Become knowledgeable about prevention strategies for preventing psychiatric sequelae.
Learning Activities
Attending Rounds
Multidisciplinary Rounds
Grand Rounds
Sub-Specialty Conference
Morning Report
Didactics
Other
Evaluation Methods
X
Attending Evaluation
X
Program Dir
Review
360 ᵒ evaluation
Other
IV.
X
X
X
Research Conference
Ethics/Comm Conference
Specialty Conference
Noon Conference
Faculty Supervision
Procedures
X
X
X
Directly Supervised Procedures
In-Training Exam
X
Videotape Review
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Readings
Morning Report
Faculty Supervision
and Feedback
Quarterly Review
Instructional Strategies (see above)
Training in human behavior and mental health will be accomplished primarily in the outpatient setting
through a formal four-week psychiatry block. This experience will include diagnostic assessment,
psychotherapeutic approaches and psychopharmacologic management techniques in psychiatry. The
resident will also learn to interact with psychiatrists, mental health providers and other allied health
providers during this four week rotation. Outpatient care of psychiatric conditions will occur longitudinally
in the resident’s continuity clinic.
Last Updated March 7, 2013
V.
Evaluation Strategies (see above)
A.
B.
C.
Observation of the resident by the Psychiatry attending.
Diagnosis documentation by the resident.
End of rotation evaluation.
VI.
Implementation Methods
This medical subspecialty consists of 4 1/2 sessions per week of psychiatry in a clinical setting at Emory
University School of Medicine, for a total of 4 weeks. This Medical Subspecialty will be under the
supervision of Dr. Firestone, Department of Psychiatry, Emory University School of Medicine.
Location:
Department of Psychiatry
Medical Office Tower, Suite 7
550 Peachtree Street, NE
Atlanta, GA 30308
404-686-8424
Contact:
Scott Firestone, MD
Assistant: Twila 404-686-8181 or 404-686-5759
Family Practice Center: 5 ½ days per week in the FMC, 4 ½ days in the Psychiatry Clinic
Call/Vacation: Call will be with the FMS @ Emory Midtown Hospital. No vacation permitted.
Supervision: Residents will be supervised by Dr. Firestone.
Conferences: The resident is expected to attend Family Medicine Thursday Didactics Conferences.
VI. Suggested Readings/Resources
Disorders Principally Diagnosed in Infancy, Childhood, or Adolescence
Daughton JM, Kratochvil CJ. Review of ADHD pharmacotherapies: advantages, disadvantages, and clinical
pearls. J Am Acad Child Adolesc Psychiatry. 2009;48(3):240-248.
Hamilton SS, Armando J. Oppositional defiant disorder. Am Fam Physician. 2008;78(7):861-866.
Safren SA, Knouse LE. Current status of cognitive behavioral therapy for adult attention-deficit
hyperactivity disorder. Psychiatr Clin North Am. 2010;33(3):497-509.
Searight HR, Rottnek F, Abby S. Conduct disorder: diagnosis and treatment in primary care. Am Fam
Physician. 2001;63(8):1579-1589.
Smucker W, Hedayat M. Evaluation and treatment of ADHD. Am Fam Physician. 2001;64(5):817-830.
Substance Use
Last Updated March 7, 2013
Bayard M, McIntyre J, Hill KR, et al. Alcohol withdrawal syndrome. Am Fam Physician. 2004;69(6):14431450.
Delirium and Dementia
Adelman AM, Daly MP. Initial evaluation of the patient with suspected dementia. Am Fam Physician.
2005;71(9):1745-1750.
Gleason OC. Delirium. Am Fam Physician 2003;67(5):1027-1034.
Mood Disorders
Ebell MH. Point-of-care guides: screening instruments for depression. Am Fam Physician.
2008;78(2):244-246.9
Sharp LK, Lipsky MS. Screening for depression across the lifespan: a review of measures for use in
primary care settings. Am Fam Physician. 2002;66(6):1001-1009.
Spitzer RL, Kroenke K, Williams JB, PHQ Primary Care Study Group. Validation and utility of a self-report
version of PRIME-MD: the PHQ primary care study. J of Am Med Association. 1999;282(18):1737-1744.
Anxiety Disorders
Fenske JN, Schwenk TL. Obsessive-compulsive disorder: diagnosis and management. Am Fam Physician.
2009;80(3):239-245.
Ham P, Waters DB, Oliver MN. Treatment of panic disorder. Am Fam Physician. 2005;71(4):733-739.
Lange JT, Lange CL, Cabaltica RBG. Primary care treatment of post-traumatic stress disorder. Am Fam
Physician. 2000;62(5):1035-1040.
Schizophrenia
Schultz SH, North SW, Shields CG. Schizophrenia: a review. Am Fam Physician. 2007;75(12):1821-1829.
Somatoform Disorders
Oyama O, Paltoo C, Greengold J. Somatoform disorders. Am Fam Physician. 2007;76(9); 1333-1338.
Eating Disorders
Williams PM, Goodie J, Motsinger CD. Treating eating disorders in primary care. Am Fam Physician. 2008;
77(2):187-195.
Personality Disorders
Ward RK. Assessment and management of personality disorders. Am Fam Physician. 2004;70(8):15051512.
Additional Resources
Last Updated March 7, 2013
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: Primary Care
Version. 4th ed. Arlington, Va: American Psychiatric Publishing Inc; 1995.
Gillies RA, Manning JS. Mental health. Prim Care. 2007;34(3):445-681.
Goldman LS, Wise TN, Brody DS, eds. Psychiatry for Primary Care Physicians. 2d ed. Chicago, Il:
American Medical Association; 2003.10
Pingitore D, Sansone R. Using DSM-IV primary care version: a guide to psychiatric diagnosis in primary
care. Am Fam Physician. 1998;58(6):1347-1352.
Stuart MR, Liberman JA III. The Fifteen Minute Hour: Practical Therapeutic Interventions in Primary Care .
3rd ed. Philadelphia, Pa: Saunders;2002.
Website Resources :
American Psychiatric Association: http://www.psych.org
American Psychological Association: http://www.apa.org
eff: 20 January 2013
Last Updated March 7, 2013