Innovative continuing medical education program for paediatricians: A model for the delivery of mental health services

Abstract

Paediatricians have described themselves as feeling insufficiently trained to manage young people (and their families) with significant psychosocial distress and mental illness – who can comprise a large proportion of their practices. A continuing medical education program for a group of four paediatricians who treat the paediatric mental health needs of a large Ontario catchment area with few mental health resources is described. At a monthly educational and consultation clinic, the paediatricians discuss and personally interview their own patients and referrals while a child psychiatrist and a psychiatric social worker, using a two-way mirror, assist them to develop psychosocial interviewing skills and techniques, and diagnostic formulations.

A continuing medical education (CME) program for paediatricians, designed to enhance their role in the management of mental health problems in the young population, is described. This program employs a paediatric psychiatrist and a psychiatric social worker, who function as consultants as well as educators.

THE DEMAND FOR MENTAL HEALTH CARE SERVICES FOR CHILDREN AND FAMILIES

Young people and their families who seek health care assistance for psychosocial problems or psychiatric illness often turn first to their paediatricians for help. Some reports (1–4) estimate that children with some form of psychosocial distress or dysfunction comprise 10% to 30% of paediatricians’ practices. In the Ontario Child Health Study II (4), over 18% of the province’s children and youth met the criteria for at least one psychiatric disorder (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 3rd edn, revised [DSM-IIIR] [5]), and two-thirds of those with one disorder met the criteria for two or more disorders. Only one of six children with a disorder had, in the preceding six months, received any form of intervention for the disorder.

This large group of children and families, if they seek medical help, often first contact their paediatricians and family doctors. At this point, the problems are generally in the early stages of development, are relatively uncomplicated and may be reversible.

The paediatric literature (6) has drawn attention to the new ‘morbidity’ of social and behavioural disorders, but paediatricians have described feeling inadequately trained to recognize and treat mental health disorders in children and families (7). Several authors (6–8) have discussed paediatricians’ low rate of identification of psychosocial problems. Medical schools and postgraduate training programs do not emphasize the study of mental health disorders in the curricula of paediatric training. In 1980, over 50% of paediatricians who responded to a Canadian national survey (9) rated their training in adolescent medicine and psychosocial paediatrics “inadequate in quantity and poor in quality”.

Even when a psychosocial diagnosis is made, the patient, the family and sometimes even the physician may remain reluctant to refer the problem to a child psychiatrist. Paediatricians have sometimes expressed frustration at the long waiting lists of psychiatrists. Child psychiatrists, on the other hand, could not service this large volume of children, if they were identified.

Paediatric consultation-liaison psychiatry is a branch of psychiatry specifically directed to the diagnosis and treatment of paediatric conditions and diseases resulting from the interactions of systems, including psychosocial, social and biological factors. Two models used by consultation-liaison psychiatrists in their clinical work are client-centred and consultee-centred psychiatric consultations (10). In the client-centred model, the client is the patient or family who has been referred for a complete psychiatric assessment or treatment to the psychiatrist. In the consultee-oriented model, the consultee is a primary care physician who is assisted by consultation to identify and manage psychological issues that may affect the patient’s and family’s condition. This approach includes an educational function; the consultation is generally focused on specific questions asked by the consultee.

CME FOR PAEDIATRICIANS

Paediatricians who may not have access to psychiatric consultants may pursue educational programs (seminars, lectures and workshops) designed to enhance their ability to identify and treat mental health problems in young people.

Anderson and Harthon (11) studied the effects of improving nonpaediatric physicians’ psychiatric knowledge of issues in the diagnosis and treatment of mental health. They found, in a controlled trial, that a brief intervention (a single educational session) improved the diagnostic accuracy on specific DSM-IIIR disorders and treatment recommendations of participants compared with those of a control group taken from those on a waiting list for an educational session. However, this research was not directed towards paediatricians or family physicians treating children. Study of physicians’ learning patterns (12) and the effectiveness of CME interventions (13) has indicated that traditional methods such as mailed material and didactic lectures usually fail to change physicians’ performances.

The Collaborative Office Rounds program founded in Virginia supports small discussion groups that meet at regular intervals to discuss mental health aspects of paediatric care. The groups, which consist of paediatricians and psychiatrists, are jointly led by paediatricians and child psychiatrists. The program has received high marks on evaluation by the participants and teachers using a wide range of evaluation techniques (14). Similar programs have been described since 1950 when Michael Balint led British general practitioners in discussion seminars that applied psychoanalytic principles to primary medical practice (3). Although these programs are valued highly, they do not provide ‘hands-on’ methods of learning and teaching where learners are trained by being observed while they interview their patients.

Other educational programs aimed at enhancing physicians’ diagnostic acuity and skill at treatment have focused on developing interviewing skills. Interviewing as a skill is considered one of the most important tools available to physicians in all branches of medicine (15). Good interviewing skills contribute to improved accuracy of medical diagnosis and treatment outcome of any medical intervention. Empathy, active listening and sensitivity to nonverbal communication have all been identified as important components of the interviewing process. These qualities are especially necessary during interviews about psychosocial distress and illness, where attending to nonverbal messages, hidden agendas, and covert and paradoxical communication becomes central to the understanding of the issues. Moreover, in the young patient, the role of the family in the genesis or maintenance of a particular psychosocial symptom demands a particular kind of interviewing skill peculiar to the family (16). Interviewing an individual child, an adolescent or a whole family requires different skills and techniques. This kind of attention to communication styles and patterns often requires the special training more often found in child psychiatry than in paediatric medical educational programs.

While teaching these skills can be difficult, increasing a learner’s active participation in the learning process and providing good models in the role of teacher can increase the acquisition of good interviewing skills. Consequently, the design of an educational program to enhance physicians’ interviewing skills should allow the learner to interview patients personally as well as give the learner opportunities to model a teacher who also interviews during the education process.

Paediatricians are often highly skilled in interviewing patients and their parents about problems likely largely caused by an organic factor. Interviewing that is more psychosocially oriented, however, often requires a somewhat different approach, often necessitating interviewing the family. Consequently, the physician may need to change her or his interviewing style according to the problem at hand, although many basic principles, such as the art of active listening and empathy, remain important aspects of the process irrespective of the specific problem.

BENEFITS OF THE CONSULTEE-ORIENTED MODEL

Child psychiatrists have the potential to be an excellent resource for the teaching of medical psychosocial interviewing to paediatricians. Consultee-oriented psychiatric consultation can provide a forum where physicians enhance their psychosocial interviewing skills and a resource for the paediatrician who wishes to manage the psychosocial problems of her or his patients.

A major goal of the consultee model is to enhance the consultee’s personal skills in the identification and treatment of psychosocial problems while simultaneously consulting indirectly on the patient. For this model to be effective, the consultee (the paediatrician) must also wish to implement the consultant’s (the psychiatrist’s) recommendations rather than give complete control of the management of the case to the consultant.

As an educational and service model, the process benefits from a clear identification of a problem, early hypothesis generation and the ability of the psychiatrist to use the medical model to conceptualize mental health problems. The use of the medical model is necessary because the consultant must use the language of the consul-tee rather than the language of his or her own specialty to ensure that recommendations and concepts are understood.

One of the major goals of the Psychiatric Consultation Liaison Service at The Hospital for Sick Children, Toronto, Ontario is to assist paediatricians, surgeons and allied health care staff with the identification and treatment of mental health problems in children and families. To achieve this goal, the authors have increased their use of the consultee model in recent years. Using this model, they attempt to serve the large volume of children and families who never see a psychiatrist, although they do seek help from their paediatricians and health care professionals. If, at the same time, these children are managed by their paediatricians, the use of the psychiatric consultation services may be directed to the more difficult problems and psychiatric illnesses in children and their families, improving the delivery of mental health resources.

Psychiatrists using the consultee model need, however, to be skilled educators as well as clinicians.

A COMMUNITY APPLICATION

In addition to the hospital’s Psychiatric Consultation Liaison Service, CME programs specifically aimed at enhancing their skills in the diagnosis and treatment of mental health problems in children and families have been provided to community paediatricians. For example, since October 1993, using a consultee model, a child psychiatrist and a psychiatric social worker have consulted a group of four paediatricians in a town in central Ontario where there are few mental health resources. These physicians are consultant paediatricians who are referred a considerable number of patients with behavioural, learning and emotional problems from a large catchment area. These paediatricians estimate that this referral pattern results in these patients comprising 20% to 40% of their practices (personal communications).

The authors designed a CME program to address this situation. A ‘hands-on consultee-oriented psychiatric program’ was designed in which the paediatrician was invited to participate actively in the psychiatric consultation. The patients and families were asked by their paediatrician to consent to a process of psychiatric consultation that included a mental health team (psychiatrist and psychiatric social worker) who would provide an educational opportunity for their paediatrician while simultaneously providing a psychiatric consultation on the specific concern.

A consulting/teaching program was developed in the home town of the paediatricians, during which, for one day per month, the paediatricians invite their patients (five to six per day), accompanied by their families, to attend a clinic where the consultant psychiatrist and psychiatric social worker use the consultee model to enhance the skills of the paediatricians and provide indirect services to the patient and family. The main objectives of this program are to enhance the paediatricians’ psychosocial interviewing skills and promote their personal use of the diagnostic formulation followed by treatment interventions.

This model requires the psychiatrist and social worker to review the chart notes sent by the consultees before the clinic date and to prepare relevant articles for teaching. Appointments with families on the clinic date are made in pairs, as described below.

During the clinic, all four paediatricians meet with the psychiatrist and social worker (the team). The team reviews the notes on two cases, and the group generates hypotheses regarding relevant issues in the case and considers differential diagnoses (1 h). Then two paediatricians who have each invited a patient to the clinic, having formed a hypothesis with the group, concurrently interview their respective patient and family as follows.

• One paediatrician interviews the first patient while the psychiatrist and the two paediatricians not involved with either family observe and discuss the interview behind a two-way mirror.

• In another room, the psychiatric social worker interviews the second patient and family collaboratively with the second paediatrician.

The patient’s family is interviewed to gain a broader understanding of the child’s problems in the context of his or her family and social environment. Both of the interviewing paediatricians are required to conceptualize the psychosocial problems within the context of family relationships according to the information gathered. The interviews progress for 35 to 45 mins; then the interviewers excuse themselves and the whole team reconvenes. The team members discuss the interview techniques, differential diagnosis and treatment options (15 to 20 mins). The paediatrician, the social worker and the second paediatrician then return to their respective interview rooms to complete the assessment of the two cases (30 mins). Note that one paediatrician interviews alone (hands-on) while the other does so with the social worker (modelling).

It is very important that the patients seen in this manner are those of the paediatrician. These patients have more trust in the process; with guidance, they are able to discuss and disclose issues to their paediatrician more easily in this context.

After engaging in the consultee-oriented psychiatric clinic for five years (1993 to 1998), one day per month, the four paediatricians have all described an increased comfort and ability to diagnose psychosocial problems. They have also noted that they are now personally treating many of the young people and their families whom, in the past, they would have referred to scarce local psychiatric resources or to large centres many miles away (both with long waiting lists). In five years, the authors have seen approximately 200 new cases, the majority of which have been followed by the paediatricians. Depending on the nature of the problem, the paediatrician sees the patient and/or family once per week to once every three months. The most common problems are somatoform disorders, attention deficit disorders and pervasive developmental disorders, equally distributed. If a major psychiatric illness is identified, the patient is referred to a psychiatrist for a full assessment (such referrals are not commonly needed). These physicians also describe an increased ability to apply the principles of interviewing, diagnostic formulation and management learned from individual patients to other patients in their practices. The paediatricians have evaluated this program by describing their opinion of the changes in their practices. All four paediatricians have described an increased confidence in diagnosing and treating paediatric psychiatric conditions (personal communication). One paediatrician stated “I handle the psychiatric diagnoses much better that I [did] before. I am willing to follow them [patients] where, in the past, I would have referred them”. All four paediatricians described a 10% increase in their personal treatment of paediatric mental health problems. The specific problems that they were more comfortable diagnosing and treating were attention deficit hyperactivity disorder, depressive and anxiety disorders, eating disorders, functional pain disorders and family communication issues. All four paediatricians agreed that they could deal with these types of paediatric problems on their own, or sometimes by a telephone conversation with a psychiatrist (Dr Rose Geist). The four paediatricians fund the teaching time of the psychiatrist and social worker through a teaching fund provided by their hospital. It is important to note that the four paediatricians are an interested and capable group of physicians whose ability to use the CME effectively is partly a result of their personal and professional qualities and abilities. Well-motivated, capable paediatricians such as these can be an excellent mental health resource.

FUTURE ELABORATION

We are currently designing a study to determine the effectiveness of this CME design for paediatricians before we institute the program on a larger scale. We hope to include the perceptions of the family and patients of the effectiveness of this model. To date, many families have communicated to us that this type of consultation is useful to their paediatrician and hence to themselves. We plan to use a hands-on, consultee-oriented teaching model. Our aim will be once more to enhance interviewing skills, diagnostic formulation and treatment interventions, this time those of a large group of community paediatricians who manage psychosocial issues as well as some psychiatric illnesses and disorders in young people and their families. We hope to demonstrate objective measurable gains made by paediatricians in the area of acquisition of psychiatric knowledge, skill in psychosocial interviewing techniques and diagnostic formulation for children, adolescents and their families. We also anticipate that paediatricians will make fewer referrals to mental health resources following the CME program and will manage many of the psychosocial problems of their patients personally.

CONCLUSIONS

The CME program described above may have far-reaching consequences for many children and families who suffer with mental health problems that may otherwise have remained unrecognized or untreated. The optimal method of addressing these issues and this population may be to increase the teaching of psychosocial interviewing principles and paediatric mental health in the paediatric curricula in medical school. In the meantime, CME programs for paediatricians described above may serve as a model for enhancing the delivery of mental health services to a large group of young people and their families.