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What Do You Know About Family Medicine?

Posted By Jennifer Ayres, Thursday, October 2, 2014

Jennifer Ayres, PhD is a graduate of the Behavioral Science Family Systems Education Fellowship program. If you are interested in applying, please click here.

“What do you know about family medicine?” 

It was 07:00 PST and I was participating in a phone interview with the program and associate directors of the family medicine residency in Austin.  I had woken up two hours earlier to prepare a brief response to that simple question, so that I sounded simultaneously honest and self-assertive.

“Very little.  However, I know a lot about mood disorders, trauma, substance abuse, personality disorders, and family therapy.  If you’re wanting someone to treat those issues and teach others to do the same, I know how to do that.”  

My first day as a behavioral science educator occurred approximately three months later. The first two years were rough, despite excellent support from the program director and my faculty colleagues.  The credentialing process took six to eight months.  My predecessor was gifted, experienced, and talented in areas that I was (and am) not.  People missed him.  It took almost a year to grasp that teaching psychology graduate students and family medicine residents necessitated a different skill set.  Thus, most of the labor-intensive power point lectures I wrote were ineffective, despite their excellent research reviews and catchy graphics.  Some of the residents were thrilled that I was there, others were suspicious of me and my intentions.  Support group attendance was abysmal.  One of my first resident evaluations included a comment that I had very little to contribute to his/her resident education because I did not understand what being a physician entailed. In the last half of my second year, we had a leadership change after our program director resigned and our associate director assumed leadership. 

The first two years were rough 


Our new program director and I met to discuss if my chosen amount of clinical care (25-30 scheduled patient hours/week) reflected a deeper issue that needed program support. The truth was obvious to both of us. I still thought and functioned as a practicing clinical psychologist because I had not adopted the mindset of a behavioral science educator. We agreed that I would shift to a weekly caseload of 10-15 scheduled patients within six months and that I would seek mentor(s) to help me with this career transition. Several months later, she forwarded me an email about a new fellowship sponsored by the Society of Teachers of Family Medicine (STFM). The primary objective of this yearlong fellowship was to mentor new behavioral science educators.  Four years ago, I was accepted into the inaugural class of STFM’s Behavioral Science/Family Systems Educator Fellowship (BFEF).  

My favorite program evaluation question is “What do you think you will remember from this experience in five years?”  Here is what I remember about the fellowship and the advice I pass along to my colleagues who are new to this field.  It is intended particularly for those who have achieved career success in other areas and are making a professional identity shift from that career to behavioral science education.

(1)    There are resources available that will make your job easier.

(2)    Teaching residents and teaching mental health students require different strategies and techniques.

(3)    There is a wonderful conference every September in Chicago (“The Forum”) and most presentations will be applicable to your work.  Attend, if possible.

(4)    Other people also struggle(d) to integrate behavioral health into programs that are focused on the medicine aspects of teaching family medicine. Support is available.  Reach out.

(5)    Be patient.  It takes at least three years to have a resident cohort that does not remember the program without you. 

(6)    Some residents will need several years of professional practice before they realize that behavioral health is a necessary component of family medicine. Keep the labor-intensive power points handy because someday they may shift from ineffective to a desired resource.

(7)     Apply for the fellowship and join this community.  You will not regret it. 

I was struck by how many people wore gold beads The first night of the Forum involves an event known as the “Gathering In.” This event brings together new and experienced behavioral science educators to discuss an issue in our field. I attended for the first time during my fellowship year. We participated in an activity that involved wearing different color beads to indicate our number of years in family medicine education. I was struck by how many people wore gold beads, which indicated greater than 25 years of experience in our field. That number seemed unimaginable to someone in the first month of her fourth year and I could not envision myself attending the Forum in 2031 when I would reach gold bead eligibility. Now I predict that several of us from my BFEF cohort will be there, wearing our beads proudly and welcoming new members to their first Forum.  



Jennifer L. Ayres, Ph.D. is the director of behavioral health services at the University of Texas Southwestern Austin Family Medicine Residency Program.  She is a clinical psychologist who completed a postdoctoral fellowship in child abuse and trauma.  Prior to her current position, she worked as a trauma psychologist in community mental health centers and was an adjunct professor of psychology. Her interests include trauma in primary care, resident self-reflection and support, supervision of psychology students in integrated behavioral healthcare settings, and palliative care/family medicine collaborations.



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If You Want to Get the PCMH Working, Hire a Psychiatrist

Posted By Andrew Pomerantz, Thursday, September 25, 2014

Dr. Pomerantz's post is the second in a 3-part series leading up to the 2014 CFHA Debate at the Conference in Washington DC. The debate will present major issues that have yet to be clearly resolved in the professional literature.

Let’s assume that you managed to find the end of the rainbow and found that elusive pot of gold.  Being the good PCMH (Patient Centered Medical Home) fanatic that you are, you decide to spend it all on integrating mental health services into your medical home.  Alas, you find the price of gold has dropped and all you have is enough to hire one full time therapist, one and a half nurse care managers OR one measly day per week of a psychiatrist. No one in his or her right mind would choose the latter of those three but I am here to argue on behalf of it anyway; for two reasons: 



Reason 1:  Past is prologue to the present

First, see Dr. Simmons’s recent blog entry arguing that the leader of the PCMH should be a physician. I won’t repeat the points he made about the depth and breadth of training of family physicians, other than to say that psychiatrists have similar training, encompassing psychological, social, biological and spiritual aspects of human health and well-being (OK, I hear you and will withdraw the claim for the generalization about spiritual – I am one of the lucky ones who has worked intensively with clergy for decades).

From the earliest days of healthcare (shamans, etc), organized societies have identified specific individuals as healers, whether by divine choice or by schooling and training.  At times they were treated as slaves to the masses but, thankfully, long before I came around, we were getting a much better deal.  Like it or not, our culture still carries the belief that we physicians are the only ones with the depth of knowledge to help them attain or maintain health.  The buck stops with us. Do I like that?  Not particularly.  I’d much rather share the burden but, when it comes to societal norms, third party reimbursement or medicolegal liability, we are “it.”  

Without a psychiatrist, patient outcomes are at risk 

Randomized clinical trials (such as IMPACT and RESPECT) using nurse care managers have clearly demonstrated their value in achieving the triple aim. Patient outcomes are improved, patients like the care and costs are reduced.  But care management protocols require a supervising (not consulting) psychiatrist to review cases, make recommendations, do some troubleshooting and identify patients who need more than telephone care.  Without a psychiatrist in the mix, costs are still reduced and patients might be happy but outcomes are at risk.  Better to have a psychiatrist working in the PCMH and have him or her train primary care nurses to run the protocols.  PC nurses often do much better than mental health nurses because they don’t digress into therapy but stick to the protocols. 


As for therapists, first let me say that my closest professional colleagues are therapists.  Some of my friends as well, though I prefer being around people who don’t do anything like what I do.  They are great but usually lack the biological understanding of the mitochondria gone wrong or the demyelination progressing or any one of a number of physiological perturbations that often masquerade as troubles needing therapy.  As a consultation psychiatrist I’ve seen too many patients getting treated for panic disorder while their thyroid goes unchecked or patients with early multiple sclerosis being treated for conversion reactions.  Behavioral presentations of serious illnesses or drug interactions often get in the way of the PCP evaluation and it’s up to the psychiatrist to sort it all out.  Someone has to be looking at the cases before jumping into therapy.

Reason 2:  Odysseus

No, not Oedipus.  Odysseus, husband of Penelope, son of Laertes and Anticlea and so on. Odysseus faked mental illness in a futile attempt to avoid winding up in what became the Trojan War.  Once in the war, he is credited with coming up with the idea of the Trojan Horse.  The Greeks presented this hollow wooden horse filled with soldiers and led by a front man to the Trojans and the rest is history (truth be told I have a tough time distinguishing myth from history but after a certain period of time it doesn’t matter).   “Beware of Greeks bearing gifts” is a common phrase even today.

Why the digression?  Let’s say everyone follows my recommendation in this blog. When all that we are doing to improve healthcare becomes ancient history that one-day-a-week psychiatrist will be known as our front person for a horseload of psychologists, social workers, peers, nurses and others.  The psychiatrist, while often maligned by some medical colleagues, is still “one of us” when viewed by the PCP.  The MD after the name immediately generates a trust that PHDs, RNs, LPNs, MSWs and others often spend years trying to establish.  Get me in the door and after I say for the hundredth time “need someone else to help get that A1C down and get the pain under control,” they’ll be begging for the rest of the team.


Dr. Pomerantz is the National Mental Health Integrated Care director for the Veterans Health Administration and Associate Professor at the Geisel School of Medicine at Dartmouth (which he prefers to think of as the Dr. Seuss School of Medicine).  He spent the first 12 years of his career as a PCP carrying his little black bag around the hills of central Vermont before training in psychiatry in hopes that it would make him a better PCP.  Unfortunately, he never went back, though he works virtually from an office just down the street from his former practice.  If he ever gets broadband at home, he’ll work from where he belongs.  He still has his little black bag, just in case. 


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If I Knew Then What I Know Now: Research As Reflection

Posted By Christina L. Vair, Tuesday, September 23, 2014

Christina Vair, PhD, is the 2013 CFHA Fellowship Award recipient. Below is her reflection on her research project.

As the old saying goes, “hindsight is 20/20.”

With the 2014 CFHA conference nearly upon us, I cannot help but think back on last year’s conference, in particular, my receipt of the 2013 CFHA Fellowship Award. In doing so, I have found that oft used phrase referenced above coming to mind regularly. Looking back over the course of this past year, I appreciate how this particular project was inspired by and, in many ways encapsulates, my own professional journey. Though I am certainly excited to present the findings of my study on advanced psychology trainees’ perspectives on preparation for practice in integrated care settings, this forum grants me the unique opportunity to reflect on the process of conducting this research, rather than just the outcome. Through undertaking this project, I have been provided with an opportunity to reflect on my own learning over the last several years and contemplate where I’m headed in the future.



My interest in developing an academic understanding of the primary care psychology trainee perspective is rooted in my own personal training experiences. I first stumbled into the world of integrated care during my last year of graduate school.  Though I was quite naïve to the concept of integrated care at that time, I was none-the-less tasked with providing brief assessment and treatment to older adults attending a day heath care program. What might have simply been a one-time, “been there done that” training experience touched off a desire to develop a career as a psychologist in integrated care. This was the first time in my training as a psychologist that I felt as if things really “clicked” for me. The whole person, patient-centered approach to care, the consideration of the interrelationship between mental and physical health, and the dynamic, team-based approach resonated with me on many levels.   

From that first experience, I was hooked. I had found my professional “home.” Next came an internship with emphasis in behavioral medicine, then a postdoctoral fellowship focused on primary care-mental health integration with the Department of Veterans Affairs Center for Integrated Healthcare. These increasingly focused opportunities further opened doors that solidified my dedication to integrated care, and in turn, my desire to learn more about what other trainees like me were experiencing in their journeys into primary care psychology.  As the intensity of my training increased, I found myself regularly wondering how other trainees found the path to primary care psychology, whether they too intended a career in this field, and what they needed to succeed in this pursuit. These questions set the stage for my research proposal to investigate the trainee perspective, particularly as a review of the literature on training models for behavioral health providers in integrated care appeared to lack this consideration.

I found myself thinking, "what if I knew then what I know now?" 

Flash forward to a year later. A survey was designed, distributed nationally, piloted along with the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ)1, a recently developed measure of fidelity to model adherent behaviors in providing mental and behavioral health care in integrated care settings. Responses from across the country trickled in, and a data set was born. Analyses were undertaken, and various themes emerged. All the while, with each iterative step, I found myself learning new and different things.  I found myself thinking often about my own professional path, and wondering, “what if I knew then what I know now?” 


One particularly salient response that I found myself pondering in relation to that question was a desire to learn to embrace the inherent challenge of having dual identities. One particular duality that sprang to mind was how to balance being both a clinician and researcher. Though I had been training as a “scientist-practitioner” since graduate school, conducting this study was truly the first time that I authentically felt like a “scientist” thus far in my career. Within scientist-practitioner programs, students are theoretically taught to equally value clinical practice and research, and to appreciate the reciprocal and potentially mutually beneficial relationship between the two. Though internship had helped me feel as if I had developed solid clinical “muscle,” my sense of identity as a scientist was comparatively puny. I found that I had learned to “walk the walk” as a clinician, but was not yet comfortable in my ability to “talk the talk” of a clinical scientist. 

Having had several rich opportunities to explore assorted supportive roles on research teams prior, this project represented my first foray into the role of a principal investigator. Up until this point, I had learned the basics of integrated care in a mostly experiential manner, and found my knowledge wanting in regard to the theory behind the practice. Delving headlong into the scholarly literature on training models, core educational components, and the development of competencies for practice in primary care psychology provided a solid foundation for learning the language of integrated care. Understanding and adopting this lexicon has facilitated my ability to not only articulate more thoughtfully and concisely what it is I “do” as a psychologist in primary care, but has also helped me define where I see myself going in the future. Further, exploring and engaging with this literature has also helped me develop an awareness of the gaps in my own training thus far, and presented the opportunity to develop goals to address the areas in which my own competence lags.

This lexicon helped me define where I see myself in the future 


So where do I go from here? How do I use what I have learned from this experience to move forward, to continue to develop as an integrated scientist and clinician, and help shape the field of primary care psychology? Research is of little use if it’s not disseminated. Then of course every good study has a “Future Directions” section. 

As another old saying goes, “the journey of a thousand miles begins with a single step.”      



1. Beehler, G. P., Funderburk, J. S., Possemato, K., & Vair, C. L. (2013). Developing a measure of provider adherence to improve the implementation of behavioral health services in primary care: A Delphi study. Implementation Science, 8(19). doi:10.1186/1748-5908-8-19


Christina L. Vair, PhD is a licensed clinical psychologist with the Center for Integrated Healthcare (CIH) at the VA Western New York Healthcare System (VAWNYHCS) in Buffalo, NY.  Prior to her current role as a clinical researcher, she completed a two-year postdoctoral fellowship with the VA Advanced Fellowship Program in Mental Illness Research and Treatment (MIRECC) with the CIH that focused on improving the health of veterans through enhancing primary care-mental health integration. During her post-doc and internship with the VAWNYHCS, Dr. Vair provided mental and behavioral health services in primary care, chronic pain management, behavioral medicine, and long-term care. Dr. Vair earned both her MA and PhD in clinical psychology with emphasis in Aging and Geropsychology from the University of Colorado, Colorado Springs. Her research interests including exploring mental health concerns of the aging population within the primary care (PC) medical setting, dementia screening and treatment in PC, and improving the implementation of primary care-mental health integration through provider training, fidelity assessment, and the utilization of measurement in guiding care.  

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Only a Physician has the Experience, Training, and Expertise to Lead the PCMH Team

Posted By Paul Simmons, Thursday, September 11, 2014

Dr Simmons’s post is the first in a 3-part series leading up to the 2014 CFHA Debate at the Conference in Washington DC.  The debate will present major issues that have yet to be clearly resolved in the professional literature.  The question for Dr Simmons’s debate with Dr Susan McDaniel will be “Does the PCMH require that a physician be the team leader?”

The patient-centered medical home (PCMH) is all the rage nowadays, despite recent evidence that the “team-based” model of primary care delivery does not lower service use or total costs, nor does it improve care quality significantly1.  Although populated by highly-educated graduate degree holders who should probably know better, PCMH and collaborative care advocacy is often an exercise in cart-before-horse confirmation bias.  Advocates want collaborative care teams to work, so they design, execute and publish studies that make them look like they work.  Where is the null hypothesis?  Where is the study that seeks to show that team-based collaborative care does not work and, much to the researchers’ collective surprise, it actually does?  I fear that we’d still be bleeding people if real medical research were done this way.  One marvels that a negative study like the one above was published!



Now, some PCMH true believers are advocating that someone, anyone, other than physicians should lead the teams on which the collaborative care approach is based. Nurse practitioners, physician assistants, behavioral health assumes physical therapists, chiropractors and homeopaths are not far behind to accede to the throne.  This democratic, egalitarian idea is bad for primary care medicine and for patients.  Below, I will explain why.

This democratic, egalitarian idea is bad for primary care medicine and for patients 

But first, an analogy:  I boarded a flight the other day (of course airline analogies are required - all the quality improvement types are in love with medicine-as-airline-industry metaphors) on my way to yet another PCMH conference.  As I crossed the threshold, I was greeted by a chipper flight attendant.  Looking to my left through the cockpit door, I saw the pilot and co-pilot going through their preflight checklist.  About a half hour into the flight, a plume of black smoke emerged from the right side turbine.  I looked worriedly from my window up toward the cockpit, where the pilot, co-pilot and two flight attendants were having a team meeting.  I could overhear bits of their discussion.  To my shock, the pilot and co-pilot were asking one of the flight attendants what they should do!  Not usually one to speak up, I raised my trembling hand and politely interrupted, “Er, Captain - shouldn’t you be flying the plane?  I mean, you’ve got years of experience, hundreds of hours in simulators dealing with problems like this, and the flight attendant...well, doesn’t (all due respect to him).”  The pilot held his hand up to stop me.  “Sir, he said, “this is our new passenger-centered, team-based model of flight, and the flight attendant is the team leader today.” 


Obviously, this is a ridiculous scenario.  Pilots on airliners are in charge because they have the experience, training and expertise - they know the most about the plane, how it works, and how problems should be managed.  To switch analogies, the military has not historically advocated team-based operations led by junior enlisted men, and there are very good reasons for this.  When lives are on the line and important decisions need to be made, the person with the most experience, training and expertise should make those decisions.  Perhaps collaborative care advocates have forgotten that patients’ lives and health are in our hands - perhaps medical care in modern America doesn’t feel like a life-and-death, serious responsibility - but it is.  It should be approached with the moral weight it deserves, not as an opportunity for committee-based social experimentation meant, one might suppose, to inflate the perceived importance of certain professional groups.

The possession of a medical doctorate, in the United States, certifies that its holder had completed a certain depth and breadth of training, regardless of what state or graduate school awarded the doctorate. Family physicians (to focus on one specialty) complete 11 years and 21,000 hours of standardized training regulated by one licensing body, the American Board of Family Medicine.   Furthermore, though it may seem anachronistic and quaint to cynics, physicians take an oath that has historically defined our profession:  to put patient interests always above our own.  This oath gives physicians a moral burden of responsibility not shared by others.  The ultimate responsibility for our patients’ well-being, like the well-being of troops under a general’s command, falls to us and cannot be transferred to other “team members” when convenient.

However, if advocates of team-based, collaborative models want to stand on a democratic approach, then they should listen to what patients want:  “72 percent of American adults prefer physicians to non-physicians when it comes to health care, 90 percent of adults would choose a physician to lead their ‘ideal medical team’ when given the choice, and by a greater than two-to-one margin, adults see physicians and family physicians as more knowledgeable, experienced, trusted and up-to-date on medical advances than non-physicians.”2

We should listen to what patients want 


So other clinicians want to lead the collaborative care team?  This perspective suggests not only a low opinion of physicians, our professionalism and our training, but a low opinion of what it means to work in a team.  Is there not nobility and usefulness in performing one’s vital, though limited, role as part of the patient’s care team?  Is being designated the “leader” the only viable way to make oneself indispensable and, when it comes down to it, to get paid?

If so, then I have little confidence, as American health care flies toward the mountainside with engines failing, that those who are least qualified to fly the plane will get us safely back home.  All parts of the crew are valuable, whether we’re talking air travel or medical care, but not everyone is equally qualified to lead.


1.    Friedberg, Mark W., et al. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA 311.8 (2014): 815-825. doi:10.1001/jama.2014.353

2.    AAFP 2013 Dec 18, “Americans Want Physicians Handling Their Health Care”. Retrieved from


Dr. Simmons is a faculty physician at St. Mary's Family Medicine Residency.  He received his medical doctorate from the University of Colorado, and completed his residency in family medicine in 2002.  He practiced full-spectrum family medicine in rural communities in Wisconsin and Colorado before joining the St. Mary's faculty in 2010.  He is an advocate of evidence-based medical practice, a merciless critic of wishful thinking, an armchair philosopher, and an avid spoiler of domesticated animals.

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Transparent Reflection

Posted By Jeff Ring, Thursday, September 4, 2014

The floor of this cozy office that has served as my professional home for the past nineteen years is littered with folders, charts, articles and books.  I pick up a yellowed transparency from my early years of teaching and hold it up to the light.  “B is for Background; A is for Affect…”

I catch my own reflection on the shiny plastic…an uncanny vision of the teacher I am today…thinner hair…graying temples.  Wiser? Yes.  Confident?  Thank goodness!  I glimpse how far I have evolved from the naïve, tender behavioral scientist who began his integrative care and teaching journey here in 1995, at that time with ‘high tech transparencies!’



Throughout this process, I have been reflecting on an amazing human energetic pull which mystically draws us to a certain profession or avocation, as it has drawn me to collaborative care with physicians.  “Calling” is a remarkable human phenomenon.  It consists of heeding an internal voice…a tugging on the soul…an illuminated pathway on an otherwise gray and muddled map of life.

When my parents divorced and I felt as if the entire world had broken apart, a therapist provided me with a caring vision of a way forward.  She also helped me cope with a mother who was navigating several chronic medical conditions.  Later in middle school I realized that learning and speaking Spanish came easily to me.  These three threads wove together in a vision of someday providing precious integrated mental health services in Spanish to the underserved Latino/a community of my native Los Angeles.

"Calling" is a remarkable human phenomenon How many people can say that they have lived out their calling as I have, with deep fulfillment, for almost twenty years? I am grateful for the opportunity to serve.  I am grateful for how much I have grown in treating patients and in shepherding residents to bloom into exquisite healers (mostly in underserved communities!).  I am grateful for program directors and colleagues who have patiently mentored me along the path to become the teacher I am today.  I am grateful for the enthusiastic welcoming of my ideas, input and interventions in the shared mission of caring for vulnerable patients with residents on a steep, exhausting learning curve.  I pack to leave with great ambivalence and a heavy heart. 


My days are now mostly filled with tearful goodbyes. Moreover, my days are filled with direct, honest conversations about my impact on others and their impact on me. These exchanges happen with residents, patients and colleagues. I swim daily in the humble waters of sadness, appreciation, disappointment, joy and spiny questions about my decision to leave.

Very soon, someone new will sit at this desk, and eventually will gather the courage to walk down the hall and dive into collaborative teams with medical colleagues and learners. What are the pearls of collaborative, integrated care that I carry with me into my next endeavor and which I happily share with my replacement? These include: Gifts, Curiosity, Reflection, and…of course…Transparency.


My mother was a gifted and creative special education teacher, and I have taken her dedication to learning into my work.  I hunger to know more and to understand others more deeply.  Each patient provides a new challenge of how to help, and how to discover the tools that empower us as a team – physician and psychologist – to bring relief, support, acceptance and change.  The joy of working in a collaborative learning relationship is the same joy of attending college as a learner...that of uncertainty, investigation and discovery.  To work in a situation where my psychological curiosities interplay with medical colleague’s medical curiosities is to throw rocket fuel on both the learning process as well as on patient care.  Diversity of perspective is precisely the propellant that I have found so intellectually invigorating. 


James Hillman, the gifted Jungian Analyst, wrote that experience does not become meaningful without essential reflection.  Our physician colleagues are incredibly busy, battered by challenging patients, painful narratives, overwhelming documentation demands, and personal burnout potential.  A unique role for the Behavioralist is providing a place and space for reflection on one’s work, and self-reflection on one’s internal experience.  Moreover, we serve as reminders of, and cheerleaders for, a regular mindful experience of inner reflection.  My goal has always been to train outstanding physicians who have a long shelf life, protected from the caregiver burnout inherent in this work.  The encouragement of and modeling of reflective practice is an essential nutrient toward this goal, and a rich foundation of the psychological contribution to enhancing care.

Reflective practice is an essential nutrient and a rich foundation 



Truth be told, there are things that we will never fully comprehend:  A mysterious fetal demise.  A tumor that disappears without treatment.  An unexpected death in a seemingly healthy youth outside of the expected lifecycle.  The culture of medicine seeks to determine an answer for every clinical presentation.  This attitude is inculcated in blazing Socratic pimping on medical rounds, and boils in the hearts of dedicated doctors who desperately prescribe the optimal cure.  The Behavioral Scientist often serves that essential ethical role of reminding colleagues of what cannot be known.  Leah Hager Cohen’s aptly titled book I Don’t Know: In Praise of Admitting Ignorance’ reminds us that it may not always be optimal to pretend an understanding that we do not possess.  It may be unfair to wear such a mask in front of patients, and we may pay a greater personal price than we realize when we do so.  Might there not be value in joining the other in a shared experience of ambiguity.  I have strived to work in an honest, transparent way, and to hold the same expectation for honest transparency in return from colleagues and in their work with patients.  


Almost twenty years later, ‘B’ still stands for Background and ‘A’ still stands for Affect, even if they now twirl with graceful entrances on Power Point slides or swoop through a Prezi forest!  I am grateful for my nineteen years in collaborative medical care and education, and for all the gifts I have received.  I am grateful to CFHA for this invitation to transparent reflection in preparing this blog, allowing me the opportunity to move my own wealth of experience into deeper personal meaning.                                  

What’s next for me?  I better take a deep breath, bend down, and get this office floor cleaned up to make way for the next behaviorist to take my place.  I smile at the remarkable journey that lies ahead for that fortunate individual, and I look back wistfully at a time long ago when I first arrived.  


Jeffrey M. Ring, Ph.D. has served as Director of Behavioral Sciences and Cultural Medicine for the past nineteen years at the White Memorial Family Medicine Residency Program in the underserved community of Boyle Heights in Los Angeles.  He is Clinical Professor of Family Medicine at the Keck School of Medicine at the University of Southern California.  Dr. Ring is the first author of Curriculum for Culturally Responsive Health Care: The Step-by-Step Guide for Cultural Competency Training (Radcliffe Oxford, 2008). In October, he begins as a Principal Consultant for Health Management Associates, assisting organizations in enhanced delivery of integrated health and behavioral care to vulnerable populations.


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(Don't) Climb Every Mountain

Posted By Randall Reitz, Thursday, August 28, 2014

“Climb every mountain,”


--Theatrical claptrap


"Ford every stream.”


--Musical rigamarole


"Follow every rainbow,"

--Rodgerian drivel 


"'Til you find your dream.” 


--Hammersteinian Hokum 



While this counsel might make sense in a world where singing nuns marry strumming captains, it should never be the theme song for integrated care.

Lest you think I’m being overly dramatic, I’ll explain with a story. This summer I had the pleasure of visiting the mountain countries of Europe with Ana and our children.  One of the highlights was a day trip to Grindelwald, Switzerland.  I had visited this alpen village 14 years previously and my descriptions of the bucolic valley had the kids primed for a thrilling day of fanciful chalets, rugged edelweiss, merry cows, and alpine slides.



Arriving in the town, I quickly got my bearings off the tourist map and oriented myself to the enormous crags that crowned one entire side of the valley.  We excitedly set off to hike up the chosen mountain, rent scooters, and then zip down the switchbacks.  Unfortunately, over the next 2 hours we marched up, down, and across the town, just trying to find the trailhead to get us started.  We enquired with many people who each seemed to give us conflicting directions. The signs were all written in German.


And then it dawned on me that we were pointed toward the entirely wrong side of the valley.  Based on my memories from the previous trip and the map (which emphasized form over function), we had focused on the wrong set of peaks.  After turning the map 180 degrees the correct landmark was immediately apparent, but our children were exhausted and in no way interested in an additional 2 hours of hiking.  They had lost faith in their father’s orienting skills and now only wanted ice cream and the community pool.


In our day’s pursuits, we shouldn’t have climbed every mountain, but rather the 1 right mountain. We shouldn’t have followed the happy images of a rainbow map, but rather referenced reliable data. 


We need confidence that we are climbing toward the correct peak 

Integrated care strives to be an evidence-based best practice.  While it is too soon for us to positively affirm that our models are all empirically certified, we should at least hold ourselves to a standard of not implementing operations and interventions that have been debunked by the literature. Or, returning to my story, we need to have confidence that we are climbing toward the correct peak.


And similarly, as Alfred Korzybski famously opined “The map is not the territory”. As scientist-practitioners we rely on the scientific and scholarly literature to guide our steps across the lay of the land.  For this reason, our progress in the integrated care terrain is often predicated on the accuracy of our discipline’s maps and the helpfulness of our road signs. 


At this year’s CFHA conference, participants will have numerous activities to find their own bearings and contribute to the scholarly maps of our terrain.  I’ll highlight 2 opportunities:


DEBATE:  Over the past 10 years of the development of integrated care, the following 3 assumptions have been central to our efforts:

1.       The patient-centered medical home is the ideal setting for achieving the Triple Aim of improved patient experience, improved population health, and reduced cost. 

2.       Integration of psychotherapists into primary care is the key first step in building integrated settings.

3.       Clinical teams should be led by physicians. 


But, what if each of these assumptions were wrong?  What if each these core tenants oriented us to the wrong mountain and we would have been better served by investing our time and resource summiting entirely different peaks?


On Friday, morning Jodi Polaha and I will host a debate in which 1 contestant will make the empirical and theoretical case for 1 of these assumptions and his/her opponent will attempt to debunk the assumption or make the case for a different peak more worthy of our efforts.  Our debaters will be Susan McDaniel, Sandy Blount, Ben Miller, Barry, Jacobs, Andrew Pomerantz, Jeff Goodie, and Paul Simmons. The audience will choose the winners, who will be awarded a signed copy of the losers most revered publication.

Come See the Debate! 


WRITING WORKSHOP:  On Thursday, Lauren DeCaporale-Ryan and Laura Sudano will convene a free pre-conference workshop targeted for early career professionals seeking to contribute to the professional literature of all formats (research reports, case studies, theoretical analyses, personal narratives, and professional blogs). In addition to instruction from Colleen Fogarty, Larry Mauksch, Susan McDaniel, Matt Martin, and myself, each participant will benefit from 1-to-1 coaching related to a manuscript they submitted to the workshop faculty before the conference.  


Onward then, to climb relevant mountains, ford reasonable streams, and follow evidence-based rainbows in pursuit of our dreams.  Rodgers and Hammerstein it is not, but we suspect you’ll leave equally inspired.


Randall Reitz , PhD, LMFT is the Director of Behavioral Sciences at the St Mary's Family Medicine Residency in Grand Junction, CO. In addition to training residents he also directs a fellowship in Medical Family Therapy. His scholarly pursuits include medical family therapy, professional development, healthcare ethics, and integrated primary care.

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Why Do I Write

Posted By Colleen Fogarty, Thursday, August 21, 2014

Today I sit at my desk, having blocked out time to write and cleared several piles of paper off my desk, (okay, honestly, pushed them behind the computer where I could no longer see them), facing an nth revision of a paper that has been rejected by two journals.  Discouraged by the work in front of me, I again face the question “Why do I write?”

“A perfect time,” I think, “to write that blog for CFHA, plugging our preconference session on writing!”

Does writing this essay represent procrastination from the real task at hand, revising the manuscript before me? Or does this post represent an honest self-appraisal of the inevitable roadblocks, or “writer’s blocks” that all writers face?

Why do I write?

Sometimes when I’m asked this question, or ask myself, I wax philosophical about the importance of sharing experience with a wider audience, the role writing can play in helping me know what I think, and the academic currency writing can generate in larger circles.

Why do I write?

Aren’t there plenty of other things I could or should do?--Teaching residents, seeing my own patients, documenting evaluations for learners, writing clinical notes for patients. Administrative tasks galore in my roles in residency and fellowship education. I sandwich in the writing; one more thing to do! Sometimes I DO write because I AM stubborn. No way I’m going to let this lug of text that I’ve invested time in, go into the metal file or circular bin.

Why do I write?

That’s another question altogether. Why me, indeed? The person who suffered the indignities of the red pen from college writing instructors after having been awarded the Veterans of Foreign Wars “Voice of Democracy” essay contest prize during high school? Who sits today amidst a stack of marked up manuscripts, desperately trying to revise a paper in ways small and large. Who, like others in academic medicine, can feel no small dose of “imposter syndrome” when it comes to writing.

Why do I write?

Writing? Really? Why bother? It’s only patient volume in the form of my own patients and my residents’ patients that brings in the revenue to keep the lights on, after all. But the nagging voice of experience keeps saying, “Do it! Show them you have something to say!”

I slog back to the paper, pull new articles to review and reference, incorporate changes, discard ideas that I thought were truly revolutionary and reviewers found unhelpful, and allow myself to know, finally, that this revision won’t be finished today. But I have to coach myself to keep at it. Block the time, do the work, the slow, sometimes agonizing work of putting idea to word, word to sentence, sentence to paragraph, and slowly, slowly, build my thoughts.

For me, writing is a journey and a destination. Arriving at the destination requires embarking on, and continuing the journey. The rest stops, roadblocks, breakdowns, and route changes characterize the journey. Sharing these with others helps keep perspective that the journey is important, and allows us to collectively rejoice when we have reached the destination. 

Writing is a journey and a destination 

So, after sharing my writing roadblock I hope that you will join me and a team of colleagues, at the CFHA pre-conference “
From dissertation to dissemination: An interactive writing workshop.”

We will share the joys of writing, and offer strategies to address the inevitable barriers and frustrations that exist in the life of any writer, no matter how experienced. I look forward to sharing your writing journey!

 Colleen Fogarty, MD, MSc, is the Director of the Faculty Development Fellowship and Assistant Residency Director at the University of Rochester/Highland Hospital Department of Family Medicine. She earned her medical degree at the University of Connecticut School of Medicine and completed residency at the University of Rochester.  Dr Fogarty has additional training in Family Systems from the University of Rochester and a Master of Science in Epidemiology and Biostatistics from the Boston University School of Public Health. A community health center “lifer” she has worked at CHC’s in rural Michigan, rural and urban western New York, and South Boston. She now provides care for patients and families at Brown Square Community Health Center (CHC), the site of her residency practice. Dr. Fogarty’s publication record includes both empirical and creative work. Her scholarship includes work in primary care identification and management of mental health conditions, intimate partner violence, and cultural humility training. Her empiric publications have appeared in Family MedicinePreventive MedicineThe Clinical Teacher, and other journals.  


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Lessons in Not Reinventing the Wheel: What MLP Can Learn from Other Integrated Care Models

Posted By Maggie Eisen, Thursday, August 14, 2014
(This is blog post is a reprint of a piece by Maggie Eisen on July 23rd, 2014. Click here for the original post. Reprinted with permission.) 

As someone who recently helped start a medical-legal partnership (MLP) in Philadelphia, I have found that there are important lessons to be learned about integrating services, not just from other MLPs, but from our healthcare partners themselves who already embrace other models of interprofessional, collaborative care.  After working my way through 
Phase I of the 2014 MLP Toolkit, I wanted to offer two additional pieces of advice to anyone starting an MLP:
  • Mine a potential health care partner’s internal landscape and history for examples of service integration, whether successful or not.  Indeed, advice and technical assistance from the National Center for Medical-Legal Partnership (NCMLP) and from other MLPs will be essential to your planning and implementation processes.  However, it’s critical to dedicate equal attention to unpacking the history and experiences of the place where you plan to integrate legal advocates and learn all you can from their past attempts at service integration.  As Phase I of the MLP Toolkit mentions on page 6, “Addressing psychosocial and care coordination needs have been increasingly accepted as critical to improving health, and both social workers and patient navigators have been integrated into the healthcare team at most healthcare institutions.”  Leveraging these types of experiences, lessons learned, and best practices will likely streamline your integration process, making it more efficient and effective.  They have lessons to teach MLPs, and an individual healthcare institution’s personal history with these types of projects may inform their willingness to partner with legal services.
  • Explore websites and publications authored by thought leaders from organizations in parallel movements like Collaborative Family Healthcare Association (CFHA), which was established around the same time as the first medical-legal partnership at Boston Medical Center.  Just as NCMLP espouses the importance of fostering relationships across disciplines to “build a better healthcare team,” CFHA “envisions seamless collaboration between psychosocial, biomedical, nursing, and other healthcare providers, and views patient, family, community, and provider systems as equal participants in the healthcare process.”  To get started, I recommend reading a recent blog post on interprofessional integration processes by Dan Marlowe, PhD, LMFT on CFHA’s website.
Medical-legal partnership and all other “strains” of integrated care delivery should not be considered as ends in themselves; rather, they are iterative processes, deeply dependent on thoughtful cultivation of trusting, equitable relationships.  These critical relationships should be made horizontally and vertically, within and across organizations and movements, as we strive together to achieve the healthcare Triple AimAnd making use of existing infrastructure and familiar operational procedures is a strategic way for MLP practitioners to anticipate and answer institutional resistance to integrating legal advocates.

Maggie Eisen is the Director of Medical-Legal-Community Partnership at Philadelphia Legal Assistance.  Their medical-legal partnership works with the Philadelphia Department of Public Health, Ambulatory Health Services Division. She writes for the blog "Bridging the Divide: Trends, Topics, and Tips in Medical-Legal Partnership".

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Joint Principles 2.0: The Pursuit of the Real Medical Home

Posted By Matthew P. Martin, Thursday, August 7, 2014
(This blog post is based on the recent press release by the Families, Systems, and Health journal)

Constructive criticism and I have a, well, complicated relationship. I welcome criticism and then sometimes run away from it with my arms wide open. The first manuscript I ever submitted for publication was ripped to shreds by the reviewers. The little writer inside of me slipped into a coma after that doozy. But I survived and my writing vastly improved.


It’s not always easy to swallow criticism but how else do we improve? Here are some well-worn analogies that might illustrate this point. Criticism is the asphalt that lines the royal road of progression. How about this one? Criticism is the currency of the science kingdom. It allows us to operate the marketplace of innovation.


OK. You get the point: when someone shines a stadium light on your overseen deficits, just know that it’s for the best.

So why was I glad to see the recent call for integrating behavioral health care into the Patient-Centered Medical Home (PCMH)? Is it because I love behavioral health? Well, yes, that is true. But more importantly I value progression. This new report calls for making behavioral health care a central component of the PCMH. Isn’t science great?!

Here is what the new report calls for:

• Have a whole person orientation
• Help patients adopt healthy behaviors and treat common mental disorders
• Be coordinated and integrated within teams rather than fractioned between providers who do not collaborate
• Emphasize safe, high quality care
• Make access to behavioral health service as available as access to medical care
• Use payment models that promote shared care and shared responsibility by primary care teams

It has taken this long to make a formal call for recognizing the importance of behavioral health in the PCMH The original Joint Principles were published in February 2007 at a time when J. K. Rowling had announced the release date of her final Harry Potter book, the Indianapolis Colts had beaten the Chicago Bears in Super Bowl XLI, and George W. Bush was still POTUS. That was seven years ago. It has taken this long to make a formal call for recognizing the importance of behavioral health in the PCMH. But I’m OK with that because scientific progress marches onward. In fact, the authors of the Joint Principles 2.0 (my title) stated “PCMH is an innovative, improved, and evolving approach” (my emphasis). We are headed in the right direction.

Despite the numerous endorsements by major professional organizations for Joint Principles 2.0 (I count at least seventeen), there are still significant concerns about the current state of the PCMH model. The June 2014 edition of Families, Systems, and Health features commentaries from eight health care organizations that offer support and criticism for the Joint Principles. Here are some of the actual comments:

• “The treatment of patients is best done in collaboration with intimate networks and larger community and cultural connections” (
full article)

• “Medical homes integrating behavioral health [should] follow principles that extend leadership and participation to all fully qualified providers, including nurse practitioners” (full article)

• “[t]he Joint Principles could underscore further the vital role of the family in a PCMH. … the supposition of a physician-led health care team proposes an overly narrow model.” (abstract)

• “Separate and unique confidentiality requirements for behavioral health conditions are deeply associated with the still-too-present discrimination and stigma connected to mental disorders” (abstract)

So, is there a Joint Principles 3.0 on the horizon? Will the next vision for PCMH include close collaboration with families, a more flexible leadership position, and unified behavioral and medical documentation systems? I certainly hope so. But even the most sound and well-worded criticism can fall on flat ears. If the real medical home is going to emerge, it’s not going to be with bullhorns and proclamations. It’s going to be through tough-as-nails research and constant critical analysis. It took seven years to even start talking about new PCMH principles. Will it take another seven years to start practicing them? Progression can be slow at times, but hopefully not that slow. If the real medical home is going to emerge, it’s not going to be with bullhorns and proclamations 

Matt Martin, PhD, LMFT is a licensed marriage and family therapist and current Director of Applied Psychosocial Medicine at the Duke/Southern Regional AHEC Family Medicine Residency Program in Fayetteville, NC. He is current editor of both CFHA blogs. His interests include integration of behavioral health services in primary care settings, behavioral science curriculum development, family-centered primary care, and self-awareness development in family medicine residents. Email:

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No Triple Aim without Collaborative, Integrated Care

Posted By Maribel Cifuentes, Larry A. Green, Thursday, July 31, 2014
It seems that everywhere you go people are talking about collaborative, integrated healthcare with new found urgency and enthusiasm these days. The many reforms occurring in our healthcare system since the implementation of the Affordable Care Act have raised national awareness about the need for behavioral health and primary care integration in order to realize the Triple Aim, and propelled us to action – lest we miss out on this singular opportunity to make collaborative healthcare the standard of care for every person in our country.

​But did you know that CFHA has been advocating for this model of care for the past 20 years? In 1994, the “Wingspread Conference” brought together the pioneers in collaborative family healthcare, which led to the creation of CFHA. The following year (1995), CFHA held its very first meeting in Washington DC at the Omni Shoreham Hotel. It’s a happy coincidence that this year’s CFHA conference will again take place in Washington, DC at the same historic hotel. In the past 20 years we’ve come far as an organization and as a community of members. While there are still many pressing issues that require our attention, it seems that the opportunity for the field to take the next quantum leap has arrived. At this year’s CFHA conference we have an incredible opportunity to “leap together” by bringing CFHA members and conference attendees together with policy makers, federal agencies, and national associations to join forces in advancing the adoption and sustainability of collaborative healthcare.

This year’s program has all the elements you’ve come to know and love from CFHA conferences While some may find this prospect very exciting, some may also be thinking “I’m not a policy wonk. What can I really expect to gain from this year’s conference?” We want to assure you that this year’s program has all the elements you’ve come to know and love from CFHA conferences, plus more!

We have lined up four outstanding plenary sessions that will explore the role of health policy and economics, mental health promotion and prevention, leadership for practice transformation, and implementation and evaluation in the context of collaborative family healthcare. Meet this year’s distinguished plenary speakers – you’re sure to love them.

Economics, Delivery System Reform, and Behavioral Health Integration: Don’t Be Left Behind
Richard G. Frank, PhD
Deputy Assistant Secretary for Planning and Evaluation
US Department of Health and Human Services
Mental Health Promotion and Prevention in Primary Care: An Idea Whose Time Has Come
William R. Beardslee, MD
Gardner-Monks Professor of Child Psychiatry
Harvard Medical School

Transforming Primary Care Practices in Pursuit of the Triple Aim: How Great Leadership can Make or Break the Deal
Marci Nielsen, PhD, MPH
Chief Executive Officer
Patient Centered Primary Care Collaborative

Implementation, Evaluation, and Getting to the Triple Aim
Russell Glasgow, MS, PhD
Visiting Professor, Department of Family Medicine
Associate Director, Colorado Health Outcomes Program
University of Colorado School of Medicine

Deborah Cohen, PhD
Associate Professor, Department of Family Medicine
Oregon Health & Science University

On the first day of the conference, you will be able to take part in three terrific Preconference Workshops aimed at developing your skills and sending you home with practical tools for your day-to-day work. And did you know that this year there is a FREE Writing Workshop for students and early career professionals? You will learn from CFHA’s most expert and prolific writers in an interactive, hands-on setting. Sign up early, as space is limited.

You can expect to have many excellent concurrent sessions to choose from, organized around 7 content areas - (1) Focus on individuals and families, (2) Redesign of primary care services and structures, (3) Prevention and health promotion, (4) Sustainability and cost control, (5) System integration, (6) Education and training, and (7) Research and evaluation. And this year you will be able to download a convenient application that will allow you to view program details online through your mobile device. How cool is that?

Opportunities for networking and fun at the conference will abound. You can look forward to speed mentoring, dine-arounds, morning exercise offerings, and tours of the city.

Join us at this year’s CFHA Annual Conference, and come share your own ideas and innovative work while you learn with leaders in the field about the latest advancements and the most pressing issues necessary to bring about greater adoption and sustainability of a collaborative model of care. You are what makes CFHA great, and more than ever we need your voice, knowledge and passion to make this conference a success. Register now and don’t miss out on early bird registration fees, still available through September 15.
You can expect to have many excellent concurrent sessions to choose from 

Maribel Cifuentes, RN
Larry A. Green, MD
2014 CFHA Conference Chairs

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Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA

What We Do

CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.