The Future of Internal Medicine

Why Become an Internist-Psychiatrist?
Roger Kathol, M.D., Founder
University of Iowa Combined Internal Medicine and Psychiatry Residency Program

The Patients

Patients with concurrent physical health and mental health and substance use disorders (MH/SUD) present with a complex interaction of illnesses that thwart the ability of clinicians in the current medical system to support them, let alone effectively treat their conditions.  They truly are the patient outliers, orphans in a medical world that has difficulty combining general medical and psychiatric care.  This is one of the most tangible rewards of a successfully trained internist-psychiatrist, to be able to effect positive clinical outcomes in patients that few others can treat, in fact, that few others even wish to have as their patients.

Without question, internists-psychiatrists take care of some of the most interesting, challenging, demanding, and rewarding, patients.  Having the skills, through combined training, to reverse the downward spiral of patients who have failed treatments, often in multiple areas within the healthcare system, leaves the internist-psychiatrist with a sense of accomplishment that few other practicing physicians experience.  Daily, they are presented with diagnostic and therapeutic puzzles, the love of any good internist, while at the same time addressing personal, social, emotional, and behavioral factors and illness features that confound the ability of patients to improve.

The Excitement

Advances in the integration of physical and mental health care are just launching.  Those who enter this area of practice will, in a real sense, be a part of a revolution in medicine.  As a result, during the next decade, internist-psychiatrists will have a wide variety of options at their fingertips and will participate in the development of a new and expanding area of medical practice.  Many, in fact, will be able to create their own practice environment as interest in better ways to address the needs of complex, and, significantly, high cost, patients gains importance.   Research opportunities will grow and specialist training will expand.

Those with combined training will be trail blazers.  They will have the ability to change outcomes in patients with comorbid illness because of their training and the skills they have developed.  They will lead efforts to improve care for underserved and ineffectively-treated patients who are trapped at the interface of medical disciplines.  Unlike other practitioners, dedicated to the care of patients with combined illness, however, internist-psychiatrists will have a particular advantage.  With credentials in two specialties, they belong to two guilds, the internal medicine guild and the psychiatry guild.  As a member of both, it is possible to orchestrate cross-disciplinary opportunities that can only happen when ownership by both disciplines is needed for success.

The Opportunity

In the past ten years, opportunities for physicians with training in internal medicine and psychiatry have expanded dramatically. They include, but are not limited to:

• Integrated medical and psychiatric outpatient clinics, usually located in medical settings, e.g. stepped care (McArthur Foundation, Hartford Foundation, Robert Wood Johnson Foundation), shared care (Canadian system), primary care psychiatry (VA system), and combined community mental and physical health clinics
• Integrated medical and psychiatric inpatient units, e.g. University of Iowa Hospitals, Portland Hospital (Maine), University of Southern Illinois, St. Mary’s Hospital (Michigan), Massachusetts General Hospital, Duke University Hospital, and many others
• Integrated substance use disorder programs, e.g. primary care-based buprenorphine clinics, general medical clinic-based alcohol screening and brief intervention, primary care based physical health, alcohol detoxification, and rehabilitation programs
• Delirium prevention and treatment; often associated with medical psychiatry inpatient units
• Psychiatric consultation in the medical setting, both inpatient and outpatient
• Physical health intervention and prevention programs for the chronic and persistently mentally ill, e.g. state and county mental hospitals, and correctional facilities
• Specialty combined physical and mental health/substance use disorder treatment programs, e.g. eating disorders, oncology programs, end stage renal disease programs
• Integrated physical and mental health/substance use disorder administration, policy making

The Value

Compelling evidence now shows that:

• More than 30% of patients with chronic physical disorders, including heart disease, diabetes, asthma, and end stage renal disease, have a concurrent psychiatric condition.  An equal or greater number of patients with MH/SUDs either have a co-existing physical disorder or are seen more frequently for unexplained physical complaints in the physical health setting.
• General medical and psychiatric illness outcomes for patients with comorbid illness are substantially worse when present in the same patient.  Treatment in segregated general medical and psychiatric practice settings perpetuates these poor outcomes.
• Patients with MH/SUDs use twice the amount of physical health services compared to those who do not have MH/SUDs.  Further, patients with MH/SUDs contribute, more than any other studied population, to disability costs for employers.
• 80% of health service use by those with MH/SUDs is for general medical assessment and intervention.  Therefore, relatively little is spent on psychiatric care.  Our current system, with segregated physical and MH/SUD intervention strategies, from independent medical and mental health sectors, makes integration of care and reversing adverse economic and clinical outcomes near impossible.

Internist-Psychiatrists will have the backgrounds and expertise to lead change on behalf of patients with combined medical and psychiatric illness, those with the poor outcomes noted above.  Domains in which they will contribute include:

1. Clinical - coordinate and integrate efficacy-based, holistic healthcare practices and interventions
2. Administrative - develop/create innovative practice settings which bridge medical and psychiatric care
3. Education - advance understanding of holistic care for medical patients with psychiatric problems and MH/SUD patients with physical health comorbidity in both general medical and psychiatric training programs
4. Research - contribute to new knowledge about how to best alter outcomes in complex patients
5. Health policy - transform a segregated system into one in which psychiatric care becomes an integral part of physical health

For additional information about Dr. Kathol's work, please visit his website.