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I Believe There's No Such Thing as Work-Life Balance

Posted By Katherine Fortenberry, Friday, June 7, 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 there’s no such thing as work-life balance. I think this every morning when I leave for work, watching my two-year-old son press his face against the front window and wave at me as I back down the driveway. It comes up again at work, as I guiltily feel relieved when a patient cancels and I have an unexpected half hour to work on a behavioral science presentation for residents. There is always somewhere else that I should be, and something else that I should be working on.

As a working mother who has been a chronic perfectionist and overachiever, the pressure is always there. If I’m not careful, this pressure turns into guilt. I miss my son’s doctor’s appointment, and I can’t translate his toddler-speak as easily as I think I should be able to. At work I fall hopelessly behind in answering emails, while wondering when I’ll have time to submit that paper for publication. It’s easy to start berating myself for not being more efficient, for not accomplishing more at work, and then not getting home in time to start dinner.

As the Behavioral Science Educator in our Family Medicine Residency Program, I teach work-life balance. Residents vent in support group about the endless patient demands, of long nights, of stress in their marriages, of their own emotional struggles. So I encourage them to focus on their goals, to reflect on the things they’re grateful for, and put their energy toward what they value most. Take steps to change what stressors can be controlled, and learn to release the ones that cannot.
I hear these words as I say them to our residents, and I resolve yet again to start taking my own advice.

I hear these words as I say them to our residents, and I resolve yet again to start taking my own advice. And sometimes I can successfully do this. Yet other times, I compose emails in my head as I rock my son to sleep. Or a patient’s struggles sparks one of my own worries, and I find my mind drifting off into my own troubles. Then my work life and my personal life collide into each other, and I wonder what kind of hypocrite I am that I presume to tell our residents how to live their lives better.

Perhaps I should admit to myself that I can’t achieve balance. Maybe part of me will always want to be in the other part of my life, somehow both working more and spending more time with my family. It hurts to think that I may never be able to spend all the time I want with my son. But I know fighting this guilt won’t help. Instead I focus on changing my relationship with it, and remind myself that even if there isn’t enough time, wishing to be in the other part of my life only takes me away from where I am now. So I close my eyes and I focus on the feel of my son’s soft hair against my cheek. I focus on the pain in my patient’s voice. I slowly take a deep breath. This is my only moment.


Katherine Fortenberry
Katie Fortenberry is a licensed clinical psychologist and the behavioral health coordinator at the University of Utah Family Medicine residency program. She received her bachelor’s degree from The University of Alabama, and her master’s degree and Ph.D. in clinical and health psychology from the University of Utah. Dr. Fortenberry completed her pre-doctoral internship at the Memphis VAMC, and a postdoctoral fellowship in primary care psychology at the University of Mississippi Medical Center. Her professional interests include psychological adjustments to chronic health conditions with a focus in diabetes, as well as cognitive-behavioral and interpersonal approaches to treating anxiety and depression in the primary care setting. In her leisure time, Dr. Fortenberry enjoys hiking, camping, and exploring Utah with her husband, son, and dog.

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Pediatrics, Integrated care, and the Family-Centered Medical Home

Posted By Karen Schetzina, Friday, June 7, 2013
Developing a Professional Identity

Karen's post is the final installment in this series.
Click here to read the first, second, third, and fourth posts.

I appreciate the opportunity to comment as the final post in this series from my perspective as a pediatrician and medical educator. Reading the comments of Drs. Reitz and Bishop and Mr. Ellison has provided me as a medical provider with greater insight into the challenges that psychology and family therapy colleagues may experience as part of an integrated primary care health team. This type of dialogue is important. In addition to developing one’s own professional identity, understanding each others’ roles and perspectives are keys to functioning effectively in interprofessional teams.

Acquiring effective written and oral communication skills and developing a common language among disciplines (and familiarity with our different dialects) is also essential. Even in the inpatient environment, where everyone is providing care under one roof and mostly within the same room, care can be uncoordinated if communication among providers, patients, and family members is poor.

I share the opinions that educators should do more to ensure that trainees develop broader skills, experience a range of clinical models, and be afforded early educational opportunities that are interprofessional and collaborative. Spreading innovations and improvements within groups, including educational reform within institutions, can be challenging however, due to the characteristics of the innovation itself, the willingness or ability of those involved to adopt the changes, and the organizational culture and infrastructure to support change.

This series has provided a stimulating discussion of the evolution of professional identity, influence of provider personality on practice style, balancing tradition with innovation, and the value of inter-professional collaborative training experiences.

An international commission of professional and academic leaders in medicine, nursing, and public health recently published a framework in the journal Lancet for transforming health science education that is relevant to this discussion. The commission called for educational reform to improve health systems, including "interprofessional and transprofessional education that breaks down professional silos while enhancing collaborative and non-hierarchical relationships in effective teams” (Frenk et al 2010).
The current prevalence of behavioral risks and chronic conditions and associated demands on our health system calls for training professionals and fostering systems for integrated care. Providing team-based, integrated care with nurses, physician, psychologists and other health professionals within the primary care setting can help in achieving the goal of a family-centered medical home and improve patient outcomes. Institutions, including ours, are beginning to develop and expand interprofessional academic health science curricula to address cross-cutting relevant core competencies including roles & responsibilities, interprofessional communication, teams & teamwork, and values & ethics.

Leadership from institutional officials and educators as well as influence from health system employers under pressure to demonstrate improvements in care delivery by their health care teams may continue to drive this educational reform.

I would like to thank my fellow bloggers and readers for their comments. This series has provided a stimulating discussion of the evolution of professional identity, influence of provider personality on practice style, balancing tradition with innovation, and the value of interprofessional collaborative training experiences. I look forward to similar discussions with colleagues around integrated care in the future.

Karen Schitzina

Karen E. Schetzina, MD, MPH, FAAP is Associate Professor and Director of Community Pediatrics Research in the Department of Pediatrics at East Tennessee State University Quillen College of Medicine.

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Identity and Archetype in Family Medicine

Posted By Caroline Dorman, Thursday, May 23, 2013
Developing a Professional Identity

Caroline's post is the 3rd installment in this series. Click here to read the first, second, and third posts.

How and where does a family medicine doc optimize care for her patients?

How does she develop a professional identity that is robust enough to last through her life and career?

Family Medicine is a field of archetypal legends. My archetypes came from the wild west: Dr. Quinn Medicine Woman and the Lone Ranger. I wanted to be the one person who could see my patients' needs clearly and save the day by treating them promptly and properly. An admirable fantasy in many ways, this egocentric professional identity requires subsuming of a physician’s own family and personal needs in order to function as a superhero for patients.

My own career and ongoing development of professional identity is an example of this process. Having been "called" to rural medicine, I practiced in a town of 7000 after residency. I assumed care of every patient in the ED who was bereft of a provider. I delivered ALL of my patients’ babies...including canceling vacations in order to do so. I ran group visits for Diabetes in the evening rather than eating at home. After four years of practice, 4000 of the 7000 people in town considered me their physician.

My partners, LPNs and MAs were allowed to assist in patient care but never, in my mind, to lead.That was because I also assimilated the other family medicine archetype: the superstar quarterback. This approach to my professional identity led to disillusion and exhaustion. For a time, my commitment to working 90-120 hours a week in order to accomplish all of this was well rewarded with the ego boost of being considered the best. Patients were led to expect 24 hour attention from me and I was destined to disappoint. My own physical health suffered.

Family Medicine is a field of archetypal legends.

My archetypes came from the
wild west: Dr. Quinn Medicine Woman and the Lone Ranger.

While some may consider this approach to be patient centered, it was in fact physician-centered because it did nothing to ensure the stability and consistency necessary for ongoing patient-centered care. Rather, it fostered an unrealistic dependency. The care was focused on the physician because the patients were focused on the physician.

In contrast, with the PCMH model and the collaborative care setting, patients are able to expect just as much from their health care provider team. Indeed, their expectations are much more realistic because the responsibility is shared and thus, ideally, its provision is much more robust.

Mental health providers are better trained overall to resist the quarterback role in their patients' lives. Their ability to share this approach with family physicians in the collaborative care setting, and to model the conducive behavior for them, is one of the many arguments in favor of collaborative care. Nonetheless, individual practitioners do often isolate themselves from a patient's care team. They may find themselves shouldering a quantity of responsibility for the patient's well being that they cannot maintain and that would be more patient-centered if shared with others.

I’ve concluded that the characteristic, whether inherent or learned, most helpful for collaborative family physicians is humility. Humility allows the practitioner to relinquish the superhero role. Rather than being the brains of the operation, or quarterback...we act more like a fullback. We clear the way for our patients to reach their own goals. We cooperate with each other so that our personal strengths are put to the best use.

In so doing, we allow time for a continued personal identity that parallels our professional identity. Time spent fostering professional and personal relationships creates a more robust and, therefore, a more long-lived professional career.

So, I can assert without exaggeration, that collaborative care saved my identity as a full-spectrum family physician. Without team-based care I was faced with choosing between my full-spectrum practice and the rest of my life. With collaboration I can foster my identity without jettisoning the rest of my life.

There is one caveat to this success story, however. I was forced to reconsider my Dr Quinn Medicine Women archetype. Unfortunately, collaborative care is mostly impossible to practice in rural America. The financial models and operational supports don’t yet exist in towns of 7000 people. So, I moved to a larger town where I practice in a residency setting that has the advantages that can sustain collaboration.

As to the previous blogs:

I agree with Dr Reitz's hypothesis that collaborative clinicians benefit from extroversion, self-direction and multitasking (I’ll call this constellation of attributes ESM). Nonetheless, I would suggest that these habits are generally chosen and self-fostered over a period of time. Even if we scrutinize the successful old-timer rural family doc we see, in many cases, some form of tight knit team that includes perhaps, his wife, nurse, assistant and patients. Even the most introverted, task-focused among us (like these old-timey doctors we want to emulate) can and do develop some degree of ESM over time in order to better serve their patients.

The question, then, is the rate at which an individual provider maximizes her ESM by experiencing Chickerings vectors of identity development and how able she is to continue to experience them over time so as to hone their practice more and more to her patients’ benefit.

At St Mary’s Family Medicine Residency, our faculty and residents foster our skills in a collaborative setting wherein providers who see themselves as fullbacks quickly become the most adept at allowing patients to run their own medical lives. As a member of the patients team we block for them, accept handoffs at times, and occasionally run ahead for a pass.


Caroline Dorman

Dr. Dorman joined the faculty of St Mary’s Family Medicine Residency after practicing nine years in Craig, Colorado. She completed medical school at the University of Oregon and her residency at St Mary’s. In recognition for her work in rural medicine, she was the 2009 Colorado Family Physician of the Year

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A Graduate Student Perspective of Professional Identity Development

Posted By Jeffrey Ellison, Thursday, May 16, 2013
Developing a Professional Identity
Jeff's post is the 3rd installment in this series. Click here to read the first and second posts.

The comments of Dr. Reitz and Dr. Bishop in this series to date bring to mind a recent conversation with several of my fellow graduate students. In this conversation, my peers suggested that: 1) integrated practice is less complex and thus less effective than traditional methods of clinical practice, and 2) mental health providers with sub-doctoral training are qualified to provide collaborative care services, so why would a psychologist want/need to do it?

When I first began writing this post, I had planned to formally rebut my peers’ "misconceptions” of integrated primary care (Had they actually read the research?); to finally set-the-record-straight about integrated primary care (What about psychotherapy? There are plenty of very qualified and competent sub-doctoral level providers with expertise in traditional psychotherapies!); and to prove to everyone that the practice of integrated primary care is actually a worthwhile endeavor (Even for a psychologist!). As I read through the other blog contributors’ posts, however, I began to sense that the conversation that I had with my peers was not about the "facts” of integrated care at all. Instead, this conversation may have been a representation of our divergent professional identities.

But how do students 3, 4, or 5 years into their respective programs develop such different professional identities? In the initial post in this series, Dr. Reitz discussed how trainees pass through Chickering’s seven "vectors” multiple times throughout their educational journeys. In the first years of graduate training, the "identity” that all trainees develop (Chickering’s 4th vector), though broad and rudimentary, is likely fairly uniform across trainees. As trainees undertake more clinical experiences they pass through Chickering’s vectors again and again (e.g., during beginning practicum, advanced practicum, and internship, etc.).
Trainees are particularly
vulnerable to identifying
with the first thing
(i.e. model, theory, etc.)
with which they become
confident and competent.

Through this process, students hone and focus their professional identities based on many factors including personalities, interests, and specific experiences. Inevitably, as a result of this process, students will conclude their training with unique and personally tailored professional identities. Increased job satisfaction, career investment, and productivity are all likely positive side-effects of this process. Additionally, this process promotes variety within our respective fields, thus allowing our fields to remain flexible and adaptive even in this ever-evolving healthcare environment.

Unfortunately, there are also downsides to our increasingly divergent professional identities. In the conversation I described above, neither my peers nor I were able or willing to stray from our narrowly defined professional identities. We took the same classes, participated in the same clinical experiences, worked with the same supervisors, and progressed though the same clinical psychology program, but we seemed to have nothing in common! How could this be? In reading again through the previous posts, I realized that the reason that it may have seemed that we had nothing in common was that, though we had well developed individual professional identities, we had poorly developed group professional identities (e.g., we had only vaguely and narrowly defined concepts regarding what it really to be a clinical psychologist or mental health provider). In other words, we had become so focused on "the trees” that we could not see "the forest.”

I recognize this as a problem specifically within the clinical psychology training process, however, I would bet that the same problem occurs within other fields as well. I hypothesize that this hyper-focus on specialization (i.e., sole focus on developing an individual professional identity) has its roots in the first years of training. When trainees enter graduate school, they typically come from a undergraduate programs where they were likely considered highly competent and top-of-the-class. When they enter graduate school, however, they are again inexperienced "newbies,” who have to prove themselves in a new program. Because of this, trainees are particularly vulnerable to identifying with the first thing (i.e., model, theory, etc.) with which they become confident and competent. Students become fixed on domains in which they are competent instead of continuing to explore new things (i.e., models, theories, etc.) and struggling with incompetence again. Granted not all trainees are seduced in this way, but in my case, it certainly makes sense. My initial practicum experiences occurred in integrated primary care, a setting where I am still exclusively practicing today.

In writing this, I am not trying to suggest that it is not okay to specialize or that it is a necessarily a mistake to become enamored with the first experiences in which you taste confidence and competence.I am suggesting, however, that it is important for trainees to carefully analyze their motivations.I also think that it may be important to rethink the structure of training programs so that they may have introductory experiences (i.e. not just book work) in a wide range of clinical models and theories prior to specialization.As such, I completely agree with Dr. Bishop’s assertion that providing students with inter-professional and collaborative experiences very early in their training may help facilitate the development of a more broadly defined professional group identity.


Jeff Ellison

Jeff Ellison is an advanced student in the clinical psychology Ph.D. program at East Tennessee State University. In his current externship placement he provides behavioral health services to patients presenting in primary care and community health settings across the state of Tennessee via videoconferencing. His research interests include: the integration of primary care and mental health; the use of technology (e.g., videoconferencing) in expanding access to behavioral health care; rural mental health care; and dissemination, implementation, and quality improvement for primary care and mental health settings. In his free time, he enjoys running, hiking, biking, and exploring the outdoors with his family.

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Sound but Flexible Identity Development: A Challenge for Behavioral Clinicians

Posted By Tom Bishop, Thursday, May 9, 2013
Developing a Professional Identity
Tom's post is the 2nd installment in this series.  You can read the first post here.

I certainly appreciate Dr. Reitz’s assertions of a developmental progression in professional identity formation as one prepares to work within integrated care. It does seem intuitive that one would pass through each of Chickering’s seven "vectors” as they progress through training and service as a primary care provider. It is also seems plausible, and very much supported by observances in the field, that there is a personality style, or as Dr. Reitz postulates, a "collaborative identity” that tends to lend oneself in being a good "fit” for serving within integrated care.

That said, I believe that taking another pass at McDaniels et al (2002) curricular article may provide more clarity to why some clinicians excel at integrated care and embrace innovation over traditional roles. McDaniels comments, "Psychologists-in-training need to develop the skills that solidify their identity as psychologists” and that having a "positive professional identity” would serve one well in working within primary care.

I am led to recall an experience I had with a couple of students in training. They were sharing the tension they experienced in learning the core skills and attributes of what it means to be a psychologist while considering what their work would look like within a primary care setting. They voiced concern that working in an integrated care setting, especially at that start of the training, would be too "narrow,” and limit the development of their clinical skills in some way. I believe that these concerns are closely tied to how one understands what it means to be a "psychologist.”

More recently, the field of psychology has begun gravitating back toward a more comprehensive identity. I say "gravitating back” because Lightner Witmer who is considered by many to be the father of modern clinical psychology understood psychology as collaborative, scientific, and as a catalyst for addressing problems. According to one reference: "Witmer never intended for clinical psychology to become segregated from other helping professions, particularly medicine and school psychology” (Brown, Prime, & Wade, 2012, pg. 1). However, this vision for the field has not been the prevailing image or impetus of training. "Indeed, Witmer envisioned a unified yet multifaceted discipline that possessed many progressive and innovative ideas that were lost or ignored over the course of the 20th century”
(See pg 2 where Brown et al discuss Routh, 1996).
One reason clinicians
may flounder within integrated
care is that they have come to embrace a more "contained” perception of what it means to
be a clinical psychologist,
medical family therapist, social worker, or school psychologist

Put broadly, then, one reason some clinicians flounder within integrated care is that they have come to embrace a more "contained” perception of what it means to be a clinical psychologist, medical family therapist, social worker, or school psychologist, and that perception is inherently independent rather than collaborative.As a corrective, training programs might emphasize the importance of core, foundational skills that would allow a behavioral clinician to collaborate with others rather than become "soloist.” It may also be critical to stress that our training allows us to be good at what we do, and that we are not to become something that we are not. Elliott and Klapow (1997) suggested that "We must broaden the professional options for our trainees by emphasizing behavioral science expertise versus mental health service provision.”

In returning to Dr. Reitz’s discussion of Chickering’s model as providing a means of examining professional identity formation, there is at least one other consideration. Perhaps training and early career experiences are more characteristic of what Erikson and James Marcia described as a time of crisis in one’s sense of occupational and social identity. This period of professional life is fraught with the search of "fit,” growth, conflict, and tension.

While personality is a factor, early career clinicians identification with their profession may be more characteristic in how they have wrestled with what it means to be functioning as a behavioral clinician. Some may have entered into training and work with a great deal of uncertainty and little reflection or consideration (Identity Diffusion), while others may have gone in full throttle with little exploration of what their particular field (e.g., psychology, social work, etc.) could encompass (Identity Foreclosure). Still others may truly be in crisis where they are unsettled and desire more from the work that they are doing, which seems to fit Dr. Reitz reflections on establishing identity (Identity Moratorium).

Perhaps "controlled and supported crisis” is what may be helpful in training and in challenging trainees to consider a broader conception of their discipline. It may be that McDaniel and the other authors were speaking of Identity Achievement when they commented how having a solid identity would prepare one for working within integrated care. They would possess the core understanding, skill set, and commitment for what it means to be a psychologist.

In summary:

  1. The success of a clinician in integrated care is inherently linked to how we portray, teach, and model a comprehensive understanding of what it means to be a particular behavioral health discipline, whether that is a psychologist, social worker, medical family therapist, or any other. Trainers want to foster the development of a sound identity for that discipline.
  2. At the same time, trainers could do better at challenging trainees in developing broader skills and in challenging their notions of what it means to be a psychologist, social worker, etc. It seems that this would be facilitated by having training opportunities that are more inter-professional and collaborative. These opportunities would, perhaps, create conflict and crisis in roles and functioning within an interdisciplinary team.
  3. While personality is certainly a factor in what leads one to consider a career in integrated care, this could be said of any profession, ie…why does one person become a plumber vs an engineer? Perhaps an analogy would be the contrasts of a jazz musician who is classically trained and a musician of another genre of music – they are each well versed in the foundations of their craft, but express these skills in varying ways.

I am certain and hopeful that the next response will challenge many of these premises.


Thomas Bishop

Dr. Bishop joined the faculty at the Johnson City Family Medicine Residency program at ETSU/Quillen Medical School in March of last year after serving several years with Cherokee Health Systems as a Behavioral Health Consultant and pediatric primary care psychologist. Thomas received his Psy.D. in Clinical Psychology from Wheaton College with an emphasis in the integration of psychology and theology, and a Masters degree from Central Michigan in general experimental psychology with an emphasis in brain injury and recovery of function.  His professional and research interest include primary care, rural and organizational health, faith and medicine, positive psychology in medical care, sports psychology, and neuropsychology. Perhaps most important, he and his wife Barb, who is brilliant in math, and have three children, two in college and one that thinks she should already be in college. They are often found together on a trail, running, or camping.

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Developing a Professional Identity

Posted By Randall Reitz, Friday, May 3, 2013
Developing a Professional Identity

Why do some clinicians excel at integrated care while others flounder?

Why do some of us embrace innovation while others yearn for traditional models?

The development and orientation of one’s professional identity plays a central role in predicting success in integrated care. This 5-week blog series will present professional identity development from numerous perspectives. Following this initial post, each week we will host posts that react to and build upon the previous blog from the perspective of a different discipline:

May 9th—Psychology

May 16th— Graduate student

May 23rd—Family Medicine

May 30th—Pediatrics

 What is Professional Identity?

My interest in this topic was first piqued by the McDaniels et al (2002) curricular article for training primary care psychologists. The authors observe that "Psychologists-in-training need to develop the skills that solidify their identity as psychologists. Psychologists who have a positive professional identity are most likely to be able to work in collaborative primary care settings.”

Intrigued by this comment, I set out to investigate professional identity development. I found precious little in the health education literature, and nothing specific to integrated care. About the closest thing I could find was an article that applies the Chickering Theory of Identity Development to medical residency education. The Chickering Model describes 7 "vectors” through which trainees and students pass during professional development. They are:

1. Developing competency

2. Managing emotions

3. Developing autonomy

4. Establishing identity

5. Developing mature interpersonal relationships

6. Developing purpose

7. Developing integrity

Most theorists apply Chickering’s 4th stage, "Establishing Identity,” to under-graduate education and look at the global self-concept (e.g. cultural identity, appearance, self-worth, social role). However, I would assert that professionals pass through each of Chickering’s vectors at each level of training. The level of stress and the pace of development become more manageable with each new training or employment experience, but the vectors are clearly experienced.

For example, nearly all of us can identify our own experience with the vectors upon entering grad school or medical school. We are finally entering the realm of our chosen vocation and we don’t want to screw it up. Looking back at my experience at Indiana State University, here are the cognitions I recall with each of the Chickering vectors:

Developing competency"I need to learn Excel, SPSS, Powerpoint, email (yes, I’m that old) at the same time I figure out Minuchin, Bowen, White, and de Shazer. I was able to fake my way through undergrad, but this is a whole new level of expectation”.

Managing emotions"I’ve got my supervisor behind the 2-way mirror witnessing a completely out-of-control couple in the middle of a screaming melted down. Chest tightening, palms sweating, thoughts racing, tongue stuttering, just keep it together for the sake of the couple.”

Developing autonomy—"OK, the first day of my off-campus internship site. I’ll have weekly meetings with my on-site supervisor and the program faculty, and I can consult with them by phone if I need. I can be successful here.”

Establishing identity—"I’m a narrative therapist who has been able to help many couples and families. People with a similar skill level as me have gone on to careers in academia, why not me? I love what I’ve read about collaborative care, and working with physicians. People scream less in medical settings.”

Developing mature interpersonal relationships"I’m the only person in my program who fancies collaborative care. How can I bring them along? Which potential mentors could bring me along?

Developing purpose—"For the last 6 months of my masters degree, I haven’t read a single assigned reading, preferring instead to read texts and articles on collaborative care and medical family therapy. I’ve also sought out any case I could find with a connection to physical illness.”

Developing integrity—"I’m confident in my core family therapy skills and in my ethical practice. While my opportunities to collaborate have been limited, I’ve demonstrated professionalism in my accessibility and proactivity.”

Each additional career stop has offered a fresh experience with the vectors, but with the benefit of the competency and connections made with previous steps:

Doctoral program → Internship → Clinic management → Residency faculty

Each of these experiences has broadened my perspective regarding collaboration and has deepened my commitment to our field.

In my supervision and employment of medical and behavioral health providers in integrated settings, I‘ve come to appreciate that these settings are like the Briar Patch from the Uncle Remus stories: either noxious or nonpareil. While some clinicians have a preternatural, innate collaborative ability, others can’t get out of their own way. I believe the key differences come from a professional identity that grew out of personality. Perhaps controversially, I will assert that the collaborative identity is a triad of characteristics: extroversion, self-direction, and multi-tasking ability. And, while I will make an exception for extroversion among physicians, I won’t do so for behavioral clinicians.

In support of my triad, I believe that just about everyone who is drawn to primary care and behavioral health settings comes with some desire to improve the human condition. However, this desire manifests itself differently based on one’s professional identity. Some clinicians are tailor-made for a traditional community mental health setting that provides clearly defined roles, schedules, and patient panels. They provide amazing service to some of the most marginalized and afflicted people in our communities. Others have the entrepreneurial chops to build their own private practice through competition in the free market.

I’ve seen several of these types of clinicians fail or flounder in collaborative settings. I find that the private practice entrepreneurs never accept that they are a small, but important piece of a large and sophisticated system. They also struggle to accept that the physician is the sine qua non of primary care, whereas the behavioral clinician is the added value. Among clinicians trained for community mental health, the lack of structure and the need for constant networking can seem tedious. They find the daily onslaught of new referrals and "other duties as assigned” maddening and would much rather provide continuity services to a known patient panel.
Perhaps controversially,
I will assert that the
collaborative identity is a
triad of characteristics:
Extroversion, Self-direction,
and Multi-tasking ability.

In contrast, the great collaborator draws energy from the non-stop, unpredictable heterogeneity of integrated practice. We couldn’t tolerate the drudgery of eight 50-minute hours. We would also feel terribly hampered by not having "our team” to help out. And by "our team”, I don’t mean the other behaviorists, I mean the nurses, front desk, case managers, and physicians of my pod. Rather than feeling competition by sharing care with clinicians with different skills and scopes of practice, we are drawn to being a round peg in a square hole. And, based on the developmental newness of integrated care, rather than being intimidated by cutting new trail in our professional settings, successful collaborators share a pioneering spirit.

Those are my beliefs about the collaborative professional identity. I’m hopeful that the next posts in our series will:

1. Contradict many of my assertions;

2. Explain how this identity can be trained;

3. Expand the discussion to be more relevant to medical clinicians.


Randall Reitz

Randall Reitz, PhD, LMFT is the founding editor of CFHA Blog and Families and Health blog. He is the Director of Behavioral Sciences at the St Mary's Family Medicine Residency in Grand Junction, CO where he directs a collaborative training program for family physicians, medical family therapists, and psychologists. He is co-chair of the 2013 CFHA conference in Denver, CO.

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Early Career Leadership (ft. Mandela, Obama, and Beyoncé)

Posted By By Laura Sudano (ft. Reitz), Saturday, April 27, 2013
Updated: Thursday, May 30, 2013

Laura and Randall's
post is the last
in a 5-part series on
leadership in
collaborative care.


If you have been in your chosen career for more than five years, please disregard this blog.

Stop reading now.

It is not intended for you.

Your persistence is starting to creep us out.

There, much better. Now we can speak candidly.

Early career professionals are in a tough spot. Not only are we asked to carry more than our weight in proving ourselves, we do it with the limited networks and without the influence of people who are already established in their careers. Facing this double whammy, what can we do to exert leadership? How can we utilize those who are willing to help us in moving the field in the direction we believe is most fruitful?

Well, for starters, we can learn from Nelson Mandela, Barack Obama, and Beyoncé Knowles.

In Nelson Mandela’s autobiography, "Long Walk to Freedom,” he described his leadership style as follows:

"A leader is like a shepherd. He stays behind the flock, letting the most nimble go out ahead, whereupon the others follow, not realizing that all along they are being directed from behind.”

Meanwhile, across the Atlantic, US historians parse political narratives to identify a "doctrine” that encapsulates a president’s leadership style. The emerging "Obama Doctrine” is a Mandela-esque "Leadership from Behind”. This doctrine is described in both glowing (here, here, and here) and derisive (here, here, here, and here) terms.

For Obama supporters, leadership from behind describes a president who has assembled a team of brilliant rivals that follows a rigorous process to hash out a consensus. They describe Obama as a president who is willing to allow all branches of government a role and in international affairs they see him as diplomatic and insistent that America not go it alone.

While Mandela and Obama are obviously world leaders elected to high offices, we wonder if "leadership from behind” might be the optimal approach for early career professionals who are positioning themselves for future collaborative care leadership.
Mandela Obama Beyonce

Another figure from which we ECPs can learn is American singer, songwriter, dancer, and actress, Beyoncé Knowles. Like Obama and Mandela, Beyoncé has been a role model for leaders and young professionals alike. Her unparalleled entrepreneurial business savvy has been on display since an early age. She is always re-defining herself and developing as an artist.

From a collaborative perspective, she promotes women musicians by having an all-female band (as seen on Super Bowl XLVII Halftime Show here) and collaborating with artists outside her genre including Sean Paul, Shakira, Justin Timberlake, and Lady Gaga. Through collaborating with other early career musical leaders she asserts her own identity (influencing) and remains open to others (being influenced).

Although ECPs may feel that they are still in a learner’s position, consider the following question, "How can I be influential to those around me when I’m still in training?” Asking the question of how you could be influential allows you to examine where you have been in your professional career and where you would like to go. And most importantly, who is coming with you. More specifically, reflecting on the unique aspects that you bring (or brought you) to the field of integrated care and how you can access and expand your network to influence the field accordingly is something that ECPs can do right now.

Building allegiance and support among current leaders can help you, the ECP, to lead from behind. One can achieve this by presenting ideas to those you look up to as current leaders in the field and join collaboratively, whether it be for a paper, a presentation, or interviewing the individual(s) for a class project.

Another approach to early career leadership is lifting others in your cohort. To riff off the many versions of Advice, Like Youth, Probably Just Wasted on the Young by Mary Schmich (see here), your colleagues, like siblings, are "the best link to your past and the people most likely to stick with you in the future.” Lifting others in your cohort and staying connected to others who you’ve met through networking is an invaluable relationship. Similar to you approaching current leaders in your field, presenting your ideas to colleagues is invariably impacting others. As a result, you build your network and display your ideas to others so that you can continue to lead from behind.

Leadership from behind for ECPs may appear as a pro-active approach to an unfortunate reality. However, as ECPs, we have an obligation to influence and be influenced. As systemic thinkers, we know the value of moving away from a linear approach (e.g., people are depressed because of an imbalance of chemicals in the brain) to a systems approach (e.g., psychosocial factors play a part in depression). As such, we should move away from the top-down approach (e.g., implementing what our leaders have shown us) to a cyclical approach (e.g., presenting our ideas to colleagues/leaders and in turn, have them be influenced by us).

We hope this post will spark conversation about how ECPs "lead from behind” and (if any mid- to late-career people stuck it out) how mentors have witnessed ECPs "leading from behind.”

Here are questions to consider:

1. What are limitations faced by ECPs seeking leadership opportunities?

2. What can be done to overcome these obstacles?

3. Who are your role models in early career leadership?

4. What are other leadership styles you have seen to be effective for ECPs?

5. Does a feminist perspective support or discourage "leading from behind”?,

Laura Sudano

Laura Sudano is a Marriage and Family Therapy doctoral candidate at Virginia Tech and works as a Medical Family Therapy fellow within the Family Medicine residency at St. Mary’s Hospital in Grand Junction, CO. She currently serves on the Denver 2013 CFHA conference planning committee and is the co-chair for CFHA's Social & Networking Committee.
Randall Reitz
Randall Reitz should not have contributed to or read this blog.  The possibility that he still considers himself an early career professional is delusional, laughable, and probably creepy.

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Professional Pearls: Perspectives on Passion and Priorities

Posted By Jeri Hepworth, Friday, April 26, 2013

Jeri's post is the fourth
in a 5-part series on
leadership in
collaborative care.

Twenty-four hours in a day, thirty days in a month, twelve months in a year, thirty-five or forty years in a career – how do we want to spend those hours? What do we want to accomplish, what do we care about? These concerns of time management consultants are also salient for those of us fortunate enough to be collaborative consultants whether in clinical practice, administration, policy or academia. The better we work with others, the more frequently we will be invited to take on new roles.


Yet the success of new invitations and opportunities can easily slide into stress and distress. We all know colleagues who, when asked about their life, say, "Way too busy”. And though it can be tempting to consider them important in their many roles, I also find myself wanting to distance. I prefer to socialize, work, and learn from others who do not always appear overwhelmed. We want colleagues and leaders who manage their anxiety and their time, not those who act frenetically like Kramer from the Seinfeld episodes. So how can we do it? How can we take advantage of the multiple opportunities around us without letting them take advantage of us?


I do not pretend to always do it well myself, but I enjoy helping individuals and systems consider their passions and priorities. This has included clinical work with families, team and organizational development, and mentoring of other professionals. As Director of Faculty Development programs for our medical school, it is a privilege to support leaders, or faculty who are considering promotion, and help them think about what they do well and how they can be more successful.


Just like clinical work, it is easier to do it than write about it. My response is to simplify, and to organize my thinking as "Pearls”. It is also fun to use alliteration, so I suggest a list of pearls that includes: Passion, Plan, Prioritization, Pro-action, Prioritization, Promotion of Others, and Play.


What’s yourpassion? A powerful group exercise is to have people share why they decided to enter their career. Generally, it reflects deep meaning about wanting to make a change or an impact. Reminding ourselves of our ongoing larger commitments is core to professional success. We may not know how we are going to make the difference or what exactly we will do, but stating our core values and purpose helps us form a personal mission statement – a statement that can be used to measure the relevance of new opportunities.


What’s your plan?Create your plan to reflect your personal mission statement as well as a realistic appraisal of your interests and energy for new opportunities. Assessing interests seems relatively intuitive. Does this new opportunity excite me? Does it add to my evolving personal mission, or will it distract me and move me further away from the things I most care about? Opportunities for administrative roles are prime examples that require careful consideration. If I take on this Director position, for example, will I really be able to help set the direction of the clinic, or will I spend most of my time involved with budgets?


Assessment of energy is a second factor. Do I care about this opportunity enough to work more? Or if I take on this role, what will I give up? This is the place to consider the developmental trajectory of a career. Early in my career, I made a choice to work three-quarter time, but not when my children were infants and enrolled in excellent child care near their father. Instead, I created more flexibility after I had gained my first academic promotion (part of my personal mission). At that time, my children were in public school, and I was able to participate more with them in sports and after school programs (also part of my personal mission).


A caveat holds for executions of plans. Interviews of later stage satisfied professionals rarely identify a rigid plan about how they achieved success. Instead, most report that they generally knew what they were interested in, but they were also open to new opportunities. The challenge is to take the time to measure those new opportunities against the most important ruler – that of personal passion and commitment.

How can you prioritize according to your plan? There are at least two factors that can help us make choices that move us toward our personal definitions of success. One is to select those opportunities that reflect alignment between our personal mission and the goals of our larger systems. The second is to prioritize activities and opportunities that we can and will actually do.


A clinician in a consulting practice may agree to give a series of parenting talks to a community group because the presenter cares about affirming families in the community (part of their personal mission). Giving those talks also helps market the collaborative practice (alignment with larger system mission). Colleagues skilled in collaboration know how to create win-wins.


The second factor about prioritization is to promise carefully, something I have not always done well. Sometimes opportunities seem so exciting that we jump for them without determining whether we have the skills or whether we can prioritize the time to complete them. Opportunities do not help us meet our goals if we have to apologize for not getting a promised task completed. Just as in personal interactions in which negative comments count far more heavily than positive comments, work that is late, incomplete, or poorly done is remembered far more than work which was appropriately done.


How can you be pro-active without being pushy? Sharing a plan with others helps provide personal commitment. It also makes it clear what help one can use from others. Pro-active professionals ask for formal and informal mentoring, and let others know what they are interested in achieving. "Graceful self-promotion” includes volunteering for an activity, letting a colleague know of an achievement, or informing another why you will not consider an offered opportunity. "Thank you so much for asking me to write the book review. I want to do a good job, and I feel this is not in my area of expertise. But I’d be very interested in reviewing a book about health system redesign. Could you keep me in mind for something like that?”


How can we best promote others? Great leaders celebrate others. Collaborative care professionals know why recognition is important and how to do it well. Appreciation – whether done privately through conversation, emails or notes, or publicly through other forums, builds relationships. Recognition of others creates a culture that facilitates success for many. In the example above, in which the opportunity to write a book review was turned down, a further statement can be helpful. "My colleague would do a great job with this book review. Can I give you her name?” Or, "Would it be helpful for me to think about who might be do a good job with this review and get back to you?” (And then, since it is a promise, make sure you do get back.)


What is the relevance of play? Successful people find ways to create play in their personal life as "balance”, but also find joy and play in their work. A sense of play leads to renewal, re-vision, and frequently gratitude. We are fortunate people to be able to engage in work that we have chosen, that is meaningful, and that we enjoy. We are doubly fortunate to be able to continue to determine how we change and grow in our work.


Play is not an add-on, but a responsibility. Play allows us to remember our passion, refine our plans, and prioritize our efforts. Our work is too important to be left to those who just put in their time.

Jeri Hepworth

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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Integrated Primary Care: the (Somewhat Extended) Elevator Speech

Posted By Alexander Blount, Thursday, April 18, 2013

Sandy's post is the third
in a 5-part series on
leadership in
collaborative care.

One of the roles of leadership in a field is being comfortable speaking on behalf of the field. To do that, it helps to have a clear summary that is understandable to someone outside the field. One name for that summary is an "elevator speech. It is called that because it designates what a person could say to another person while making conversation riding together a few floors in an elevator.

I had an opportunity to try out my skills at the elevator speech for integrated primary care not long ago on an airplane. I was seated next to a gentleman for a couple of hours but we didn’t start to speak until the last 10 minutes of the flight. He was a guy who has to fly a fair amount because he has several small businesses. The businesses were quite varied. He was clearly a self-made guy who was doing OK but was not extremely successful, an entrepreneur on a comparatively small scale. He knew about doing everything his own way and he made his own decisions. It was not in an elevator, but we were changing elevation and the length was only slightly longer that a 15 floor ride in a high rise. This is not verbatim, but close, and the last line is a quote.

The conversation went something like this:

Bob: So, do you come to San Diego on business or pleasure?

Sandy: Business, I’m here for a conference on integrating mental health into primary care.

Bob: What’s the advantage of doing that?

Sandy: It’s the best way to improve the health of the people who come to Primary Care. Primary care is where people bring all the problems that theydon’t know what to do about. A lot of times those problems, even the problems that are clearly physical, are related to the fact that they don’t take care of themselves. They are depressed or they are anxious, or they drink too much, or they don’t eat right, or don’t take their medicine, so they feel bad, so they hurt. When people are hurting it tends to make them more anxious or more depressed, or they drink more, or exercise less. If the doctor says he/she can take care of the part that hurts but they are going to send them to a mental health service or a substance abuse service for their anxiety, or depression, or drinking, a majority of the people don’t go. For them it doesn’t feel like two separate things. It feels like one thing. It’s only when you bring a person who can deal with anxiety and depression and alcohol use problems into the primary care and put them on a team with a doctor that the patient feels like he/she can get their whole situation cared for. It even costs less because if the person doesn’t get the whole situation dealt with effectively, they tend to go other places like emergency rooms to try and get enough care to relieve their various pains.

Bob: I’m trying to imagine what that would be like in the doctor’s office. How would it work?

Sandy: Well, if you came because you had a pain or because it was time for your physical, the doctor might talk to you about how your life was going or give you a screening test that would take about 5 minutes. The test would help pick up if you were having troubles with depression or anxiety or drinking. And if any of thoseseemed to be a part of the situation that you’re bringing, the doctor might call in a psychologist or a clinical social worker or some other person that they would probably call a behavioral specialist. The doc might introduce you to the behavioral specialist and go see another patient or two while the both of you talked. Just like primary care doctors take care of everyday kinds of problems after they make sure it’s nothing that’s going to kill you, behavioral specialist would probably do the same. He/she would ask you a couple of questions to be sure that you weren’t in a very serious or dangerous situation but then they would focus on getting you better as quickly as possible. They might work with you to find something that you like to do everyday, which actually has been shown to start improvement for people with depression, orthey might teach you some breathing exercises that actually make a difference with people with anxiety. When the doctor came back in the behavioral specialist might make a recommendation to the doctor about whether the doctor might consider prescribing you some medicine. You might come back to see the behavioral specialist a time or two to be sure that things are heading in the right direction. But in the long run you just go back to working with your doctor and the behavioral specialist would be somebody who would be available if you ever needed them again.

Bob: That sounds terrific, sign me up!


Sandy Blount

Alexander Blount is Director of the Center for Integrated Primary Care and Professor of Family Medicine and Psychiatry at the University of Massachusetts Medical School in Worcester, MA.  At UMass he has developed training programs in Primary Care Behavioral Health and Integrated Care Management that have already trained 2000 people for the workforce needs of the transformation of healthcare. His books include Integrated Primary Care: The Future of Medical and Mental Health Collaboration and Knowledge Acquisition, written with James Brule’.  He is Past President of the Collaborative Family Healthcare Association, a national multidisciplinary organization promoting the inclusion of mental health services in medical settings and he is past-Editor of Families, Systems and Health.

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Leading though Building Strategic Partnerships

Posted By Rusty Kallenberg, Thursday, April 11, 2013

Rusty's post is the second
in a 5-part series on
leadership in
collaborative care.


Whenever one chooses to develop a vision that deviates from "the norm” and build something that is new, different, ahead-of-the-curve, yea – "disruptive” – strategic partnerships are necessary for both survival and success. Looking back on the 10 year development history of our "Collaborative Care” Team here at UCSD Division of Family Medicine we have learned the following lessons about building strategic partnerships.

1. Your own clinical team. Incorporating mental/behavioral health (M/BH) services within one’s own clinical operation is, as we all know, a substantial organizational challenge that involves policy, process and culture. The details of the first two have been well addressed in many of the presentations at CFHA over the past few years. The cultural challenges are a bit more subtle, a bit under the table, but no less important.

Here in San Diego, we began with an assessment of clinician attitudes to gauge the perceived need, responsibility and skills to detect and attend to M/BH patient problems. Once we had concurrence among most of our clinicians we were able to introduce M/BH clinicians to "help” our PCPs handle the frequent M/BH problems they encountered. This interaction spread person-to-person from the usual early adopters. Close communication (both written and verbal) between the clinical sides over patient care work helped build the collegial bridge needed for true collaboration. The most difficult challenges were/are over clinical space utilization where the dollars/hr. generation potential still favors medical care vs. M/BH care. We have tried to solve this in various ways but the strategic relationship that makes this happen peacefully is between our CC Director (also a practitioner) and our office managers and medical directors. If they are on the same page then problems get worked out.

Broad Lessons:

- Assess/build consensus among clinical team that M/BH patient problems are important and their responsibility

- Ensure multiple convenient communication pathways between PCPs and M/BH clinicians

- Ensure close working partnerships between clinical office-level leadership and CC leadership


2. Partnering M/BH teams. Seems like a no-brainer but this will play out in many different forms depending on your setting. Here at UCSD it involved connecting with our Dept. of Psychiatry as a first step due to their "all things psychological are our business” view of the world. We gradually weaned them off of this position and now handle all M/BH clinician hiring, billing and clinical operations of our CC Team efforts as part of our Family Medicine clinical shop. Having internal licensed M/BH leadership has been key to our development of internal policies and processes of collaborative care delivery and relating to the clinical office leadership as noted above. Through their efforts we have developed and assessed universal screening for depression, increased coverage for warm-handoffs, and a plan for broadening the definition of M/BH services to include health coaching.

A special strategic partnership we have built is with the University of San Diego’s Marital and Family Therapy (MFT) Training Program. This has allowed us to greatly expand our service delivery reach while training more collaborative care-oriented M/BH clinicians for the community. This works well in our academic training environment and allows for inter-professional training involving our family medicine residents to occur as well. This is a very fast growing international movement in health professions training. Trainees allow the "multiplier effect” through converting licensed M/BH clinicians into clinical supervisors, thereby being able to serve many more clients than those licensed folks could serve alone.

Broad Lessons:

- Establish clear shared/mutual/joint "ownership” of M/BH services within your clinical operation with your M/BH provider group

- Identify and empower local M/BH leadership

- Consider establishing precepting relationship with local M/BH training programs


3. Operational Support Teams. These come in many varieties but are always crucial to ongoing management success for Collaborative Care teams. They cover a broad span include provider licensing and privileging, billing and insurance coverage, chart documentation and electronic health records, and practiced data analysis. We have spent much time to establish and nurture close working relationships with the many departments and supervisors in charge of these services at UCSD. This involved credentialling MFTs on our rosters of approved M/BH clinicians and getting them approved by our local insurance providers, working out billing codes for M/BH services within our clinical shops where they represented new books of business, and working out specific rules with our compliance office re: including and integrating M/BH chart notes within the primary care medical record – which greatly facilitates PCP-M/BH communication. This latter task required specific negotiation about wording of M/BH clinical notes in ways that reassured the compliance folks but did not hamper clinical communication.

Electronic medical records applications represent a topic deserving of special mention. Our system is fully computerized so the success of any new clinical operation is in part due to how well it is integrated into the EMR our clinicians use all the time. So we have worked to accomplish total integration of our CC Team’s work from appointing/scheduling to documentation of clinical notes to inter-provider communication and ultimately, data analysis. This required lots of communications with the various EMR build teams and an understanding with our EMR leadership that we considered our CC Team services as integral to our clinical operation.

Finally, with regard to data analysis on the back end of care – we feel that this is absolutely critical to knowing what’s working and what needs further refinement. We have long funded an internal data analyst who we direct, and whose job is to analyze our clinical shop data for whatever purposes we designate. The success of this person is dependent on the strategic relationships we have built with all the owners of clinical and financial data in our Medical Center. As a consequence our data analyst has the "keys to the castle” for all the data systems in our institution. We are able then to generate reports on productivity, costs and increasingly on clinical outcomes of interest to both clinicians and researchers. Some of these services have required us to fiscally support them and we have determined that at times this is ultimately in our best interests.

Broad Lessons:

- Map all processes needed to carry out the CC mission and determine who owns these processes in your clinical setting and establish working relationships with all of them

- Make clear your operational needs in order to deliver the best patient care possible – as this is a goal all such support folks should be committed to serving

- If you have an EMR – use it to support and integrate your CC services.

- Be willing to potentially compensate for support services rendered if they are new or "above and beyond the call”


One really cannot do anything truly "collaborative” if one isn’t successfully partnered with strategic allies. Because integrating M/BH services into medical care sites is still often "revolutionary” and "disruptive” – it does take collective effort across the board. Building strategic partnerships both internally and externally requires prospective partners to understand the vision you are trying to achieve. That vision – of better and more complete, whole person care – should be a shared goal of all who are in the health care delivery business.


Rusty Kallenberg

Dr. Gene "Rusty" Kallenberg has beenChief of the Division of Family Medicine and Vice Chair of the Dept. of Family and Preventive Medicine at University of California, San Diego since 2001. Previously he was the Chief of Family Medicine and Asst. Dean for Curricular Projects at George Washington University where he was from 1982-2001. He has been a member of CFHA for the past 16 years (with some gaps!). Dr. Kallenberg currently serves as one of the four Clinical Foundations Directors of the new UCSD Medical School Integrated Scientific Curriculum and runs the Ambulatory Care Apprenticeship component as well. He also is the Director of the new UCSD Center for Integrative Medicine which started operations in 2010. 


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Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA

What We Do

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.