by J. Paul Burney, Ph.D. and Edward R. Davidson, Ph.D.
This article provides one example of how to complete the required practicum element in postdoctoral training in psychopharmacology.
The Conroe Family Medicine Residency Program (CFMRP) located in Conroe, Texas, was formed in 1979 as the Montgomery County Medical Education Foundation. It is accredited by the Accreditation Council for Graduate Medical Education. CFMRP is in an alliance with the Conroe Regional Medical Center, a 322-bed hospital, and is the only residency program in the hospital. CFMRP is also in alliance with the Conroe Medical Education Foundation and the Lone Star Community Health Center, a Federally Qualified Health Center.
The CFMRP is located in the Lone Star Community Health Center (LSCHC), a 22,000 square foot state-of-the-art family practice center that opened in January 2003. The LSCHC is equipped with: 24 exam rooms; 2 procedure rooms for medical evaluations such as fetal heart monitoring, colonoscopy, and flexible sigmoidoscopy; a laboratory; a pharmacy; and an X-ray room. Additional services include psychological triage and brief counseling, psychiatric medication consultation, dental, and pharmacy services.
CFMRP has seven faculty, five associate faculty, one nurse practitioner, and 21 residents in a three-year residency-training program in family medicine. This program provides services to an average of 25,000 patients a year. The Children Health Insurance Program, Medicaid, Medicare, and Public Assistance Program are the typical payers, or the patients are indigent.
In this preceptorship, we spent one-half of one day per week at the CFMRP and had formal face-to-face supervision once a week for a period of one hour. We also had daily ad hoc case consultations with the on-call faculty preceptor and residents.
The guidelines for the preceptorship were as follows:
- The preceptor was a faculty member who was a residency trained MD or DO.
- The preceptorship was for one year with a minimum of 100 patients seen for case supervision.
- The preceptor agreed to meet for a minimum of one hour per week to review cases, which included a case presentation consisting of comprehensive history, differential diagnosis, rationale for medication and medication choice, target symptoms to be monitored, dosing, and side effect profile.
- The preceptor agreed to serve as the supervisor for the trainee to provide quarterly performance evaluations with comments and a final evaluation with a written summary.
- The trainee completed an initial report of patient data for all cases as well as a follow-up progress and medication report.
Residents, faculty members, and occasionally members of the nursing staff referred patients with a variety of mental disorders. The types of patients ranged from more serious mental illness, such as mood disorders to more moderate conditions, such as adjustment disorders.
We spent approximately one hour with each patient for an initial evaluation and approximately 15-30 minutes with each patient for follow-ups. We typically saw one or two new patients and two or more follow-up patients each week. Each patient room had a computer terminal that allowed access to the medical and laboratory records.
At the beginning of each session, we were given a patient printout providing information on the patient's last attending physician visit, the reason for referral, and a diagnostic code sheet requiring diagnosis and signature. We evaluated the patient, formulated a diagnosis, and provided a recommendation for any needed medication and medication changes.
Many times, medication was not necessary and patients were seen for psychotherapy only. There were numerous times we recommended the reduction or the streamlining and consolidation of medications. Patients who required services outside of the expertise of the facility were referred to other community-based services. We documented our evaluations and recommendations into the computerized medical records as well as separately onto paper forms as required for preceptorship documentation.
In face-to-face formal supervision, each of us provided case consultations consisting of general subjective psychosocial information, observations, assessment, and a plan(s) for psychotherapy, medication or no medication recommendations, and referral, as needed. We were expected to justify our recommendations based on the latest psychopharmacology knowledge and research as well as appropriate psychological practices. These case consultations and supervision were very collaborative and often resulted in extensive conversations about ideas and suggestions beneficial to the patient and the resident.
In addition to seeing patients, we provided regular academic lectures or training to the residents on psychological subjects approximately two times a month depending on the needs of the program, faculty, and residents.
We made a one-year commitment to the CFMRP. During that time, we expected to fulfill our preceptorship requirements of seeing 100 cases. In spending one half day per week, it actually took two years to meet the 100 cases required by the preceptorship. We each stayed an additional two months to complete the follow-ups and terminations of active cases. During the extra two months, we continued to see new cases and emergencies, thus we ended our preceptorship with an excess of the 100 cases required. During our preceptorship, we were considered adjunct faculty, provided consultations to the faculty and staff, and were invited to faculty meetings, retreats, and training.
This preceptorship was an extremely effective and productive model for prescribing psychologists and physicians working together in a collaborative arrangement for the benefit of patients. Our prior didactic pharmacological training provided an excellent base for the preceptorship. The faculty and residents were impressed with our training and knowledge, both as potential prescribing psychologists and professionals. This preceptorship was an incredible learning experience.
Paul Burney, Ph.D., is currently in private practice in Conroe, Texas. Dr. Burney's clinical interest is in family therapy. Dr. Burney is President of the Texas Psychological Association and a member of APA's Practice Organization's Committee for the Advancement of Professional Practice (CAPP), serving a two-year appointed term (2004-2005). Dr. Burney serves on CAPP's Prescription Privileges Subcommittee and as a liaison for business and practice. Dr. Burney is adjunct faculty for Our Lady of the Lake University, and Sam Houston State University, and is a professional mediator for the Montgomery County Dispute Resolution Center and private clients.
Edward R. Davidson, Ph.D. (not pictured), is currently in the independent practice of clinical psychology. Prior to this, he was a staff psychologist for a large mutli-specialty medical clinic organization in Houston, Texas. He completed his Ph.D at the University of South Carolina in 1987 and then a post-doctoral fellowship at the University of Texas M.D. Anderson Cancer Center. His practice interests are in family systems treatment and organizational consultation.