In the first part of this two-part account, we outlined important steps for C/MFT students who are interested in MedFT to take in preparation for clinical work in medical contexts. In this section (part two), we outline strategies for trainees to follow once they have their foot-in-the-door of a medical facility. These include functioning as an anthropologist, conducting one’s self sensitively vis-à-vis medical colleagues, using supervision effectively, and aligning your work to fit within the culture of integrated care.
Function as an Anthropologist
One of the most common mistakes we see new MedFT trainees make is to charge into a healthcare site like a "bull in a china shop”, touting her/his systems-paradigm as a panacea that everyone has heretofore been missing. This can be off-putting to medical providers, insofar as the turf that trainees are entering is medical (not behavioral). These contexts are – by design – hierarchical and mental health providers are lower on this hierarchy. A well-prepared trainee understands and respects this, and is thereby careful to conduct her/himself in a manner that communicates this insight and respect.
God gave you two ears and one mouth for a reason 1. As a new trainee, then, it is important that you engage with medical colleagues as a person eager to learn more than you want to (or at least show a desire to) teach. Observing precepting sequences in a medical residency (i.e., consultations between resident learners and faculty supervisors), learning about what types of patient presentations are common to particular sites (e.g., depression and diabetes in primary care, grief and loss in respite care), and asking questions when doing so is not disruptive are excellent ways to do this. Having already learned medical language (qhs, PRN, b.i.d., etc.) facilitates these processes, alongside equipping you to read/understand patients’ charts, and to write your own notes in the same manner.
Key here, too, is to actively talk with, befriend, and learn from professionals other than physicians (e.g., receptionists, care coordinators, medical assistants, nurses). These personnel can often describe and translate the structure and care processes of a clinic better than physicians, administrators, or others comparatively "higher up” on the medical hierarchy. They also tend to know more about patients’ and families’ internal worlds, struggles, and resources. Insofar as one of the key roles a MedFT plays is in-liaison between respective "parts” of a medical system’s "whole”, lower-ranking (in a hierarchical sense) personnel are essential partners.
And a final word about Medicine’s hierarchy: Yes, behavioral health providers are trumped by medical providers in terms of social/professional status, income, etc. But there is a difference between honoring this hierarchy (and learning how to function within it) and resigning to the notion that you, as a MedFT, do not have anything to offer (or that what you offer is less important). Go into these systems with caution. Listen to and learn from your colleagues. Gain their respect and regard. As you do, the care and contributions you offer will evolve, as will the interdisciplinary collaboration that you collectively advance as a team.
|Listen to and learn from your colleagues. Gain their respect and regard
Behave and Conduct Yourself Sensitively
It is important for MedFT trainees to understand what medical providers have been through to secure the positions they have, and to conduct one’s self with sensitivity to this. Medical education is remarkably difficult (if not straightforwardly abusive). Residencies cap scheduled education and patient care at 80 hours per week, and include regular on-call sequences that last up to 24 hours at a time. Patient panels are often in the hundreds, and it is not uncommon for these patients to die. Extensive research has shown that medical trainees endure higher rates of depression, anxiety, suicidality, substance use, somatic problems, and relationship-dissolution and divorce as compared to other types of graduate learners and/or the general population. No training program or sequence in C/MFT compares – even closely – with this type of intensity or rigor.
Equipped with this understanding, then, you as a MedFT trainee should be careful to not complain about how exhausted you are after a 10-12 hour day. This type of day is a normal day – if not an "easy” or "light” day – for medical providers. Similarly, complaining about the intensity of one of your cases, time that you are missing from family, etc., can elicit negative reactions from medical colleagues. You can be seen as wimpy, entitled, or fitting conventional stereotypes of the isolated private practitioner who works in a comfortable office, sets her/his own hours, and caters to a wealthy clientele. Once this impression is made, it can be hard to regain your persona as a valuable and engaged member of a healthcare team.
Strategies for making Supervision Effective
One of the earliest contexts in which MedFT trainees feel a divide between their work and "traditional” C/MFT is within university-based supervision. As students meet together to discuss cases, MedFTs can feel "out of place” by nature of having higher intensity and/or complex cases. While your colleagues talk about depression or couple discord, you (as the MedFT) might talk about patients who are struggling with a chronic illness or a family’s (and/or your own) experiences in coping with death. Because these presentations are not as common with C/MFT students, peers can struggle to effectively brainstorm with and help you. This can result in your feeling isolated or disconnected from your C/MFT peers, and/or feeling forced to proceed in cases (and manage self-of-therapist issues) with less support.
|Participating in dual-supervision facilitates the expansion of your skillsets
You, then, are charged with finding a champion or on-site supervisor (even if s/he represents a sibling discipline). Indeed, it is common for MedFT trainees to be supervised at their university while synchronously participating in supervision with a Medical Social Worker or Health Psychologist. This facilitates a purposeful combining of conventional C/MFT and MedFT training and approaches. For example, utilizing a long-term insight-oriented therapy modality may be less possible or impactful in MedFT, but its primary tenets (e.g., attachment, poor family-of-origin differentiation) may still be applicable. Participating in dual-supervision (conventional + MedFT) facilitates the expansion of your skillsets to best fit clinical practices and activities to immediate presentations at-hand.
Other resources and competences specific to MedFT practice include, but are not limited to, motivational interviewing, brief solution focused therapy, conducting PHQ-9 assessments, completing disability or workers’ compensation documents, and assisting physician colleagues with complex citizenship applications and paperwork. All of these require that you make time to do "extra” homework in skill-development. Leaning on aforementioned mentors within Medicine can help you navigate this, and further-enable you to assist others who follow (aligning with Medicine’s adage to "Learn one, do one, teach one.”)
Align your Practice-Patterns to Fit with the Culture of Medicine
For a MedFT to function as a collaborative colleague, s/he must adjust her/his practice patterns away from conventional mental health service models. The standard "50 minute hour” that you were taught in graduate school is one of the first places to do this. If medical providers are seeing patients every 15-20 minutes, you (as the MedFT) are not going to be very accessible if you schedule your appointments on-the-hour. This does not mean that you cannot see some patients/families for this amount of time (indeed, some are best served this way), but – to be clear – you cannot only do this.
The steps that your will take as a MedFT student and trainee to gain entry into a medical practice will vary in accord to the practice that you are entering. Some practices will be familiar with and maintain strong buy-in for MedFTs (e.g., a primary care site that has organized its services to align with contemporary developments in the medical home movement). Other practices may not have included a MedFT on their team before, but are amenable to trying this out based on a perceived need that systems-informed mental health providers could offer (e.g., a neonatal intensive care unit in which newborn infant deaths and families’ efforts in coping are commonplace). Conversely, some sites may be resistant to hiring you, for reasons like finances (i.e., not seeing how MedFTs could bring additional revenue) or administrative discomfort with negotiating new territories in referral, scheduling, or billing systems. Some trainees, then, will be able to get into MedFT placements with relative ease. For others, this process could be difficult. However things go – on any place along this continuum – it is our view that the lessons and strategies outlined in this two-part account will help you in the journey.
1. Diogenes, L. (1901). The lives and opinions of eminent philosophers. London, UK: George Bell & Sons.