Brief Report
A Novel Approach to Medicine Training
for Psychiatry Residents
John Onate, M.D., Robert Hales, M.D., M.B.A., Robert McCarron, D.O.
Jaesu Han, M.D., Dorothy Pitman, M.D.
Objective: A unique rotation was developed to address limited
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.
Methods: The number of patients seen by the service and the
number of psychiatric consults was determined from electronic
records for the 2005–2006 academic year. Evaluations by psy-
chiatry residents completing the rotation were reviewed. Three
internist-psychiatrists and one family medicine-psychiatrist pro-
vided supervision.
Results: A total of 1,255 patients were treated during the 2005–
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.
Conclusion: Training psychiatry residents in internal medicine
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.
Academic Psychiatry 2008; 32:518–520
Received November 20, 2006; revised May 1 and August 1, 2007; ac-
cepted August 22, 2007. The authors are affiliated 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).
Copyright 䊚 2008 Academic Psychiatry
518 http://ap.psychiatryonline.org
S ince the 1970s, the American Board of Psychiatry and
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 2004–2005 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 first-
year psychiatry residents the opportunity to work in an
ambulatory care setting collaboratively with the jointly
trained attendings.
Description of the Program
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
Academic Psychiatry, 32:6, November-December 2008

county psychiatry patients who met primary care eligibility
criteria could receive their medical care from a first-year
psychiatry resident and a jointly trained internist/psychia-
trist or family medicine/psychiatrist in the county’s 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
(3–5). 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 (6–8).
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 program has just been established.
Academic Psychiatry, 32:6, November-December 2008
ONATE ET AL.
Results
For the 2005–2006 academic year, the attendings and
residents conducted 550 psychiatric consultations, both
formal and informal, for the primary care attendings. Fur-
thermore, during 2005–2006, 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 first year, the most common medical condi-
tions encountered in psychiatric patients were diabetes type
1 and 2, hypertension, hypercholesterolemia, coronary heart
disease, chronic renal insufficiency, hypothyroidism, hepa-
titis C, gastroesophageal reflux disease, seizure disorders,
migraine headaches, and community-acquired methicillin-
resistant Staphylococcus aureus skin infections.
The psychiatry residents’ 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 (n⳱7, SD⳱0.76), and that the overall
rating of training site and rotation had an average score of
4.43 out of 5 (n⳱7, SD⳱0.53).
Here are representative comments on the rotation from
the residents:
“The 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.”
“Great 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.”
The residents found the rotation, compared with other
medicine rotations, to provide both training and clinical
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MEDICINE TRAINING FOR PSYCHIATRY RESIDENTS
experiences that were more applicable to psychiatry resi-
dency.
Discussion
Training psychiatry residents in internal medicine can be
accomplished in a creative fashion when the teaching and
supervision is provided by jointly trained attendings in in-
ternal medicine/psychiatry or family medicine/psychiatry.
The positive results of this pilot project led to another un-
expected initiative: a joint internal medicine/psychiatry
residency that began to recruit residents beginning with the
July 1, 2007, academic year. The primary care-psychiatry
initiative played a large role in bringing together the six
jointly trained attendings in the department to develop a
medicine/psychiatry division that seeks to integrate the
educational and clinical research opportunities in this
area. The department already has a family medicine/psy-
chiatry residency program that was established in 1995.
This program has two residents in each year of training,
and the internal medicine/psychiatry residency will also
have two residents in each year.
Future Programs
The next initiative that will be instituted sometime in
the 2008–2009 academic year will be the provision of the
other 2 months of psychiatry residents’ medicine rotation
at an internal medicine/psychiatry inpatient unit. This pro-
gram is being established by the Northern California Vet-
erans Administration, located at Mather Air Force Base,
a 15-minute drive from the UC Davis Medical Center. The
rotation is scheduled to begin in the early part of 2009.
The medical director of this new facility will be a jointly
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trained family medicine/psychiatrist. The training and su-
pervision of the other 2 months of the psychiatry residents’
medicine rotation will be provided at this facility. Conse-
quently, the 4 months of the psychiatry residents’ medicine
experiences will consist of 2 months of ambulatory care
medicine and 2 months of inpatient internal medicine,
both at facilities in which the training and teaching are
provided by jointly trained attendings.
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