American College of Physicians: Internal Medicine — Doctors for Adults ®


Psychiatry for the Internist: Interactive Session Teaches the Psychiatric Interview

By Stacey Butterfield

Major depression is second only to hypertension as a clinical diagnosis in the United States, affecting nearly 15 million people-almost 7% of the population-in a given year. Most of these people are treated by primary physicians, not psychiatrists.

At Internal Medicine 2007, three interactive sessions on "The Psychiatric Interview in Primary Care" helped internists learn the specialized language and tools involved in screening primary care patients for conditions like depression, bipolar disorder and post-traumatic stress syndrome. A final session this morning provides practicing internists with specific tools and information that they need about psychiatry for their practice today.

"The language of psychiatry is not highly specialized-it's pretty understandable-but it's very specific, and many practicing general physicians may not understand that," says Robert Schneider, FACP, associate professor of psychiatry at Virginia Commonwealth University and the chair of the sessions.

"If a patient is described as anxious and depressed, that's very non-specific, and may or may not be a disorder. It's like saying that someone is coming in with a cough and a fever," Dr. Schneider said. "To reach a specific psychiatric diagnosis, clinicians must understand the major mood disorders they might see in primary care." These diagnoses are classified under the acronym MAPSO: mood, anxiety, psychosis, substance and other-organic.

During the workshops, held Thursday, Friday, and Saturday mornings in the Herbert S. Waxman Learning Center, participants learned to use MAPSO as an organizational structure for a broad psychiatric knowledge base that is still efficient for an internist to learn. The discussion focused on how to ask questions about psychiatric problems, using non-judgmental, open, direct and plain language, along with something called the "explain, then inquire" technique.

"Patients are well-informed and respond well when the clinician is transparent in their rationale for questioning," explains William T. Nay, Ph.D., an assistant professor and director of research in ambulatory psychiatry in VCU's Department of Psychiatry and one of the session's faculty. "For example, you might say, 'You've mentioned a problem with nightmares. Sometimes this can go along with experiencing a psychological trauma. Let me ask you, have you ever been a witness to, or a victim of ...'"

Handheld audience participation devices, a new tool this year, allowed the participants to offer possible answers and pose questions about what participants wanted to learn, guiding the direction of the workshop as it happened. "For example," says Dr. Schneider said, "Do they need to have more emphasis on discussing trauma with patients and when you might do that, or do they need more information on acute traumatic responses?"

In six separate sessions, standardized patients reinforced the lessons of the workshop, as well as specialized sessions on bipolar disorder and posttraumatic stress disorder.

Simulated patients act out the disorder, assess the participant's knowledge and leave the role to become teaching associates. "They'll give feedback: How well are you screening for mania or talking about suicidality? What language are you using? What are your skills in working with the labeled disorder?" Dr. Schneider said.

Through "contracts for change," Dr. Schneider will follow up with participants in six months to see if they're instituting what they learned.

"I had to become a psychiatrist in order to learn how to teach psychiatry to internists," says Dr. Schneider. "But I learned psychiatry as an internist, and that's the way I teach it."

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