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.