As I write this column, the Register is in the midst of completing a major filming project. We have gathered together a group of experts in integrated healthcare and are using the services of a professional videographer firm to record a series of 10 instructional seminars that will guide psychologists who are interested in expanding their practice in this important direction.
Each presenter is focusing on a vital area of integrated care, to include explicit direction on how to implement an integrated practice, a primer on healthcare economics that affect integrated care service delivery, issues surrounding billing, coding, and funding for psychologists working in the integrated environment, a familiarization with common medical conditions that the psychologist will encounter in such environments, and a primer on psychological and pharmacological management of common behavioral conditions in the integrated environment. This series of presentations, along with important reference material, will be made available to our credentialed psychologists and doctoral students this fall.
We believe that this material presented by experts such as Parinda Khatri, Kent Corso, Jeffrey Goodie, Bob McGrath, Trish Gallagher, Neftali Serrano, and others will provide immediately applicable knowledge and skills that psychologists wishing to work in integrated care can employ. But I have two lingering questions: the first is whether we will actually apply the knowledge these experts have provided, and the second is whether we, as a profession, will understand that such training should be integral to our graduate curricula, and not merely seen as a postdoctoral add-on.
Psychologists who have worked directly in the sprawling, inefficient and extremely expensive American medical system recognize a few things: First, we are working in a system that does not particularly value psychological expertise. Take for example the fact that the U.S. taxpayer funds graduate psychology education in the amount of between 8-10 million dollars annually. This amount, tenaciously lobbied for by the Education Directorate at APA, is federally appropriated to subsidize internship training in organized healthcare delivery settings. Graduate medical education, on the other hand, is funded by the U.S. taxpayer to the tune of over 10 billion dollars annually—and as they say in Washington, a billion here and a billion there starts to add up to some real money. There are, of course, plenty of good reasons why this funding differential exists. Medical care is much more expensive than psychological care, and, without downplaying the importance of psychological interventions, treatments for urgent physical needs—heart attacks, traumatic injuries, cancer, and infectious disease, among others—take priority over most psychological care.
But there are many irrational reasons why these disparities exist, and we need to continue to challenge these irrationalities if we are to play a part in making the U.S. healthcare system better and more efficient. Don Berwick from the Institute for Healthcare Improvement commented in an editorial in the March 3rd issue of the Journal of the American Medical Association that if we are to achieve the triple aim of integrated health care—better care, better health, and lower cost—we must tackle the thorny issue of physician’s guild prerogatives, among other problems such as exorbitant profit-seeking by hospitals, pharmaceutical firms, and individual practitioners.
If we are to be true agents of change, we must work within the system to change it for the better. Too often, however, our vision is hobbled by our heritage, and unless we have the foresight to expand beyond traditional graduate educational parameters we will not effectively train the next generation of psychologists to be integrated healthcare workers. Without mincing words, healthcare systems are not going to hire psychologists because of our belief, however well-founded, that our skills make us effective administrators, supervisors, or mediators. If we don’t have the skillset to be hired for one reason only—to provide effective interventions in the integrated environment—we aren’t going to be hired at all. And this means we must expand on our training to be more inclusive of the core skills other providers bring to the primary care environment.
Many physician educators have long decried the inefficiency of medical training in the U.S. It takes at least seven years for a physician with the most basic residency training to complete their education, and much longer for those with specialty (often surgical) skills. But when we understand that it also takes on average seven years for a psychologist to complete the academic and clinical training required for licensure—and sometimes longer—we recognize that as a profession we are equally at fault. Our education is still centered in the academy, which has clung overlong to models that provide future healthcare providers with little of the medically oriented knowledge and skills they will need to use in the practice environment. However robust our training in biological bases may be, without a clinical exposure to pathophysiology, pharmacology and psychopharmacology, we lack knowledge that other integrated care providers see as commonplace.
The future of healthcare is integration. Current models are imperfect but we all recognize that if we are to optimize patient health we must stop seeing physical and psychological well-being as separate phenomena. This means that we as a profession must take seriously the obligation to impart the comprehensive training needed to be effective agents of change in the integrated environment. Time to get to work!