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Integrated Care Thought Leader Series: Benjamin Druss, MD, MHP

Posted By Cheryl Holt, Thursday, September 26, 2013

(This blog post is a reprint of a piece by Cheryl Holt from August 6th, 2013. Click here for the original post. Reprinted with permission)

"That’s the next direction that [organizations] need to go, bringing substance abuse back into the discussion. We need to go past just the integration of primary care and mental health care to a more Whole Person Care."

It has been my pleasure to talk with Dr. Benjamin Druss for this edition of the Integrated Care Thought Leader Series. Having had the privilege to work with Dr. Druss on various integrated care projects over the past few years, I have come to respect not only his keen insight into what’s needed beyond the horizon for the care of people with behavioral health disorders, but the compassion and dedication he brings. His humility and brilliance are evident upon introduction; he’s a true visionary. Dr. Druss, my mentor and my friend, has provided inspiration to me in my work and outlook on the world of healthcare, integration, and beyond.

Dr. Druss, world-renown researcher in health policy, has made a significant contribution to healthcare and the integration of behavioral health and physical health. He has impacted the lives of many individuals as a result. As the first Rosalynn Carter Chair in Mental Health, Dr. Druss is working to build linkages between mental health, general medical health, and public health. He works closely with Carter Center Mental Health Program, where he is a member of the Mental Health Task Force and Journalism Task Force. He has been a member of two Institute of Medicine Committees, and has served as an expert consultant to government agencies including the Substance Abuse and Mental Health Services Administration, the Centers for Disease Control, and the Assistant Secretary for Planning and Evaluation. He serves as professor at Rollins School of Health Policy and Management at Emory University.

Dr. Druss’s research focuses on improving physical health and healthcare among persons with serious mental disorders. He has published more than 100 peer‐reviewed articles on this and related topics, including the first randomized trial of an intervention to improve medical care in this population in 2001. His research is funded by grants from the National Institute of Mental Health and the Agency for Healthcare Quality and Research, and he serves as a standing member of an NIMH study section. He has received a number of national awards for his work.

Dr. Druss, Dr. Silke von Esenwein, and their colleagues at Emory University are currently conducting an exciting NIMH research trial, The Health Outcomes Management and Evaluation (HOME) Study. As described on the website: There is an urgent need to develop practical, sustainable approaches to improving medical care for persons treated in community mental health settings, this study will test a novel approach for improving mental health consumers based on a partnership model between a Community Mental Health Center and a Community Health Center. When this study is completed, it will provide a model for a medical home for persons with severe mental illness that is clinically robust, and organizationally and financially sustainable.

Dr. Druss received his bachelor’s degree from Swarthmore College in 1985, earned his medical degree from New York University in 1989 and later his master’s in public health from Yale University in 1995. He is also board certified in psychiatry. He trained as a resident in general internal medicine at Rhode Island Hospital and in psychiatry at Yale University School of Medicine. Click here for more information about Dr. Benjamin Druss.

Advancement in integrated care through the years

Dr. Druss was one of the first to address the physical health concerns among people with serious mental illness and substance use disorders, particularly among the public sector populations in urban regions. During our discussion on integrated care, he addressed areas of change over the past 18 years that has had the greatest impact on the advancement of healthcare for people with serious mental illness. He described the world of Health Information Technology as a frontier that, over the past 10 years, has resulted in changing policies and procedures in healthcare. These changes have had significant impact on the ability for healthcare organizations to share information, resulting in improved care for patients.

Dr. Druss advises that the next stage needed for healthcare is to begin "broadly looking at other social determinants of health.” The focus should be on an approach to healthcare that is person-centered. The concept of addressing population health and creating a system of care will be a more effective approach to improving health outcomes moving forward. He recommends that substance abuse must be brought back into the discussion, and to go past just the concept of integration of physical health and mental health, toward a more "whole person care” approach.

What do you foresee for the field as we move forward?

Dr. Druss: Clearly there’s going to be major changes in how care is delivered. I think there’s a lot of opportunity moving forward with new public sector models, Medicaid, patients with medical homes, and also the promise of new technologies moving forward as well.

I’m very optimistic; I think things will certainly be very different five years from now. We’re in a period where things are evolving very quickly and we don’t know exactly what the world will look like, but I think we can say that things will look different—and that things will look better.

Research has to change as well. I’m mostly a researcher and lot of what we’ve been doing is slow-paced. The slow-paced process by which we develop a model, and then test it over a five year period. You apply for a grant and then you test it for five years, then it’s another two years before it’s published. So we’re going to have to be looking for more ways for understanding data and evaluating programs. I think the new technologies will help, their more wide-spread availability will help. Just as the health system needs to change—and is changing—health research is going to need to change as well.

The funding agencies still are gradually coming to that point. NIMH has a new program that they are looking to fund that looks at natural experiments out in the community. So I think that’s the sort of research that we’re going to need to see more of in the coming years—good, careful, thoughtful evaluations of some of the demonstration projects going on out in the community.

What barriers to integration to you currently see?

Dr. Druss: I’d say that a lot of community mental health centers are still on this part of the learning curve in terms of learning about integration, such as how potential partner organizations work, [such as] Federally Qualified Health Centers. [CMHC’s] often lack information technology infrastructure that makes it easier to do the work. There are some places, some community clinics, and other organizations that are out in front on these issues, that are early adopters, and there’s some that are trying to figure it out and hopefully will learn from the experience of those organizations that are further ahead.

Thank you, Dr. Druss, for your dedication to improving the health and quality of life of so many who live with serious behavioral health conditions. Click here for a list of research projects and publications by Dr. Druss.

Be sure to check back soon for our next Thought Leader, Larry Fricks, pioneer in the Peer Support movement.


Cheryl Holt, MA, CEO of Behavioral Health Integration Consulting, LLC, is an advocate for the integration of behavioral and primary healthcare for whole-person health and assists organizations in adopting a whole-health focus. She is active in social media promoting integrated care, behavioral health policy, and global mental health. She blogs regularly via the Behavioral Health Integration blog and manages LinkedIn's Behavioral Health Integration group and the Behavioral Health Integration page on Facebook. You can follow her on Twitter: @cherylholt, @BHPCIntegration, and @WorldMentalHlth

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My Experience Mentoring Behavioral Science Faculty: Getting Back Much More Than I Gave

Posted By Kathryn Fraser, Thursday, September 12, 2013

"The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires.”

- William Arthur Ward

I honestly never imagined how rewarding it would be to help others who are starting out on their path as behavioral medicine faculty. In my own experience as a new behavioral science faculty member, I was sometimes ignored, criticized, and questioned straight to my face about my knowledge and my credibility. Fortunately, a series of very supportive program directors and fellow faculty helped me through some tough times and helped me find my voice. I often imagined what it might be like for new behavioral scientists who felt less than supported in their jobs.

My experience being a small-group mentor in the Behavioral Science/Family Systems Educator Fellowship (BFEF) was truly magical. My co-mentor and I were both focused on fostering an environment of growth and encouragement—we wanted to help the fellows to spread their wings and also feel well grounded in this unique field. Advising the fellows on teaching activities was only a small part of what we did. The bigger tasks were teaching them about self-care, helping them develop a strong professional identity as behavioral faculty, and helping them set professional boundaries. It is easy to feel like you are on the periphery since behavioral science is often considered by residents to be a small part of what they really need to learn. We try to help the fellows understand that their contributions are crucial to one of the cornerstones of family medicine—the physician-patient relationship.
We wanted to help the fellows feel well grounded

The mentoring we received from the leaders of the BFEF was phenomenal. At planning meetings I felt like I was part of a think tank helping to pave the way for the future of behavioral science. This group helped bring out the best in me as a teacher and a mentor. Their support, warmth, and kindness made them excellent role models for the small-group mentors as we attempted to provide a safe, effective growing space for our up and coming fellows.

Perhaps the most important life lesson I got from this experience was how to develop my skills as a leader in medical education. As residency faculty, we must see ourselves as leaders and role models for our residents. As behavioral science faculty, we must embrace the leadership role we have in our own particular niche, which helps provide the building blocks of the communication and relationships skills so necessary for family physicians. 

If you get the opportunity to mentor folks who are early in their career, take it. There is no greater gift as a teacher than to have the feeling of inspiring others, except perhaps inspiring others to also be an inspiration to their own students.


Dr. Kathryn Fraser is a licensed psychologist and Behavioral Medicine Coordinator in the Halifax Health Family Medicine Residency Program, Daytona Beach, Florida.  Her professional interests include anxiety and stress management, the physician/patient relationship, women’s issues in psychotherapy, and cultural competency in health care.  In her free time she enjoys yoga, cooking, reading, and spending time with her family and dog at Florida’s state parks and beaches.
(This piece was originally posted on the Society of Teachers of Family Medicine blog. Reprinted here with permission)

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2013 CFHA Conference - Early Registration Ends Soon!

Posted By Colorado Conference Co-Chairs, Wednesday, September 11, 2013


Our conference aims to disrupt the status quo at all levels

Early bird registration ends this Friday, September 13th. Click here to register today!
 

A stressed single mother sees her physician, therapist, and case manager at the same time

= Disruption x 1.

A physician provides a warm hand-off of a couple who just lost their child

= Disruption x 2.

A first group medical appointment for pediatric obesity attracts 5 families

= Disruption x 15.

A family doctor is embedded into a community mental health center

= Disruption x 1,000.

A charitable foundation launches a state-level integration initiative              

= Disruption x 100,000.

A national insurance company introduces advanced payment for PCMH clinics          

= Disruption x 10,000,000.

We collaborators are disrupting the status quo of healthcare every day.  Sometimes disruption occurs through an intimate conversation in an exam room.  Other times disruption occurs in the halls of power in congress and corporations.  Our conference aims to disrupt the status quo at all levels:

  • Some of you seek clinical skills to practice one patient or family at a time.  You will find those skills.

  • Some of you seek operational insights to overcome obstacles facing your healthcare system.  We have convened the experts you need.

  • Some of you seek financial models to sustain integration in your clinic or community.  We have answers from communities just like yours.

A lot has changed in the five years since Colorado first hosted the CFHA conference.  At a state level, integrated care has advanced from a smattering of clinics to a coordinated, statewide standard.  At the national level, we have advanced from a radical voice from the wilderness to finally catching the attention of the highest level decision makers.  This year’s conference will champion the disruptions we’ve caused and provide you with the tools and knowledge to alter the status quo where you live and practice.

In addition, we’ve planned a lot of Colorado-style fun and networking.  From beer-tasting, to bus trips to Boulder, to speed mentoring, we aim to please. 

Thanks for joining us, and have a great conference!

Colorado Conference Co-Chairs 

Amy Davis

Laurie Ivey

Ben Miller

Sam Monson

Randall Reitz

Laura Sudano 

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The Great Debate

Posted By Benjamin Miller, Thursday, September 5, 2013


This is the third post in a series of "blasts from the past". These classic posts will highlight issues that are just too important to collect dust in the archives. The series will be off and on for the next several weeks. Enjoy!

(This piece was originally posted on September 21, 2012)

Changing healthcare requires an ability to gracefully navigate between competing interests and ideologies. Depending on "where you sit,” what type of change you want may be different than what your neighbor wants. Change is relative, and aims, goals, and objectives are often dependent on who you are professionally and who you work for. Integrating care, specifically behavioral health and primary care, brings out some of the best and worst of this "where you sit” phenomenon.

To this end, CFHA will host a presidential-style debate for the Friday plenary at our October 4-6 conference in Austin. We will grapple with the question: "Will collaborative care be a mainstream healthcare model within a decade?" To get you excited for this event, our blog today presents the opening statements of our 4 debaters. As the moderator for the plenary session it will be my job to engage these leaders and hear all sides of the argument. Who will win this debate? Whose side will come out on top? That decision is up to you, dear reader.

Randall Reitz

Randall Reitz PhD
is CFHA's Director of Social Media and the the Director of Behavioral Sciences at the St Mary's Family Medicine Residency in Grand Junction, CO.

Collaborative care is still a gangly, pre-pubescent David amongst the Goliaths of healthcare. We lack the scale, strength, and resources of the major industry players. That being said we are on the precipice of something great. Within the next decade the clinical, operational, and financial aspects of collaborative care converge to push our model into the mainstream of healthcare:

  • Clinical:We now have empirical evidence published in top scientific journals that demonstrates the proven effectiveness of collaborative care in terms that even the most hardened insurance executive or corrupt government official could not deny.

  • Operational: The simple reality is that we have experienced exponential growth in the adoption of collaborative care operations at all levels of the American healthcare system. We have already conquered the public sector and are within a decade of conquering the entire system.

  • Financial:Our research and policy advocacy has already won the hearts and minds of policy makers. The teeter-totter of policy and payment is already reaching the tipping point at which the laws, regulations, and reimbursement standards will align to insist on financially sustaining collaborative care as a wholly necessary, fully-funded, and central feature of American healthcare.

Paul Simmons

Paul Simmons MD is a faculty physician at St. Mary’s Family Medicine Residency Program in Grand Junction, Colorado. He enjoys Apple products, black coffee, fountain pens and eponyms.


In this group of true believers, I have the honor of standing boldly as the lone skeptic who has not yet drunk of the collaborative care Kool-Aid. There are several reasons that collaborative care will not, unlike flying cars, be mainstream by 2022.

  • First, the collaborative care clan cites supposedly supportive studies that are flawed, biased and not generalizable to the real world. The evidence-based emperor has no clothes.

  • Second, collaborative care will not be able to overcome its own vagueness and impassioned, but unfocused, hand-waving. If advocates cannot clearly and rigorously define what they’re advocating, passion fails to persuade.

  • Third, the fevered dream of collaborative care will be exposed to the harsh, bright light of financial and payment system realities.

Despite these hard truths, I can hardly hope to persuade the diehards who have pledged their lives and fortunes to the cult of collaboration. Disillusionment is difficult, but we should always prefer reality to the pipe-dream of wishful thinking.


AJ Jayabarathan

Ajantha Jayabarathan MD
20 years of practice in primary care, 10 years of working on television and radio, 8 years of association with the Canadian National working group on shared mental health care, 16 years of raising a family while living in Nova Scotia, Canada, inform my opinions of how health care is evolving in 2012.


Yes and No… so states my reading of the tea leaves of time.

In ten years’ time, if Obamacare is actualized in the United States of America, integration of mental and physical health through collaborative, co-located mental and physical health services will become the mainstream model of care. If the injection of funds and faith into this model of care is thwarted by the politics of 2012, the rate of uptake of this model will be slower and the United States might well be left ten years behind as health care evolves because of this model in the rest of the world.

Meanwhile, in Canada, Australia, New Zealand and the United Kingdom, this model of care has already seeded fertile health care fields and is growing in strength, outcomes and diversity. Coupled with the parallel explosions of the information age via the internet, virtual social networks via social media and electronic management of health care it has steadily gained momentum …..and is now unstoppable.


Eduardo Sanchez

Eduardo Sanchez MD is
Vice President and Chief Medical Officer, BlueCross/Blue Shield-Texas

Opining as a health plan chief medical officer, I believe that the health system will have evolved to a collaborative care model by 2022. The direct and indirect medical costs associated with behavioral health, when it is not recognized and not well managed, can no longer be ignored.

Employers and health plans are beginning to appreciate that better employee health status correlates with higher productivity and an upside bottom line and that medical costs decrease and, more significantly, workplace productivity improves when behavioral health is appropriately and "collaboratively” managed. As a result, employers (whether they are corporate America, small business owners, government, and non-governmental organizations) and health plans across the United States will join health care providers and patients to accelerate the realization of a competent, considerate, culturally-relevant, compassionate, collaborative health system.

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Requiem for Family Medicine

Posted By Paul D. Simmons, Thursday, August 29, 2013


This is the second post in a series of "blasts from the past". These classic posts will highlight issues that are just too important to collect dust in the archives. The series will be off and on for the next several weeks. Enjoy!

(This piece was originally posted on August 2nd, 2012)

Family medicine is a young specialty, a mere forty-three years old (1). Unfortunately, family medicine will be extinct before it reaches its 70th birthday if current trends continue and—although I write as a family physician who educates family medicine residents and loves the idea and ideals of family medicine, I say—this might not be a bad thing. Several forces, both from within and external to family medicine, are conspiring to make us irrelevant, unnecessary and obsolete. We’ve all seen the Match Day trends (2). Each year until 2010, fewer medical students pursued training and careers in family medicine, and the slight increases over the last few years are largely attributable to more family medicine residency positions available. We cannot fill our available positions with US graduates. Many of those who match in family medicine are trained in a shrinking spectrum of skills. Many new graduates quickly jettison any broader skills they may have had in the name of work-life balance (3). Across the country, specialists and insurers implicitly or explicitly argue that family physicians cannot and should not be doing surgical (or non-surgical) obstetrics, endoscopy, minor surgery, ICU care or hospital medicine (4). We are often complicit in this effort to minimize our domain of practice, again in the interest of lifestyle or avoiding liability.

As our skills and practice scope are diminishing, a wave of mid-level practitioners (i.e., physician assistants and family nurse practitioners) are moving into primary care medicine (5,6,7). They share many of our same skills, are able to prescribe and order just as we are in a growing number of states, and are paid less. Most of these so-called "physician extenders” do excellent work and are viewed as equivalent to physicians by many patients. It is inevitable that health systems, policy-makers and third-party payers will soon realize—with dollar signs in their eyes—that these practitioners are inexpensive physician substitutes rather than physician "extenders.” All of the skills, more empathy and a similar scope of practice without the egos or paychecks of physicians.
Paul D. Simmons
Our support for the Patient-Centered Medical Home (PCMH) model, while predicated on admirable ideals, could easily be speeding our demise.

Sadly, family physicians are ill-equipped to resist our own demise because we lack a clear sense of what, exactly, it is we do. Not only does the public have little sense of how a "family doctor” differs from an old-fashioned "GP” or an internist, many of us have a difficult time explaining the distinction apart from defensively sputtering, "We’re a specialty, too!” Family medicine, some say, takes care of 90% of medical problems that present in the outpatient setting. Of course, so do internists (for adults), pediatricians (for children), and emergency physicians (for everyone). Family medicine, some say, provides continuity of care over the lifespan. Perhaps thirty years ago this was true. Now, however, vanishingly few family physicians will spend a career in the same location, taking care of the same population.

Even more troubling, however, is a deeper sense of inadequacy within the family physician’s psyche. Yes, I take care of adults, but can I really do so as well as an internist? Yes, I take care of children, but can I really do so as well as a pediatrician? I may deliver babies, but can I really provide the same quality of care as an obstetrician? If the reader balks at these questions, consider: if your wife were to experience a pregnancy complication, and you had the option, would you ask for an obstetrician or a family physician? If your child was suddenly struck with serious illness, would you bring her to a pediatrician or a family physician? We claim we are "equal” to our specialty colleagues—yet when serious or complex illness strikes those we love, we may find we have been playing doctor and we want a Real Doctor to step in to save us. Do patients sense this as well?

The larger medical world certainly seems to have detected our impotence. Family physicians exert minimal or no influence in determining our own payment structure, nor are our protests taken seriously. The Accreditation Council of Graduate Medical Education (ACGME) frequently ignores or delays our specialty’s recommendations or intentions (8). The AMA/Specialty Society Relative Value Scale Update Committee (RUC) continues to perpetuate an unjust payment model despite our protests (9). Family physicians are not the doctors that come to mind when patients think of disease-detecting, mystery-solving "experts” at the Mayo Clinic or Cleveland Clinic, nor do many tertiary- and quaternary-care institutions see a significant role for us in their delivery of medical care. Our medical journals are of comedically dubious quality, and we seem to be best at publishing, if anything, within the review article genre (10).

Family physicians exert minimal or no influence, ... nor are our protests taken seriouslyOur support for the Patient-Centered Medical Home (PCMH) model, for example, while predicated on admirable ideals, could easily be speeding our demise. The PCMH model rests on the idea of team-based care, where many of the functions previously carried out by physicians are delegated to nurses, medical assistants and case managers. This is intended to free up the physician to deal with the "hard” cases for which we are best suited. The problem is: we are not best-suited. The endocrinologist is best-suited to deal with the complicated, uncontrolled diabetic patient that cannot be brought under control by the nurse practitioner’s efforts. Similarly, the cardiologist is best-suited to deal with the refractory hypertensive; the gastroenterologist with the complicated hepatitis C patient. The family physician, in the PCMH model, is an unnecessary (and expensive) middle-man who has very little to add to the best management efforts of a high-functioning team operating with evidence-based protocols and guidelines. Inevitably, someone in authority will realize this cost-saving, simplifying fact.

Our support for the Patient-Centered Medical Home (PCMH) model, for example, while predicated on admirable ideals, could easily be speeding our demise. The PCMH model rests on the idea of team-based care, where many of the functions previously carried out by physicians are delegated to nurses, medical assistants and case managers. This is intended to free up the physician to deal with the "hard” cases for which we are best suited. The problem is: we are not best-suited. The endocrinologist is best-suited to deal with the complicated, uncontrolled diabetic patient that cannot be brought under control by the nurse practitioner’s efforts. Similarly, the cardiologist is best-suited to deal with the refractory hypertensive; the gastroenterologist with the complicated hepatitis C patient. The family physician, in the PCMH model, is an unnecessary (and expensive) middle-man who has very little to add to the best management efforts of a high-functioning team operating with evidence-based protocols and guidelines. Inevitably, someone in authority will realize this cost-saving, simplifying fact.

While our specialty shrinks and delegates itself out of existence, some of us take refuge in the ridiculous romanticism of "biopsychosocial” or "patient-centered” or "holistic” flag-waving—as if patients would rather have sympathetic hand-holding than competent, efficient, expert medical care. That’s all fine, of course. We’re generally nice people. But while we’re spending our collective efforts on patient focus groups, learning acupuncture, satisfaction surveys, lifestyle balancing acts and "restoring the mystery” to medicine, our colleagues in internal medicine, pediatrics, obstetrics, critical care, surgery and emergency medicine are taking care of actual seriously sick people and showing that they can do a better job of it than we can. Perhaps we should step aside and let them get back to work.

REFERENCES:

1. Piscano, NJ. (n.d.) History of the Specialty. From American Board of Family Medicine website. Retrieved from https://www.theabfm.org/about/history.aspx.

2. Porter, S. (2012) Family Medicine Match Rates Increase Slightly. AAFP News Now, American Academy of Family Physicians. Retrieved from http://www.aafp.org/online/en/home/publications/news/news-now/education-professional-development/20120316matchresults.html.

3. Kotmire S. (2012) Shrinking Scope of Practice Raises Questions About Future of Family Medicine Training. Leader Voices Blog, American Academy of Family Physicians. Retrieved from http://blogs.aafp.org/cfr/leadervoices/entry/shrinking_scope_of_practice_raises.

4. Should Colorectal Surgeons and Family Doctors Perform Colonoscopy? (2012). Gastroenterology.com, retrieved from http://www.gastroenterology.com/featured/should-colorectal-surgeons-and-family-doctors-perform-colonoscopy.

5. Rough G. (2009). For many, a nurse practitioner is the doctor. Arizona Republic. Retrieved from http://www.azcentral.com/news/articles/2009/02/21/20090221nursepractitioners0220.html.

6. Horrocks S, Anderson E, Salisbury C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal 324: 819-23. Summary retrieved at http://apps.who.int/rhl/effective_practice_and_organizing_care/SUPPORT_Task_shifiting.pdf.

7. Flanagan L. (1998). Nurse practitioners: growing competition for family physicians?Family Practice Management 5(9): 34-43. Retrieved from http://www.aafp.org/fpm/1998/1000/p34.html.

8. Wood J. (2012). Changing training standards for maternity care. Leader Voices Blog, American Academy of Family Physicians. Retrieved from http://blogs.aafp.org/cfr/leadervoices/entry/changing_training_standards_for_maternity.

9. AAFP Opts to Remain in the RUC (2012). AAFP News Now, American Academy of Family Physicians. Retrieved from http://www.aafp.org/online/en/home/publications/news/news-now/inside-aafp/20120313rucdecision.html.

10. Van Driel L, Maier M, De Maeseneer. (2007). Measuring the impact of family medicine research: scientific citations or societal impact? Family Practice(2007) 24 (5): 401-402. Retrieved from http://fampra.oxfordjournals.org/content/24/5/401.full.

 

Paul D. Simmons, MD FAAFP, is Extremely Junior Faculty at St. Mary's Family Medicine Residency in Grand Junction, Colorado where he serves mainly as a negative example for malleable trainees. He practiced family medicine, including obstetrics and endoscopy, for several years in rural eastern Colorado and Wisconsin before joining St. Mary's. His interests include antique Jungian archetypewriters, obscure eponymous diseases, superhero movies, Sherlock Holmes and misanthropy.

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Integrated Care Thought Leader Series: Alexander “Sandy” Blount, EdD

Posted By Cheryl Holt, Thursday, August 22, 2013

(This blog post is a reprint of a piece by Cheryl Holt from July 9th, 2013. Click here for the original post)

"It’s very hard to do integrated care and still think of mental health and physical health.”

Welcome to the first in the Integrated Care Thought Leader Series. This series will focus on the forward-thinking individuals who have had the foresight to envision possibilities in the healthcare industry's future. I'm pleased to begin the series with a man who has been instrumental in advancing integrated healthcare.

Alexander Blount, EdD, better known to most as "Sandy," has played a very important role in bringing the integration of behavioral health and primary healthcare to its current prominent focus within the healthcare industry. Dr. Blount is credited with coining the term integrated primary care in his 1994 publication, "Toward a System of Integrated Primary Care," Blount A, Bayona J. Family Systems Medicine, 1994;12:171-182.

He currently serves as Professor of Clinical Family Medicine and Psychiatry at the University of Massachusetts Medical School in Worcester, MA and Director of Behavioral Science in the Department of Family Medicine and Community Health.  He teaches resident physicians the psychosocial skills of primary care practice and founded the post-doctoral Fellowship in Clinical Health Psychology in Primary Care.  He was previously Director of the Family Center of the Berkshires in Pittsfield, MA and a faculty member at the Ackerman Institute for the Family in New York. He has more than thirty-seven years experience as a therapist, teacher of physicians and therapists, administrator and lecturer in the US and abroad.  He is a member of the National Integration Academy Council and has had a leadership role in state and national efforts developing healthcare policy.  His books include Integrated Primary Care: The Future of Medical and Mental Health Collaboration published by W. W. Norton and Knowledge Acquisition, written with James Brule', published by McGraw-Hill.  Click here for more information about Dr. Blount.


It’s an honor to talk with Dr. Blount about the integration of behavioral health and primary care. Yes, he admits that he is optimistic about the direction in which the field is moving! His enthusiasm is almost palpable, with a freshness that belies the number of years he has devoted to the advancement of this revolutionary approach to healthcare. It’s apparent that this enthusiasm easily holds the attention of the students he teaches at UMASS.

Dr. Blount is a visionary whose diligent efforts and perseverance have made great strides toward bringing attention to the widespread failure to address the individual patient as a whole. He graciously agreed to provide insights for Behavioral Health Integration Blog:

What do you see as being the greatest barriers for successful integration of behavioral health and primary care services?

Dr. Blount: I see two things:

First are the barriers that have always been there: regulatory barriers that are built on the idea that mental health and medical services have to be kept separate, financial barriers that only pay fee for service and define services as what is delivered in specialty mental health, and cultural barriers on the part of both medical and mental health people that make working together difficult without some cultural broker who can make the connections and translations necessary.  These have been our problems historically, and happily with the ACA and the PCMH movement, these are reducing.

We will need a four-fold increase over 2010 levels in behavioral health clinicians
The second area is the barriers caused by our own success.  Because integrated care is becoming more possible and is proving itself, there is pressure to start programs in settings where there is little understanding of what it entails and little time and resources to prepare for the change.  People are getting put into integrated programs or co-located, who aren’t trained for it and didn’t pick it. They don’t know what to do. They go in and do specialty mental health. They do what they’ve been trained to do…and it doesn’t work. Then administrators, who may have been skeptical initially, thought this was a fad, see this failure and think "oh yeah, I was right,” it was more inconvenient than useful. We felt we had to develop a training program at UMass Medical School available to these folks to prevent just this form of failure.

Also because there is sometimes a faddishness about integration, you get some administrators who become "true believers” who really don’t know how to do this. They see a presentation,  and they say this is what we are going to do–and they start it without any depth of understanding. It’s sort of the administrative version of the clinician that doesn’t work. We need clinicians who are fully oriented to integrated primary care and leaders who are aware of the difficulties of making these changes and who can develop the buy-in from the whole practice. Integrated pilot programs are often funded on three year cycles.  Places like the DIAMOND Project in Minnesota, where they’ve had some real time to make it work, say that it’s more like a five year cycle from beginning to fully transformed practice.  I fear that federal and private funders will think it will happen faster than it does and will turn away.

Another barrier to our success is the workforce crisis we are facing.  All of the government projections of what will be needed for behavioral health workforce, when compared to the number of people who are being trained, say we will have a terrible deficit, and those projections were made without any calculation of the workforce that has proved to be needed in mature integrated settings.  When word gets out that we will need a four-fold increase over 2010 levels in behavioral health clinicians in Federally Qualified Health Centers alone, not to mention the rest of the health system, the true magnitude of the problem will become clearer.

What excites you about the field today?

Dr. BlountOne, is absolutely the transition in payment models that may make a great leap forward happen. Essentially those models let us implement the clinical routines of integrated care. Up to now the payment models have dictated routines that weren’t very integrated.  Paying for health, rather than for services allows us to deliver evidence based care by the clinician best able to do it at the point that it is most sensible and acceptable to the patient.   Having it actually knitted into the flow of care makes a big difference.

And the other thing that I see happening is a transformation in how we conceptualize mind and body, illness and health.   It’s very hard to do integrated care and still think of "mental health” and "physical health”. The categories just begin to break down because they don’t describe the way people present. They don’t describe how problems form over the years. We’ve had science now for a good while on the plasticity of brain and the way that experience changes the brain and the brain changes experience. The current science even describes the way that experience changes what genes are expressed at various points in a person’s development.  In other words, the science of the brain has been there but the way of thinking in our day-to-day clinical lives has not because we have been enacting models build on conceptions of separate domains.  As we enact integrated clinical routines, we will begin to think differently.  We create the likelihood that the science of the brain will be mirrored in the unity of our conceptions about people and how we try to help them.
As we enact integrated clinical routines, we will begin to think differently

So I think, at least in the places that are more developed, the places that integrated care gets to be mature, you begin to see different forms of conceptualization and hopefully we’ll be documenting those, writing about those, helping to pull others along. There aren’t many places where integrated care is really mature. The places that are mature are very different in numerous ways that don’t initially seem to be connected to integration. The question of "isn’t integration interesting, how do we work on it?” just goes away and the questions are about new ways of helping patients, new groups of patients we can understand better, and new ways of involving patients on their care teams.  How we involve people in their own care, how we get past the doctor as leader and authority to doctor and the team as teachers and facilitators, that’s really the next piece. And when that is going well, I think that integrated care will sort of already be there.

Will you look into your crystal ball for us and tell us what you foresee in the future for integration?

Dr. Blount:  Let’s imagine that we get it right in terms of mature programming, mature routines of integration as far as our workforce allows.  Then we begin to be able to think about health and illness differently, and the whole set of concepts, the models that we have of understanding health and illness and how to influence those begin to move. I foresee the time when there’s a foundation of mature integrated care that we will be looking at great leaps forward in theory or great research leaps forward with greater understanding of what and how we should be researching. That’s one optimistic thing.

And when I look in my crystal ball I think we are going to have states that begin to have whole-state programs that are starting to be implemented and organized so that we can begin to look at the impact of integration on a really big scale.

Thanks so much to Dr. Blount for sharing his insights in the premiere of the Integrated Care Thought Leader series!

Check back soon for a conversation on integrated care with Benjamin Druss, MD, MPH, Rosalynn Carter Mental Health Chair and Department of Health Policy and Management Professor at Emory University.


Cheryl Holt, MA, CEO of Behavioral Health Integration Consulting, LLC, is an advocate for the integration of behavioral and primary healthcare for whole-person health and assists organizations in adopting a whole-health focus. She is active in social media promoting integrated care, behavioral health policy, and global mental health. She blogs regularly via the Behavioral Health Integration blog and manages LinkedIn's Behavioral Health Integration group and the Behavioral Health Integration page on Facebook. You can follow her on Twitter: @cherylholt, @BHPCIntegration, and @WorldMentalHlth

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Using Direct Observation for Team Development and Collaborative Training

Posted By Larry Mauksch, Thursday, August 15, 2013


This is the first post in a series of "blasts from the past". These classic posts will highlight issues that are just too important to collect dust in the archives. The series will be off and on for the next several weeks. Enjoy!

(This piece was originally posted on September 6th, 2009)

A great way to flounder or fail in system change is to avoid relationship development between team members. When we examine efforts to integrate collaborative designs, relationship development is often given short shrift or completely overlooked. For example, the recently published initial evaluation results from the medical home National Demonstration Project found team function suffered (Nutting et al, Ann Fam Med 2009;7:254-260). One way to build teamwork is to use direct observation of day-to-day practice. I have been experimenting with this strategy for 15 years and below I will share some experiences.

Since we began the mental health internship in collaborative care within our Family Medicine Residency in 1996, the first month for the new intern is spent shadowing residents and faculty. Observing helps the intern learn about the challenges of family practice and it spawns many new relationships. Our residents and medical students observe one another regularly as well.

In 1998 I was invited to spend a year training providers, serving patients and designing a system of care in an indigent primary care clinic. During the first half of the year I regularly observed the primary care providers, teaching them interview and primary care psychotherapy skills and forming relationships. My behavioral health practice grew rapidly. A few years before I arrived a local agency had placed a counselor in the clinic. Six months later the counselor was withdrawn due to lack of referrals despite being in a clinic where 50% of the patients had one or more mental disorders. Looking back, it appears that little was done to create relationships with this new team member.
Collaboration is hard won without adequate relationship development ... It takes time.

In my work with health care organizations to train primary care teams to be more efficient and effective in communication with patients, a standard portion of training is peer observation. When the lack of team coordination between medical assistants and physicians became a common theme, I began asking physicians how often they had observed their medical assistants or if medical assistants had observed them. The answer was almost always the same—team observation had never occurred. I began having these dyads observe one another and discuss how to increase the quality and efficiency of patient flow. These primary care dyads or "teamlets” (see Bodenheimer, Ann Fam Med, 2007, 5:547-461) immediately began dissecting day-to-day processes to improve systems of care.

Collaboration is hard won without adequate relationship development. One way of forming relationships is to curiously watch each other provide patient care. It takes time. Trainees need to be sensitive to how feedback is delivered and remember that watching someone else promotes observation of one’s self.

Many of you have other strategies to promote team development or perhaps use similar approaches. What experiences have you had where team development went really well or stumbled?

Larry Mauksch

Larry Mauksch is a Senior Lecturer in the Department of Family Medicine, University of Washington School of Medicine, in Seattle, Washington and a consultant and trainer for health care system transformation. He has spent the last 26 years training medical students, residents, mental health professionals, practicing physicians and nurses in interviewing skills, team development, and the diagnosis and management of mental disorders. He is a core faculty in the Washington State Department of Health, Medical Home Collaborative, serves on the Society of Teachers of Family Medicine (STFM) program committee and on the Council of Academic Family Medicine Competency Measurement Task Force. He is the past chair of the Collaborative Family Health Care Association and of the STFM Group on Physician Patient Interaction. Mr. Mauksch has provided faculty development on communication training to medical schools and residency programs across the United States. He has developed patient centered communication training programs catered to the needs of specific organization using inside champions as role models and collaborators.

 

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We now return to our regularly scheduled programming

Posted By Matthew P. Martin, Tuesday, August 13, 2013

The blogs have taken a small break this summer to soak up the sun, grab some Italian ice, and pass the baton from one editor to the next. Randall Reitz has been the editor and energy behind CFHA’s blogs since the first maiden voyage on August 31st, 2009. Since that time there have been exactly 178 posts on the flagship CFHA blog. The second blog, Families and Health, was first launched on November 18th, 2011 and has produced 80 blog posts. The subjects have ranged from "Collaborative Care Needs a Theme Song” to "Dejected Views on Family Hating”. Truly, the blog contributors have been creative and productive!

As I have recently thought about the CFHA blogs, I have paused to ask myself this question: if a blog piece is posted on the internet and only a few people read it, is it still worthwhile? The answer is a resounding: YES! First, blog writing helps us to improve our own writing. Most of us have been trained in technical writing, but blog writing is a whole other creature. It requires fresh, creative thinking and expression that can stretch our minds and abilities. Second, blog writing helps us to connect with and inspire each other. Think of how you feel after a conference. For me, my mind is overflowing with ideas after I connect with like-minded colleagues post-conference. In one sense, social media helps us to sustain those relationships and energy beyond the conference hall.

Third, we leave a digital footprint on the vast Internet landscape when we write blogs. When people search for information on collaborative and integrated care, we want them to find and read our blogs. Fourth, blog writing helps us to craft our "brand voice”. We are involved in the selling of a brand, a product called collaboration. We can practice using our "voice” through written expression and dialogue. Honestly, it’s not always easy explaining the power and practice of collaborative care. I only get silence and blank stares when I describe what I do to my grandparents. Imagine being able to sell collaboration to a stranger during a thirty-second elevator ride. That is the value of blog writing.

So now we return to your regularly scheduled blogging. I am very grateful to Randall and all the other contributors who have helped over the past four years. We plan to continue posting on a weekly basis. Over the next several weeks while we gain momentum, we will post a combination of new and classic ("oldies but goodies”) blog posts. As the next editor, I actually hope that you will not hear from me very often. In fact, just forget that I am the editor and enjoy the blogs. Before you do forget who the editor is, let me make two announcements. First, we have a live survey that we invite you to complete for the sake of improving the blogs. Please click here for the survey. Second, if you have any writing itches that can be scratched by contributing to the blogs, please contact me through my email address below. Happy blogging!


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


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A View from the Other Side: One MFT's Story of Family, Illness and Loss

Posted By Shelley L. Meyers, Saturday, June 22, 2013

Some time ago, I wrote this "open letter" to a master's level Marriage and Family Therapy ethics class. I was the teaching assistant at that time and thought that the family crisis I had just experienced would be relevant and applicable to many of the issues discussed in class. I am not sure why, but I never sent the letter. I actually forgot about writing it until recently when I was searching my computer for documents related to my current doctoral course in Medical Family Therapy. My hope is that my story will facilitate discussion about some of these issues and possibly provide some additional insight into the experience of a family dealing with a loved one's terminal illness. I recognize that the events may not be typical or standard procedure and do not wish to imply that they are; this is one person's perspective.

An open letter to the Fall 2011 MFT Ethics Class:

I wanted to share a personal experience with you all that highlights some of the recent issues you have been studying in class regarding ethics in general, as well as medical family therapy and end-of-life issues. Please note that I asked for permission from those mentioned below prior to sharing this with you and also changed some names.

A little background info… my husband is from Canada, and the majority of his family live in the province of British Columbia. In early to mid-October my mother-in-law Heather had some medical tests done as she was losing a great deal of weight and had little appetite for foods other than liquids. On October 19th, we were informed that she had cancer but the exact type was undetermined. It was in her lung, liver and lymph nodes but the source would need to be determined via biopsy in order to figure out the course of treatment (you learn a lot about cancer during these times). When we first learned that she was ill, we planned a visit at Christmas since both my husband and I would be out of school for break and he would have some time off from work. When we got information about the extent of her illness, we purchased tickets to fly out on November 5th. The oncologist told us that "you might want to come sooner”, which is obviously NOT a very good sign, and we rushed to fly out on Friday, October 28th.

By this time, Heather has been admitted to the hospital and a biopsy was done on Thursday the 27th (yes, that’s right…8 days after the diagnosis). We were told that we were "lucky” that it had been moved up a day earlier to Thursday as it was originally going to take place on Friday. So, we wait for results that, honestly, probably wouldn’t matter. At this point, Heather was very ill and any potential treatment would most likely cause more harm than good. During all of this, Heather’s family doctor had told her that she had three weeks to live. We didn’t realize this conversation between the doctor and Heather had taken place until later.

My husband Shayne and I saw Heather in the hospital on Saturday the 29th. She looked ill and fatigued, but not as sickly as I had been expecting considering the diagnosis. Shayne’s sister Connie and her husband were there as well. Connie had been bearing much of the burden of this situation as she lived in the same town as their mom and was spending time at doctor’s appointments and at the hospital. She and her husband Andy also have one adult and two younger children at home and had to manage their normal family responsibilities. Shayne, Connie and I spent as much time as possible with Heather at the hospital. Andy, Heather’s sister, and the kids were there quite often as well. Heather was in a room with another patient who also had visitors often (and usually loud) which made things awkward at times.

We also had a meeting during that weekend (in the TV lounge, but at least no one else was in there) with Heather’s family doctor. Obviously we had some questions. One thing I asked the doctor was why she (the generalist) was the one explaining the diagnosis and possible outcomes rather than the oncologist (the specialist). She became very defensive, appeared to be insulted, and said that she was trying her very best to help Heather, that she was working tirelessly, that she was here on the weekend to meet with us….etc. etc. Her tone and her defensiveness surprised and angered me. A few minutes later I felt the need to excuse myself from the conversation and wander the hospital stairwells, eventually finding the "Sacred Space” room (similar to a chapel). After some crying and yelling, I composed myself and returned. By that time, the family doctor had gone to check on something and I spoke with Connie. Connie told me that she had asked the doctor a question regarding the biopsy procedure. The doctor became teary-eyed, then began talking about how horrible it was for her to lose her dad.

Heather’s illness began to progress. She was noticeably weaker and having difficulty with breathing. On Monday the 31st, we met with the oncologist with Heather at her bedside as well as…in the hallway outside of Heather’s room. She discussed Heather’s prognosis with us and mentioned the possibility of hospice care. My husband and I had originally planned to return home to Pittsburgh the following weekend and asked about the feasibility of coming back for another visit with my mother-in-law, maybe near the Christmas holiday. The oncologist looked at me and said, "we’re talking a few days to a few weeks”. Of course the entire conversation was extremely emotional for the whole family, but excruciatingly painful for Shayne and Connie. As for me, I felt trapped and helpless. I have never felt as useless as I did in those moments when I had no way to "fix” the situation or ease the pain. I also struggled with the practical questions that came up for me…. had anyone asked Heather about her plans? What if she did die soon? What would she want? How does all this stuff happen? Would we have enough time? How do we pay for all of this? Who do we call? Of course, my stomach churned at the thought of even bringing up any of these issues.

So, Monday the 31st was Halloween night. Shayne and Connie wanted to stay with their mom overnight at the hospital. Andy wanted to spend as much time as possible there too. The kids went trick-or-treating that night, so I waited for them at the house until their dad got there. Later I returned to the hospital and stayed with Shayne and Connie.

By late Monday or early Tuesday, Heather was not able to clearly communicate. She slept almost constantly, and when she was "awake”, it was difficult to tell if she was able to understand what was happening around her. The nurses told us that most likely she had some awareness, so we continued to talk to her, stroke her gently and hold her hand. They were able to move her to a private room, which was very helpful.

There’s another twist to the story. Shayne has a 12-year old son, Brian, who lives about three hours’ drive from this town. Brian has an older sister, Ariel, who is 17. She is not Shayne’s biological daughter, however he has always been a father-figure to her. I called their mother Vanessa to explain the most recent circumstances though she was already aware that Heather was ill. Vanessa said that she was allowing the children to make the choice as to whether or not they wanted to see Heather. She said that they had a very difficult time when her [Vanessa's] father died from cancer nine years ago. She also said that Brian really didn’t feel comfortable coming and that Ariel was "on the fence”. I tried very hard to maintain my composure. I said that I was only relaying the information, however I would not want anyone to have regrets later should they miss this opportunity to see her. She said she would call me back. She called a short time later and said that Ariel would take a bus the next morning and that Vanessa's brother and sister-in-law would be picking her up as they lived in this town. I made the assumption that Brian was still not going to be coming. I didn’t ask.

Later in the day on Tuesday we realized that the nurses no longer came in at regular intervals to check Heather’s vital signs (no, she did not have the machine that continually monitors them). We made the assumption they were "telling us without actually telling us” that there was little time left. Shayne and Connie barely left their mother’s side, even hesitating to go get something to eat. That evening (Tuesday) I went back to Corinna’s house and gathered some supplies. Most of the immediate family was jammed into that hospital room…me, Shayne, Connie, Andy, and Heather’s sister, Aunt Rose. Connie’s oldest son Darrin stayed as well and fortunately we were able to find friends to watch the younger boys. There was one recliner-type chair in the room and a couple of regular chairs. I found a yoga mat in Connie’s linen closet that I brought along with some blankets and pillows. We tried to sleep at least a little bit. I napped on the yoga mat for a little while but later went to the TV lounge to sneak some sleep on a sofa. Aunt Rose went to the lounge too, and everyone else stayed in Heather's room.

Wednesday morning, 3 am, Darrin comes into the lounge. He said, "She’s gone”. I felt my stomach churn (and actually still do as I write this) and a sense of panic accompanied by horrible guilt. I so desperately wanted to support my husband and in the moment he would need me the most I wasn’t there. Damn! I was so angry with myself and thought about that part in the Bible where Jesus tells the disciples (my paraphrase), "Geez, couldn’t you guys stay awake for even an hour???”

I hurried to the room. The sadness was almost tangible; the crying and wails of despair broke my heart. The guilt I already felt was intensified by my relief that Heather’s struggle was now over. I had prayed that if God didn’t see fit to heal her could He at least take her home quickly. My prayer had been answered. I know now and I even knew then that I did not "want” her to die, but I still felt awful.

After some time a few of us looked at each other having absolutely no idea what to do next. I went to the nurse’s station to ask and was given the necessary information. Eventually we gathered our things and left Heather’s room, an experience that felt somewhat odd and…. I don’t know… callous? Disrespectful? We waited for the doctor to arrive and make the "official” pronouncement. She arrived, spoke with us briefly and then finally, we all went back to the house. At about 7 am I called Vanessa and gave her the news. Ariel did not take the bus to her aunt and uncle’s house at that point. Vanessa asked me to keep her informed about any memorial plans.

Obviously we now had a lot to do, including planning for a memorial and other preparations. This is a difficult process in any situation, but it becomes even more stressful when little has been discussed or prepared in advance. It’s also a very expensive undertaking. Heather had a very limited income and a sparse life insurance policy. Of course, none of us have much extra income either so there was the added stress of figuring out how we were going to pay for all of this. We finally made the necessary decisions at the funeral home then worked quickly to prepare a memorial service.

Let me fast-forward a bit. We pulled together a beautiful service for Heather which was held on Saturday morning, November 5th…coincidentally, the day we had originally planned to arrive in Canada. After the service, which in large part was scheduled based on our plans to fly back home that Saturday night, we had lunch with several family members and friends including Vanessa, Ariel and Brian. We then had to make a 6-drive back to Seattle, return the rental car and catch our red-eye flight back to Pittsburgh which included a lovely layover in New York at JFK.

So, why in the world am I writing all of this (and, honestly, there is MUCH more but this experience is emotionally exhausting)? Well, it may sound strange but I thought of your class several times during all of this. So many issues seemed to arise that were either potential ethical dilemmas or blatantly obvious ethical mishaps. In addition to the ethical issues involved, there were numerous times that I shook my head and thought about how things could have been done differently from a therapeutic standpoint. How could a MFT have approached the situation in a more helpful way? How could MFTs help to educate medical personnel so that they might better serve their patients and their families?

These are some of the questions and thoughts I had and wanted to share with you. Even if you never "answer" me back, I thought it would be a rare opportunity for you to enter the world of one particular client/family and consider the ways in which you might encounter these issues in your own work. I hope that as you contemplate some of these things you find it useful.

· How do you feel about giving clients information about "how much time they have left"? Is it helpful, ethical, honest? Is it potentially harmful?

· How can you respectfully bring up issues such as terminal illness or funeral arrangements/plans with clients and families?

· What is the role of hospital staff when it comes to providing information to clients and families? If it is "bad news", should they leave that to a therapist? Where should they talk? With/without the "patient"?

· How can hospitals provide more respectful and compassionate care for families without incurring a great deal of expense?

· Think about the dilemmas faced by blended families. What is the role of the non-parent spouse (me) in this kind of situation? How involved should this person be regarding communication with their current spouse's ex?

· How much decision-making power should a parent give to a child? What are your thoughts about Vanessa's perspective regarding the children visiting their grandmother?

· How would you address the intense feelings of guilt experienced by someone who lost a loved one, including the "I should/could have done more" statements?

Tags:  family medicine  family therapy  oncology  primary care  terminal illness 

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I Believe That Behavioral Science Faculty Face an Uphill Battle

Posted By Molly Clark, Thursday, June 20, 2013

I Believe Series Logo

The "I Believe" series is a month-long co-blog on behavioral science education in partnership with the Society of Teachers of Family Medicine (STFM). Please check back each week.

 

I believe that although behavioral science faculty can have years of training, experience, and can add so much to the improvement of our patients, we continue to have an uphill battle in proving our value within medical settings. As I recruit people to our program, I make the statement that Family Medicine is like working with family for me and feels as comfortable as home. I am fortunate to work with some of the best people I know personally and professionally. In addition, I have met some great people from around the United States who work in Family Medicine and share similar attributes as my colleagues. However, my experiences have not always been a happy and easy.

Although I came into a program with prior experience within Family Medicine and there had been an established behavioral medicine program, I was faced with the challenge of having to prove my expertise and value to our residents. My strategy was to set boundaries and stick with them at all costs. In my first year, I received evaluations from the residents that ranged from "she is extremely helpful” to "she is not welcome here.” In my second year, I was met with slightly more challenges. While providing feedback during resident check outs, some residents would sit to where I was completely to their backs as they presented a case. My evaluations included comments such as, "you’re not a real doctor” or "you’re not welcome in the physician lounge because you are not a physician...in fact you should not be considered faculty.”

While those are not pleasant experiences, I think one of the worst experiences was when I sat down for lunch in the physician lounge and residents either left or the ones coming in sat in a different area. There were times I would go to my office, sit down and feel completely ineffective. I hate to admit it, but there were times I cried. All the while, my physician faculty stood beside me, supported me and told me that this would get better. They asked for my input, consulted me when the residents would not, and gave me more responsibilities.

As I am completing the lecture,
I recognize an old familiar
feeling, stare into the audience
and realize that I might as well be promoting the sell of snake oil.

In subsequent years, things began to change. I started to receive pages from residents and curbside consults to ask me my thoughts about their patients. I was even asked by a resident if they could do a rotation with me. My evaluations began to include comments of "excellent,” "extremely helpful,” and "wished I could see her more in clinic but I know she has other duties.” In one of my more recent experiences, a resident asked me what they should do for a patient’s joint pain. When I responded that I was a psychologist and not a physician, the resident laughed and said "oh, yeah, I forgot.”

I’ve grown to have relationships at the medical center across physician specialties and seemingly have a positive reputation. So, as I am feeling confident that I have overcome bias and have proven my worth as a member of the interdisciplinary team, I walk proudly to another medicine department to give a lecture on physician wellness. As I am completing the lecture, I recognize an old familiar feeling, stare into the audience and realize that I might as well be promoting the sell of snake oil as a cure for various medical ailments. I sigh and go back to the Department of Family Medicine, where I feel at home and am satisfied with my accomplishments. I’ll leave the job of establishing the value of interdisciplinary care in that discipline to another individual and hope they will one day be as valued there as I am in Family Medicine.


Molly Clark

Molly Clark is currently an Assistant Professor and Fellowship Director in the Department of Family Medicine at the University of Mississippi Medical Center (UMMC). She received her doctoral training in Counseling Psychology at the University of Southern Mississippi, completed her residency at the University of Missouri-Columbia, and fellowship in Health Psychology at the University of Mississippi Medical Center. She also holds an appointment in the Department of Human Behavior and Psychiatry at the UMMC. Dr. Clark’s area of specialty is in behavioral medicine with particular interests in obesity, sleep, and mood disorders in primary care. She also has an interest in teaching and training medical students and residents. She has a number of publications and national presentations in these areas of interest.




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