Transcript Distinguishing Restrained Eaters from Eating Disordered

Psychologists and Primary
Care Physicians: A Training
Model for Creating
Collaborative Relationships
Barbara A. Cubic, Ph.D.
Associate Professor
Eastern Virginia Medical School
Main Objective
Psychologists and primary care physicians
are well positioned for innovative,
interdisciplinary collaborations. This
presentation will review models of clinical
care collaboration and interdisciplinary
training of physicians and psychologists
which result in an egalitarian process and
produce better patient outcomes.
Learning Objectives
 Following this presentation participants will
be able to:


Describe the opportunities and challenges of
integrated care
Consider ways to enhance the competencies of
psychologists and primary care providers
through innovative training models
Term
Source, context, connotation
Integrated
Care
Tightly integrated, on-site teamwork
with unified care plan. Often connotes
close organizational integration as well,
perhaps involving social and other
services
Related to the concepts of Medical Home, a singlesite, regular source of care for individuals seeking a
broad range of biomedical and behavioral health care
services and Patient-centered care “Care that is
respectful of and responsive to individual patient
preferences, needs, and values and ensuring that
patient values guide all clinical decisions” (IOM,
2001).
Goal is an Integrated Care Model
 Focus on biopsychosocial
rather than just biomedical or
just psychosocial aspects of
care.
 Fluid, egalitarian team process


Needs excellent communication
Needs respect & understanding
of diverse backgrounds,
philosophies, & viewpoints of
team members.
 Trade-off of provider
autonomy for better patient
outcomes.
Psychologist
Pharmacist
Patient
&
Family
Physician
NursePractitioner
Creating Collaborative Relationships
with Primary Care Providers
Differing Perspectives
 Primary Care Patients





Have Multiple Medical and Psychological Needs
Most Come in Only When Symptomatic
Expect a Brief Visit and that Pharmacological
Treatment(s) will be Offered
Psychological Advice or Intervention is
Unexpected and Often Unwanted
Referral to Mental Health Seen as Stigmatizing
Differing Perspectives
 Primary Care Providers





Have Large Caseloads of Patients with Multiple Medical
and Psychological Needs
Need to Prioritize What to Address at Each Visit
Ultimately Accountable for Care Provided by Extenders
View of “My Patient” Leads to Expectations
• Coordination of Care
• Exchange of Information with Consultants
Time Pressures
Differing Perspectives
 Psychologists





Confidentiality Given Utmost Importance
Operate Largely in Context of Ongoing
Relationships with Patients
Expect to Complete In-depth Assessments
Trained to Offer Interventions in Units of Time
(e.g. generally 1 hour visits)
Generally Provide Solicited Psychological Advice
or Intervention to Patient or Patient’s Advocate
Psychologists as Team Members Improve
Dx & Rx of Mental Disorders
In an integrated care model Psychologists
can become especially valued because….
 Highly trained in an area many
physicians feel poorly equipped to
treat
 Easily adapt to multiple environments
 Interpersonally skilled
Psychologist’s Contributions
 Use empirically based treatment
methods


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Facilitate adaptation to chronic illness,
disability, and life changes,
Facilitate behavioral change
Co-manage disorders with medical and
psychosocial determinants.
• Understanding of motivational & learning theories
• Cognitive Behavioral Therapy
• Stress management
Psychologists also have a unique
contribution to make regarding
ACGME Competencies
 The ACGME Website provides a toolbox of
assessment methods and examples of use
 Creativity is needed to determine specialtyspecific and institutional-specific application
 We’re experts in the development and validation
of assessment approaches


can offer institution-wide, cross-specialty assessment
especially in domains of communication and
interpersonal skills
Psychologists will be especially
valued because…..
 A lack of time, educational expertise
(especially regarding assessment) and funds
mean meeting competencies are a challenge
for program directors
 ACGME often recommends nontraditional
assessment methods, such as standardized
patients (SPs) and our training prepares us
well to objective evaluate interpersonal
interactions
What We Learned at EVMS from a
Collaborative Training Model
Grant Title
INTEGRATING PSYCHOLOGY INTERNSHIP
TRAINING IN A PRIMARY CARE SETTING
Grant Authors
Barbara A. Cubic, Ph.D.
Funding Source
HRSA
Other Funded Collaborators on the Grant
Daniel Bluestein, M.D.
Kathrin Hartmann, Ph.D.
The EVMS Clinical Psychology
Internship Program
 EVMS is a community based medical school founded in 1976 in
Norfolk, VA
 Norfolk is part of the Tidewater area of southeastern VA, consisting of
7 cities with a population exceeding 1.5 million
 Internship Program is in the Department of Psychiatry which has a
strong psychology division with 8 full time psychologists on faculty
 Internship has existed since 1976-77 and has been APA accredited for
30 years
 Accepts 6-8 interns from approximately 120 to 160 applications each
year
The EVMS Ghent Family
Medicine Residency Program
 EVMS is a community based medical school founded in 1976 in
Norfolk, VA
 Norfolk is part of the Tidewater area of southeastern VA, consisting of
7 cities with a population exceeding 1.5 million
 Ghent Family Medicine Residency is in the Department of Family and
Community Medicine which has 12 full time faculty
 Residency has existed since 1975 and it is an accredited three-year
program which meets all the training requirements of the American
Board of Family Medicine
 Accepts approximately 5 residents per PGY year
Interdisciplinary Behavioral
Medicine within the Internship
 Internship had a behavioral medicine rotation in the Dept.
of Family and Community Medicine (DFCM) in mid
1990's
 Training was highly successful for both the interns and
DFCM residents, but program lacked funding
 Funding through a 2002-2004 HRSA GPE grant allowed
us to place 2 psychology interns on major rotations a year
with family medicine residents (each for 6 months at a
time)
 Current HRSA grant is designed to allow us to move
towards a complete model of integrated care with every
intern rotating in primary care settings 1 day a week or
more
Purpose/Rationale of Our Training
 Model rests on reasons why mental health disorders are
under diagnosed and under treated in primary care:
The stigma of mental illness
 Primary care providers’ limited
knowledge of psychiatric disorders
 Confounds created when mental illness
coincides with chronic physical illness
 Time constraints for primary care
providers

Purpose/Rationale of Our Training
(continued)
 Model also rests on the rationale for
interdisciplinary training:


Historic separation of medical and psychological
training leading to limited understanding of the
different backgrounds, values, professional models,
and ideologies
Often resulting in redundancy of effort, turf battles,
and mixed, confusing, or negative messages to
patients
EVMS Grant Objectives
 Enhanced patient care
 Immediate access to mental health consultation
and treatment
 Optimal patient-treatment matching
 Special exposure to underserved populations
 High accountability of services provided
 Complete integration of mental health issues into
overall primary care management
 Creation of a workforce that is culturally
competent and prepared to provide integrated
care
Proposed Educational Model
 Designed to teach psychology interns subtleties
of working in primary care while concurrently
fostering education of DFCM residents in core
competences, e.g. basic doctoring skills, mental
health, and behavioral health
 Psychology interns placed in the role of
educators, consultants, and service delivery
agents in primary care settings and trained sideby-side with DFCM residents
EVMS Grant Methodology
 Joint patient care delivery
 Additional didactics added to DFCM seminar
series
 Joint intensive and collaborative supervision by
Dr. Cubic and DFCM faculty for both psychology
interns and DFCM residents
 Specialized training in geriatrics
 Specialized training in cultural diversity
 Interns write a paper about a medical condition
and psychology resources/interventions that can be
of assistance to the patient and provider
Settings for the Training
 Morning rounds in an inpatient setting
 Consultation in an outpatient primary care
practice
 Carefully created opportunities for exposure to
geriatric populations and children in a either a
treatment program for attention deficit disorder
or in a school program for at risk children
Number of Patient Contacts by
Setting
160
140
120
100
80
60
40
20
0
Outpatient
Neurofeedback
Inpatient
Assisted Living
Nursing Home
Gender Distribution of Patient
Population Across all Settings
Males
36%
Females
64%
Racial Distribution of Patient
Population Across all Settings
Other
1%
African
American
48%
Caucasian
51%
SES Distribution of Patient
Population Across all Settings
High
1%
Middle
51%
Low
48%
Age Distribution of Patient
Population Across all Settings
>65
39%
<19
16%
19-35
11%
36-50
51-65 16%
18%
Main Psychosocial Issues
Addressed Across all Settings
Other
16%
Cog Px
11%
Mood D/O
51%
ADHD
14%
Sub Use
Anx
4%
4%
Main Concepts Underscored
with Interns
Speaking a New
Language:
“When in Rome
do as the
Romans Do”
As a psychologist you are like a foreigner
in a new country. It is your job to learn
the language, not their job to adapt to
you.
Skills need for a Psychologist to
Thrive in Integrated Care
 Most Vital Skill
 Supervised Formal
or Informal Training Experiences in Primary
Care Should be a Prerequisite
 Avoid Intimidation
Learn Medical Terminology
Let the Unique Skills Psychology Offers Speak
for Themselves/Provide Practical Advice
Must Have a Good Sense of Humor
 Understand Concept of a Treatment Team
 Full Disclosure to the Patient about What Will
and Will Not be Shared
 Understand the Dilemmas Created by Secrets
 Differentiate Between What Needs to be Shared
Versus What is Private
 Use Written Consents in Specific Circumstances
as a Safeguard
Welcome Interruptions
As the Expert in Interpersonal Interactions You
can Facilitate the Team Process
Rely on Oral Communication Primarily esp. if
Treating Patient in the
PCP Office (with brief notes
to document interactions with the
patients or discussions with providers)

Respect the Roles
of Others
Forget What You Learned About Report
Writing In School!!!
PCPs are not Impressed with Theories,
Lengthy Details or Specific Test Scores.
Focus on Final Conclusions and
Recommendations!!!
(Brief Interactions or Therapy Sessions)
 Succinct 1-2 Paragraph Descriptions
 If Documenting in Medical Record

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Use Different Color Paper or Designate a Section as the
“Mental Health Record”
Use Clear Headings
SOAP Notes the Norm
Word Issues Carefully (e.g. conversation about a marital affair could be
worded as “discussed interpersonal stressors”)
 If Documenting in a Separate Chart Periodic
Updates in the Form of a Letter to the PCP Should
be Done
(Psychological Evaluations)
 Reports in the Form of a Letter to the PCP Should
be Done (1-2 Pages Max)
 Most Common Headers
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History of Present Illness (1-2 Paragraphs Max)
Prior History (Only Most Relevant)
Behavioral Observations (Quick MSE)
Test Results (In Language PCP Can Understand)
Diagnostic Impressions (Generally Axis I and II)
Case Conceptualization (Main Findings Reviewed)
Treatment Plan (Bulleted, Specific, Practical Recommendations)
 Offer to Discuss Impressions Further If Needed
Primary Care Visits Are Usually 15 Minutes
Describing Your Role to the Patient to Expedite
Interaction (e.g. “I’m Dr. Cubic, a clinical psychology, and your
physician, Dr. Bluestein, has asked me to discuss strategies
with you for coping with your headaches”)
Stick to the Issue at Hand
CBT and Interpersonal Approaches Work Well
Have Patient Handouts on Key Issues
Offer Broad Based
Clinical Skills
Rule of Thumb is that
80-85% of Presenting
Problems should be Managed in the Office
Know Your Limitations but Recognize that You
Likely Know More about Most Mental
Health Issues than the Other Providers
Be Prepared to be Asked to Comment about
Psychotropic Medications (general comments are within
your scope of practice, but specific recommendations are not unless you meet
APA Level III training)
Carry a Tool Box
Assessment Measures
(e.g. PRIME-MD Patient Health Questionnaire;
Beck Depression, Anxiety, Hopelessness Scales;
Geriatric Depression Scale; Cognistat; Conner’s;
MMSE)
Patient Handouts
(e.g. Coping with Depression, Relaxation Scripts, AA Meeting Directories, Pointers
for Parents with Children with ADHD, Sleep Hygiene)
Referral Information
(e.g. Keep an index of services, support groups, and internet resources for issues of
bereavement, cancer, cardiovascular disease, diabetes, domestic violence,
fibromyalgia, parenting, pregnancy, senior citizens, social services, substance
abuse, STDs, transportation)
“I think Sarah has anorexia nervosa, let’s set
up a family meeting”
VERSUS
“In the last 3 months Sarah’s weight has dropped 18 lbs. She hasn’t had a
menstrual cycle and she is starving herself intentionally. My findings
on the Eating Disorder Inventory-II suggest that she has a high degree
of dietary restraint and poor interoceptive awareness. Her body image
issues place her at risk for a negative prognosis if we don’t involve her
family immediately in her care. Are you comfortable with me setting
up a meeting between you, me, the dietician, Sarah and her family?”
Professional Development:
Strategies for Overcoming Obstacles
Referrals
Documentation
Coordination of
Care
Billing
The House of Medicine
Working as a Psychologist from the
Inside Out
Uncompensated
Activities
Consultations
in PCP Setting
Consultations
in Your Office
Generic
Referrals
Specialty
Referrals
EVMS Evaluation Methods
 Patient Contact Reports
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# of patients seen, # of patients identified with
mental health issue, other relevant tracking data
Pre and Post Physician’s Belief Scales
Trainee Satisfaction Ratings
Patient Satisfaction Ratings
Pre and Post Tests on Knowledge of Primary
Care Medicine, Attitudes about the Elderly and
Issues in Treating Children
Pre-Grant Scores on the
Physician’s Belief Scale
for the DFCM Residents
(Higher Scores Reflect More Negative Beliefs about Identifying
and Treating Psychosocial Issues)
Minimum Maximum
Score
Score
57
83
Mean
Standard
Deviation
69.89
9.85
Feedback Survey Scores from the
DFCM Attendings at 6 months
1= Strongly Disagree to 4 = Strongly Agree
Item
#
Item Content
Mean
1.
….lead to an increased emphasis on
psychosocial issues overall
3.50
2.
….enhanced my comfort in treating
psychosocial pxs
3.17
3.
….I am more likely to investigate
psychosocial pxs with my patients
3.50
Feedback Survey (continued)
1= Strongly Disagree to 4 = Strongly Agree
Item
Item Content
#
4.
….had no impact on the way I deal with
psychosocial issues with patients
Mean
1.50*
*On Item #4 a Lower Score is More Positive
5.
6.
….encouraged me to consider both organic 3.50
and psychosocial pxs in patient care
concurrently
….I am more likely to routinely
3.17
investigate psychosocial issues myself
Feedback Survey Scores from the
DFCM Attendings at 6 months
1= Strongly Disagree to 4 = Strongly Agree
Item #
Item Content
7.
….enhanced GFP residency training
8.
I would be less likely to consult with a psych
intern about a patient…. If they were not in
the GFP setting
9.
I view the psych intern as an important
personal resource in maintaining my
emotional well being
….enhanced the care received by patients at
GFP
10.
Mean
3.50
3.30
2.50
3.67
In Summary, the Training Expands
the number of Psychology Interns
and Family Medicine Residents
that are prepared to work within an
Integrated Interdisciplinary Model
and Prepares both set of Trainees
for a Number of Other Settings