James R. Bray, PhD
Primary care psychology is a growing area of practice. There are increased pressures on primary care physicians (PCPs) to diagnosis and treat a broad spectrum of health problems that include both biomedical and psychosocial concerns. PCPs treat over 60% of all mental health problems in the United States, without assistance from psychologists. We are frequently not part of the primary health care system, even though psychologists are often the most highly trained mental health and substance abuse professionals functioning in these communities. Our isolation from primary care is often due to a lack of training and competency to work in this arena. This article will briefly review some of the competencies needed to successfully practice in primary care. For a more complete discussion of these issues see Primary Care Psychology (Frank, McDaniel, Bray & Heldring, 2004; especially chapter by McDaniel, Hargrove, Belar, Schroeder & Freeman), Handbook of Primary Care Psychology (Haas, 2004) and Bray (2004). PCPs need help with patients who suffer from a broad range of behavioral and mental health problems and assistance with chronic health problems, such as cardio-vascular disease, diabetes, etc. Psychologists can provide important diagnostic services, information about use of psychotropic medications and psychotherapies for treatment (Bray, 2004). Successful collaboration with PCPs needs to be a win-win business relationship for everyone.
PCPs seek to solve a patient care problem, obtain feedback and information about their patients’ status and progress, receive referrals back from the psychologist and reduce their hassle with patient care. Psychologists can provide important diagnostic information about the patient, recommend additional treatment options, provide information about progress of psychotropic medications and help increase patient compliance and satisfaction (Haley et al., 1998).
It is important to remember that PCPs are considered generalists and work with all kinds of patients (undifferentiated symptom patterns). Likewise, to work most effectively as a psychologist in primary care it is important to function as a “generalist” behavioral health provider who is able to effectively collaborate with medical practitioners. Training in family systems or contextual theory is particularly useful because it facilitates the behavioral health provider’s ability to take a “broader” viewpoint and negotiate roles and relationships with both physicians and patients.
1. Basic knowledge of primary care medical practice. Primary care practice is very different from psychological practice. These differences include the way the office is organized, staffed, patients are handled, and expectations for referral and collaboration. It is imperative to successfully work in primary care that the psychologist understands how PCPs practice and is willing to adapt and accommodate to primary care practice styles (see Driscoll & McCabe, 2004 for an example of a private practice).
Primary care practice relies on biomedical research, technological solutions, hierarchical relationships, strong sense of personal responsibility for patient outcomes, emphasis on clinical methods and experience, and often specialized, pragmatic thinking. The PCPs job is to find an answer for and fix the patient’s problem. In other words, the primary goals are to cure disease and alleviate symptoms. If the PCP cannot attain these goals, the goals become maintenance or restoration of functioning. The adage “just don’t stand there, do something,” aptly describes one modus operandi of physicians (Bray & Rogers, 1995, 1997).
To gain familiarity with primary care practice, ask to work with a PCP in his/her office. Many PCPs welcome psychologists to practice in their offices either part-time or full-time. In addition, PCPs often have medical students work with them and they will often welcome a psychologist to spend time with them seeing patients. This direct experience provides a quick way to learn about medical practice and to develop a strong relationship with the PCP and their staff.
2. Learn to speak the language of biomedicine. This competency is strongly linked to the first one. Unlike the diversity of psychological theories and practice, medicine is based on the biomedical model. All medical personnel (physicians, nurses, other support personnel) use a common language for describing and understanding functioning and problems (Bray & Rogers, 1995). Psychologists need to be familiar with this language. For many medical subspecialists, the model of illness is almost completely biomedical, but primary care physicians advocate a biopsychosocial model that more aptly describes their clinical care in ambulatory settings (Rakel, 2002). In addition, there is a growing emphasis on evidence-based medical practice, which fits well with evidence-based psychological interventions.
3. Basic knowledge of common medical problems seen in primary care. While PCPs take care of many acute and self-limiting health problems (e.g., colds, flu, etc.) they spend the bulk of their time addressing chronic health problems such as diabetes, hypertension, and high cholesterol (Rakel, 2002; Schappert, 1999). To successfully treat many of these problems requires behavior changes (medication compliance, life-style modifications) that can be provided by psychologists. The top five mental health problems seen in primary care are: depression and mood disorders, anxiety (GAD and panic disorder), somatization disorders, substance abuse disorders, and eating disorders (Barrett, Barrett, Oxman, & Gerber, 1988; Philbrick, Connelly, & Woff, 1996). Psychologists need to know how to diagnose and treat these disorders, as they appear in primary care, and to understand how they relate to other medical conditions. There is a high co-morbidity of certain chronic health problems and mental disorders. For example, patients with uncontrolled diabetes often suffer from depression and the depression interferes with medication and life-style compliance. Likewise, patients with uncontrolled hypertension often over use alcohol and other substances and do not maintain adequate diet and exercise regimes. These are all issues that can be helped by psychological consultation.
Primary care patients rarely come to their PCP and say, “Doc, I am depressed—give me Prozac.” Most patients with a mental disorder present to their PCP with a somatic complaint (sleep problems, fatigue, heart palpitations, vague pain) and are often in the beginning stages of the disorder. PCPs do not use the DSM-IV to diagnose mental disorders; they use the ICD-9. There is a large literature in primary care that describes mental health problems in these settings. This research indicates that the initial presentation and course of mental health problems in primary care is different from what is seen in a typical psychological or mental health setting. Thus, it is essential to be familiar with this research and not rely solely on research conducted in mental health settings (see the chapters in Haas, 2004 for examples).
4. Collaborative practice skills. Psychologists are often viewed as part of the primary care health team and collaboration with other team members is essential for optimal patient care. Within this framework, psychologists need to be skilled in developing good working relationships with PCPs and their staff, providing and modeling clear communication with other disciplines, collaborating in the development of an integrated treatment plan, providing brief “curb-side” consults, and able to refer and manage consultations with other providers (McDaniel et al., 2004).
PCPs strive to have long-term relationships with their patients and provide continuity of care that includes comprehensive, continuous services in sickness and in health (Rakel, 2002). Thus, feedback on patient progress is essential to the PCP. Most PCPs only want a brief note (1 to 3 paragraphs, no longer than one page) about your work with the patient. They want a diagnosis, a brief explanation of your treatment plan, and any recommendations you may have to improve patient care. It is also important to help the patient return to his/her PCP for follow-up visits. Arranging for follow-up visits is a way of continuing to market your services to the PCP.
In summary, to develop a successful primary care psychology practice, it is necessary to develop specific skills and competencies that go beyond basic training in clinical psychology. Much of our training as psychologists is useful as a basis to develop a primary care psychology practice. There are many opportunities to develop these skills through a variety of formal and informal training experiences. There are a number of excellent publications and CE programs on working in primary care that are available at state and national psychological association meetings. It is essential that psychologists work in primary care to provide the necessary services to patients and to expand our contributions to the health and welfare of our nation.
James H. Bray, PhD, is Director, Family Psychology Programs and Associate Professor in the Department of Family and Community Medicine and Psychiatry, Baylor College of Medicine, 3701 Kirby Drive, 6th Floor, Houston, TX 77054, (713) 798-7751,
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