A young woman experiences a psychotic break in the hallway of a busy family practice clinic, unnerving the staff and nearby patients with her arm-flailing and jumbled screams about death.

The family of a diabetic patient in the early stages of dementia cannot account for why the patient’s blood sugar levels and blood pressure are veering wildly out of control, despite a carefully prescribed regimen of medications, diet, and exercise.

A patient with chronic back pain returns to the clinic for the fourth time this month, angrily complaining that the "rude and incompetent" resident failed to call in the correct prescriptions to the pharmacy over the weekend.

Scenarios like these regularly play out in family practice clinics and training programs, pitting patients’ emotional and psychological needs against the real-life time and resource limitations inherent in primary care medicine.

Relying on what is often minimal training, family physicians and residents manage the medications and then find themselves conducting psychosocial triage – referring the most complex patients to outside mental health resources when possible, and delivering seat-of-the-pants psychotherapy, motivational interviewing, or crisis counseling in 15-minute doses when it is not.

The less obvious cases, in which smoldering anxiety, grief, substance abuse, or depression underlie physical complaints, may go untreated in the rush of patients and a reimbursement system that has failed to catch up with mandates to employ meaningful behavioral health care in the medical home.

At the Glendale Adventist Family Practice Residency Program in suburban Los Angeles, residents have a back-up plan when their diagnostic skills, medication options, and time run short. Training alongside the 24 residents are five predoctoral interns in clinical psychology, available to assist with crisis management, psychoeducation, and short- or long-term psychotherapy.

They serve for a year, receiving supervision from a multidisciplinary faculty team that includes a psychologist, social worker, psychiatrist, and clinical pharmacologist.

Candidates from graduate psychology programs tend to be "self-selected," arriving with an interest in the biopsychosocial care model and a team approach to psychological care, said James Pathman, Ph.D., the program’s director of behavioral science.

Early on, many of those interns establish relationships with family medicine residents to facilitate care of complex patients through "flags" within the electronic medical record, hallway conversations, and family meetings, he said.

In other cases, collaborative interactions are more spotty and crisis based, leading the program to consider a new approach in which a psychology intern will be embedded as an immediate "go-to" behavioral consultant in each of four resident treatment teams.

Wrapping psychological training and care into the family practice clinic acts as a natural but significant extension of the "overt emphasis on whole person care" that forms the backbone of family medicine training, Dr. Janet Cunningham, program director, said in an interview.

Dr. Cunningham worries less about residents’ abilities to handle "red flag cases" – crises involving overt abuse, suicidality, or psychosis – than the less obvious but very real issues buried in a "sub rosa level of psychological distress," she said in an interview.

By observing psychology trainees interacting with patients and families, the "disease-based model" drilled into the residents during medical school gradually gives way to a more layered understanding of the interplay between patients presenting complaints and their overall lives, including their personalities, histories, and social and family environments, said Dr. Julie Howard, director of women’s health for the program.

"I love the modeling aspect," she said.

Integrated Training Pioneers

Joint training of residents and psychology doctoral or postdoctoral students has existed in a handful of programs since the 1980s, following the lead of such pioneers as Susan H. McDaniel, Ph.D., at the University of Rochester, N.Y. Soon thereafter, programs quietly developed in places such as the University of Rochester; Eastern Virginia Medical School in Norfolk, Va.; and the University of Colorado at Denver.

No one can say with certainty how many such training programs exist today, although efforts are underway to survey ACGME-accredited family medicine training programs to answer that question and assess interest in fostering such arrangements in the future.

In Grand Blanc, Mich., Mark E. Vogel, Ph.D., has seen the residency program at Genesys Regional Medical Center evolve from one in which trainees learned their respective professions separately in shared clinics – "co-located" training – to one of truly integrated care.

"In the old days, [psychology interns] saw patients in their offices, and if residents came with questions they could help them," he recalled in a telephone interview.

Today at Genesys, nine postdoctoral fellows in psychology routinely interact with 70 residents in primary care (family practice, internal medicine, and ob.gyn.), conducting assessments, gathering for hallway consults, and creating integrated treatment plans.

Beyond shadowing residents and providing feedback, psychology fellows accept a wide range of patients for intense, brief, solution-focused psychological care, following a "warm hand-off" from a resident or faculty member in the examining room, said Dr. Vogel, director of behavioral science and psychology at the medical center. Such cases then become the focus of multidisciplinary education and case planning sessions.

In one recent example, a psychology fellow noticed the disengagement of a young mother of a newborn with special needs, something a resident had overlooked in the room.

"She was really quite depressed, and her needs were so paramount she couldn’t attend to the needs of the crying child," said Dr. Vogel.

Beyond assessing the mother for postpartum depression and providing her care, the psychology fellow was able to use the example as a "teaching moment" for the primary care resident comanaging the case.

"We’ve found that case-based teaching works much better than a lecture," said Dr. Vogel.

Bridging the Disciplinary Divide

To be sure, a cultural divide separates medicine and psychology, and each joint training program must find ways to bridge differences in terminology, style, and the structural delivery of care.

Psychologists, especially, are realizing that their softly lit cultural model of long-term therapy in 50-minute sessions may not conform to the increasingly recognized psychosocial needs of large numbers of primary care patients.

"We have to prepare people for the way the world is going to be, not the way the world is now," Dr. Nancy B. Ruddy, a psychologist with Mountainside Family Medicine Residency Program in Verona, N.J., said at a session on integrated training during the annual meeting of the American Psychological Association.

The Genesys model, featured at a different session at the meeting, may be a snapshot of how that world may look.

An evolving focus on mental health in primary care may find psychologists as regular collaborators in community practice, but with a focus that is more immediate, time limited, and problem focused than the care they have historically provided.

"Some psychologists have strong reservations about moving in this direction – and I consider those concerns reasonable, as it is a pretty significant alternative to the traditional model of the psychologist as a provider of individual psychotherapy," said Dr. Robert McGrath, director of a certificate program in integrated primary care in the psychology department at Fairleigh Dickinson University in Teaneck, N.Y.

Others, he said, "are increasingly excited about increasing opportunities for integration."

Family medicine residency programs may also be taking note.

At Genesys, a recent survey of faculty members and primary care residents found a substantial increase in overall satisfaction 2 years into the integrated care program.

On a scale of 0-5, they considered the integrated approach helpful to patients (mean rating, 4.1) and even more helpful to providers (mean rating 4.2), according to pilot data presented at the APA’s annual meeting.

The range of diagnoses referred for psychological care vastly increased, and scores declined on standardized mental health scales administered to 247 patients over 16 months. On the Patient Health Questionnaire (PHQ-9), mean scores declined from 15 to 8.9, while mean scores on the GAD (Generalized Anxiety Disorder scale) declined from 13 to 9.4, Melissa Gray, Ph.D., a graduate of the fellowship program, reported at the meeting.

Who Pays for Integrated Care?

One significant challenge for residency programs remains how to pay for integrated care, especially in a down economy and an era of shrinking reimbursements for even the most traditional types of primary care.

Financial realities are sometimes at odds with a widespread philosophical commitment to whole-person care, and a recent position paper from the American Academy of Family Physicians emphasizes the obligation of every physician to access mental health care for their patients, "whatever the mechanism."

So far, psychologists appear to be taking the lead in developing funding mechanisms for joint training in the primary care specialties.

The Genesys program "took the big jump" to become accredited as a postdoctoral training site by the American Psychological Association, a laborious, expensive, and time-consuming process. As a result, the program can partially cover its costs by billing the Centers for Medicare and Medicaid for some behavioral health services.

"Are we making money? No. Breaking even? Not quite," said Dr. Vogel. But, he added, "People see the value added to the program, and the faculty has become our biggest supporter."

What had long been a healthy partnership, he noted, has become a "great marriage" with the cultivation of an integrated behavioral care model that dovetails with objectives of the National Committee on Quality Assurance and the American Academy of Family Physicians.

"These are exciting times," said Dr. Vogel. "A lot is happening that is moving us into the next iteration of this approach."

Disclosure: Betsy Bates Freed, Psy.D., completed her internship in clinical psychology at the Glendale Adventist Family Practice Residency Program mentioned in this article.

Integrated FP, Psychology Residencies Enhance Primary Care