by Mark E. Vogel, Ph.D., ABPP, Heather Kirkpatrick, Ph.D., ABPP, and Maria Fimiani, Psy.D.
As medical care moves well into the 21st century, there are increasing calls for enhanced integration of psychology and medical practice. With the focus on healthcare quality improvement we have seen efforts to increase coordinated care, eliminate unnecessary steps or hand offs, increase use of patient-centered teams, and improve access to care (IOM, 2001; Berwick, 2008). At the same time efforts focus on lowering per capita cost of healthcare for a population (Berwick, 2008). Integration of behavioral healthcare in primary care can help achieve these challenging goals. This paper illustrates our experiences in teaching and working in this type of training environment.
INTEGRATED CARE MODELS
The term integrated healthcare (IHC) can be defined by the dimensions considered (staffing, organizational framing, population treated, system of care structure and other variables). Doherty, McDaniel, & Baird (1996) suggest a five step hierarchical model of increasing levels of integration and collaboration between mental health professionals and medical physicians and nurses. Their model describes the strengths and limitations of each level of integration and the settings and types of problems appropriate to each. Strosahl (1996) outlines a three level model for partitioning care according to the needs of the population. Additional models focus on integration for different types of patients (i.e., the chronic high utilizing patient, a specific age of disease category, etc.). For the purposes of this article, we focus on three levels of collaboration: co-location of services, consultative/collaborative, and fully integrated. Co-location is a natural given that a working relationship starts with physical proximity. Our model goes beyond this entry point to develop more consultative/collaborative care in which there is a shared medical record, efforts to coordinate care, and a basic understanding and appreciation for each other’s roles in the care of the patient. Finally, some elements of our program operate in a fully integrated care model where psychology and medicine function as a coordinated team.
The point of care for our integrated environment is the primary care setting. A major portion of mental health care is rendered in the primary care setting, and always will be (deGruy, 1996). Nearly half of all mental health care is delivered through primary care settings and non-psychiatric physicians prescribe approximately 75% of all psychotropic agents in the U.S. (Gallo, 2000; Williams, 1989). Surveys have shown that for patients diagnosed as either generalized anxiety disorder or clinical depression, it was the primary care/family physician (48%) who first made the diagnosis. (National Mental Health Association, 2001). At the same time, numerous primary care physicians (PCPs) experience frustration that many of the most common physical complaints in primary care often have no diagnosable organic etiology.
On a broader level, primary medical care has placed a new emphasis on the “Medical Home” that promotes strengthening and supporting the patient-physician relationship (American Academy of Family Physicians, 2008). This model entails a central resource with a competent team and active involvement by informed patients. It focuses on accessible, continuous, comprehensive, family- centered, coordinated, compassionate, and culturally effective care that promotes a continuous healing relationship. Integration of mental health care in this medical home opens the door to care that is more accessible to the patient, allows for whole person care (not carved out), is team focused and coordinated within the system, and improves overall quality and patient satisfaction.
TRAINING PROGRAMS FOR PRIMARY CARE HEALTH PSYCHOLOGY
In order for this type of integration to more fully develop, psychologists and PCPs need to be trained to work and function in this collaborative environment. It is unlikely that providers who have been schooled in their closed, non integrated systems will suddenly work as collaborators when they graduate from residency/fellowships and become practitioners. Since its conception in the 1970’s, family practice has appreciated and included behavioral science education into their residency curriculum (Garcia-Shelton & Vogel, 2002), welcoming psychologists and other mental health professions as a core part of their training faculty. More recently, the two physician residency accreditation bodies (ACGME and AOA), placed a strong emphasis on training in the Core Competencies. These competencies include, among other things, an emphasis on providing patient care that is compassionate, appropriate and effective and the demonstration of effective interpersonal and communication skills. These revised accreditation requirements have opened more opportunities for behavioral science faculty to be included in the training of physicians in internal medicine and pediatrics. Psychologists can and do contribute much to the training of physicians. But for psychologists to be considered effective educators and collaborators in a medical environment there is much they need to learn and appreciate about the medical culture.
Psychology training programs for learning this type of collaborative work are limited. Since 1987, Genesys Regional Medical Center (formerly St. Joseph Hospital and Flint Osteopathic Hospital) have offered a two-year postdoctoral fellowship in primary care health psychology. This program is part of the Consortium for Advanced Psychology Training (CAPT) and is affiliated with Michigan State University, Flint Area Medical Education. The CAPT fellowship program is accredited by the American Psychological Association.
During its evolution, the fellowship began with full integration within in a family practice residency and has expanded over the years to include internal medicine, obstetrics, and podiatry residency programs. The program was created to train psychologists to be consultants, collaborators, and teachers to PCPs in the broad area of the behavioral sciences. The overall goal is to bring the physician and psychology trainees together in an integrated and organized program to enable them to build relationships, increase collaboration, and learn from each other as colleagues.
CO-LOCATION & PHYSICAL ENVIRONMENT
The first place to start with developing collaborative working relationships is the physical environment. In our outpatient clinic settings, the health psychology fellows and faculty are integral to the residency teaching and clinical setting. Their offices are positioned in close proximity to the exam rooms and where the physician faculty precept cases. While more space might have been available to us on a separate floor or down the hall, we chose to be located as closely as possible to where physicians perform their daily tasks. If one colleague is in session with a client, we work to make sure that another has his/her door open and is available for the curbside consult. This reduces barriers to seeking consultative advice from the psychologist. In the inpatient environment, we work on the units of the hospital, make rounds with the medical teams, and are easily visible to residents. The goals are to be seen, considered, and utilized.
Our model combines consultative and collaborative elements in various forms within the combined training program.
Didactic Teaching: The behavioral science curriculum for family medicine & internal medicine residency programs can be structured in various ways and still meet accreditation guidelines. While standard curriculum develops a working knowledge of common DSM-IV diagnoses and the PCP’s role in management of these conditions, our program places an increasing emphasis on patient-centered care and on the relationship building that is central to the medical home. The psychologist’s role is to help the physician appreciate the whole person approach to care and the value of a continuous healing relationship in effecting behavioral change. In addition, our didactic teaching examines the medical interview and helps the physicians be more effective at negotiating and setting an encounter agenda, developing focused interviewing skills, handling strong emotions, increasing collaboration with patients, and knowing when and how to transition to more traditional doctor-centered care.
Shadow/Video Precepting: One method of teaching and effecting change in the medical interview is for the psychologist to shadow or observe through video the encounter. Our teaching status in the residency programs makes this method of precepting a natural for both the physician and patient. When conducting this type of work the psychologist’s typical role is that of an observer who provides feedback to the physician outside the examination room, yet there are instances when our feedback is needed more immediately. Through this process, the psychology fellow learns more about medical culture, the pace of primary care, and the complexity of care with the primary care physician as their teacher. Likewise, the psychologist demonstrates and teaches new skills to the physician.
Hospital Consultation & Rounds: When the PCP transitions to the inpatient medical setting, the role of the psychologist may range from the traditional consultant (with formal referrals) to being part of the inpatient rounding team. The consultant role generally concerns patients with mental health disorders which are having an influence on the medical care and treatment of the patient. When rounding with the medical team, the psychologist’s emphasis is more on teaching and education of the team members, but in this situation too, the psychology fellow is also learning .
Individual Psychotherapy: When patients are referred to our outpatient psychology service our function is that of a consultant. These referrals include the full range of conditions and ages that are typical for a primary care setting. The patient’s diagnosis may be typical of general clinical practice (depression, anxiety, etc.) or may be more clinical health psychology in nature (coping with chronic or life changing illness, psychiatric conditions co-morbid with medical illness, pain management, adherence to medical advice, and lifestyle change). There is regular communication, face to face and written, about these shared patients with documentation typically in the same record. Both providers share an appreciation for what each brings to patient care.
CROSS TRAINING AND INTEGRATION: A CLINICAL APPROACH
Perhaps one of our most significant adaptations of psychology to medicine is approaching behavioral science teaching using the “see one, do one, teach one” training axiom, a method familiar to physicians. Unlike traditional psychology training, which often includes devouring textbooks and articles on a particular mental health condition before going near a patient, physician training occurs at a much more rapid pace over a significantly shorter time frame. Not surprisingly, resident physicians are much more interested in actually treating patients with behavioral health issues in vivo. Heeding their recommendations, we modified our behavioral science curriculum to include specialty clinics in which the psychology fellow and physician resident apply the didactic materials and interventions with actual patients. The result has been a cross-pollination of training, application of skills with immediate feedback for improvement, and improved patient care in our ambulatory clinic. Two of our specialty clinics are described below.
ADHD Assessment Clinic: PCPs are challenged to meet the demands for the evaluation of Attention Deficit/Hyperactivity Disorder (AD/HD). Baseline assessment of resident physicians within our family medicine residency program suggests that many are skeptical of a media driven diagnosis, unfamiliar with basic screening measures for AD/HD, and overwhelmed by how to address such a request during a 15-minute appointment. Didactic sessions alone did not seem to assist the residents with understanding the multifaceted approach to assessment and treatment. Further, traditional referrals to psychology for an initial evaluation left the psychology fellow overloaded with AD/HD assessment cases. This model was one in which services were co-located at best. In addition, there were disjointed work-ups of cases due to lack of continuity among referring and treating physicians. It appeared that utilizing a traditional method of teaching led to minimal application of learning.
The AD/HD Assessment Clinic allows the physician and psychologist to conduct a complete evaluation of the patient from start to finish. We were intentional in our choice of assessment measures, ensuring that the measures chosen were appropriate for use in a primary care clinic setting. Prior to being scheduled in the Clinic, assessment measures and a biopsychosocial history questionnaire are completed by parent and teacher and returned to our office for scoring by the psychologist. Resident physicians are educated in the interpretation of the results and the history questionnaire is reviewed by both the psychologist and physician to determine clarifying questions for the clinical interview. Physicians are trained in the implementation of a DSM-oriented differential diagnosis checklist for use during the clinical interview. They are also given a physical exam form specific to the Clinic that includes appropriate medical screening cues (e.g., vision, hearing, lead level, etc.). The Clinic is run by the psychology fellow and the resident physician on the Behavioral Science Rotation. The case is precepted by a psychology supervisor and faculty physician. Psychology fellows are trained to act in a supervisory yet collaborative role to the resident. The resident physician precepts the cases with a physician faculty member, to give them practice in formulating an assessment, treatment, and plan.
A recent patient evaluated in the AD/HD Assessment Clinic was a 17-year-old male who presented with his mother for the appointment. Assessment measures completed by both his parent and teacher suggested sub-clinical levels of inattention and hyperactivity but indicated clinically significant levels of both anxiety and depression. The biopsychosocial history questionnaire revealed a recently diagnosed learning disorder for which the patient was receiving services from the school system for the first time this year. It further noted a family history of depression and anxiety disorders. The physical exam conducted by the physician was within normal limits. The clinical interview co-conducted by the psychologist and physician clarified the anxious and depressive symptoms and indicated evidence for diagnoses of major depressive disorder and generalized anxiety disorder. The patient noted he has had depressive and anxious symptoms for several years and has never been treated. He indicated that the services he is receiving through the school system this year have been helpful to date, but he continues to experience difficulty concentrating. A discussion with the patient and parent regarding the results of the assessment measures in addition to the clinical interview and physical exam resulted in commencement of a psychotropic medication written by the physician and a referral to the psychologist for outpatient psychotherapy. Both patient and parent appeared satisfied with the results of the Assessment Clinic. Appropriate treatment based on accurate diagnosis occurred.
Lifestyle Change Clinic: It is no surprise that promotion of healthy behavior and preventive medicine are cardinal features of primary care. What is surprising is just how challenged physicians are to successfully address such issues. Discussions with both our resident and faculty physicians indicated their frustration in managing behavior change in their patients (e.g., smoking cessation, weight management, sedentary lifestyle, non-compliance with medication and other treatment recommendations, etc.). Many engaged in overly directive, paternalistic approaches to the management of such issues (“You must quit smoking or you will die.”) and were left feeling less than satisfied with the outcome. Although we had been teaching didactics on health related behavior change and motivational interviewing, it appeared that the application of the model and motivational interviewing techniques were not occurring. And so, the development of the Lifestyle Change Clinic began. Resident physician and psychology fellow work together to address smoking cessation, weight loss, and sedentary lifestyle issues with patients referred by the physicians. It is during this Clinic that resident physicians have the opportunity to apply the stage of change model and motivational interviewing techniques while receiving immediate feedback from their psychology fellow colleague.
Cross-training continues to occur as resident physicians become aware of the importance of several key factors: patients’ readiness to change, levels of motivation, and confidence to change behaviors. Psychology fellows are enlightened by the impact smoking and obesity have on a variety of medical conditions and the long term health effects of medications to manage such conditions. Both trainees gain an appreciation for the slow progress of changing behavior while patient satisfaction appears to increase because dedicated time is made for addressing such concerns. As physicians’ confidence increases and efficiency improves via continued practice with such interventions in the Clinic, they are more likely to utilize such interventions with their own patients during scheduled office visits.
Perhaps what is most striking about this Clinic is the physician’s and psychologist’s ability to see several patients who are in various stages of change and have a fruitful discussion about the realities of successfully changing a patient’s behavior. This reflective discussion paired with patient encounters allows resident physicians the ability to measure success in changing their patient’s behavior with a different stick. Whereas previously they may have considered themselves unsuccessful, reporting dissatisfaction with patient encounters, they now view success via small yet measurable steps along the behavior change continuum.
The integration of psychology fellow and physician resident training via these specialty clinics has had significant positive impact on both types of trainees. Among the many benefits of this model, the psychology fellow gains clearer insight and understanding of the rapid pace of primary care and the needs of their physician colleagues while the physician residents acquires an appreciation and skill set for behavioral medicine interventions and techniques that improve patient care and satisfaction.
Real world barriers exist in our practices regarding better integration of behavioral medicine and primary care. One barrier is the rigidity of professional identity and training. Having been trained in relatively poorly integrated mental health settings, we as psychologists bring with us the mindset of the traditional mental health model. In this model, patients are seen in 45- to 50-minute sessions that occur weekly, and divisions of responsibility between physicians and psychologists are clear. Psychologists address mental health and behavioral issues, and physicians address medical problems and prescribe medications. When both physicians and psychologists define their roles in rigid traditional ways, integration is difficult. In our experience, when new providers collaborate to meet a patient’s needs, both sides tend to approach the patient in cautious and rigidly defined ways. It is risky to extend oneself beyond traditional areas of training, and our ethical code is clear about not practicing beyond one’s area of competence. We have sought to address this barrier by providing training in new areas (e.g., a psychology faculty member is currently enrolled in a prescribing psychology training program) and frequent collegial consultation. Recognizing new ways of working with patients outside of the traditionally accepted prescriptions for change is difficult for both us and our physician colleagues. The importance of trusting relationships within which to risk new approaches to patients is crucial to mitigating this barrier over time.
Another barrier unique to our setting is the constant turnover of learners, and the constraints of an academic medicine practice in which learners have other responsibilities beyond the practice of primary care medicine. Each year we begin training with approximately 18-20 new physicians, and 1-2 new psychologists. We are in collaborative practice with approximately 65 physicians. A constant crop of new psychologists and physicians to educate about the value and practice of an integrated setting is quite challenging at times, and limits our abilities to integrate to higher levels. The majority of our resident and faculty physicians see ambulatory patients one-half day to 2 days per week. This schedule, along with our own, leads to times where we may not see a physician for weeks at a time. This clearly hampers our efforts to fully integrate.
Finally, a third barrier to further integration is the financial reimbursement structure of clinical services. The long term medical cost off-set savings of integrated care is not easily understood by administrators and difficult to document. Seeing patients and billing our services in the traditional mental health model may be the most time-efficient and financially lucrative, at least in the short term. Until recently, few insurers were reimbursing the health and behavior assessment codes. This meant that many of our specialized skills could not be reimbursed for patients who did not meet criteria for a mental health diagnosis. In addition, independent psychologists are sometimes challenged to be credentialed on managed care and Medicaid panels without supervision by a psychiatrist, which our primary care clinics do not have. This also limits our ability to see many individuals. Working within medical settings that employ billing/ credentialing/ coding professionals competent in mental health reimbursement and/or engaging in selfeducation in this area are two potential solutions to this problem.
In our collective years of practicing integrated behavioral care, we have learned many lessons. One has been the importance of perceived availability of the psychologist by the physician. Earlier in this article, we addressed the availability as it relates to physical space, but availability also depends upon psychological approachability. We often strive to convey that unless we are physically with a patient, we are available for consult, help, or intervention at any time. Open doors and frequent check-ins make it easy for us to be consulted. Being willing to see any patient for any reason increases the likelihood that we will be consulted again. Even though a referral may not be a good fit, we are willing to offer our opinion, an evaluation, and our services if appropriate. Many times we may see a patient for the practice not necessarily because we are making leaps of progress, but because we can play our part in taking care of this patient in the primary care practice. We may relieve pressure on the physician by being able to tolerate certain emotions or behaviors that they find personally stressful. This relationship works both ways— there are patients for whom physicians connect better than we, or are able to effect change where we cannot.
Another key lesson learned over the years is the role of relationship building in the practice of medicine. In our experience, physicians do not begin to use us just because we excitedly announce that we available for consults. New residents and faculty seldom use us at all, and when they do consult us, it is primarily in traditional mental health ways. They are unfamiliar with our training and have little sense about what happens in the therapy hour. The more physicians get to know us as individuals, the more likely we are to be consulted. This happens with other disciplines as well. When surgeons, gynecologists, and podiatrists have been co-located in our offices, relationships formed and increased consultation happened, as physicians value just-in-time formal or informal consultation. PCPs begin with us just as they begin with other disciplines. They send a patient to us, and then see what happens. Certainly there is formal feedback regarding the case when documentation is sent back to the PCP. However, in more integrated settings, as relationships are formed, informal feedback is also communicated. Trust increases, and physicians begin to perceive us as providers whose aim is to enhance clinical care of the patient, while also helping with the load.
A 50-year-old woman who has moderately severe cardiovascular disease and social phobia was seen by the health psychologist. She was also drinking quite heavily. She was very reluctant to tell her physician about the drinking out of fear of judgment and getting the lecture but has granted permission for the psychologist to communicate with her PCP. By approaching the physician during a relative down time, the psychologist was able to communicate not only the patient’s drinking and her fear, but how the physician could approach this issue within the context of the patient’s fear of judgment. The physician was, in turn, able to educate the psychologist about his specific concerns regarding her drinking. This was helpful to the psychologist to provide targeted information to the patient to help encourage her sobriety. This leads to a better outcome for the patient where her drinking and her social phobia were addressed by both providers, using up-to-date information and techniques.
When working on shared cases, both psychologist and physician develop updated information or techniques to use with other patients. With increasing numbers of shared patients, the physician and psychologist build increasing levels of trust and skill that allow further integration. The relationship is the glue that allows higher levels of integration to happen.
As this level of trust deepens, we have also been surprised by the shaping of each discipline over the years as we practice in an integrated fashion. Cross-fertilization occurs when both sides are willing to risk new ways of providing care. The areas of our practice that are most integrated allow physicians and psychologists to borrow skills from one another at higher levels. Cross-fertilization happens naturally as each side models effective techniques.
When we began our diabetes group medical visits, the psychologist managed the group process, as this was a familiar skill from group therapy and the physician was apprehensive about this aspect, and the physician addressed all of the clinical content and decision making. Over time, the physician began to help with the facilitative aspect of the group. At the same time, the psychologist began to instruct patients on how to transform his or her HbA1c into an average blood sugar for the past few months. As a result of participation in the group, the psychologist was able to use this learning on blood sugars, HBA1c’s, and lipid values and increasingly appreciate the importance of this information for other patients, who were not in the group. The physician began to incorporate more refined counseling skills with his other patients. As the psychologist encourages the techniques of motivational interviewing, the physician was able to highlight the critical information to educate patients about their behaviors. Initially, the psychologist provides the process while the physician provides the content. Over time, both providers are doing both, while constantly being updated by the other with new information and better techniques.
Finally, a lesson learned over the years is the ability to gently change medical culture. This does not happen overnight (and when really has any culture been changed overnight?) When we are available, in relationship, and willing to be changed by medicine, psychologists do become part of the medical culture. But we bring tenets of our own culture as well. One key difference in training that emerges in this cross-cultural experience lies in the area of responsibility. Psychologists learn early on that the patient is responsible. Traditional medical culture, however, encourages a more paternalistic approach. While medicine recognizes problems with paternalism and is attempting to move to a more collaborative focus with patients, the seeds of paternalism are present in subtle ways. We find that new physicians continue to feel responsible for their patient’s outcomes and choices. We can more effectively question this assumption because we are present in the medical culture, but bring our outsider’s view with us. We can help our physician colleagues recognize that ultimately the responsibility for the patient changing does not lie on the physician’s shoulders.
Our training program has the overall goal of bringing physician and psychology trainees together in an integrated and organized program to enable them to build relationships, increase collaboration, and learn from each other as colleagues. As trainees of this program move on into their eventual practice locations, the model provided to them will help shape and inform how and where they choose to seek this type of collaboration in the future. If healthcare is to be improved, training of providers in working in this type of IHC environment is a necessary start for future change.
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Mark E. Vogel, PhD, ABPP, is Director of Behavioral Science and Psychology at Genesys Regional Medical Center in Grand Blanc, Michigan. He is chief psychologist for the Consortium for Advanced Psychology Training, a post-doctoral fellowship for clinical psychologists. Within the Family Practice Residency program, Dr. Vogel directs the behavioral science education of residents and coordinates the research education for these residents. Dr. Vogel obtained his doctoral degree in clinical psychology from the California School of Professional Psychology-Los Angeles. He is the former chair of the Group on Behavioral Science in the Society of Teachers of Family Medicine. Since 2001 he has been Executive Director for the Association for the Behavioral Sciences and Medical Education. Dr. Vogel has been credentialed by the National Register since 1990.
Heather Kirkpatrick, PhD, ABPP, received a PhD in Counseling Psychology from the University of Illinois at Urbana-Champaign. She completed a postdoctoral fellowship in rehabilitation - related research at the University of Missouri Hospital in 1998. After completing a two-year postdoctoral fellowship with CAPT in Primary Care Health Psychology, she joined the Internal Medicine faculty at Genesys Regional Medical Center. Primary professional interests include women’s issues, medical education, and chronic pain management.
Maria Fimiani, PsyD, is the Associate Director of Behavioral Science for the Family Medicine Residency Program at Genesys Regional Medical Center in Grand Blanc, MI. She received her doctoral degree in Clinical Psychology from Nova Southeastern University in Fort Lauderdale, FL and completed the APA accredited, two-year clinical health psychology fellowship with the Consortium for Advanced Psychology Training at Genesys Regional Medical Center. Dr. Fimiani’s professional interests include consultation-liaison, medical education, behavioral health psychology, and cognitive behavior therapy.