Received November 20, 2006; revised May 1 and August 1, 2007; ac- cepted August 22, 2007. The authors are af\ufb01liated with the Department of Psychiatry at the University of California, Davis School of Medicine, in Sacramento, Calif. Address correspondence to John Onate, M.D., University of California Davis, Department of Psychiatry, 2230 Stock- ton Blvd, Sacramento, CA 95817; onatej@saccounty.net (e-mail).

outpatient internal medicine training in psychiatric residency by the University of California, Davis, Department of Psychiatry and Behavioral Sciences, which provides medical care to patients with mental illness.

number of psychiatric consults was determined from electronic records for the 2005\u20132006 academic year. Evaluations by psy- chiatry residents completing the rotation were reviewed. Three internist-psychiatrists and one family medicine-psychiatrist pro- vided supervision.

2006 academic year. The quality of the educational experience was positive, with an overall rating of 4.43 on a scale from 1 to 5, with 5 being the highest.

can be better integrated into their psychiatry education in a cre- ative fashion when the teaching and supervision is provided by jointly trained attendings in internal medicine/psychiatry or fam- ily medicine/psychiatry. The success of the rotation contributed to the development of a combined internal medicine and psy- chiatry residency program.

Neurology has required psychiatry residents to com- plete 4 months of training in internal medicine. This re- quirement is completed during postgraduate year 1 (PGY- 1), or the internship year. Often the clinical assignments involve an inpatient internal medicine rotation at a general hospital.

We discovered through periodic meetings with residents in PGY-1 during the 2004\u20132005 academic years that resi- dents were often assigned to the intensive care unit or the coronary care unit. It was thought that such experience was not appropriate for the ambulatory care type of medicine that the residents would use as clinical psychiatrists. In addition, the department had recruited several faculty members who had training in both internal medicine and psychiatry or family medicine and psychiatry. After con- sultation with these faculty members, we decided to at- tempt a more innovative program that would allow \ufb01rst- year psychiatry residents the opportunity to work in an ambulatory care setting collaboratively with the jointly trained attendings.

Most of the faculty in the Department of Psychiatry and Behavioral Sciences at the University of California, Davis School of Medicine (UC Davis), work in clinical settings operated by the Sacramento County Division of Mental Health. Recently, from State of California tobacco tax rev- enues, Sacramento County built a new ambulatory care building near the campus. This facility provides medical care for Sacramento County patients who have no insur- ance coverage and meet county eligibility requirements. Because the chair of the department of psychiatry also serves as the Medical Director for Mental Health Services for Sacramento County, one of us (REH) contacted the Director of Mental Health for Sacramento County to ask for her support in developing a pilot project in which

county psychiatry patients who met primary care eligibility criteria could receive their medical care from a \ufb01rst-year psychiatry resident and a jointly trained internist/psychia- trist or family medicine/psychiatrist in the county\u2019s Primary Care Clinic. With the support and active collaboration of the Director of Primary Care for Sacramento County, the pilot project was organized.

During 2 of their 4 months in internal medicine, psy- chiatry residents provide medical care to eligible patients in the Primary Care Clinic. Supervision is provided by three jointly trained internists/psychiatrists and one fam- ily medicine/psychiatrist. In addition, the director of the program (JO) developed a consultation program county- wide in which physicians who work at any of the four county-operated clinics, homeless intervention programs, or other intensive service programs could refer psychi- atric patients who had no insurance and met other eligi- bility criteria to the Primary Care Clinic to have medical evaluations.

There is an extensive literature about the increased rates of medical illness in psychiatric patients (1). This is espe- cially true for psychiatric patients with chronic and severe mental disorders (2). Consequently, we thought that es- tablishing such a referral program could considerably re- duce the medical comorbidity of psychiatric patients re- ceiving care in Sacramento County. Another pressing problem is that psychiatric disorders in medical patients are often going unrecognized by primary care physicians (3\u20135). An additional purpose of this combined service was to develop a collaborative consultation arrangement with primary care physicians so that they could refer pa- tients with psychiatric disorders for evaluation and treat- ment (6\u20138).

An educational program was also established in which the jointly trained faculty give bimonthly presentations to county primary care physicians, internal medicine residents, medical students, and rotating psychiatry residents on the assessment and management of common psychiatric prob- lems encountered in the primary care or medical setting. This education program has been quite successful. In ad- dition to the primary care attendings, internal medicine res- idents who rotate through the clinic also attend these ses- sions.

Another educational program was recently established in which the jointly trained attendings go out to the psy- chiatry clinics bimonthly and provide educational pro- grams on common medical problems that the psychiatry attendings will encounter in their patients. This aspect of the educational programhas just been established.

For the 2005\u20132006 academic year, the attendings and residents conducted 550 psychiatric consultations, both formal and informal, for the primary care attendings. Fur- thermore, during 2005\u20132006, 1,255 uninsured patients from the county psychiatry clinics, substance abuse treat- ment centers, jail, and community were seen by combined faculty and psychiatry residents, with the majority being treated for both psychiatric and medical disorders. In ad- dition, we held six conferences for primary care physicians addressing common psychiatric issues such as hepatitis C in the dual-diagnosis patient population, anxiety disorders, geriatric psychiatry, the mental status examination in the primary care setting, psychosomatic disorders, and depres- sion treatment in the primary care setting.

During the \ufb01rst year, the most common medical condi- tions encountered in psychiatric patients were diabetes type 1 and 2, hypertension, hypercholesterolemia, coronary heart disease, chronic renal insuf\ufb01ciency, hypothyroidism, hepa- titis C, gastroesophageal re\ufb02ux disease, seizure disorders, migraine headaches, and community-acquired methicillin- resistantStaphylococcus aureus skin infections.

The psychiatry residents\u2019 responses to this new program were quite enthusiastic. A review of evaluations by resi- dents after completing the rotation from the UC Davis performance analysis report showed that the rating of su- pervision offered through the service had an average score of 4.29 out of 5 (n\ue0017, SD\ue0010.76), and that the overall rating of training site and rotation had an average score of 4.43 out of 5 (n\ue0017, SD\ue0010.53).

\u201cThe diversity of the patient population, the quality of the attendings and their teaching, and the general work envi- ronment made for one of the best atmospheres for learning medicine and primary care that I could hope for. This ro- tation is not simply a less painful way to satisfy our board requirements for medicine. It is a shining example of the importance of maintaining a strong base of medical knowl- edge and the inextricable interface between medical illness and psychiatric illness.\u201d

\u201cGreat site to learn [from] medicine-interested, enthusiastic faculty who seemed to care about our learning medicine as much as . . . noncombined, medicine faculty . . . Enjoyed having combined faculty teach us medicine.\u201d