INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 45(4) 357-365, 2013
TRAINING FAMILY MEDICINE RESIDENTS TO PRACTICE COLLABORATIVELY WITH PSYCHOLOGY TRAINEES*
JOHN H. PORCERELLI, PHD, ABPP Wayne State University School of Medicine SHANNON L. FOWLER, MA University of Detroit Mercy WILLIAM MURDOCH, MD, FAAFP TSVETI MARKOVA, MD, FAAFP CHRISTINA KIMBROUGH, MD Wayne State University School of Medicine
ABSTRACT
Objective: This article will describe a training curriculum for family medicine residents to practice collaboratively with psychology (doctoral) trainees at the Wayne State University/Crittenton Family Medicine Residency program. Methods: The collaborative care curriculum involves a series of patient care and educational activities that require collaboration between family medicine residents and psychology trainees. Activities include: 1) clinic huddle, 2) shadowing, 3) pull-ins and warm handoffs, 4) co-counseling, 5) shared precepting, 6) feedback from psychology trainees to family medicine residents regarding consults, brief interventions, and psychological testing, 7) lectures, 8) video-observation and
*Financial support for the collaborative care training program was provided by the Wayne State University Department of Family Medicine and Public Health Sciences. Manuscript based on material presented at the 33rd Annual Forum for Behavioral Science Education in Family Medicine, 2012. 357 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.45.4.f http://baywood.com
358 / PORCERELLI ET AL.
feedback, 9) home visits, and 10) research. The activities were designed to teach the participants to work together as a team and to provide a reciprocal learning experience. Results: In a brief three-item survey of residents at the end of their academic year, 83% indicated that they had learned new information or techniques from working with the psychology trainees for assessment and intervention purposes; 89% indicated that collaborating with psychology trainees enhanced their patient care; and 89% indicated that collaborating with psychology trainees enhanced their ability to work as part of a team. Informal interviews with the psychology trainees indicated that reciprocal learning had taken place. Conclusions: Family medicine residents can learn to work collaboratively with psychology trainees through a series of shared patient care and educational activities within a primary care clinic where an integrated approach to care is valued. (Int’l. J. Psychiatry in Medicine 2013;45:357-365)
Key Words: training
collaborative care, family medicine, residency training, psychology
There is a plethora of data supporting the claim that primary care is the de facto mental healthcare system in the United States [1, 2]. Despite the fact that the majority of Americans with mental health disorders are seen solely by primary care physicians (PCP) [3, 4], the specialty mental healthcare system remains fragmented and difficult for patients to access [5]. In addition, psychiatric/ behavioral symptoms and disorders are often missed by PCPs [6, 7]. These problems have led to several models of collaborative care, including coordinated, co-located, and integrated care models. The latter represents a model where PCPs work together with behavioral health practitioners within a shared system involving primary care teams. Efficacy of various models of collaborative care has achieved empirical support [8-11]. This had led to efforts by some primary care residency programs to develop educational models for residents and psychology trainees (at various levels of doctoral training) to work collaboratively [5, 12-17]. Most of these program descriptions focus on the training of psychologists. Therefore, this article will describe a curriculum put in place by the Wayne State University/Crittenton Family Medicine Residency Program to provide residents with the opportunity to develop interprofessional collaborative skills by working along side predoctoral (masterslevel) psychology trainees in the family medicine outpatient clinic. More specifically, a description of the shared clinical and educational experiences will be provided followed by data from a brief survey about the experiences of the program by the residents.
TRAINING IN COLLABORATIVE CARE /
359
METHODS Setting The collaborative care training program is within a family medicine residency clinic located in a suburb of a large metropolitan city in the midwestern United States. The program houses 18 residents (six in each of 3 years of training). In addition there are six board certified family physicians, one board certified health psychologist, five medical assistants, and one licensed nurse. For the past 3 years, four half-time advanced doctoral students from local training programs in clinical psychology are recruited for the clinic. The psychology trainees undergo an orientation to the clinic, which includes shadowing residents for two weeks (without intervening), reading articles on team-based care in the patient-centered medical home, and reading two primers to primary care health psychology. During the orientation period, trainees meet with the supervising psychologist on a daily basis to discuss their shadowing experiences with an emphasis on points of possible collaborative interventions. Trainees are also provided guidelines for each of the collaborative encounters. This year’s group of trainees is being trained to use the EMR system in the clinic. Progress notes from all types of clinical encounters and psychological testing reports will soon be paperless. The outpatient clinic where the majority of the collaborative training occurs has earned the designation of a Patient Centered Medical Home (PCMH) by Blue Cross/Blue Shield of Michigan (BCBS-MI). The PCMH is focused on patient centered, comprehensive, coordinated, and accessible care, with a commitment to quality and safety [18]. By implementing PCMH principles in residency education, the program has received a commendation by the Accreditation Council of Graduate Medical Education (ACGME), the organization that accredits all medical residency programs in the United States. The clinic also participates in the Mackinac Learning Collaborative [19], an experiential learning program that is funded by BCBS-MI for the development and refinement of PCMH practices. This year’s training initiative is focused on the integration of behavioral health in primary care. Collaborative Clinical and Educational Experiences Several clinical and educational activities have been implemented to provide residents with the opportunity to learn interprofessional collaborative skills. These include: 1) clinic huddle; 2) shadowing; 3) pull-ins and warm hand-offs; 4) co-counseling; 5) shared precepting; 6) feedback from consults, psychosocial interventions, and psychological testing; 7) lectures; 8) video-observation and feedback; 9) home visits; and 10) resident scholarship projects.
360 / PORCERELLI ET AL.
Clinic Huddle
The clinic huddle is a brief (5-minute) meeting prior to the start of the morning and afternoon clinic involving the clinic staff, faculty, psychology trainees, and residents. The purpose of the huddle is to give a review of all of the patients (and their presenting problems) scheduled for that particular half-day. Special attention is paid to patients who may need to be seen jointly by a physician and psychology trainee. Shadowing
Shadowing refers to psychologists working side-by-side with family medicine residents. At least one psychology trainee is available to shadow a physician on any given half-day. Throughout the year, each resident will have numerous opportunities to have psychology trainees shadow them. Trainees see all of the resident’s patients with them and provide whatever behavioral health support that may be needed. This could include obtaining additional health history information, providing assessments for stress, psychological symptoms or disorders, assessing readiness for change for unhealthy behaviors (e.g., smoking or alcohol misuse), initiating healthy behaviors (e.g., exercise) for chronic disease management, or providing self-help information (e.g., sleep hygiene). A recent study from the family medicine center clinic describes the type and frequency of psychosocial interventions offered by residents and trainees during collaborative encounters [17]. These interventions include: 1) psychiatric symptom/disorder assessments; 2) behavioral interventions (e.g., behavioral activation or stress management techniques); 3) lifestyle and chronic disease management (e.g., exercise, smoking cessation, and pain management); 4) psycho-education (e.g., handouts and referral information about domestic violence); 5) supportive interventions (e.g., validating and normalizing comments); and 6) parental interventions (e.g., recommendations for childcare and family functioning). Pull-Ins and Warm Handoffs
Residents who don’t have a psychology trainee shadowing them can request an on-the-spot consultation from a psychology trainee for either an assessment and/or intervention. This can be done with or without the resident in the exam room. When such a consult is requested by the resident at the end of his or her visit with the patient, it is called a warm handoff. The psychology trainee meets with the patient while the resident moves on to their next patient, provides care (assessment or intervention), then gives same-day feedback about the patient to the resident for the development of an integrated care plan. If the resident is unavailable, same-day feedback will be provided through HIPAA-secured e-mail. Residents include pertinent information from the psychology trainee into the patient’s chart note.
TRAINING IN COLLABORATIVE CARE /
361
Co-Counseling
Although the psychology trainees offer short-term counseling (one to six 30-minute sessions) to clinic patients, some patients prefer co-counseling (i.e., talking with the resident and psychologist concurrently; also referred to as dual interviewing [14]). This is common in the subset of patients that would otherwise never see a mental health professional on their own (or even when referred to one). One approach that we have found useful for such patients is to have the resident suggest that they “talk together” with the behavioral health specialist. This makes the encounter feel psychologically safer for the patient. This often leads to brief (10- to 15-minute) co-counseling sessions at the end of their appointment. A small number of patients prefer talking briefly with a behavioral health specialist each time they come to the clinic, but only if their physician is with them! Shared Precepting
Whenever residents and psychology trainees work together on patient care, the dyad meets with a physician and psychology preceptor to review their assessment, diagnoses, and plan. Information is presented by both participants. Preceptors model their biopsychosocial orientations by integrating information from residents and psychology trainees. Feedback from Consults, Brief Interventions, and Psychological Testing
Whether psychology trainees provide pull-in assessments, brief interventions, or psychological testing, they provide feedback to the resident with the goal of developing a more integrated plan of care. Lectures
Faculty members of the residency program foster collaboration by including psychosocial dimensions of all disease entities in their lectures. For example, in the lecture on Type-II diabetes mellitus, readiness for change assessment combined with evidenced-based psychosocial interventions for weight management, exercise, and smoking cessation are included. Video-Observation and Feedback
With patients’ consent, shadowing (dual interviewing), pull-in and warm handoffs, and co-counseling encounters are observed in real time by the faculty psychologist in a specifically designed video-observation room. Brief feedback is provided before, during, or after the precepting with the faculty physician. These brief teaching opportunities allow for reinforcement of the positive skills
362 / PORCERELLI ET AL.
exhibited by each participant as well as an opportunity to offer suggestions for future encounters. Home Visits
Family medicine residents are required to complete six home visits during their training. It is recommended (and actually preferred by residents) to have a psychology trainee accompany them and carry out a psychosocial assessment as part of the visit. Screening and assessment information gathered by the psychology trainee during the visit is included in the patient’s chart note by the resident. Research
Family medicine residents are required to complete a clinical case study during their PGY-2 year and a scholarship project before graduation. Although not required, several residents have included a psychology trainee on their study team. For example, a resident wrote their case study on the collaborative care of a patient with fibromyalgia. In addition to the medical management of the disorder, the treatment included sessions of emotion-focused psychotherapeutic interventions. Another resident collaborated with a psychology trainee on a study that assessed co-morbid depressive and anxiety disorders in African-American women with somatization symptoms. Physician and psychologist faculty mentor this collaborative research. RESULTS The combination of these 10 experiences provides our family medicine residents with rich opportunities for collaboration that result in mutual learning for both residents and psychology trainees. Surveys of residents at the end of the year suggest that we are achieving our goals as a program. In June of 2012, residents from all 3 years of training (N = 18) responded to three survey questions on a 6-point Likert scale (1 = “strongly disagree” through 6 = “strongly agree”): 1) I learned new information or techniques from working with the psychology trainees for assessment and intervention purposes; 2) collaborating with psychology trainees enhanced my patient care; and 3) collaborating with psychology trainees enhanced my ability to work as part of a team. The percentages of residents responding to the questions with either a 5 (agree) or 6 (strongly agree) were 83%, 89%, and 89%, respectively. Informal exit interviews of the psychology trainees revealed that they had learned a great deal about the following areas: learned how to work as a member of a healthcare team; expanded their knowledge about psychotropic medication; developed a greater appreciation of the psychological and behavioral struggles of patients with chronic medical illnesses (e.g., diabetes and pain-related conditions); and learned about the culture of medicine.
TRAINING IN COLLABORATIVE CARE /
363
DISCUSSION Residents across all primary care specialties need to develop skills in collaborating with behavioral health practitioners. We have described a series of clinical and educational activities to foster collaboration between family medicine residents and psychology trainees. Although behavioral science and psychiatry training has always been a part of family medicine residency training, this role has often been filled, at best, by a single mental health practitioner. Through the inclusion of a psychology training program, residents have been able to work closely with trainees to develop collaborative skills. Our brief survey indicates that family medicine residents feel that they are not only gaining knowledge about psychological and behavioral issues, they indicate that they are learning more about psychosocial interventions. This will be particularly important for those residents who may work in rural or urban areas without the clinical support seen in large academic medical centers. In addition, residents feel that the collaboration enhances patient care and perhaps, most importantly, is helping them to become better team players—an imperative to the success of any PCMH [20]. One of the barriers to the implementation of the program has been attitudinal on the part of a minority of residents, especially those whose medical school and clinical training prior to residency has been more physician-centered as opposed to patient-centered. These residents tend to delegate tasks to the trainees and minimize or avoid collaborative interactions. Faculty physicians have been helpful in addressing residents’ resistances through modeling their own use of collaborative care. Video-observation of encounters by residency faculty with tactful feedback and suggestions to residents challenged by this model has been particularly helpful. On a larger scale, the success of this collaborative training model depends on multiple prerequisite steps, starting with the establishment of a strong psychology training program within a primary care residency. This requires dedicated departmental resources. It should be noted that often a single part-time mental health professional is used to fulfill the ACGME requirement for behavioral science training and many residency programs only dedicate .2 or .3 FTE to such a position. The curriculum we have described requires a full-time doctoral-level psychologist (because of the psychological testing and research components). In the current time of decreasing funding for GME training, it is challenging to design and implement such programs, which go beyond accreditation requirements and are focused on excellence and innovation in medical education. Beyond funding, the sustainability of the project depends on chair and program director appreciation of its value and support of the supervising psychologist.
364 / PORCERELLI ET AL.
REFERENCES 1. Regier D, Narrow W, Rae D, Manderscheid R, Locke B, Goodwin F. The de facto U.S. mental health and addictive services system: Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry 1993;50:85-94. 2. Kessler R, Stafford D. Primary care is the de facto mental health system. In Kessler R, Stafford D, editors, Collaborative medicine case studies: Evidence in practice. New York, NY: Springer, 2008:9-21. 3. Academy of Psychosomatic Medicine. Mental disorders in general medical practice: An opportunity to add value to healthcare. Behavioral Healthcare Tomorrow 1996; 72:55-62. 4. Katon W. The epidemiology of depression in primary care. International Journal of Psychiatry in Medicine 1987;17:93-112. 5. Pisani AR, LeRoux P, Siegel DM. Educating residents in behavioral health care and collaboration: Integrated clinical training of pediatric residents and psychology fellows. Academic Medicine 2011;86:166-173. 6. Kroenke K, Spitzer RJ, Williams JB, Monahan PO, Lowe B. Anxiety disorders in primary care: Prevalence, impairment, comorbidity and detection. Annals of Internal Medicine 2007;146:317-325. 7. Dilts SL, Mann N, Dilts JG. Accuracy of referring psychiatric diagnosis on a consultation liaison service. Psychosomatics 2003;44:407-411. 8. Blount A. Integrated primary care: Organizing the evidence. Families, Systems, and Health 2003;21:121:133. 9. Blount A, Shoenbaum M, Kathol R, Rollman BL, Thomas M, O’Donohue W, Peek CL. The economics of behavioral health services in medical settings: A summary of the evidence. Professional Psychology: Research and Practice 2007;38:290-297. 10. Craven M, Bland R. Better practices in collaborative mental health care: Analysis of the evidence base. Canadian Journal of Psychiatry 2006;(Suppl. 1):7S-72S. 11. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: A cumulative meta-analysis and review of longer term outcomes. Archives of Internal Medicine 2006;166:2314-2321. 12. Garcia-Shelton L, Vogel ME. Primary care health psychology training: A collaborative model with family practice. Professional Psychology: Research and Practice 2002;33:546-556. 13. Talen MR, Fraser JS, Cauley K. Training primary care psychologists: A model for predoctoral programs. Professional Psychology: Research and Practice 2005;36: 136-142. 14. Blount A, DeGirolamo S, Mariani K. Training collaborative care practitioners of the future. Families, Systems, and Health 2006;24:111-119. 15. McDaniel SH, LeRoux P. An overview of primary care family psychology. Journal of Clinical Psychology in Medical Settings 2007;14:23-32. 16. Cubic B, Mance J, Turgesen JN, Lamanna JD. Interprofessional education: Preparing psychologists for success in integrated primary care. Journal of Clinical Psychology in Medical Settings 2012;19:84-92. 17. Porcerelli JH, Fowler SL, Klassen B, Murdoch W, Sklar ER, Wright BE, Morris P. Behavioral health assessments and interventions of residents and psychology trainees during dual interviewing: A descriptive study. Family Medicine 2013;45:424-427.
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18. Agency for Healthcare Research and Quality. Developing and running a primary care practice facilitation program: A how-to guide. Rockville MD: AHRQ; December 2011. Publication No. 12-0011. Available at www.ahrq.gov 19. Practice Transformation Institute. Mackinac Learning Collaborative, 2011. Available at http://www.transformcoach.org/EducationCME/MackinacLearningCollaborative. aspx 20. Markova T, Mateo M, Roth LM. Implementing teams in a patient centered medical home residency practice: Lessons learned. Journal of the American Board of Family Medicine 2012;25:224-231.
Direct reprint requests to: John H. Porcerelli, PhD WSU Family Medicine Center 1135 W. University Drive, Suite 250 Rochester Hills, MI 48307 e-mail: [email protected]
TRAINING FAMILY MEDICINE RESIDENTS TO PRACTICE COLLABORATIVELY WITH PSYCHOLOGY TRAINEES*
JOHN H. PORCERELLI, PHD, ABPP Wayne State University School of Medicine SHANNON L. FOWLER, MA University of Detroit Mercy WILLIAM MURDOCH, MD, FAAFP TSVETI MARKOVA, MD, FAAFP CHRISTINA KIMBROUGH, MD Wayne State University School of Medicine
ABSTRACT
Objective: This article will describe a training curriculum for family medicine residents to practice collaboratively with psychology (doctoral) trainees at the Wayne State University/Crittenton Family Medicine Residency program. Methods: The collaborative care curriculum involves a series of patient care and educational activities that require collaboration between family medicine residents and psychology trainees. Activities include: 1) clinic huddle, 2) shadowing, 3) pull-ins and warm handoffs, 4) co-counseling, 5) shared precepting, 6) feedback from psychology trainees to family medicine residents regarding consults, brief interventions, and psychological testing, 7) lectures, 8) video-observation and
*Financial support for the collaborative care training program was provided by the Wayne State University Department of Family Medicine and Public Health Sciences. Manuscript based on material presented at the 33rd Annual Forum for Behavioral Science Education in Family Medicine, 2012. 357 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.45.4.f http://baywood.com
358 / PORCERELLI ET AL.
feedback, 9) home visits, and 10) research. The activities were designed to teach the participants to work together as a team and to provide a reciprocal learning experience. Results: In a brief three-item survey of residents at the end of their academic year, 83% indicated that they had learned new information or techniques from working with the psychology trainees for assessment and intervention purposes; 89% indicated that collaborating with psychology trainees enhanced their patient care; and 89% indicated that collaborating with psychology trainees enhanced their ability to work as part of a team. Informal interviews with the psychology trainees indicated that reciprocal learning had taken place. Conclusions: Family medicine residents can learn to work collaboratively with psychology trainees through a series of shared patient care and educational activities within a primary care clinic where an integrated approach to care is valued. (Int’l. J. Psychiatry in Medicine 2013;45:357-365)
Key Words: training
collaborative care, family medicine, residency training, psychology
There is a plethora of data supporting the claim that primary care is the de facto mental healthcare system in the United States [1, 2]. Despite the fact that the majority of Americans with mental health disorders are seen solely by primary care physicians (PCP) [3, 4], the specialty mental healthcare system remains fragmented and difficult for patients to access [5]. In addition, psychiatric/ behavioral symptoms and disorders are often missed by PCPs [6, 7]. These problems have led to several models of collaborative care, including coordinated, co-located, and integrated care models. The latter represents a model where PCPs work together with behavioral health practitioners within a shared system involving primary care teams. Efficacy of various models of collaborative care has achieved empirical support [8-11]. This had led to efforts by some primary care residency programs to develop educational models for residents and psychology trainees (at various levels of doctoral training) to work collaboratively [5, 12-17]. Most of these program descriptions focus on the training of psychologists. Therefore, this article will describe a curriculum put in place by the Wayne State University/Crittenton Family Medicine Residency Program to provide residents with the opportunity to develop interprofessional collaborative skills by working along side predoctoral (masterslevel) psychology trainees in the family medicine outpatient clinic. More specifically, a description of the shared clinical and educational experiences will be provided followed by data from a brief survey about the experiences of the program by the residents.
TRAINING IN COLLABORATIVE CARE /
359
METHODS Setting The collaborative care training program is within a family medicine residency clinic located in a suburb of a large metropolitan city in the midwestern United States. The program houses 18 residents (six in each of 3 years of training). In addition there are six board certified family physicians, one board certified health psychologist, five medical assistants, and one licensed nurse. For the past 3 years, four half-time advanced doctoral students from local training programs in clinical psychology are recruited for the clinic. The psychology trainees undergo an orientation to the clinic, which includes shadowing residents for two weeks (without intervening), reading articles on team-based care in the patient-centered medical home, and reading two primers to primary care health psychology. During the orientation period, trainees meet with the supervising psychologist on a daily basis to discuss their shadowing experiences with an emphasis on points of possible collaborative interventions. Trainees are also provided guidelines for each of the collaborative encounters. This year’s group of trainees is being trained to use the EMR system in the clinic. Progress notes from all types of clinical encounters and psychological testing reports will soon be paperless. The outpatient clinic where the majority of the collaborative training occurs has earned the designation of a Patient Centered Medical Home (PCMH) by Blue Cross/Blue Shield of Michigan (BCBS-MI). The PCMH is focused on patient centered, comprehensive, coordinated, and accessible care, with a commitment to quality and safety [18]. By implementing PCMH principles in residency education, the program has received a commendation by the Accreditation Council of Graduate Medical Education (ACGME), the organization that accredits all medical residency programs in the United States. The clinic also participates in the Mackinac Learning Collaborative [19], an experiential learning program that is funded by BCBS-MI for the development and refinement of PCMH practices. This year’s training initiative is focused on the integration of behavioral health in primary care. Collaborative Clinical and Educational Experiences Several clinical and educational activities have been implemented to provide residents with the opportunity to learn interprofessional collaborative skills. These include: 1) clinic huddle; 2) shadowing; 3) pull-ins and warm hand-offs; 4) co-counseling; 5) shared precepting; 6) feedback from consults, psychosocial interventions, and psychological testing; 7) lectures; 8) video-observation and feedback; 9) home visits; and 10) resident scholarship projects.
360 / PORCERELLI ET AL.
Clinic Huddle
The clinic huddle is a brief (5-minute) meeting prior to the start of the morning and afternoon clinic involving the clinic staff, faculty, psychology trainees, and residents. The purpose of the huddle is to give a review of all of the patients (and their presenting problems) scheduled for that particular half-day. Special attention is paid to patients who may need to be seen jointly by a physician and psychology trainee. Shadowing
Shadowing refers to psychologists working side-by-side with family medicine residents. At least one psychology trainee is available to shadow a physician on any given half-day. Throughout the year, each resident will have numerous opportunities to have psychology trainees shadow them. Trainees see all of the resident’s patients with them and provide whatever behavioral health support that may be needed. This could include obtaining additional health history information, providing assessments for stress, psychological symptoms or disorders, assessing readiness for change for unhealthy behaviors (e.g., smoking or alcohol misuse), initiating healthy behaviors (e.g., exercise) for chronic disease management, or providing self-help information (e.g., sleep hygiene). A recent study from the family medicine center clinic describes the type and frequency of psychosocial interventions offered by residents and trainees during collaborative encounters [17]. These interventions include: 1) psychiatric symptom/disorder assessments; 2) behavioral interventions (e.g., behavioral activation or stress management techniques); 3) lifestyle and chronic disease management (e.g., exercise, smoking cessation, and pain management); 4) psycho-education (e.g., handouts and referral information about domestic violence); 5) supportive interventions (e.g., validating and normalizing comments); and 6) parental interventions (e.g., recommendations for childcare and family functioning). Pull-Ins and Warm Handoffs
Residents who don’t have a psychology trainee shadowing them can request an on-the-spot consultation from a psychology trainee for either an assessment and/or intervention. This can be done with or without the resident in the exam room. When such a consult is requested by the resident at the end of his or her visit with the patient, it is called a warm handoff. The psychology trainee meets with the patient while the resident moves on to their next patient, provides care (assessment or intervention), then gives same-day feedback about the patient to the resident for the development of an integrated care plan. If the resident is unavailable, same-day feedback will be provided through HIPAA-secured e-mail. Residents include pertinent information from the psychology trainee into the patient’s chart note.
TRAINING IN COLLABORATIVE CARE /
361
Co-Counseling
Although the psychology trainees offer short-term counseling (one to six 30-minute sessions) to clinic patients, some patients prefer co-counseling (i.e., talking with the resident and psychologist concurrently; also referred to as dual interviewing [14]). This is common in the subset of patients that would otherwise never see a mental health professional on their own (or even when referred to one). One approach that we have found useful for such patients is to have the resident suggest that they “talk together” with the behavioral health specialist. This makes the encounter feel psychologically safer for the patient. This often leads to brief (10- to 15-minute) co-counseling sessions at the end of their appointment. A small number of patients prefer talking briefly with a behavioral health specialist each time they come to the clinic, but only if their physician is with them! Shared Precepting
Whenever residents and psychology trainees work together on patient care, the dyad meets with a physician and psychology preceptor to review their assessment, diagnoses, and plan. Information is presented by both participants. Preceptors model their biopsychosocial orientations by integrating information from residents and psychology trainees. Feedback from Consults, Brief Interventions, and Psychological Testing
Whether psychology trainees provide pull-in assessments, brief interventions, or psychological testing, they provide feedback to the resident with the goal of developing a more integrated plan of care. Lectures
Faculty members of the residency program foster collaboration by including psychosocial dimensions of all disease entities in their lectures. For example, in the lecture on Type-II diabetes mellitus, readiness for change assessment combined with evidenced-based psychosocial interventions for weight management, exercise, and smoking cessation are included. Video-Observation and Feedback
With patients’ consent, shadowing (dual interviewing), pull-in and warm handoffs, and co-counseling encounters are observed in real time by the faculty psychologist in a specifically designed video-observation room. Brief feedback is provided before, during, or after the precepting with the faculty physician. These brief teaching opportunities allow for reinforcement of the positive skills
362 / PORCERELLI ET AL.
exhibited by each participant as well as an opportunity to offer suggestions for future encounters. Home Visits
Family medicine residents are required to complete six home visits during their training. It is recommended (and actually preferred by residents) to have a psychology trainee accompany them and carry out a psychosocial assessment as part of the visit. Screening and assessment information gathered by the psychology trainee during the visit is included in the patient’s chart note by the resident. Research
Family medicine residents are required to complete a clinical case study during their PGY-2 year and a scholarship project before graduation. Although not required, several residents have included a psychology trainee on their study team. For example, a resident wrote their case study on the collaborative care of a patient with fibromyalgia. In addition to the medical management of the disorder, the treatment included sessions of emotion-focused psychotherapeutic interventions. Another resident collaborated with a psychology trainee on a study that assessed co-morbid depressive and anxiety disorders in African-American women with somatization symptoms. Physician and psychologist faculty mentor this collaborative research. RESULTS The combination of these 10 experiences provides our family medicine residents with rich opportunities for collaboration that result in mutual learning for both residents and psychology trainees. Surveys of residents at the end of the year suggest that we are achieving our goals as a program. In June of 2012, residents from all 3 years of training (N = 18) responded to three survey questions on a 6-point Likert scale (1 = “strongly disagree” through 6 = “strongly agree”): 1) I learned new information or techniques from working with the psychology trainees for assessment and intervention purposes; 2) collaborating with psychology trainees enhanced my patient care; and 3) collaborating with psychology trainees enhanced my ability to work as part of a team. The percentages of residents responding to the questions with either a 5 (agree) or 6 (strongly agree) were 83%, 89%, and 89%, respectively. Informal exit interviews of the psychology trainees revealed that they had learned a great deal about the following areas: learned how to work as a member of a healthcare team; expanded their knowledge about psychotropic medication; developed a greater appreciation of the psychological and behavioral struggles of patients with chronic medical illnesses (e.g., diabetes and pain-related conditions); and learned about the culture of medicine.
TRAINING IN COLLABORATIVE CARE /
363
DISCUSSION Residents across all primary care specialties need to develop skills in collaborating with behavioral health practitioners. We have described a series of clinical and educational activities to foster collaboration between family medicine residents and psychology trainees. Although behavioral science and psychiatry training has always been a part of family medicine residency training, this role has often been filled, at best, by a single mental health practitioner. Through the inclusion of a psychology training program, residents have been able to work closely with trainees to develop collaborative skills. Our brief survey indicates that family medicine residents feel that they are not only gaining knowledge about psychological and behavioral issues, they indicate that they are learning more about psychosocial interventions. This will be particularly important for those residents who may work in rural or urban areas without the clinical support seen in large academic medical centers. In addition, residents feel that the collaboration enhances patient care and perhaps, most importantly, is helping them to become better team players—an imperative to the success of any PCMH [20]. One of the barriers to the implementation of the program has been attitudinal on the part of a minority of residents, especially those whose medical school and clinical training prior to residency has been more physician-centered as opposed to patient-centered. These residents tend to delegate tasks to the trainees and minimize or avoid collaborative interactions. Faculty physicians have been helpful in addressing residents’ resistances through modeling their own use of collaborative care. Video-observation of encounters by residency faculty with tactful feedback and suggestions to residents challenged by this model has been particularly helpful. On a larger scale, the success of this collaborative training model depends on multiple prerequisite steps, starting with the establishment of a strong psychology training program within a primary care residency. This requires dedicated departmental resources. It should be noted that often a single part-time mental health professional is used to fulfill the ACGME requirement for behavioral science training and many residency programs only dedicate .2 or .3 FTE to such a position. The curriculum we have described requires a full-time doctoral-level psychologist (because of the psychological testing and research components). In the current time of decreasing funding for GME training, it is challenging to design and implement such programs, which go beyond accreditation requirements and are focused on excellence and innovation in medical education. Beyond funding, the sustainability of the project depends on chair and program director appreciation of its value and support of the supervising psychologist.
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REFERENCES 1. Regier D, Narrow W, Rae D, Manderscheid R, Locke B, Goodwin F. The de facto U.S. mental health and addictive services system: Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry 1993;50:85-94. 2. Kessler R, Stafford D. Primary care is the de facto mental health system. In Kessler R, Stafford D, editors, Collaborative medicine case studies: Evidence in practice. New York, NY: Springer, 2008:9-21. 3. Academy of Psychosomatic Medicine. Mental disorders in general medical practice: An opportunity to add value to healthcare. Behavioral Healthcare Tomorrow 1996; 72:55-62. 4. Katon W. The epidemiology of depression in primary care. International Journal of Psychiatry in Medicine 1987;17:93-112. 5. Pisani AR, LeRoux P, Siegel DM. Educating residents in behavioral health care and collaboration: Integrated clinical training of pediatric residents and psychology fellows. Academic Medicine 2011;86:166-173. 6. Kroenke K, Spitzer RJ, Williams JB, Monahan PO, Lowe B. Anxiety disorders in primary care: Prevalence, impairment, comorbidity and detection. Annals of Internal Medicine 2007;146:317-325. 7. Dilts SL, Mann N, Dilts JG. Accuracy of referring psychiatric diagnosis on a consultation liaison service. Psychosomatics 2003;44:407-411. 8. Blount A. Integrated primary care: Organizing the evidence. Families, Systems, and Health 2003;21:121:133. 9. Blount A, Shoenbaum M, Kathol R, Rollman BL, Thomas M, O’Donohue W, Peek CL. The economics of behavioral health services in medical settings: A summary of the evidence. Professional Psychology: Research and Practice 2007;38:290-297. 10. Craven M, Bland R. Better practices in collaborative mental health care: Analysis of the evidence base. Canadian Journal of Psychiatry 2006;(Suppl. 1):7S-72S. 11. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: A cumulative meta-analysis and review of longer term outcomes. Archives of Internal Medicine 2006;166:2314-2321. 12. Garcia-Shelton L, Vogel ME. Primary care health psychology training: A collaborative model with family practice. Professional Psychology: Research and Practice 2002;33:546-556. 13. Talen MR, Fraser JS, Cauley K. Training primary care psychologists: A model for predoctoral programs. Professional Psychology: Research and Practice 2005;36: 136-142. 14. Blount A, DeGirolamo S, Mariani K. Training collaborative care practitioners of the future. Families, Systems, and Health 2006;24:111-119. 15. McDaniel SH, LeRoux P. An overview of primary care family psychology. Journal of Clinical Psychology in Medical Settings 2007;14:23-32. 16. Cubic B, Mance J, Turgesen JN, Lamanna JD. Interprofessional education: Preparing psychologists for success in integrated primary care. Journal of Clinical Psychology in Medical Settings 2012;19:84-92. 17. Porcerelli JH, Fowler SL, Klassen B, Murdoch W, Sklar ER, Wright BE, Morris P. Behavioral health assessments and interventions of residents and psychology trainees during dual interviewing: A descriptive study. Family Medicine 2013;45:424-427.
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18. Agency for Healthcare Research and Quality. Developing and running a primary care practice facilitation program: A how-to guide. Rockville MD: AHRQ; December 2011. Publication No. 12-0011. Available at www.ahrq.gov 19. Practice Transformation Institute. Mackinac Learning Collaborative, 2011. Available at http://www.transformcoach.org/EducationCME/MackinacLearningCollaborative. aspx 20. Markova T, Mateo M, Roth LM. Implementing teams in a patient centered medical home residency practice: Lessons learned. Journal of the American Board of Family Medicine 2012;25:224-231.
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