Frequently Asked Questions About Combined Residency Training In Family Medicine and Psychiatry [the FMP FAQ]

Version 03 revision 1 (December 17, 1999)

Ron Risley, M.D. mailto:ron@risley.net

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1 About this FAQ

1.1 Who maintains and publishes this FAQ?

This FAQ is maintained by Ron Risley, M.D., PGY-4 in the combined family practice/psychiatry program at the University of California, Davis Medical Center (UCDMC) in Sacramento, California. mailto:ron@risley.net
http://ron.risley.net

This FAQ has no direct affiliation with UCDMC; it is produced on my own time, with my own computers, and distributed using my own servers (though it may be mirrored or linked by official sites).

1.2 Who are the other contributors?

Anyone with information on combined family medicine and psychiatry training is welcome to contribute. I reserve the right to edit contributions arbitrarily and capriciously. Contributed material will be identified by the contributor's initials in [brackets]. Unattributed paragraphs are mine. Contributors thus far are:

1.3 What is the history of this FAQ?

The FAQ gets posted monthly (more or less) to the fpPsychList. If there are changes since the previous monthly posting, it gets a new version number. When changes occur during the month, the online edition will be updated rapidly (as my schedule allows) and given a revision number.

Paragraphs that are new or changed since the last new version are marked by a *, and are in green in the HTML edition.

1.4 This text-only FAQ is hard to navigate. Is there an easier way?

There is an HTML (World Wide Web) version available on line. It has a table of contents with live links. It is also updated more frequently than the text version: http://fmp.risley.net/fmpfaq.html

1.5 You idiot! Your facts are completely wrong! Whom should I flame?

You can send a polite correction directly to me. Better yet, join the FMP email discussion list and get your correction sent immediately to all the interested parties. Still feeling like fire and brimstone? I have a special address just for flames. mailto:ron@risley.net
http://risley.net/lists.shtml
mailto:flames@risley.net

1.6 Where can I get the latest revision? How can I find out more? How can I keep up-to-date on new developments?

Check my website. If you want to be sent updates as they occur, as well as participate in discussions about the FAQ, subscribe to the FMP email discussion list either by web form or by email. (21Feb2004 the list is currently closed --RR) http://risley.net/residency/
http://risley.net/lists.shtml
mailto:fpPsychList-on@risley.net

2 What is fm/psych combined residency training?

Anyone who has spent time in a primary care clinic realizes that a significant amount of psychopathology accompanies most medical illness. Anyone who has spent time on a consult-liaison psychiatry service knows that medical illness can precipitate or worsen psychiatric disorders. Anyone who has treated fibromyalgia or chronic fatigue syndrome knows that these and many other conditions combine psychosocial stressors, somatic illness, and psychological defenses in ways that aren't easily separated.

Training in family medicine can prepare you to approach and treat an incredible variety of patients with an astounding array of illnesses. Yet, even programs with a strong emphasis on behavioral medicine don't prepare doctors to effectively treat any but the most routine disorders commonly classified as psychiatric.

Training in psychiatry can give you a strong biopsychosocial approach to patients and teach you to work with "difficult" cases, but three or four years of dedicated psychiatric training can cause atrophy of one's other clinical skills.

Combined training gives you focused, in-depth biopsychosocial training while expanding and sharpening your primary care skills.

2.1 How long are combined programs?

All of the program that I am aware of are five years.

[JN] All combined programs must be 5 years. This is mandated by the agreement between the two Boards. Any accredited combined program must get approval from each Board before they can commence training residents. The FP Program Director get approval from the FP Board and the Psychiatry Program Director gets approval from the Psychiatry Board.

[JN] There is a fairly extensive document written by both Boards which outlines the requirements of the combined program. I do not know if it available on line. [I haven't been able to find it. I will obtain and post a copy if I can get the necessary permissions. --RR]

[MM] Dr. Nuovo is quite correct that there is what has been called "the 10 page white paper" that describes what must be done to have an accredited, Combined Family Medicine--Psychiatry Residency Program in the United States. Among many things, the white paper states that the program must be 5 years in length, and that under normal circumstances, residents can only enter into the R-1 year. Programs can request the permission of the two specialty boards to accept specific residents into the R-2 year, and this permission is usually granted. No one can enter the program at R-3 or above (this is a FAQ in my e-mail).

[MM] The 10 page, double spaced, double sided, guideline for establishing a Combined Family Medicine--Psychiatry Residency Program is dated October 1994 and it was mailed to all Program Directors of traditional Family Medicine Residency Programs in February 1995 with a cover letter from Dr. Young, who was then the Director of the American Board of Family Practice. The ABPN did the same thing at about the same time for all of the Program Directors in traditional Psychiatry programs. The "white paper" was typed on plain paper (no letterhead or signatures), and I have never seen it in any printed form or publication. When I submitted the article on practicing Family Physician--Psychiatrists to the JABFP, they were reluctant to talk to me at first because they couldn't find anything in print that stated that such an accredited combined program really was recognized by the ABFP & ABPN. That was 1996, but I still haven't seen the original guidelines printed anywhere. Obviously, program directors of accredited programs all have their original copies, but it would be nice if the Boards would allow "publication" (perhaps electronic) of the guidelines, just as the ACGME puts its institutional requirements and program requirements for residencies out on the web.

2.2 What board(s) will I be eligible for?

The program here at UCDMC is accredited by both the American Board of Psychiatry and Neurology (ABPN) and the American Board of Family Practice (ABFP). I assume the other programs are as well, but this is probably a good thing to specifically clarify with each program when you interview. http://www.abpn.com
http://www.abfp.org

2.3 How do they squeeze seven years of training into five years?

For many years, psychiatry programs began in the PGY-2 year after a medicine or transitional intern year. Though many programs now begin in the PGY-1 year, most will still accept PGY-2s after an internship in other disciplines. A family practice intern year satisfies the requirements of most all psychiatry programs. Many psychiatry programs, in other words, only have three years of focused psychiatry training. Effectively, one year is gained by sharing the intern year requirements between both disciplines.

Family practice programs have extensive board-mandated components in neurology as well as in behavioral medicine and mental health. These requirements overlap with psychiatric training. In addition, most fp programs allow for a significant amount of elective time, where residents are expected to pursue additional training in specific areas of interest (for example, obstetrics, pediatrics, and geriatrics). By sharing the mandated neurology and behavioral components, and by focusing elective time on psychiatric training, another year of training can be combined.

2.4 Will I be adequately trained in either discipline?

You will meet full board requirements in both disciplines. More importantly, I feel that each discipline complements the other. My primary care skills have benefited immensely from my psychiatric training, and I am a better psychiatrist with my increased knowledge of non-CNS biology.

2.5 What is the training like?

It's rigorous. It's fun. It's certainly challenging.

2.5.1 Where will I spend my time?

In general, your time will be split between the psychiatry and family medicine departments. At UCDMC, combined residents switch between fm and psych every three months for the first two years, then they switch every six months.

Both boards have a one-year continuity requirement. At UCDMC this is achieved by having a six-month block of outpatient psychiatry at the end of the third year followed by another six-month block of outpatient psychiatry at the beginning of the fourth year.

There are continuity clinics and didactics for both departments which run all through the five years of training.

2.5.2 How well can two departments coordinate?

Here at UCDMC, coordination between the two departments has been nothing short of miraculous. For one week of my second year, I was scheduled to be on an inpatient psychiatric service at a hospital fifty miles away from where I was scheduled to be on an inpatient pediatric service. Apart from that, scheduling conflicts have been few and easily resolved. This, despite the fact that I was at best the second, and usually the first, combined resident in each rotation I took.

2.5.3 How do I achieve continuity with patients?

In our (UCDMC) program, family medicine continuity clinics run continuously throughout the entire five years, at least one-half day per week. The only exception is during the trauma surgery rotation (trust me, patients don't want to see you then).

Similarly, time is generally available for seeing a limited number of long-term psychiatric patients on an ongoing basis. I have carried two long-term patients since very early in my second year, and expect to have many more for the duration of the program.

An advantage of having a five-year program is the opportunities it presents for long-term continuity with patients in both disciplines.

2.5.4 Is it any harder than straight psychiatry training?

Absolutely. Squeezing a three and a four year program into five years means there is much less time for some of the less stressful elective rotations that traditional psychiatry residents take.

2.5.5 Is it any harder than straight family practice training?

Absolutely. Squeezing a three and a four year program into five years means there is much less time for some of the less stressful elective rotations that traditional family practice residents take.

I calculated that, by the middle of my third year, I had already taken more overnight call than traditional residents in fm or psych take in their entire programs.

2.5.6 Why would I want to put myself through such a rigorous program?

For the long answer, see my website. The short answer is: "Because nothing else will do."

While on a surgery rotation, the trio of surgery residents asked me how long my program was. When I told them, they looked at me astonished and said "you could have been a surgeon!" Indeed, I could have been many things, but this is the one thing that I felt I had to do. If you have similar feelings, then welcome to the One True Way.

2.6 What the heck will you *do* with your combined training?

This is, by far, the most frequently asked question in the business. Should you decide to follow the One True Way, prepare a good answer. You'll use it frequently.

2.6.1 Are there opportunities to use combined training at rural sites?

One of my fantasies is to move to a rural area that could not support a psychiatrist full time, but has a need for a primary care doctor and a mental health professional. Such a position would be fraught with boundary issues and scheduling difficulties, but the rewards could be equally magnificent.

2.6.2 Are there opportunities to use combined training in urban sites?

Substance abuse, domestic violence, poverty, nutrition, and education are all urban issues that combine biological concerns and psychosocial stressors.

2.6.3 Are there opportunities in academic medicine?

In many academic institutions, the really exciting work seems to happen at the boundaries between disciplines. Furthermore, as combined FMP residencies increase in number and grow in size, programs will be looking for physicians qualified to precept combined residents on their wards and in their clinics.

2.6.4 What about the middle-class suburbs?

Fibromyalgia. Obesity. Chronic fatigue syndrome. Anorexia nervosa. Domestic violence. Substance abuse. Multiple chemical sensitivity. Somatization disorders. Myofascial pain syndrome...

2.6.5 Is this a great way to be guaranteed a cush life and big bucks?

Sooner or later, some HMO is going to offer one of us a job where we'll act as an assembly-line primary care doc four and one-half days a week, and be the psychiatric provider for fifty thousand capitated lives on the other half-day. Then the HMO will claim that they offer psychiatric services in their plan. The guerilla physician in me won't let me take that job. http://guerillaphysician.com

2.6.6 What are combined program graduates doing now?

There aren't any yet.

2.6.7 Are there any double-boarded fm/psych doctors, and what are they doing now?

[JN] Marty McCahill published an article in the family practice literature a few years ago on the practice habits of dual-boarded FP/Psychiatrists. If I remember correctly the sample was fairly small (maybe 50 or so people). This group also got their dual-board certification the old fashioned way by doing it over 7 years.

[RR] The N was 29. The article is worth reading, though my personal belief (along with Dr. McCahill) is that the majority of doctors entering combined training have different motivations than those who boarded separately, and are likely to pursue different career paths:

McCahill ME, et al. Physicians who are certified in family practice and psychiatry: who are they and how do they use their combined skills? J Am Board Fam Pract. 1997 Mar-Apr;10(2):111-5; discussion 115-6. PMID: 9071691; UI: 97225318

2.7 Aren't you just a family practitioner with some extra psychiatry training?

It goes well beyond that. The psychiatric model for care delivery -- at least in places where it hasn't been "managed" out of existence -- brings a whole new perspective to primary care. There is a niche for practitioners thoroughly trained in both disciplines, and it is a niche that won't be filled in the foreseeable future.

2.8 Aren't you just a psychiatrist who happens to have delivered some babies and treated a lot of CHF?

Hey, there are advantages to starting analysis on the perineum. The regression experience requires far less time.

Seriously, two of the patients I see in my psychiatric practice are pregnant. Another will die this year from complications of medical illness. Many have chronic diseases such as diabetes or hepatitis C which impact on their psychological functioning. Many take exogenous hormones for non-psychiatric reasons which impact on their mood disorders. All of them, eventually, reach a point where their "medical" and "psychiatric" issues become inseparable.

2.9 You mean that you have to touch patients whom you might also have in therapy!?!

Often. Certainly, there are times when boundaries have to be carefully considered, and referrals are sometimes in order. Other times, though, it is less traumatic to receive care from someone in a trusted relationship.

2.10 Ever heard the phrase "jack of all trades and master of none"?

Ever heard the word "synergism"?

3 Where can I get fm/psych combined training?

When I applied at UCDMC, there was only one slot available. There was also only one other combined program in existence, and it (West Virginia) was out of my geographic range.

Currently, there are a number of programs available, and each program has slots for two residents each match.

3.1 What programs are available for residents seeking combined training?

I am hoping to soon have email contacts for each program. Links to the programs' websites can be found on my fmp residency page. http://risley.net/residency/#fppsy

3.2 Are there any programs in military hospitals?

I am hoping to soon have email contacts for each program. Links to the programs' websites can be found on my fmp residency page. http://risley.net/residency/#fppsy

3.3 What are the differences among the programs?

I don't know. I am hoping that residents and administrators from other programs will decide to take advantage of the opportunity to publicize their programs' strengths by making contributions to this FAQ. What little I *do* know is summarized here.

3.3.1 What is the intern year like?

Here at UCDMC, the intern year is a truly integrated experience. Interns switch about every three months from psychiatry to family practice. Some other programs make the first year a more-or-less pure family medicine experience, with little or no psychiatry until the second year.

3.3.1.1 Is there any advantage to a combined intern year?

Absolutely. I really enjoyed feeling like a full-fledged member of both departments from the very beginning of my training.

3.3.1.2 Is there any advantage to an fm-only intern year?

Absolutely. It was really a drag to still be working as a ward intern in October of my second year.

I am still not certain which model I would prefer. Comments are welcome.

3.3.2 Are there opportunities to have combined preceptors?

Not at UCDMC, at least until after I graduate :-). UCSD has Dr. McCahill, who double-boarded separately and has been the guiding light of their combined program. I don't know about the other sites.

3.3.3 Has the program been around very long?

My understanding is that the program at West Virginia University has been around the longest by several years, but didn't actually have board approval until recently. If that is incorrect, someone please let me know.

The UCDMC program took its first resident in 1995, though due to some unfortunate circumstances I will probably be the first to graduate, in 2001.

UCSD took their first residents in 1997, though they took PGY-2s that year so they will be graduating in 2001 also.

[LW] [University of Cincinnati] Lisa Cantor is our fifth year resident (and chief) and she'll graduate in 6/00. I'll add more later.

I am eagerly awaiting information from the other programs.

3.3.4 How is the program funded?

3.3.4.1 UCDMC

The UCDMC program is funded the same way as other resident positions, with the costs split between the two departments.

3.3.4.2 UC San Diego

[MM] UCSD has grant funding. Because we have our program's "out-patient medical home" at St. Vincent de Paul Village Medical Clinic (which serves the homeless community), we get grant funding from several sources through "the Village" for our work there as the Village Family Physician--Psychiatrists.

[MM] The St. Vincent de Paul Village Medical Clinic is a licensed community clinic that serves the homeless and otherwise medically un-served population of San Diego. Our patients have no health care insurance or Medi-Cal (what Medicaid is called in California). In 1998, our clinic provided 26,000 patient visits to over 8,000 different patients, with all services free of charge, including laboratory services and medications. Because approx. 75% of the homeless community have both mental illness and general health care needs, this is a perfect setting in which to practice fully integrated Family Medicine--Psychiatry. Approx. 1/3 of the homeless are families, by the way, and the residents in our program do their prenatal care/OB in the Village Medical Clinic as well. The Village is a very special place and we are looking forward to the growth of the Medical Clinic within the next couple of years. There is a link from our Combined Family Medicine--Psychiatry Residency Program's web site to the site for St. Vincent de Paul Village. http://www.combinedresidency.org

3.3.4.3 Other programs

I don't currently have information on how other programs are funded.

3.4 Where can I get more information on the programs?

Most have websites. The current list of programs with links to their websites can be found on my site (which is *not* affiliated with UCDMC). http://risley.net/mind.body/residency/#fppsy

Most importantly, if you find this FAQ useful you should sign up for the FMP discussion list, where updates to this document will be posted periodically. You can also use the list to make suggestions for revisions and improvements to the FAQ.

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Copyright 1999 Ron Risley. Permission to redistribute is granted provided the entire document, including this notice, is distributed intact and unaltered. http://www.risley.net