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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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Mirena for Crying Babies and Stickers for Older Siblings: An Image of a Biopsychosocial Physician

Posted By Scott Michaels, Tuesday, August 14, 2012
A biopsychosocial physician is one who can attend to systemic issues and mobilize patient resources. As it happens, I have had the privilege of working with such a physician. And I have taken creative liberty in recounting a peculiar patient encounter I witnessed. Some of the connections I make may also seem a bit creative.

As I was walking back to my office, I heard a large commotion in the next hallway. It turned out to be a mother and two young sons being entertained by a physician.

At first glance, a baby was crawling up his mother while crying and pining for the book the physician just stripped from his hands. I wasn't quite ready for what I saw next. In what seemed like a scene out of Monty Python, the doctor somehow harmoniously quelled the crying baby, went through an entire supply of stickers, and exhausted the reading material in the pamphlet ridden hallway.
Scott Michaels
Too often, we get so caught up in our pursuit of education, competence, and mastery of little techniques that we forget to connect with our patients.
 The physician somehow pulled off a pirouette and somersaulted behind the nurse’s station to grab what seemed like every sticker left in the clinic for the baby’s older brother. And with lightning speed he darted across the room to find seemingly nonsensical reading material for a baby. It became clear to me that this wasn’t just any old intervention; this was a master at work.

This isn't a story about when doctors lose their minds; maybe it's not a story about anything. But to me, this is a story about health literacy, a story about expanding the patient system, and a story about customer service.

You may think it is strange for a doctor to steal a book from a baby, but is it really? You may think it is strange for a doctor to replace that book with a Mirena pamphlet, but is it really? You may think what this doctor was doing may seem like nonsense, but I don't. What was really happening was a doctor planting the seeds of change.

Lesson one: what this doctor was doing was ingenious; this was a systemic intervention for health behavior change starting with health literacy. With this young brainchild knowing all there is about Mirena, and who knows, maybe next time it will be Byetta, this family will surely be healthy, knowledgeable about their health, and could teach others how to do the same.

It took me a while to understand why the older child got so many stickers. But as it so happens in primary care, patients are seen from the cradle to the grave. So this older child must've been seen by this doctor many times. And I can only imagine that the older child had already studied Mirena, Byetta, and even Abilify. Obviously, the stickers were a reward for each pamphlet the older child read.

Lesson two: expand the system! The mother of these children may not have needed Mirena, Byetta, Abilify, or really any other medication. But, this doctor expanded the system to include family members. The family is always more influential in changing and maintaining health behaviors than healthcare providers. These children can hold that young mother accountable for her health behaviors now that they’ve learned about disease processes.

The pirouette, the dash across the hallway, and what seemed like countless somersaults were not just for show. This doctor exhibited a different kind of showmanship, that is, showmanship you would see in a good salesman. These patients came for a service and who better to provide that service than a dancing, tumbling, and profusely sweating doctor?

Lesson three: your patients are customers. And as providers of a service, you have a responsibility to your customers. Sure, there are many ethical opinions, obligations, and so on. Regardless, provide service with care and enthusiasm.

Too often we forget that our patients need a little laughter; and let me tell you, this was something to laugh about.

Lesson three and a half: don't forget to laugh! This was one of the funniest things I've seen in primary care, maybe because this doctor is hysterical, but mostly because his intervention worked. This family left the clinic feeling cared for, jovial, and ready to come back.

You may realize by now, this anecdote was written in jest. However, there are some very real points here: promote health literacy, expand the patient system, provide good customer service, and use humor. Too often, we get so caught up in our pursuit of education, competence, and mastery of little techniques that we forget to connect with our patients.

I'm not encouraging all healthcare providers to abandon our quests for competency just to pirouette, somersault, and run around hallways. But I would like to encourage that we remember aspects of our practice like customer service and humor to establish meaningful patient-provider relationships.

My last pearl: this doctor was only successful because he was being himself. So when you treat your patients, remember that you don't have to be perfect. No one is; but the moment was perfect because this provider embraced who he was and the patients accepted him because he genuinely cared.

 

Scott Michaels is a Medical Family Therapy doctoral candidate at East Carolina University. He completed his Master’s degree at the University of Rochester (MFT) in 2010. He is currently the Applied Psychosocial Medicine Resident in the Southern Regional AHEC Family Medicine Residency Program in Fayetteville, NC. His academic interests include MedFT competency development and family medicine residency education.

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Exploring the "S" in BPS (BioPsychoSocial)

Posted By Melissa Lewis, Tuesday, August 7, 2012

Engel’s BPS Model has served to guide the discipline of Medical Family Therapy, reminding us to assess, acknowledge and treat each of these systems and specifically not to ignore the psychosocial when working in a medical setting. However, what exactly is encompassed in the ‘social’ realm? For social workers it may include basic living needs or connecting patients to other social service agencies. For chaplains it may be connecting the patient to a religious/spiritual community. For marriage and family therapists, it can include working to improve family relationships. Each of these disciplines is addressing important needs of patients that have been proven to aid in more effective treatment, faster recovery, and increased patient satisfaction.  

While these ‘social’ interventions are improving the health and well-being of patients, I would like to take a moment to dig a little deeper. I define the social aspects of life and health as cultural and relational ways of being. With that said, it is clear that ideas surrounding health, illness, cures, and healing will vary by individual and community. Yet we utilize ‘evidence-based’ methods that only allow for one way to see, cause and cure an illness which may be subjugating, and possibly ineffective, for the patient.
Melissa Lewis
What would you do as a MedFT if this were your patient?

Let’s continue the conversation through the comments you make!

Some interventions, such as Motivational Interviewing (MI), allow for patient goals and motivation to be accounted for. Further, Galanti (2004) suggests using the ‘4C’s (1. What do you call the problem/illness? 2. What do you think caused the problem? 3. How do you cope with the problem? 4. What concerns do you have about the problem?) can help to gain a better understanding of the patient’s view of health and illness. Next, the information gained from this assessment can be incorporated into treatment recommendations which will respect the patient’s health belief system and worldview and, therefore, are more effective.

 

I argue that a deeper and often more difficult intervention is necessary to accompany the above-mentioned techniques. I believe that using cultural humility to interact with patients will allow for some of the best health care outcomes possible. Cultural humility is the constant examination of our own biases and perspective. The regular steps of cultural competence still remain: learning/reading about a particular culture, interacting with that culture, respecting cultures other than your own. However, an additional set of criterion are necessary to become culturally humble:

1) Acknowledge that you are on equal footing as their discussant/patient-There is no better way to conceptualize health (i.e., provider vs. patient beliefs surrounding health).

2) Be aware that the discussant lives their life by a set of rules related to their family, history, and environment, which are individualized, discrete and different from your own (Ethnorelativism).

3) Be aware of how your own personal life history over time effects your thoughts, beliefs and behaviors (strengths and limitations) in relation to the discussant.

4) Acknowledge that one can never truly know the perspective of another individual or culture and that admitting your limitations opens the door to an honest conversation and does not diminish your legitimacy, credentials, or strengths and skills.

5) Does not search to become culturally competent at some distinct point, instead is continually learning about themselves and others through mutually beneficial conversations.

To demonstrate this point I offer a case example based on a real scenario:

A medical provider and her colleagues have been seeing a patient who has cancer (but has been in remission for 4 years) at 6 month intervals to ensure that the cancer (a rapid and progressive one) does not return. At the end of every visit for 4 years, the provider tells the patient and his family that he continues to be cancer-free and the family wails with joy and tears at the end of every appointment. The provider and her team have become frustrated with this response and do not understand the intense emotional reaction to what seems like a routine check-up that has resulted in the same positive outcome for many years. They hypothesize that there is some psychological trauma that the family has incurred due to this health experience that has resulted in some sort of psychological damage and are planning to refer them to psychiatric services. The patient is being seen at an Indian Health Service (IHS) facility in the Southwest United States and belongs to a Southwest tribe of Native Americans.

What do you think the provider and her team are missing from their assessment of the patient and the family? Using MI, the 4C’s, cultural humility, or your techniques to remain client-centered, what would you do as a MedFT if this were your patient? Let’s continue the conversation through the comments you make!

 

Reference:  Galanti, G.-A. (2004). Caring for patients from different cultures. Third Edition. Anthropology of Consciousness, 15, p.66–67. doi:10.1525/ac.2004.15.2.66

 

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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Caring for Family Members: In Whose Hands Indeed

Posted By Dan Marlowe, Tuesday, July 31, 2012
The Institute of Medicine released a report earlier this month, as pointed out by Lauren N. DeCaporale in the comment section of Barry Jacobs previous post (check it out), entitled The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. You can find an abbreviated report, panel recommendations, and even read the full report online here.

In it the panel throws out some interesting figures: 1) the number of adults over age 65 will rise from 40.3 million in 2010 to 72.1 million by 2030- that’s an increase of almost 60%, 2) nearly 1:5 older adults have one or more MH/SU conditions, and 3) none of these figures take into account the elderly who are or will be dealing with a chronic illness (e.g., hypertension, diabetes, COPD, CHF). However, for me, the most concerning part of the report was something that all of us already know, which is how woefully unprepared we are as a workforce to handle the impending influx of patients and their families needing our services. While many of the recommendations were spot on in terms of things like increasing reimbursement coverage for MH specialties, training curriculum redesign , re-credentialing medical/psychosocial providers around caring for the elderly, and methods for making providers more accountable for outcomes, one recommendation stood out to me in particular:

"Recommendation 4: Congress should appropriate funds for the Patient Protec­tion and Affordable Care Act workforce provisions that authorize training, scholarship, and loan forgiveness for individuals who work with or are preparing to work with older adults who have MH/SU conditions. This funding should be targeted to programs with curricula in geriatric MH/SU and directed specifically to the follow­ing types of workers who make a commitment to caring for older adults who have MH/SU conditions:

  • Psychiatrists, psychologists, psychiatric nurses, social workers, MH/SU counselors, and other specialists who require skills and knowledge of both geriatrics and MH/SU.
  • Primary care providers, including geriatricians and other physicians, registered nurses (RNs), advance practice registered nurses (APRNs), and physician assistants.
  • Potential care managers for older adults who have MH/SU conditions, including RNs, APRNs, social workers, physician assistants, and others.
  • Faculty in medicine, nursing, social work, psychology, substance use counseling, and other specialities.
  • Direct care workers and other frontline employees in home health agencies, nursing homes, and assisted living facilities (including personal care attendants not employed by an agency).
  • Family caregivers of older adults with MH/SU conditions."

The last bullet of the fourth recommendation caught my interest because it seemed like a logical way of incentivizing family caregiving by helping recoup some of the lost revenue of providing care- a cost in the billions. Looking at this led me to think about two interrelated and important questions: 1) what other ways can we incentivize family caregiving for not only the elderly but for others regardless of age or disease demographic, and 2) even with the panel's acknowledgement of family caregiving, why does this still seem to be such a low priority in overall workforce development?

So, what do you all think? What other ways can we make family caregiving a more realistic and sustainable endeavor for both patients and their families? In the end it is never enough to only point out a problem without also offering a sensible and systemic alternative.


 

Daniel 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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MedFT as Flower: Family Caregiving as Forest

Posted By Barry J. Jacobs, Tuesday, July 24, 2012

From that magical moment in the Minnesota hot tub in 1991 when Susan McDaniel, Bill Doherty and Jeri Hepworth coined the term "medical family therapy,” the field has had a slow but steady growth, sending tendrils into curricula for family therapists and other healthcare professionals and blossoming into a dozen or so certificate and degree programs around the country. For this progress, we all should be proud. But MedFT, to me, is like a delicate, hothouse orchid, assiduously watered and trimmed, surrounded by a burgeoning forest of more lush and verdant organic growth. The towering trees nearly blocking out the sun nowadays are the results of a fertile, consumer-initiated movement that took root around the same time as MedFT. That movement—now this country’s chief focus on families and illness--is called "family caregiving.”

Orchids and oaks, you say. Apples and oranges. Family caregiving, you contend, is what devoted family members do for an ill loved one; medical family therapists use systemic expertise to foster that endeavor. But while the term "family caregiving” is used to describe the sacrifices and struggles of over 60 million Americans in their provision of care to ailing relatives and friends each year, it also denotes a multi-disciplinary research, advocacy, and clinical effort with a complex infrastructure of federal, state and local support programs, disease- , relationship- and culture-specific research, and public and private funders and policy mavens.
Apples and oranges
Orchids and oaks, you say. 

Apples and oranges.

 

All that MedFT is striving to achieve—to better understand how families are buffeted by illness and disability and can continue to develop resiliently—the field of family caregiving has also striven for and has far outgrown us. 

Take research, for example. Empirical studies within MedFT are relatively few, are based on small subject groups, and have limited generalizability. In contrast, the research conducted over the past 25 years by psychologists, nurses, social workers, family physicians and others, particularly about dementia caregiving families, has been extensive, broad and deep. The original question those researchers undertook to answer—how family caregivers are affected by caring for someone with Alzheimer’s disease—has long been answered with evidence of increased morbidity (insomnia, depression, musculoskeletal problems; see Schulz & Martire, 2004) and mortality (see Schulz & Beach, 1999). These diverse researchers have also largely answered the next question—what kind of supports better help family caregivers cope (see here)—and are now working on how to translate those findings into effective public programs on the state and local levels.

Then there’s advocacy. MedFT academicians and practitioners have attempted and accomplished little in the policy arena. The powerhouse family caregiver consumer groups (e.g., National Family Caregivers Association, National Alliance for Caregiving, Family Caregiver Alliance) and other larger organizations with a strong interest in family caregiving (e.g., AARP, Alzheimer’s Association) have lobbied for and helped push through landmark federal legislation, including the Family and Medical Leave Act (1993), the National Family Caregiver Support Program (2000), and the Lifespan Respite Act (2006). Family caregiver advocates have made sure politicians know that there’s a growing constituency of Baby Boomers who want more monies earmarked for supporting their aging parents. Even in tight budgetary times, those funds have gradually increased.

The family caregiving movement’s clinical efforts might not be recognized by medical family therapists as "clinical” at all. Largely consisting of psychoeducation, screening for depression and anxiety, and providing respite care, the caregiver support programs are not particularly systemic in orientation, tending to focus on the needs of the primary caregiver. (Here’s where we have something to teach them about better harmonizing the interactions among various family members to produce better outcomes for the patient and family.) But given the widespread availability of caregiver support services, covering every county in this country, the family caregiving movement is meeting more of the basic psychological needs of the vast majority of families dealing with illness than MedFT could ever hope to achieve.

So what should all this mean for medical family therapists? A few thoughts:

  • MedFT should make every effort to become part of the family caregiving movement: That movement has been intensively collaborative, drawing on the strengths of a broad range of healthcare, legal and financial disciplines, as well as family members and patients. Yet because medical family therapists have been toiling in a few relatively isolated outposts, most family caregivers and leaders in the family caregiving field have never even heard of MedFT. I believe that the systemic expertise that we have to offer would greatly enhance the current efforts of family caregiving to roll out effective community-based programs.
  • We need to call our research family caregiving studies, not MedFT studies. Our researchers need to publish in the major journals for family caregiving, such as The Gerontologist and Aging and Mental Health. That’s how our work with be more widely recognized, disseminated and implemented.
  • We should be pitching ourselves clinically to the public and to colleagues from other disciplines on primary and specialty healthcare teams as "family caregiving experts,” not medical family therapists. This will better communicate who we are and what we do than the current identity we have. This is, in fact, truth in advertising—we are family caregiving experts!
  • Our MedFT associations—e.g., the CFHA MedFT work group and the MedFT Facebook group—should be advocating for improved services for family caregivers. We should join with dozens of other healthcare professional associations in the large and powerful coalition known as the National Alliance for Caregiving (www.caregiving.org). NAC is the single strongest voice advocating in Congress and in the academies today for the needs of families struggling with illness and disability.

In short, we need to branch out of the insular hothouse world and roam the forest. We need to cross-fertilize with other disciplines more. We need to pollinate their ideas with our own and improve their systemic understanding and efficacy. We have to trust that who we are and what we do will matter--and not just get lost in the scenery.

References

Schulz, R & Martire, L (2004). Family caregiving of persons with dementia: prevalence, health effects and support strategies, Am J Geri Psychiatry, May-June, 12(3), 240-9

Schulz, R & Beach (1999). Caregiving is a risk factor for mortality: the Caregiver Health Effects Study, JAMA, Dec. 15;282(23):2215-9

 

Barry J. Jacobs, Psy.D., Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA, has long been involved in the family caregiving movement. He is the national spokesperson on family caregiving for the American Heart Association and an honorary board member of the Well Spouse Association. Most recently, he was appointed to the Caregiver Advisory Board of AARP. He has long written the advice column for "Take Care,” the newsletter of the National Family Caregivers Association, and is also the author of The Emotional Survival Guide for Caregivers (Guilford, 2006).



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