There is a knock at
the door. An unexpected visitor has shown up at your doorstep and you already
have guests. You are really wishing they would have called ahead of time, but
alas, here they are. This unexpected visit is from someone who is important to
you, a relationship that you would like to maintain. You are having an
important and private conversation though with the guests you are already
hosting, and must decide how to balance these two important relationships that
are inconveniently colliding. Now imagine that your home is a primary care
setting, the unexpected visitor is a physician in need of your consult, and
your present guests are a couple you are seeing in therapy. In a nutshell, this
has been a common experience for me as a "co-located” therapist. Let me provide
a real life example.
My intake becomes
quiet and exhales as he looks down at the tissue he has been nervously
shredding into little bits and pieces. His body language changes and I sense
him trying to formulate the words he is about to say when there is a knock. He
tenses up as we both look at the door, and the moment for him to speak quickly
fades away. I excuse myself as I open the door and see a look on my colleague's
face that I know all to well. My colleague is a resident physician in our
clinic, and the look on her face is "Help."
I turn back to my
patient and explain to him that we are experiencing one of those special
circumstances where I must make myself available. I step into my colleague’s
office and she shares a quick summary of a patient she is currently treating, a
new mom being seen with her husband who had become tearful during their visit
and expressed some suicidal thoughts. My colleague is concerned and is hoping I
can provide some consult on how to effectively and efficiently assess for postpartum
mood disorders and this patient's safety. After some thought and a few brief
assessment questions, I make the clinical decision to join my colleague in her
visit with this patient. I am already feeling uncomfortable about leaving my
patient at such a vulnerable moment, but in an effort to be collaborative,
these are the clinical judgments that need to be made.
between behavioral health clinicians (BHCs) and physicians are an integral and
special piece of collaborative care. I share the above scenario because it
reflects the challenges I had faced in a "co-located” primary care setting.
While Hunter and colleagues (2009) reinforce that physicians are more likely to
use a BHC who is responsive and easily accessible, and that BHCs working within
the primary care setting must make themselves available at all times, my above
scenario is not the ideal.
|Constructive, supportive, didactic, opportunistic,
and at times inconvenient. For me, all of these words
described my experience with the unexpected knock on my door.|
The beauty of
co-location is that we as BHCs are available to physicians when needed, and
that our presence contributes to the care of the whole person. Specifically, I
believe that Medical Family Therapists are particularly well-suited for this
position because our training emphasizes two content areas that are
underdeveloped within many healthcare environments, 1) a systemic relational
perspective of illness and the illness experience, and 2) the inclusion of the
relational system around the patient.
is definitely heading in the right direction, it is clinically not the perfect
scenario. At the UCSD Department of Family and Preventive Medicine we are
moving in the direction of many other clinics by utilizinga system in
which "floating” therapists are available to the physicians when these consults
are desired. Our new clinic system, coined T-CARE, follows the mission of the Primary
Care Behavioral Health model in that it provides educational and systemic
changes that improve the primary care system’s ability to provide care
(Robinson & Reiter, 2006).
Constructive, supportive, didactic, opportunistic,
and at times inconvenient. For me, all of these words
described my experience with the unexpected knock on my door. As a "co-located”
BHC I was constantly doing what I could to balance the needs of my patients,
the physicians, and the physician’s patients that were driving these unexpected
consults. While our clinic moves from co-location to collaborative integration,
I am becoming more aware of the marked distinctions that exist between these
two models. The exchanges and consults that are so central to collaborative
care are still occurring, but the unexpected visitor is no longer knocking on
my door when the circumstance is clinically inopportune.
Above all, I believe that these
exchanges have allowed me to build key relationships with the primary care
staff in my clinic (convenient or not), and in the end, I wholeheartedly
believe that these connections and interactions are at the heart of
Now I must ask, what has your
experience been of the curbside consult? How do these interactions take place
at your clinic? And have you ever had to make a tough clinical decision such as
the one I described above?
Goodie, J. L., Oordt, M.S., & Dobmeyer, A.C. (2009). Building an Integrated
Primary Care Service. Integrated behavioral health in primary care:
Step-by-step guidance for assessment and intervention (pp. 11-20). Washington,
DC: American Psychological Association.
Robinson, P. & Reiter, J. (2006). A mission and a job
description. In 1st edition, Behavioral
consultation and primary care: A guide to integrating services (pp. 29-58). New
Cassidy Freitas is an MFT Intern practicing at
the UCSD Department of Family and Preventive Medicine. She is a recent graduate
from the University of San Diego, and is in the process of pursuing MFT doctoral programs.