The Register Report, Spring 2009 The Impact of Behavioral Medicine on Primary Care Practice and Training in the Department of Family Medicine at Harbor UCLA Medical Center by: Harriet Boxer, Ph.D. and Jed Grodin, Ph.D. Return to Table of Contents

It is undeniable that psychology has a great deal to offer primary care physicians. Historically, primary care physicians are at the front lines of providing mental health care to their patients. This has included both the initial identification of a mental health problem as well as ongoing mental health care, including providing psychotropic medication. There is a growing awareness in primary care of how mental health issues and behavioral patterns can influence the outcome of many medical issues.

The importance of mental health training in Primary Care has been recognized by the Accreditation Counsel for General Medical Education (ACGME) which has designed Core Competencies that emphasize psychological factors such as effective interpersonal and communication skills for physicians. In addition, residencies must provide a psychological support system for the residents during their training. Psychologists frequently fill the role of providing training in behavioral medicine and also provide the residents with individual and group opportunities to explore their own emotional and behavioral functioning in the context of providing care to their patients.

Primary healthcare is increasingly focused on providing lifelong healthcare and management of chronic medical conditions. With this focus, there is an increasing awareness of the necessity of a collaborative paradigm that includes the understanding that the patient is an active participant in his/her health rather than a passive receiver of treatment. The concept of self-management support emphasizes the need to enhance patients’ skill and self-efficacy in managing their chronic illness. For this paradigm to be successful, effective communication skills and self-management techniques need to be employed consistently. These concepts are fundamental to psychology and hold a great deal of promise in helping patients with medical issues. Consequently, the potential of behavioral medicine in helping patients is being recognized and the role of psychology is expanding. This article describes how behavioral medicine is integrated into the Department of Family Medicine at Harbor-UCLA Medical Center.

The Harbor-UCLA Department of Family Medicine operates within Harbor-UCLA Medical Center, a public academic hospital that serves as a safety net provider for a significant portion of the uninsured inhabitants of the Los Angeles County.

Dedicated to training physicians to provide primary care to underserved populations, the program has 36 residents (12 per year), 3 faculty development PGY 4 Fellows and 2 Sports Medicine Fellows. The Department operates two community-based training sites and a school-based clinic that provides a combined total of 54,000 primary care patient visits per year, plus additional specialized services including office procedures, geriatrics and sports medicine consultations, EKG treadmill testing, and prenatal care.

The department features a team of three Behavioral Medicine psychologists whose duties include direct patient care; consultation and training for the residents and faculty; and participation in departmental and personnel issues. The team is comprised of one full-time psychologist who exclusively provides assessment and psychotherapy; one half-time psychologist who splits time between consultation, training, patient care services, and departmental duties; and, in collaboration with the department of psychology at Harbor-UCLA, one behavioral medicine psychology post-doctoral fellow. The postdoctoral fellow’s time is divided between consultation, assessment, and psychotherapy services.

The Behavioral Medicine team works in collaboration with family medicine residents and attending faculty and provides services in the outpatient clinic (located a few miles from the main hospital campus) and the department’s inpatient service at the main hospital. Following is a description of these duties by category in the outpatient and inpatient setting.

Collaborative Direct Patient Care: Assessment and Psychotherapy

The psychology team provides assessment and short-term psychotherapy to patients served by the department. When a question regarding psychological issues is identified by the provider, either through precepting with an attending physician or in consultation with one of the psychologists, the patient is referred to the psychology team who will meet with the patient. Assessment referrals address identifying and clarifying diagnoses of psychopathology (e.g., depression, anxiety, psychotic disorders, substance abuse), psychosocial issues such as stress management, and mental states and basic neuropsychological problems. Additionally, referrals frequently entail assistance in identifying factors contributing to difficulties with treatment, i.e., problematic health behaviors (e.g., poor diet, medication and treatment noncompliance) and personality factors potentially associated with communication and treatment difficulties. A psychologist will schedule single or multiple assessment sessions, which may include structured and unstructured interviews and objective measures and will communicate findings and collaborate on treatment plans with the referring provider.

When requested and indicated, the psychologists will initiate short-term psychotherapy with patients to address psychopathology as it relates to health behavior issues. The course of psychotherapy can range from as few as two sessions to between ten and twenty sessions and are mostly CBT-based. Some of these interventions are specifically health behavior related such as Motivational Interviewing to increase treatment adherence or coping skills training to improve stress management; while other interventions are more focused on the treatment of depression, anxiety, and other Axis I disorders independent of a patient’s medical status. In some small number of cases, the psychologist elects to extend the treatment into longer-term psychotherapy when appropriate and possible given case-load and time constraints. The psychologist remains in communication with the patient’s medical provider insofar as issues in treatment relate to the patient’s physical health.

Consultation: Inpatient and Outpatient

The psychologists consult on cases for both the outpatient clinics and inpatient hospital services. These consults are somewhat less involved than assessment referrals in that they usually take place on the spot while the patient is in our facilities either with or without direct patient contact.

On the inpatient services most consults are generated during the inpatient rounds meeting. At these meetings the residents present current cases to the medical attending and the psychologists. Residents or attending physicians will request a formal consult when a patient is presenting with possible psychopathology, e.g., depression, anxiety, thought disorders, when the patient or patient’s family may be in need of support and counseling, or when the patient or patient’s family is exhibiting behavior that interferes with treatment. The psychologist will discuss the case with the inpatient team to determine the appropriateness of the referral and will either visit the patient at bedside or will provide consultation directly to the resident without visiting the patient. If a formal consult is performed, the psychologist will communicate directly with the referring provider about the findings so that the findings can help contribute to a collaborative care plan. For example, for a recent patient presenting with non-specific pain, the consulting psychologist helped the inpatient team understand and address the patient’s health anxiety in a culturally sensitive manner while necessary diagnostic testing was conducted to determine if there was a medical cause for the pain. It should also be noted that Harbor-UCLA Medical Center has an excellent Department of Psychiatry and an active medical Consultation-Liaison service which can be consulted for issues such as active psychosis, suicidality, homicidality, and other high risk psychiatric issues.

In the outpatient clinic, informal, on-the-fly consults are more common than formal consults (which more frequently take the form of more involved assessments). In these cases, residents and attendings will contact the psychologist when they have a question about a patient who is currently presenting in the clinic. As with the inpatient services, these informal consults range from helping the resident diagnose and address clinical and sub-clinical disorders to aiding the resident in managing complexities of doctor/patient relationships.

On both the inpatient and outpatient services, the psychologist often has to be very proactive in educating the providers about the utility of a behavioral medicine consult. This is often the case when working with a newer resident who is not aware of the role of psychology in the clinic. The psychologist, therefore, must be a full participant in the rounds and the conversations in the precepting room and has to actively inquire into psychological aspects of current cases. The psychologist must work to educate the residents about the psychological dimensions of medical care and the range of resources available via the consultation process. In this way, the consultation process is an opportunity for the psychologist to provide valuable training, the topic to which we now turn. continue

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