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Let's Talk About Sex

Posted By Kenny Phelps and Tina Schermer Sellers, Tuesday, November 13, 2012
Talking about sex...It is difficult to avoid the multiple sexualized images in American culture. From Janet Jackson’s Superbowl peepshow to the popularity of the Sex and the City episodes to television programs of young girls being dressed up like 21 year old beauty queens, the messages of sex are inescapable in recent years.

While the quantity of sexual images and information has increased in our society, the quality of this information is severely lacking. Myths and misnomers about contraception and human anatomy are two examples of how we have a lot of information, but also a lot of misinformation. Additionally, the medicalization of sex has led to conceptualizations of the sexual response cycle separate from the inherent relational and systemic dynamics involved.
US Surgeon General David Satcher
"Sexuality is an integral part of human life. It carries the awesome potential to create new life. It can foster intimacy and bonding as well as shared pleasure in our relationships. Sexual health is inextricably bound to both physical and mental health" .
  --U.S. Surgeon General

Certainly, we must conceptualize sexual health as a biopsychosocial phenomenon. For the past several decades, there has been increasing recognition in medicine of the importance of sexual health and sexual health education in supporting both physical and emotional health(Foley, Wittmann, & Balon, 2010). In 2001, the surgeon general made this statement about the importance of sexuality as a contributor of overall quality of life: "Sexuality is an integral part of human life. It carries the awesome potential to create new life. It can foster intimacy and bonding as well as shared pleasure in our relationships. Sexual health is inextricably bound to both physical and mental health” (Satcher, 2001). Thus, is seems only natural that sexual health should be a part of the dialogue between patients and providers, but is it?

While professionals might recognize the importance of sexual health in the life of their patients, this is not equating to an increase in sexual education or patient assessment, treatment or referral. Sexuality is routinely overlooked in primary medicine (Owens & Tepper, 2007). Studies reveal that only 10%-30% of primary care physicians obtain sex histories (Lewis & H, 1987)(Gemson, Colombotos, & Elinson, 1991). Challenges to the progression of sexual health care range from a significant lack of sexual education for most ‘would be’ medical providers, a lack of adequate sexual education in medical school and residency, a shared ignorance and unease about sexual health between patient and provider, a lack of time (Morreale & Arfken, 2010; Foley, Wittmann, & Balon, 2010) and a complex set of biopsychosocial issues playing into a person’s sexual health and sexual satisfaction (Geraci, 2010). What role does integrated and collaborative care play in overcoming these challenges? How can medical and mental health providers working in tandem create small ripples of change that may lead to larger changes in our current rates of STIs, teenage pregnancy rates, and reports of relational discord?

We propose that integrated care and intensive collaboration between providers should be the rule rather than the exception when addressing sexual health. Providers can work together to: screen for sexual concerns (Are you currently sexually active? Are your partners men or women? Are you satisfied with your sexual life? How can I be helpful to address any sexual or relational problems you are having?); provide education on most common problems (desire, premature ejaculation, performance anxiety, erectile dysfunction, etc.); and frame intimacy/sexuality as part of a larger relational and cultural picture (How did what your parents or culture tell you about sex influence your current preferences?).

Due to the biopsychosocial nature of sex, it requires multiple providers who are wearing "different hats.” For instance, a patient with erectile dysfunction needs a thorough evaluation of current medical concerns and medications, psychiatric comorbidities, automatic thought prior and during sexual activity, and current relational satisfaction. Patients who are parents of young children also need our guidance providing age appropriate sex education to their children. Research shows that youth need 100 one minute conversations about sexuality versus one 100 minute conversation (Martino, MN, Corona, DE, & MA, 2008). The vast majority of our patients grew up in homes that were silent and often reactive to sexual curiosity. This leads to parents of young children who are unaware of how sexual curiosity is expressed by children and ill-equipped to provide ongoing sex education. This anxiety often leads to repeating the cycle, becoming mostly silent and reactive to the sexual interest of their children.

In our opinion, integrated care delivered by systemically minded professionals is an ideal place to facilitate this dialogue. In other words, let’s talk about sex with our patients…they want us to!

 

Kenny Phelps
Kenneth Phelps, Ph.D., LMFT is an Assistant Clinical Professor in the Department of Neuropsychiatry and Behavioral Science at the University of South Carolina School of Medicine. He is a member ofthe Collaborative Family Healthcare Association (CFHA)and Co-Chair of the Membership Committee. He is also a member ofthe American Association of Sexuality Educators, Counselors, and Therapists (AASECT) and working toward Certification as a Sex Therapist. Contact info: kenneth.phelps@uscmed.sc.edu
Tina Schermer Sellers
Tina Schermer Sellers, Ph.Dc., LMFT, the director of the Medical Family Therapy Post-graduate Certificate Program in the Department of Marriage and Family Therapy at Seattle Pacific University. She has been a member ofthe Collaborative Family Healthcare Association (CFHA)since 1993, is a past board member and is currently on the CFHA Advisory Board. She is also a Certified Sex Therapist with the American Association of Sexuality Educators, Counselors, and Therapists (AASECT). Contact info: tsellers@spu.edu; www.tinaschermersellers.com
 

Bibliography

Foley, S., Wittmann, D., & Balon, R. (2010). A Multipdisciplinary Approach to Sexual Dysfunction in Medical School Education. Academic Psychiatry, 386-389.

Gemson, D., Colombotos, J., & Elinson, J. (1991). Acquired immunodefiniency syndrom prevention: knowledge, attitudes, and practices of primary care physicians. Archives of Internal Medicine, 1102-1108.

Geraci, R. (2010). Sex in the Fifties. Washington, DC: AARP.

Haeberle, E. (1983). Education and Treatment in Human Sexuality: The Training of Health Professionals Report of a WHO Meeting. In Workbook Part 1 for Associate in Sex Education and Clinical Sexology Certificate. Exodus Trust.

Lewis, C., & H, F. (1987). The sexual history taking and counseling practices of primary care physicians. Western Journal of Medicine, 165-167.

Martino, S., MN, E., Corona, R., DE, K., & MA, S. (2008). Beyond the "big talk": the roles of breadth and repetition in parent-adolescent communication about sexual topics. Pediatrics.

Morreale, M., & Arfken, R. (2010). Survey of Sexual Education Among Residents From Different Specialities. Academic Psychiatry, 346-348.

Owens, A., & Tepper, M. (2007). Sexual Health - State of Art Treatment and Research. Westport: Praeger.

Reid, R., Coleman, K., Johnson, E., Fishman, P., Hsu, C., Soman, M., et al. (2010). The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout for Providers. Health Affairs, 835-843.

Satcher, D. (2001). The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior. http://www.surgeongeneral.gov/library/calls/sexualhealth/call.pdf.

Tsimtsiou, X., Hatzimouratidis, K., & Nakopoulou, E. (2006). Predictors ofPphysician' Involvement in Addressing Sexual Health Issues. Journal of Sexual Medicine, 583-588.

Wimberly, Y., Hogben, M., Moore-Ruffin, J., Moore, S., & Fry-Johnson, Y. (2006). Sexual History-Taking Among Primary Care Physicians. Journal of the National Medical Association, 1924-1929.


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JAMA Advocates for Families in Healthcare

Posted By Jo Ellen Patterson, Tuesday, November 6, 2012

Several years ago the Board of CFHA did some soul-searching about the name of our association. Some members wondered whether "family” should remain in the title since most medical care is, in fact, individual care.

I thought about the discussion that the Board had when I read a recent editorial in the Journal of the American Medical Association. A health policy expert from Johns Hopkins reiterated the importance of including families in both service delivery and policy decisions (Wolff, 2012). I was not surprised when she drew on research and policy that focused on older adults and the aging of the American population. As the baby boom generation enters old age and lives longer than any previous generation, Americans face a crisis. Who will care for aging Americans, and how will that care be paid for? Wolff quotes a Congressional Budget Office report that says, "The value of donated care probably exceeds that of any other category of long term care financing but is difficult to quantify in dollar terms” (p 1529).

Wolff goes on to note the many barriers to supporting families. She references legal barriers that exclude family members from both knowledge and decision-making capacity about their loved ones. Her description of legal and medical-culture barriers made me think of a family crisis I recently observed.
JoEllen Patterson
"Families with small children, disabled members, and chronically
ill loved ones all struggle with inclusion, confused roles, and boundary ambiguity when they
face health crises."

A hospitalized male patient had both leukemia and bipolar disorder. During his hospital stay he became violent but was restrained. His family had little understanding of his recent diagnosis of bipolar disorder and felt panic as they watched their loved one decline. Citing legal reasons and hospital policy, the floor nurses said they could not provide the family any information about his erratic behavior. Eventually his sixty year old wife and eighty-two year old mother awoke at 4:00 a.m. so they could be at the hospital by 5:00 a.m. in case the oncologist rounded that early. When that effort failed, they "camped out” in the physician’s office waiting room for five hours only to be told that the oncologist did not have consent (from a manic patient) to release medical information to them. While this difficult situation unfolded, the wife’s unspoken fear was that her violent husband would be sent home, and she would be fully responsible for his care. She simultaneously felt terrified of his violent behavior and fearful of watching his painful death. She felt overwhelmed.

Caregiver burnout, fear, guilt, and confusion are common emotions of patients’ families. In spite of families’ confused roles in health care, Wolff suggests that families now serve "as the backbone of medical and long-term care delivery” (p 1530). She also suggests that families’ contributions must be measured and documented before they can be valued. She offers specific suggestions on ways to include families:

  1. Health information should be made available to family members according to patients’ expressed wishes.
  2. Important aspects of family functioning that influence caregiving should routinely be documented in the medical record.
  3. Screening of family caregivers should be part of routine care.
  4. Family members’ presence and identity at a patient’s health care encounter should be documented, and different perspectives on the problem should also be included in the patient’s documentation.

Families with small children, disabled members, and chronically ill loved ones all struggle with inclusion, confused roles, and boundary ambiguity when they face health crises. When a patient leaves the physician’s office or the hospital, his care often becomes the primary responsibility of family members. While older patients are not the only family members that need their clinicians and family member to work together, a possible benefit of the health care crisis created by aging baby boomers could be that the American health care system finally takes the contributions of families seriously.

References

Congressional Budget Office. Financing long-term care for the elderly. Washington, DC: Congressional Budget Office; 2004.

Wolff, J. Family matters in health care delivery. Journal of the American Medical Association. 2012; 308(15):1529-1530.

 

Jo Ellen Patterson, Ph.D. is a professor at the University of San Diego. She is also a Clinical Associate Professor in the Departments of Family Medicine and Psychiatry at the University of California School of Medicine in San Diego.

Please add your thoughts regarding Jo Ellen's post. This requires logging-in to a free CFHA account.



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Where the Candidates Stand on Healthcare's Key Issues

Posted By Dan Marlowe, Tuesday, October 23, 2012

I figured with the elections right around the corner we could tip our hats to those conversations in our own MedFT-esque kind of way. Instead of a charged debate with all the trappings of finger-pointing, name-calling and record challenging tomfoolery, here is a list compiled by The Hastings Center. They are "a nonpartisan research institution dedicated to bioethics,” detailing a synopsis of where each candidate/platform stands on issues we post about here (e.g., caregiving and healthcare costs) along with other topics we might (and should) be interested in. Take a look and weigh-in below in the comments section.

A big thanks to Jackie Williams-Reade for posting this to the MedFT Facebook page, which you should all take a look at and join for more MedFT related articles and commentary.

"Healthy citizens are the greatest asset any country can have.”

Winston Churchill

 

Dan Marlowe
Dan Marlowe is the co-editor of the Growing MedFT Blog, and the Director of Applied Psychosocial Medicine for the Duke/Southern Regional AHEC Family Medicine Residency Program in Fayetteville, NC. He obtained his MS in Marriage and Family Therapy and PhD in Medical Family Therapy from East Carolina University in Greenville, NC.

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Do Medical Family Therapists Bring Value to Health Care?

Posted By Joseph Scherger, Wednesday, October 10, 2012


I suspect any family therapist reading this question would quickly say, "Yes, of course we add value to health care”. From a health care policy perspective value is not a simple intuitive concept. Value is quality divided by cost, and today every health care system is focused on becoming value driven.

That the U.S. spends way too much money on health care is well known. Our health outcomes place us low in the world even though we spend twice as much or more on health care as other industrialized countries. Our spending is not sustainable, especially in Medicare with the influx of the Baby Boomer generation. We have to figure out how to spend less money.


A new IOM report indicates that we spend 700 billion dollars in health care every year that is of no benefit to patient care. These include unnecessary tests and procedures, overly expensive drugs when generics would do fine, and excessive treatment, especially at the end of life. Rather than just squeeze this money out of the system, the potential is here for transforming the system to provide value – actually improve the quality of care while we reduce costs."The most important work
of family therapists today
is to make the case for
being vital members of
PCMH practice teams."

Information technology makes much of value driven care possible. For the first time we can look at populations of patients in detail and make proactive strategic decisions to improve their health efficiently. Diabetic patients who are well controlled are much less expensive than ones who are out of control and develop complications. Through internet applications, we can communicate and care for patients at minimal costs compared with face-to-face visits.

So what role do family therapists play in this? We know that psychosocial problems are frequent in health care and usually are masked by physical complaints. Addressing the psychosocial problems early creates great efficiency rather than waiting until every physical evaluation has been done, only to show the patient is "simply” anxious or depressed. Yet this obvious situation remains hidden from the strategic planning to too many health systems.

Regional health systems committed to becoming value-driven are joining the Accountable Care Organization (ACO) movement. Developed by the Centers for Medicare and Medicaid Services (CMS), an ACO is committed to the Triple Aim:

1. Improving the individual experience of care

2. Improving the health of populations

3. Reducing the per capita costs of care for populations

Health systems know the future of health care financing will be directly tied to achieving these aims with their care, and information systems are able to measure it. At the patient care level, teams will operate in ACOs using the principles of the Patient Centered Medical Home (PCMH). PCMH practices have advanced information and communication technologies and are able to provide continuous access to strategic, proactive care rather than the tradition of simply reacting to patient appointments. Patients become activated to play an active role in the own care, ordering desired tests and treatments, according to accepted guidelines.

The most important work of family therapists today is to make the case for being vital members of PCMH practice teams. Working alongside physicians, nurse practitioners, pharmacists and others, family therapists will ensure that patients receive true biopsychosocial care from the beginning. Independent private practice is rapidly becoming a thing of the past. Organized and integrated health systems are the future. Family therapists are not automatically included in this discussion in most settings, so becoming knowledgeable about ACOs and PCMHs is critical today. Assertive inclusion of family therapists in demonstration projects around the country is needed to ensure the proper composition of team practice in the future.

Reference for more detail on ACOs, PCMHs and the Triple Aim:

Edwards TM, Patterson J, Vakili S, Scherger JE. Healthcare Policy in the United States: A Primer for Medical Family Therapists. Comtemp Fam Ther (2012) 34:217-227.

 


Joseph E. Scherger, M.D., M.P.H., is Vice President for Primary Care & Academic Affairs at Eisenhower Medicine Center in Rancho Mirage, California. Dr. Scherger is Clinical Professor of Family Medicine at the University of California, San Diego School of Medicine (UCSD), and at the Keck School of Medicine at the University of Southern California (USC). Dr. Scherger’s main focus is on the redesign of office practice using the tools of information technology and quality improvement.


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As Rosie the Riveter Says: We Can Do It—Collaborative and Facilitative Leadership

Posted By Jeri Hepworth, Wednesday, October 3, 2012


Dr. Hepworth's post is the first in a 5-week collaborative series hosted by the blogs of
CFHA and STFM.

Please check back
each week.

As STFM President-Elect, I attended my first meeting of CAFM and Working Party. Forgive the funny names, but they represent the Council of Academic Family Medicine organizations (STFM; ADFM, the organization of departments and chairs; AFMRD, the residency directors; and NAPCRG, the primary care researchers). The Working Party includes the CAFM organizations, plus the American Academy of Family Physicians (AAFP), the American Board of Family Medicine, and the AAFP Foundation. Together, the organizations work to ensure coordinated positions and grapple with vision and leadership of family medicine. These meetings represent ideal examples of Covey’s work of being both important and not urgent, of taking the time to consider what family medicine is accomplishing, and very powerfully, what should be the next steps.

Not surprisingly, attending my first meetings of these groups was intimidating. But, on the first morning, I received this email from my husband, Robert Ryder: "You are not a non-physician. You were elected to represent the educators in family medicine. So you represent the future of family medicine. Go do good work.” I must say, I walked a bit taller after that email, and over the last couple of years of leadership within national family medicine, I take these statements very much to heart. And I want others to recognize these truths.Jeri Hepworth
"I have a
commitment to encouraging others to stand up and participate in advocacy and leadership for our common visions."


Behavioral science clinicians and educators have the skills needed for leadership in our departments, in our health care systems, in our agencies and policy-making arenas, and in our national organizations and advocacy efforts. We know how to listen and include others. We can elicit divergent views and withstand conflict. We know how valuable it is to include the views of those who feel less powerful in systems. We can tolerate the anxiety that emerges in systems under stress or facing change. We know how to help groups create goals and vision, though we sometimes need help determining whether differences actually emerged. So we know we need collaborators, and generally we know how to play well with others. If we have been successful in working in settings in which our professions were the minority, we have learned these skills. And they are exactly the skills needed for effective leadership.

I truly enjoyed giving talks as president of STFM. Unlike presentations about my work, I learned that I didn’t need to hold back, because I wasn’t talking about me. I was representing something greater than me. To be grandiose, and also accurate, I was able to talk about a future and vision of compassionate, effective health care. It wasn’t a form of bragging about my work or ideas; it became a responsibility to do the best I can to help achieve our common goals. I was given a wonderful platform and support to do so.

And the beat goes on. I will still take the opportunities to advocate for family medicine, for primary care, for integrated health care systems that are focused first on patients and families and that require the collaboration and skills of many. But I also have a commitment to encouraging others to stand up and participate in advocacy and leadership for our common visions. The Collaborative Family Healthcare Association and STFM create wonderful platforms for us to advocate. Let’s not waste these opportunities.

 

Jeri Hepworth, PhD LMFT is professor and vice chair of the Department of Family Medicine at the University of Connecticut. She is the immediate past president of STFM. Her professional work has focused on families and health, psychosocial issues in medicine, and managing personal and professional stress. Among her publications, she is co-author of 3 books: Medical Family Therapy, The Shared Experience of Illness, and Family Oriented Primary Care.

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Physician Burnout: Alarming but not Surprising

Posted By Dan Marlowe, Tuesday, September 25, 2012

Alarming, but not surprising, are the comments made in a recent news story on the American Medical Association’s website that nearly half of all physicians struggle with burnout. Even less surprising is the fact that primary care physicians (e.g., family medicine and general internal medicine) experience some of the highest rates when compared to other specialties. What this seems to translate into is an impending exodus from the field of clinical medicine by many physicians who have simply run out of steam and desire a higher quality of life overall.

Here is a link to the full article.

While this may be a problem facing medicine in general, as the article alludes to, it becomes particularly troublesome for primary care given the mounting workforce shortage the field is already experiencing. In order to meet the target of one physician for every 2000 patients, an additional 35,000-44,000 primary care providers will be needed by 2025 (Carrier, Yee, & Stark, 2012). This shotage is only compounded by the expansion of converage under the Patient Protection and Affordable Care Act (PPACA), which is projected to increase that deficit of from 25,000-45,000 by 2020.
Dan Marlowe
Dan Marlowe is the co-editor of the Growing MedFT Blog, and the Director of Applied Psychosocial Medicine for the Duke/Southern Regional AHEC Family Medicine Residency Program in Fayetteville, NC.

There have been various proposals of how to address this shortage from the proliferation of advanced practice providers (e.g., nurses practioners and physician assitants), to team-based care, to increased reimbursement rates, to the creation of primary care ‘pipelines’ that increase the number of health professionals who enter the field. However, it would seem that these solutions do not address the issue of burnout directly and treat it as a more tacit outcome of these workforce and system-based changes. The question of how to address burnout in clinical medicine is an important one, and more importantly for us, what can medical family therapists offer in this area given our systemic/relational outlook?

Carrier, E., Yee, T., & Stark, L. B. (2011). Matching Supply to Demand: Addressing the U.S. Primary Care Workforce Shortage. Retrived from http://www.nihcr.org/PCP_Workforce.html

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On the Spot with Fraught Family Caregivers

Posted By Barry J. Jacobs, Tuesday, September 18, 2012

Even before the designated hour was reached, my computer screen was filled with dozens of questions from family caregivers from around the country. When 3:00 struck, dozens more--expressing raw, vexed emotions--arrived in a long line. Scrolling through them, I saw that there were many similar questions from caregivers who feel guilty about resenting the loved ones they are caring for. Several contained consternation about demented loved ones’ resistance to having home heath aides in their homes or going to adult day care centers. There were two questions about the caregivers’ likelihood of developing dementia themselves.

I was the speaker/responder in an hour-long, live family caregiver web chat on the AARP website (here’s the link to the transcript). I felt like a grim-faced public official at the podium in a tense, post-natural-disaster press conference. I chose questions rapidly, tried to answer them soberly and succinctly, and then took a breath and plunged ahead with more questions. I was drained by the hour’s end.
Dr. Barry J. Jacobs
We have to go to them via every media outlet available to share what we know.

We have the goods they need.

It was a privilege for me to have been asked to participate in this event. The experience brought home to me two revelations:
  • There have been family caregiver advocacy organizations (e.g., National. Family Caregivers Association, Family Caregiver Alliance) providing excellent service to caregivers for 20 years. But when behemoths of the power and size of AARP (40 million members and growing) reach out to family caregivers, they set off a stampede. By recently adding a Caregiver Resource Center to its website (http://www.aarp.org/relationships/caregiving-resource-center/gettingstarted.html), AARP has helped define and legitimize the concerns of many of its members who are caring for aging parents and disabled spouses. By setting up frequent web chats with experts from its new Caregiver Advisory Panel, it has created wide-open forums for having those concerns addressed.
  • There is an evident hunger among family caregivers for the kind of information that medical family therapists and other family-oriented healthcare professionals know well. But most caregivers would never dream of seeking psychotherapy per se. Rather, we have to go to them via every media outlet available to share what we know. That could be bare-knuckled web chats or authoritative online articles or illustrative YouTube clips. We have the goods they need.

 

Barry J. Jacobs, Psy.D. is the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA and the author of The Emotional Survival Guide for Caregivers (Guilford, 2006). He was recently named to AARP’s Caregiver Advisory Panel.

 

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Where's the Family in Integrated Primary Care?

Posted By Matt Martin, Tuesday, September 4, 2012

Does anyone remember the Hostess commercials of the 1990s that included this important question: where’s the cream filling? Or about how the famous line of Wendy’s commercials that included this query: where’s the beef? A similar question arose in my mind as I recently completed a systematic review of Integrated Primary Care empirical articles for my dissertation: where’s the family?

As many of you know, Integrated Primary Care (IPC) can be an effective way for teaming up medical and behavioral health providers in treating primary care patients who struggle with behavioral health issues (e.g., depression, anxiety, substance use, treatment adherence). In practice, there is significant diversity in how IPC is delivered (e.g., psychoeducation, psychopharmacology, telehealth, psychotherapy) and by whom (e.g., physicians, nurses, psychiatrists, psychologists, social workers, marriage and family therapists). There is also growing evidence that IPC is cost-effective as well.
Matt Martin
Where's the
cream filling?


Where's the
beef?


Where's the
family?

But during my review of these IPC articles, I kept wondering why there was so little family-oriented IPC research. Out of the 112 articles I reviewed, I only found one study in which researchers mentioned anything about including family members (Reiss-Brennan, Briot, Savitz, Cannon, & Staheli, 2010). This was very surprising to me especially considering the evidence that nearly 75% of all deaths in the US may largely be attributed to unhealthy lifestyles (Mokdad, Marks, Stroup, & Gerberding, 2004) and a healthy or unhealthy lifestyle is usually developed, maintained, or changed within the family setting (McDaniel, Campbell, Hepworth, & Lorenz, 2005). Moreover, there is strong evidence that demonstrates a bi-directional relationship between family relationships and health (Kiecolt-Glaser, 1999; Kiecolt-Glaser & Newton, 2001). This paucity of family-oriented care in IPC is especially ironic given that many primary care sites have names like "Family Medical Center” or "Family Health Center” and that many primary care providers are family physicians. So, what gives? Why is there little research being done on family-oriented IPC?

There is certainly a push for family-centered care (FCC), albeit not always in primary care settings. These two hospitals, St. Jude and the Children’s Hospital of Central California, provide solid models for FCC. And consider the mission of the Institute for Patient- and Family-Centered Care which is an organization that offers ideas for implementing FCC into primary care. See here and here for PDF documents. Also, the National Alliance for Mental Illness has provided a guide for families who are being treated at integrated sites (2011). See here for a PDF document. There’s some great stuff out there for FCC!

Most of the ideas from IPFCC, NAMI, and the previously mentioned hospitals center on including family members as advisors and consultants in treatment planning. Sounds great but why does it seem like there is a disconnect between these great ideas and the clinical and research worlds of IPC? How can primary care providers (both medical and behavioral health) push for more family-friendly integrated care? And how can this more effectively be shared with the scientific community via research? Reflect on these ideas:

  • Medical and behavioral health providers who are trained in family- and systems- oriented approaches should be actively involved in not only including family members in treatment but in also publishing their work through papers and presentations.
  • These same providers can, during consultation/collaboration, purposefully help other professionals to consider the role of family members in treating a patient.
  • It would be very helpful to develop core competencies for training health professionals to include family members in IPC. Such competencies can be very helpful for training as well as for standardizing family-centered treatment.

References:

Kiecolt-Glaser, J. K. (1999). Stress, personal relationships, and immune function: Health implications. Brain, Behavior, and Immunity, 13, 61-72. doi:10.1006/brbi.1999.0552

Kiecolt-Glaser, J. K., & Newton, T. L. (2001). Marriage and health: His and hers. Psychological Bulletin, 127, 472-503. doi:10.1037/0033-2909.127.4.472

McDaniel, S. H., Campbell, T. L., Hepworth, J., & Lorenz, A. (2005).Family-oriented primary care. New York: Springer.

Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L. (2004). Actual causes of death in the united states, 2000. The Journal of the American Medical Association,291(10), 1238-1245. doi:10.1001/jama.291.10.1238

National Alliance on Mental Illness (2011). A Family Guide: Integrating Mental Health and Pediatric Primary Care. Arlington, VA: Retrieved from National Alliance on Mental Illness website: http://www.nami.org/Content/ContentGroups/CAAC/FG-Integrating.pdf

Reiss-Brennan, B., Briot, P., Savitz, L., Cannon, W., & Staheli, R. (2010). Cost and quality impact of Intermountain's Mental Health Integration program. Journal of Healthcare Management, 55(2), 97-113.

 

Matt Martin is a licensed marriage and family therapist and is currently working as a post-doctoral fellow with the Chicago Center for Family Health and the Illinois Masonic Family Practice Residency Program. He received a master’s degree in MFT from Brigham Young University and just recently completed requirements for a PhD from East Carolina University. His interests include integrated primary care, behavioral health, and family medicine residency education.


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Big Numbers on Patients’ Hearts, Spouses’ Minds

Posted By Barry J. Jacobs, Tuesday, August 28, 2012

There has long been evidence that heart attack survivors suffer high rates of depression. A new landmark study—probably the largest ever undertaken in the field of families and illness—convincingly documents that the mental health of the well spouses of heart attack survivors and victims is greatly affected as well.

Conducted by an American- Danish team led by Emil L. Fosbal, MD, PhD, a research fellow at Duke University, the study draws on epidemiological data from the Danish National Health Service registry for 1997-2008 on over 200,000 seriously ill patients and their spouses. Here is the link to the European Heart Journal article abstract. (We do not have permission to post the full text.) For a well crafted ABC News web article on the study, please see this link

The study’s main finding is that spouses of fatal and non-fatal heart attack patients have significantly higher rates of depression, antidepressant and benzodiazepine use, and suicide after the medical event than spouses of patients with other life-threatening conditions. The study’s authors’ main conclusions are that a sudden medical event is more psychologically harmful to spouses than grieving a progressive illness and that all spouses of heart attack sufferers need to be screened for emotional distress.
Dr. Barry J. Jacobs
The sudden catastrophe upends life’s desultory idyll and shatters normal family life.

In my opinion, this research article should become a mainstay of MedFT teaching and policy-making for several reasons:

  • The sheer number of patients and spouses involved in this study lends awesome power to the argument propounded in our July 3 blog post by Theodora Ooms and Jana Staton, entitled "I’m Not Her Caregiver. I’m Her Husband,” that conjugal bonds greatly impact health. Healthcare treatment of many medical conditions requires a marriage-centered, if not family-centered, approach
  • There is abundant evidence here that the psychological issues caused by sudden medical events—e.g., heart attack, traumatic brain injury, stroke—are of a different kind and intensity than those that stem from the slow, debilitating grind of dementia or MS care. Obviously, both can undermine the quality of a marriage. But the sudden catastrophe upends life’s desultory idyll and shatters normal family life. This study’s authors liken the spousal effects of a heart attack to Post-Traumatic Stress Disorder. Whether or not the well spouses meet criteria for that diagnosis, they are clearly stripped of their sense of safety. They don’t recover easily. They rue the present and dread the future.
  • The study gives credence to three tenets of marriage-centered care: Spouses should be routinely screened for depression and anxiety by physicians soon after patients’ sudden medical events. Psychopharmacological and psychotherapeutic treatment should be offered. Well spouses should be encouraged by healthcare professionals to seek support for themselves rather than just selflessly tending to patients’ demands.
  • The need is evident for psychotherapists who specialize in addressing the emotional and existential reactions of the spouses of cardiac patients. There are cardiac psychologists working in transplant centers currently who assess patients’ psychological readiness for heart transplant surgery but pay scant attention to those patients’ husband and wives. Medical family therapists are ideally trained to help patients’ spouses recover from the shock of heart attacks so that they don’t wind up becoming secondary psychological victims.

Barry J. Jacobs, Psy.D. is the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program and the author of The Emotional Survival Guide for Caregivers (Guilford, 2006). He is also the national spokesperson on family caregiving for the American Heart Association.

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Research in MedFT Country

Posted By Melissa Lewis, Wednesday, August 22, 2012

Medical Family Therapists (MedFTs) are doing increasingly important and interesting research on a broad spectrum of topics including cost offset of integrated care (IC), healthcare policy, patient-provider relationships, defining MedFT, manualizing IC interventions, and IC effectiveness, for example. Recently, I contributed to this ever growing body of MedFT literature as I published the literature review section of my recently completed dissertation on the biopsychorelational health of couples with the assistance of my dissertation committee.

As I started out on my journey to do MedFT research I asked myself:

1. ‘How is MedFT research different from other fields of research?’ and once I felt I had a handle on the difference I thought,

2. ‘How in the world am I going to carry out this complicated research?’ I offer my experience and thoughts on this process.

Melissa Lewis
One can take measures of health from all of the BPS arenas, but if health is not conceptualized as interrelated, then a reductionist, and therefore, linear perspective is relied upon.

I really wanted to ensure that if I was doing a literature review or an intervention that I did not just skimp over biopsychosocial (BPS) aspects of health but really try to provide a clear picture of each of these three areas and then demonstrate their relationship to one another. This, I believed, was the heart of MedFT and what separates it from other fields. In my research, I separated sections out by BPS domain and then systematically explained the interrelationships between each of these health arenas and my outcome variable: marital health. When gathering data on couples at their family medicine visits, couples completed a research packet that had several assessments in each health arena capturing biomarkers that are commonly provided at primary care visits, a series of psychosocial assessments pertaining to substance use and distress, as well as relational assessments to better understand the couple’s relationship health. 

Of course, the real test was how we conceptualized health. One can take measures of health from all of the BPS arenas, but if health is not conceptualized as interrelated, then a reductionist, and therefore, linear perspective is relied upon. Thus, I had to make certain to provide a fluid argument for why I was using so many measures and why they were related. I used the Stress Hypothesis Model to suggest a way for readers to understand couple’s total BPS health and the interrelatedness of the domains (i.e., stress ---> negative physical and relational outcomes, while poor medical and marital health ---> stress).

In addition, to capitalize on my MFT roots, I wanted to use a dynamic and relational perspective of health. Therefore, I collected data from patient and spouse to gain a systemic understanding of their health. In this way, data can be collected over time (at multiple intervals) and statistical modeling techniques can be used to ascertain what percentage of change in physiological stress response can be attributed to marital health versus life distress for each member of the couple. In other words, is the conflictual marriage or the life distress experience contributing more to the patient’s physiological stress response and is the wife’s or the husband’s marriage experience related more to the patient’s physiological stress response (which we know is related to increased susceptibility to illness, which is related to stress, and so on and so forth).

Obviously, as we use a non-linear, ecological perspective to conceptualize health we do a better job of describing the health event (i.e., infinite contributors to a health event that are multi-directional) than if we used a linear perspective alone. Unfortunately, data collection, data analysis, and even MedFT implications can become more complicated to undertake and require more advanced skills and time to complete the research project. For many of us, we are navigating into unchartered territories by creating and testing our own theories and models, utilizing research techniques from several other disciplines and redefining health and health interventions in hopes of contributing in a relevant and applicable way for our patients and the field of healthcare. I hope that this may spark your interest in MedFT research and am curious about how you define and carryout MedFT research. Please share your MedFT research experience with us by commenting below!


 

Melissa Lewis is a licensed Marriage and Family Therapist in North Carolina. She received her Master's degree at Arizona State University (MFT) in 2007 and her PhD from East Carolina University (MedFT) in 2012.Her research area broadly encompasses the relationship between stress response and BPSS outcomes. Specifically, she studies the stress transmission model with military couples and is also evaluating integrated care interventions aimed to reduce BPSS health symptoms in both Native American and military populations. Melissa can be contacted at mlewis@alumni.ecu.edu


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