by Kirk Stucky, PsyD, ABPP, Christine Chew, PhD, and Shannon McIntosh, PhD
Hurley Medical Center (HMC) is a 493-bed, university affiliated, urban teaching hospital for Michigan State University (MSU) and maintains cooperative affiliations with the University of Michigan and Henry Ford Health System. HMC is the primary provider of subspecialty care in the region and also a Level One trauma center in the tri-county area it services. It houses an NICU, PICU, Regional Burn Unit, and CARF accredited rehabilitation program, in addition to medical units in cardiology, oncology, psychiatry, pediatrics, obstetrics-gynecology, renal, and family practice. As a teaching hospital it sponsors numerous postdoctoral fellowship and residency programs.
THE PSYCHOLOGY DEPARTMENT
Since 1995 HMC has had an independent Department of Psychology in which all members are part of the medical staff and the department chairperson is a voting member of the Medical Executive Committee. A more thorough description of the department’s history and development can be found in a companion article (Lechner & Stucky, 2000). Department members currently participate in hospital governance and various hospital committees including credentials, ethics, and graduate medical education. By sitting at the decision making table with other physician colleagues, psychologists have been able to influence hospital policy and procedure, control the provision of services, and earn the respect necessary to practice collaboratively in a large medical setting. One of the most important by products of this involvement has been the medical staffs increased awareness that psychologists can provide a great deal more than just psychotherapy.
Postdoctoral Health Psychology Program
HMC originally started a medical psychology postdoctoral fellowship program in 1991. The Department of Graduate Medical Education (GME) has long recognized the need to maintain doctoral level training programs, including psychology, in the same department. Thus, the attending psychology staff receive their contract through the same entity that employs physician faculty. The fellowship program director is a voting member of the GME Committee, which includes all of the residency program directors, senior hospital administrators, and other selected teaching faculty and residents. This centralized administrative structure supports and emphasizes the fellowships primary purpose as a postdoctoral level training program. The importance of this broad based administrative and physician support cannot be overemphasized. Without this, aspects of the fellowship, which historically have primarily provided value added services and do not pay for themselves, would not have survived during fiscally challenging times at HMC.
Currently, HMC is one of the three hospitals within the Consortium for Advanced Psychology Training (CAPT), a collaborative postdoctoral fellowship in clinical health psychology offered by the combined resources of four sponsoring institutions: Genesys Regional Medical Center (GRMC), Hurley Medical Center (HMC), McLaren Regional Medical Center (MRMC), and the Michigan State University College of Human Medicine: Flint Area Medical Education, Inc. (MSU/FAME).
MSU/FAME serves as a vehicle whereby all three area hospitals come together as a consortium to create and implement programs in medical education and other allied health care fields in conjunction with MSU. In 1999 the consortium was the first program in the nation to receive 5-year specialty accreditation from the American Psychological Association (APA) as a postdoctoral training program in clinical health psychology. In 2002 HMC was the first hospital in the United States to obtain Center for Medicare / Medicaid Services (CMS) funding for fellowship training. More detailed information regarding this milestone accomplishment for psychology training can be found in a recently published article (Stucky, Buterakos, Crystal, Hanks, 2008).
Since the program’s inception the incoming psychology fellows have been members of the residents union and have received salary and benefits commensurate with the other medical residents. The Department of Graduate Medical Education supports the postdoctoral fellows’ salaries and receives supportive funding from a variety of service lines including obstetrics-gynecology, pediatrics, rehabilitation, and behavioral medicine. Fellows and faculty are intimately involved in the provision of medical education for medical students and physician residents. Simultaneously, psychology trainees and faculty are integrated members of various healthcare teams and participate in rehabilitation teams, medical staff rounds, trauma conferences, and other physician related training. Consequently, psychologists are typically able to collaboratively follow patients from their initial hospitalization through outpatient care.
Over the years, the practice of psychology at HMC has evolved and recreated itself several times, but has consistently maintained a strong base in medical education and direct patient care. In many ways these two activities are interlaced and occur simultaneously, but we have provided separate discussions of them for explanatory purposes. The reader will probably note that both activities are in many ways mutually dependent and compliment one another to ensure a well-rounded experience. Essentially, psychologists and physicians learn from one another on a daily basis while providing patient care. This unique and cooperative venture blends the best of both worlds – a university environment and a community setting to produce an excellent learning situation for students, residents, and fellows.
Medical education: The provision of medical education services has been a cornerstone activity throughout the fellowship program’s history. HMC is one of seven teaching hospitals for MSU and all psychology faculty and fellows have appointments in the MSU College of Human Medicine. Furthermore, Graduate Medical Education has five core programs: Internal Medicine, Combined Internal Medicine-Pediatrics, Obstetrics Gynecology, Pediatrics, and Transitional Year. There are three affiliated programs: Pediatric Dentistry, Diagnostic Radiology, and Emergency Medicine. In addition to the Psychology Fellowship program three additional fellowship programs are offered in Geriatric Medicine, Pediatric Emergency Medicine, and Trauma. A rotation in behavioral medicine is required for all residents in pediatrics, medicine-pediatrics, and obstetrics gynecology. During these block rotations faculty and fellows take residents to see patients, conduct lectures, and provide precepting during the residents various activities in order to enhance their effectiveness in patient communication and use of techniques such as motivational interviewing. A more detailed description regarding the integrated interface between medical education and patient care is provided in the section below.
Clinical Service and patient care: Relative to the other hospitals in CAPT, psychologists at HMC maintain a more intense workload with regard to patient care. Psychologists treat and evaluate patients on a variety of medical surgical units, which provides diverse training opportunities. Consequently, trainees have an opportunity to work with a variety of clinical problems that range from pediatric illness and injury, stroke, traumatic brain injury, spinal cord injury, psychological complications of acute or chronic illness, psychosomatic disorders, adjustment disorders, primary mental disorders, disorders of childhood and adolescence, and a variety of neurologic issues. Currently there are two postdoctoral fellows and three full time faculty. One fellow spends a significant amount of time interfacing with the pediatric and medicine pediatric residency program while providing clinical services to pediatric service lines. The other postdoctoral fellow provides services to adult and adolescent patients who have been admitted to various medical units or require inpatient rehabilitation. Psychologists in rehabilitation, pediatric, and trauma related services act as full-time members of the team and attend various meetings or formal rounds. Both postdoctoral fellows provide brief neuropsychological assessment, psychotherapy, crisis management, family interventions, behavioral management, non-pharmacologic pain management, and other interventions under the direct supervision of the attending psychologist. The psychologists also provide a variety of interventional skills beyond psychotherapy and assessment including team building, staff training and support, and hospital governance work.
Additionally, psychologists assist in maintaining a 24/7/365 consultation-liaison (CL) service through behavioral medicine. Psychology faculty take weekend calls periodically which in turn gives fellows exposure to more traditional mental health issues such as psychosis, suicide attempt, drug and alcohol abuse or withdrawal, depression, and anxiety disorders. The CL service provides biopsychosocial evaluation, treatment, and addresses dispositional needs for patients hospitalized on medical – surgical units. All of the practitioner’s efforts are focused on quick, accurate assessment of the problem, establishing an appropriate dispositional plan, and initiating practical solutions. Interventions and assessments are focused on immediate needs such as 1) barriers to the patient's participation in health care, 2) emotional/affective disturbances that negatively impact adherence, morbidity, and or recidivism 3) staff issues which may impact patient care, and 4) behavioral interventions that will maximize medical treatment or rehabilitative care. Due to the short length of stay for most patients, chronic issues are triaged to other clinical settings once the patient is medically stable and can be transferred. For medication recommendations or more complicated medical management issues, psychiatric nurse practitioners and psychiatrists are available, and when necessary, personally evaluate patients at the psychologist’s request.
As much as possible, a true consultation-liaison approach is taken in that the team focuses on a comprehensive assessment of both patient and staff needs, with practical recommendations offered for treatment and discharge. The psychology service has found that problems sometimes extend beyond the patient’s medical and psychological issues, and include staff counter-transference, gaps in staff education, and lack of knowledge regarding adjustment to chronic illness, psychiatric, and or neuropsychiatric disorders. As a result, the liaison portion of the service is sometimes required in order to reach the desired goal. Liaison service involves providing staff support and in-services, educating staff on the management of difficult behaviors, helping staff understand and change unproductive interaction patterns, facilitating staff-patient communication, attending to behavioral aspects of pain medication delivery, and or
modifying other system issues.
During their behavioral science rotations, residents round with the psychology team and learn about the biopsychosocial model by observing and conducting parts of the consultation. Psychologists also facilitate implementation of the recommendations for treatment and disposition planning which allows trainees to observe and learn practical skills. To consolidate the medical student and residents practical experience, psychologists precept and discuss cases openly during rounds. As educators, our goal is to expand the physician’s understanding of how psychological variables impact medical illness, prognosis, progression, and treatment response. Through this exposure trainees become sensitized and learn first-hand the interaction of psychosocial factors with medical illness, gain important insights into the value of non-medication oriented interventions, and hopefully develop a greater understanding and respect for the biopsychosocial model and its value in the treatment of all patients, not just those with a major psychiatric illness.
Concurrently, this educational model allows for cross training of physicians and psychologists, promotes shared knowledge between behavioral science and medicine, and in our opinion leads to more collaborative clinical care. The experience prepares postdoctoral fellows to view themselves as both clinicians and educators within the hospital setting. Postdoctoral fellows also learn the complexities of treating patients and interacting with medical staff within a hospital setting. Medical centers are indeed complex social-political systems with unwritten rules, hierarchies, and group norms that can only be learned through experience. Through the intensive two-year experience, the fellows come to recognize hospital and unit politics and the systemic issues that need to be taken into consideration when attempting to meet the consultation request. This is an especially valuable experience, which empowers psychologists in training who may not initially recognize their broader value. In our opinion the psychology fellows graduate with a sense of increased self-efficacy and empowerment, recognizing that their skills are uniquely valuable in a medical setting.
In summary, changes in the healthcare market place have made it necessary to change former practice patterns and construct new creative models, which continue to provide the patient with necessary psychological and medical services in a cost effective manner. Considerable pressures on hospitals to provide the same quality of service more quickly, with less staff, and at a reduced cost seem both unreasonable and unrealistic. The psychology service at HMC provides one successful alternative model to the provision of integrated quality healthcare services within the hospital environment while also providing practical training of physicians in the application of the biopsychosocial model. This has also generated is a unique setting in which parallel training of physicians and psychologists occurs daily. It is not our intention to propose this as an ideal model, but simply one that has been effective at our institution. Readers should also keep in mind that psychologists at HMC enjoy a scope of practice predicated on independent medical staff membership, hospital privileges, and active participation in hospital governance. These ingredients were essential building blocks in the creation and expansion of the service we have described.
Kirk Stucky, PsyD, ABPP, currently acts as the fellowship’s program director, chairman of the Department of Psychology, and chairman of the hospital Credentials Committee. Additional psychology faculty includes Shannon McIntosh PhD, and Christine Chew, PhD. Further information regarding the fellowship program and CAPT can be found at www2.msufame.msu.edu.
Stucky, K., Buterakos, J., Crystal, T., & Hanks, R. (2008). Acquiring CMS funding for an APA accredited postdoctoral Psychology Fellowship program. Training and Education in Professional Psychology. vol 2, issue 3.
Lechner, M. & Stucky, K. (2000). A hospital medical staff psychology department: the interface of medical education, postdoctoral psychology training, clinical practice, and medical staff membership. Journal of Clinical Psychology in Medical Settings, 7, 2, 141-148.