John C. Linton, PhD
Psychologists became active in hospitals after World War II, and their involvement was largely in psychiatric facilities, either through departments of psychiatry at medical schools or other large teaching institutions and in Veterans Administration hospitals or state hospitals, where they functioned in a supportive, typically assessment role with staff psychiatrists. During the sixties there was a rather dramatic increase in the number of psychologists working in medical schools, where in addition to clinical work they participated in research, and were active in the training of both undergraduate medical students as well as residents.
With time psychologists expanded their practices beyond departments of psychiatry, with departments of neurology depending on their neuropsychology staff for extensive evaluations of brain-behavior functioning. Neuropsychologists and rehabilitation specialists entered departments of physical medicine and hospital medical rehabilitation units to treat the head and spinal cord injured, amputees, and assist with the wide variety of other challenges rehabilitation patients face. Psychologists met the needs of chronic pain patients in Inpatient pain programs, and psychologists addressed infertility, perinatal loss, and special symptoms such as hyperemesis gravidarum in departments of obstetrics and gynecology. Psychologists became involved in primary care specialties such as internal medicine, pediatrics and family medicine, where they taught social and communication skills to residents, and treated a wide gamut of patient problems such as poor adherence to treatment, and coping with painful medical procedures. They assessed and treated nephrology patients needing dialysis or transplant and worked with surgeons doing bariatric surgery for extensive weight loss to clear patients for surgery and call attention to behavioral problems that might be exacerbated post surgically.
From rather modest beginnings, clinical health psychology has flourished over the past 25 years, as psychologists have visibly demonstrated their worth in general hospital settings. Whereas the psychiatric hospital offered a relatively stable environment, with demands more consistent with the traditional training and experience of professional psychologists, the general hospital and the complexity of modern healthcare offers a wide range of opportunities and paths to follow, with new prospects for utilizing psychological proficiency steadily emerging (Brown et al, 2002). With these growing opportunities comes the need to attend to the competencies required for skilled and ethical practice in hospitals.
One must consider the sequence of competency development during the training continuum. Until about 25 years ago, it was common for psychologists in general hospitals to be licensed and fairly seasoned. Then postdoctoral training programs developed in medical centers, often with a research focus, but also centered on specialized skills training in fairly narrow areas, such as neuropsychology, gerontology or pediatric psychology. Around that time predoctoral internships also became more common in general medical settings, often with a large medical center as the fulcrum of the training program. At first predoctoral interns arrived at these training sites with little experience in clinical health psychology from their graduate training programs, whereas in the past 20 years courses in health psychology and behavioral medicine have become some of the most cited in clinical programs (Sayette & Mayne, 1990). But even with the increase in didactics, there were limited field experiences or practica in hospitals available to graduate students before internship, whereas now students frequently come to internship having completed a number of practica assignments in hospitals near their graduate departments. It is also common for graduate students to study and anticipate the special challenges that they might face in hospital settings before actually working there (Guiffre, 2006).
So any discussion of competencies must consider the knowledge and skill level of the psychologists in question, whether considering their entry into practicum (beginner), entry to internship (advanced beginner), entry to practice (competent), new career (proficient), or advanced specialty practice (expert). Each will have specific expectations relative to their stage of development, from graduate training readiness for practicum, to lifelong learning in advanced practice. And psychologists all along this continuum are now found in general hospitals.
As suggested elsewhere in this issue of The Register Report, the examination of competencies in professional psychology has been ongoing for a number of decades, but really came into the spotlight at the Competencies Conference held in 2002 (Kaslow, 2004). As an outgrowth of this conference, the APA Board of Educational Affairs assembled a task force, the Competency Benchmarks Workgroup, to examine the assessment of competence along the sequence of professional training, with a preliminary report on their benchmarking recommendations due in November, and with at least one aim to integrate these benchmarks into accreditation standards.
Kaslow (2004) notes that foundational competencies include individual and cultural diversity and ethical practice. Core competencies include scientifically minded practice, intervention skills, consultation and interpersonal collaboration, supervision, and professional development. Those competencies unique to particular specialties build upon the foundational and core competencies. These specialized competencies are acquired last in the training sequence, require pertinent advanced knowledge, skills and attitudes, and entail more refined credentialing such as board certification. Medicine has also outlined six general competencies required of graduates from accredited medical residency programs. Two involve interpersonal and communication skills and professionalism, which are topics psychologists are well qualified to teach to residents, thereby adding to what psychologists can bring to hospital based training programs (Linton, 2005).
Specialty Competencies in Clinical Health Psychology in Hospitals
1) Knowledge: In the 1970s, one would be hard put to find any texts on the practice of clinical health psychology. The APA Division of Health Psychology was started in the late 70s, and this corresponded to a crest of interest in the practice of psychology in health, rather than mental health, settings. By the mid 1980’s there were dozens of books on health psychology, but most were intended less for practitioners than students or social psychologists, who were staking out the field from a scholarly perspective. The first publication to address hospital practice per se was the Hospital Practice Primer for Psychologists (1985) published by the American Psychological Association, which still stands as an excellent basic reference. A variety of handbooks and journals continue to serve as guides to those psychologists who choose to work in these exciting and multifaceted settings (see Belar et al. 2001, for a list of helpful publications).
Belar, Deardorff & Kelly (1987), in a classic reference, suggest that the scientist-practitioner approach is critical for the practice of clinical health psychology, given the continuous change and expansion of the field. Deciding your niche, getting comfortable and ignoring the literature is a bad idea, since the field is transforming around you constantly.
At the core level, psychologists should have education in anatomy, pathophysiology, applied pharmacology, social and psychological bases of health and disease, understand healthcare policy and the organization of hospitals, and be skilled in the assessment of and intervention with health problems. Much of what has been learned in traditional clinical training can be transferred to this new setting, but there are striking differences as well to be understood and appreciated. One must understand the course and treatment of disease, but also the environment of the health care system, which changes so rapidly that some articles on a health system topic are outdated by the time they are in print (sometimes referred to as developing community competency).
Even with rapid changes, the basics of hospital structure remain pretty much the same. Successful psychologists need to learn the formal and unspoken ecosystem of their particular hospital settings. To understand the lines of authority, one must determine if the hospital is private or public, not for profit or proprietary, stand alone or part of a corporate, religious or state-owned chain, specialized or general, and whether it is a training facility affiliated with a university. Often the collision between charity or service needs and the need to do business are predicted by how the hospital is structured (Bonecutter & Harrow, 1991). It would be ill advised to begin programs or practices that are at odds with the hospital’s values or mission, for example running counter to standards of a hospital chain with a particular religious persuasion.
Legislatures license hospitals to open and operate, but they cannot directly scrutinize hospital functioning so they defer to others, such as inspectors from the state and the Joint Committee on Accreditation of Healthcare Organzations (JCAHO), to assess the hospital’s adherence to specific standards, and to report and discipline as necessary for those not in compliance. The board of directors maintains overarching responsibility for the hospital’s operation. The next levels include the chief of staff, then the medical staff attending physicians, the hospital administrators, and the chief of the nursing staff, with different reporting lines in different settings. Within each service or department there is an administrative structure to learn. In addition, it is important to appreciate the hospital’s organization at all levels, including housekeeping, parking and security, and all of the support services. Hospitals are bureaucracies, and you must understand the layout or be secluded and marginalized.
Psychologists can be staff employees compensated directly by the hospital for their professional activities, or private practitioners privileged and credentialed to offer particular services, with fees paid by the patient. Some have a limited consultation role, typically in educational settings where they provide training for students and residents. Each role will differ to some degree, but all remain under the administrative, clinical and legal oversight of the hospital (Rozensky, 1991). It is of course compulsory to obtain appropriate privileges before beginning any work in the hospital.
Learning the language of the health care system is critical, since without this understanding you are in a foreign territory without the ability to understand what is being communicated, so taking a course in medical terminology or embarking on self-study is advised. Belar et al. (1987) make the analogy of being willing to learn enough of a foreign language to get around another country, and being willing to ask native speakers for assistance when necessary. Going on line and searching for “medical terminology” will produce a number of sites to learn about the language of hospitals, allowing for the more accurate reading and interpretation of patient charts.
The importance of mentoring cannot be overstated in hospitals. Make no mistake, you are a stranger in a strange land. Whereas in many medical schools medical students are exposed to psychologists at least briefly during a preclinical course on behavioral science, or during a third year clerkship, most students in psychology get no training or exposure to physicians or medical practice in their graduate programs. In every case psychologists represent a tiny minority of hospital staff. Their training backgrounds and the ethical code they follow is a mystery to their medical colleagues and hospital administrators. While settings vary, in most cases there are no ready guides standing by to show you the way through the hospital maze. So turn to senior health psychology colleagues, or in those cases where you are the first or only psychologist in, for example, a small, rural hospital, seek consultation from experienced hospital psychologists however you can find them, in person, through telemedicine, or on line. Flying solo and learning as you go works in some situations; hospitals aren’t one of them.
2) Skills: As noted, clinical health psychology practice depends upon the core domains of scientific facts mastered in all psychology education and training. But specialized skills are required in hospitals. In addition to understanding the culture, psychologists must capitalize on the generalization of their past education and training, while recognizing specific needs for additional skills.
Belar et al. (2001) note that most skill training for working with specific health problems involve creating one’s own curriculum, since most CE modules are not graded in difficulty and sequenced. They present a model for self-assessment and ethical expansion of one’s practice to clinical health psychology, or improvement in a current practice. They list a variety of suggested activities to implement this change in focus, and note that the inpatient medical setting is a complex environment dealing with complicated cases, and as such this is particularly important for hospital practice.
They suggest identifying a particular health care problem, such as headache or infertility, and then defining an area of focus, from primary to tertiary prevention. Do an extensive literature search to systematically review the relevant psychological literature on the topic. Contact disease specific professional and self-help groups, which may identify public policy issues related to the condition. Attend conferences and workshops aimed at the target areas of practice. Develop a relationship with a medical colleague who can serve as a guide to the area, and consult with that person regularly. As above, also identify psychologist mentors who could share both scientific knowledge as well as savvy about integrating what is known into clinical practice. Join on-line listserves for APA divisions with a possible connection to the syndrome of interest.
Determine what experiences can facilitate your learning about the significant health care culture and clinical skills when working with this group. Attend grand rounds in the department relevant to the malady to gain new information, but also to network, which is an invaluable skill in hospitals, where the results may not be immediate, but long term. If possible, be an understudy to an expert psychologist in that field, and create a peer learning group of both psychologists and other health professionals interested in this particular condition. Such peer groups often lead to joint projects and research proposals. Each time such a group is formed, psychologists are rightly viewed as important members of the team. Such interdisciplinary skill development is invaluable at any stage of training or practice (McDaniel et al., 2002).
Of particular importance is that as noted above, medical and allied medical staff members know little or nothing about the skills required for the practice of clinical health psychology in hospitals. As such, developing a peer group of psychologists, either locally or through the distance options readily available, is the best protection against substandard practice, and possible violations of standards of professional ethics.
All of the hospital players noted above, from legislators to middle managers, should have the opportunity to learn the value of psychologists in hospitals. Never miss an opportunity to make a presentation, attend a medical staff meeting or social event, consult with a law or rule maker, or provide emergent consultation if asked. Much of a psychologist’s survival and success in hospitals comes from constant visibility, making it clear to those who need to know that your profession has something to offer the mission of the hospital and the patients for whom it cares.
3) Attitude: Attitude encompasses primarily issues of ethics and professional roles. Practicing ethically in hospitals is complicated by the competing ethical standards and traditional practice patterns among psychologists, medical attendings, and their students and allied staff. These conflicts are intensified by the oversight of the federal government through HIPAA. Something as simple as a consult and chart note illustrates the point. After seeing a hospitalized patient, a psychologist must determine how much to include in a note, who will see the note, to whom this information should be directed, and the limits of his or her freedom to consult back with the referring physician. As a breed, psychologists tend to be more sensitive to patient confidentiality, tight-lipped about their findings, and are much less likely to discuss sensitive patient issues in staff meetings or with other members of the treatment team. There is even a psychotherapy section in the chart set aside for private notes, but the initial consult is not shielded in this way. Other professionals are sometimes miffed that they recommended the psychologist see the patient, and then receive what they perceive as resistance when they ask what was found. Such misunderstandings among professions often lead to barriers in interdisciplinary collaboration (Kainz, 2002), yet psychologists are required to be true to their standards of conduct.
Pope (2006) poses challenging, hospital-specific ethical questions that are out of the mainstream, suggesting for example that psychologists consider whether they are confident in the hospital’s hiring practices and supervision of its staff, since some hospital screening staff are lax in checking references, verifying degrees, internships and licenses, and fail to investigate employment histories. And if a staff member behaves improperly, are there procedures in place to identify and repair the problem? He also recommends that psychologists be aware of the ethical and legal implications of the political and financial forces that influence the hospital’s admission criteria, resource allocation, length of stay, likelihood for readmission, and so forth. Psychologists need to make sure their services are being suitably used, and are not in reality or appearance conspiring in a process that is illegal or unethical, such as billing departments that change patients’ diagnostic codes to assure more favorable funding coverage. Confidentiality is often less than optimal in hospitals, where charts are left about, patients are discussed openly in the halls, records of psychological disorders become part of the medical record and end up in the possession of insurance reviewers, and case conferences discuss patient names and their associated conditions, without adequate scrutiny of who might be attending the rounds.
Regarding professional roles, Belar, et al, (1987) recommend that psychologists be alert to the dangers of overidentification with medicine, accept the limits of their understanding, and avoid the loss of one’s roots as psychologists, such that they are caught between two worlds, and feel disconnected from both. Learn the referral customs of your physician colleagues, and be prompt in your follow up with consultations or assessments (Linton, 2004). They also suggest you be aware of your own stimulus value in dress, grooming and lifestyle, and strive to be active, energetic and engaging as you establish rapport not only with patients, but staff. Avoid professional fanaticism; remember, you are in the substantial minority. Having a good tolerance for frustration is helpful, since medical colleagues often have little interest in the emotional health of their patients, assuming this is a secondary goal to the more important physical condition of the patient. It is important to be able to cope with treating those who are physically ill, to absorb the sights, smells, and sounds of hospital rooms. And finally, the pace and schedule is challenging and unpredictable, and one must be readily available on short notice. But would I do it again? Absolutely.
John C. Linton, PhD, ABPP, is Vice Chair of the Department of Behavioral Medicine and Psychiatry at WVU Charleston. He received his Ph.D. from Kent State University. Dr. Linton's special interests include Ethics, Interpersonal Psychotherapy, Traumatic Stress Disorder/CISM, adjustment to medical conditions, and depressive disorders. He serves on the NR Appeals Board and ABPP Board of Trustees. He is also past President of the ABPP Clinical Health Board and has served on the APA Ethics Committee.
American Psychological Association. (1985). A Hospital practice primer for psychologists. Washington, D.C.: Author.
Belar, C.D., Brown, R.A., Hersch, L.E., Hornyak, L.M., Roszensky, R.H., Sheridan, E.P.,
Brown, R.T. & Reed, G.W. (2001). Self-assessment in clinical health psychology: A model for ethical expansion of practice. Professional Psychology:Research and Practice, 32,2,135-141.
Belar, C.D., Deardorff, W.W., & Kelly, K.E. (1987). The practice of clinical health psychology. New York: Pergamon Press.
Bonecutter, B. & Harrow, M. (1991). Psychology and the health care system. In Sweet,
J.J., Rozensky, R.H. & Tovian, S.M. (Eds.), Handbook of clinical psychology in medical settings (pp.11-25). Plenum Press, New York.
Brown, R.T., Freeman, W.S., Brown, R.A., Belar, C.D., Hersch, L., Hornyak, L.M. et al. (2002). The role of psychology in health care delivery. Professional Psychology: Research and Practice, 33,6,536-545.
Guiffre, A.M. (2006, October). Ethical implications of collaborative practice in primary care and psychology. Poster presented at the meeting of the West Virginia Psychological Association, Canaan Valley, WV
Kainz, K. (2002). Barriers and enhancements to physician-psychologist collaboration. Professional Psychology: Research and Practice, 33,2, 169-175.
Kaslow, N.J. (2004). Competencies in professional psychology. American Psychologist, 59, 774-781.)
Linton, J.C. (2004). Psychological assessment in primary care. In Hass, L.J. (Ed.), Handbook of primary care psychology (pp.35-47). New York: Oxford University Press.
Linton, J.C. (2005, August). Developing a career in an academic medical center. Paper presented at the annual meeting of the American Psychological Association, Washington, DC.
McDaniel, S.H., Belar, C.D., Schroeder, C., Hargrove, D.S., & Freeman, E.L. (2002). A training curriculum for professional psychologists in primary care. Professional Psychology: Research and Practice, 33, 1, 65-72.
Pope, K.S. (2006). Ethical and malpractice issues in hospital practice. Retrieved September 9, 2006 from http://www.kspope.com/ethics/hospital.php
Rozensky, R.H. (1991). Psychologists, politics and hospitals. In Sweet, J.J., Rozensky, R.H. & Tovian, S.M. (Eds.),Handbook of clinical psychology in medical settings (pp.59-81). Plenum Press, New York.
Sayette, M.A., & Mayne, T.J. (1990). Survey of current clinical and research trends in clinical psychology. American Psychologist, 45, 1263-1266.