Summer 2001 - IP; Psychologists as Doctors in Primary Care Settings

Marketing

	Psychologists Can Help Deal With School Violence: A Model Letter and Talking Points/Division 42 Public Relations and Public Education Committee
	Helping People Age Well: A New Niche Market/Michael Brickey
	Consider this Niche: Working with Foster Parents and Foster Children/Daniel L. McIvor and George “Mac” McClelland
	Psychologists as Doctors in Primary Care Settings/Jack G. Wiggins

Psychologists as Doctors in Primary Care Settings

Focus on treatment of chronic diseases is a growing aspect of primary care. The aging of our population has given rise to this populations risk for experiencing one or more chronic health conditions that must be treated and managed. Thus, primary care physicians are being called upon to shift their emphasis from care of acute conditions to treatment and of chronic illness and pain management.

This is part of the strategy of the Bureau of Primary Care of the US Health Resource Services Administration. Another part of the strategy is to integrate mental health with primary care. The Bureau of Primary Care has been convening conferences on integrating primary care and mental health in various regions and states for the past year. Some of these programs have been presented through federal/state Agencies for Health Education Centers which are available in every state. Dr. Harriet McCombs, a psychologist and Director of the Mental Health Integration section of the Bureau of Primary Care will be speaking on this topic at the APA convention in San Francisco in Room 250 of the Moscone Center at 12:00-1:50 on Monday, August 27th .

One of the major difficulties of primary care physicians (PCP) is making the transition to chronic care is that chronic conditions such as Type II diabetes, chronic obstructive pulmonary disease (COPD), arthritis, etc. require making major life style changes. PCPs, though well trained in treating disease, are poorly equipped to direct life style changes. Without life style changes the patient is likely to continue in pre-conditions modes of behavior, become frustrated, and within three to six months experience a significant degree of depression. This, of course, compounds the treatment tasks presented to the PCP. Behavior modification and teaching coping skills is the stock and trade of psychologists. Therefore, there is a natural affinity for psychologists and PCPs to collaborate in the care of people with chronic conditions.

It is ill advised and costly to wait until the patient stricken with a chronic disease has a diagnosable depression to begin the psychological rehabilitation. Stigmatizing people with a psychiatric diagnosis has been a major deterrent to obtaining timely and effective psychological care for people with chronic health problems. The approval of six new procedural codes for treating psychological sequellae of “so-called physical disorders” is long overdue. Even this description misses the point that the psychological aspects of “dis-eases” is an integral part of health and is not just an aftermath of some physiological process. Hopefully, HCFA will assign dollar values commensurate with health enhancement value of these psychological interventions.It is incumbent for HCFA to empower these new approved de-stigmatized treatment codes promptly to implement Surgeon General Satcher’s mental health vision for the future of this nation’s health. It is time to have a psychologist as a Surgeon General to assure the implementation of this integration of mental health and primary care. There are excellent psychologists in the Public Health Service who could fulfill this role with distinction and honor for the health care of the public.

Division 42’s Task Force on Primary Care has focused on these issues for the last few years with some success. Our goal has been to educate psychologists about chronic diseases. We created a web site to make research on the psychological aspects of 20 chronic health conditions available to our members. You can log on to this now by going to the Division 42 web site. Until recently, this Primary Care Task Force web site was a orphan without any links to it. Now by going to www.division42.org you can hyper link to the abstracts of psychological aspects of these 20 different chronic health conditions which can be downloaded for your patients. With this accomplished we are now in the process of reconstituting the Division’s Primary Task Force and are seeking volunteers to join with us to further this public health education effort. We need people who keep current in one or more of these health areas to supplement the references that are currently posted. Also we assistance in the posting of these supplementing articles onto the web site to keep it current. If you are willing to do any of these tasks please contact me at your earliest convenience at drjackwiggins@uswest.net. Anyone can send in journal articles they think would be of interest.

For the past year we have been looking for ways to develop educational and training opportunities in primary care to back up our assertion that psychology is primary care. Divisions 43 and 12 also have committees focusing on primary care, so this effort is now seen as a multi-divisional interest. It is particularly noteworthy that the psychologists working in Family Physician Residency Training Programs are interested facilitating the training of psychologists in the treatment and management of chronic diseases. The problem is not so much education psychologists about the treatment of chronic conditions but in introducing them into the primary care culture and teaching PCPs and psychologists how to work together in that culture.

The 45 minute or even 30 minute consultation is not a format that can be adapted easily to the primary care locale. Even 15-20 minute consultations are a luxury in most settings, including hospital consultations. Psycho-educational approaches plus brief individual interventions are the most user friendly in primary care clinics. The task is to deliver focused interventions addressing the current behaviors in question as collaborative care. A wag has defined collaborations as an unnatural act performed between non-consenting adults. Collaborative working together can enhance the work of a team of doctors, although the short time frame for psychological input may seem like diluting therapy to those who practice using longer time frames.

Kirk Strosahl, Ph.D., points out that much can get accomplish in these short primary care consultations. This is because the patient is at a teachable moment due to the focus of the primary care visit and the patient is used to brief consultations in that setting. Furthermore, even if everything is not accomplished in one session, whatever the patient learns in terms of self-management of the condition is more than he or she had before. If patients do not receive this modicum of psychological care they are likely not to receive any at all. Dr. Strosahl is a forceful advocate for delivery for psychological services in primary care setting because it allows the doctors to interact and provide collaborative care where each doctor reinforces the care of the other. It is not parallel treatment by two or more doctors mimicking the “push car” play of young boys. Collaborative care in primary care settings is truly and integrative process of melding the psychological, behavioral and medical acumen for the patient’s benefit.

David Burns uses the focused collaborative approach in his treatment of the seriously mentally ill with group treatment methodologies with good effect. Individual psychotherapy can be more effective if the doctor and patient can focus on the same question with same goals in mind. After all, it is what the patient can learn and use outside of the therapeutic contact that determines the effectiveness of the therapy. If the patient becomes dependent upon the learning inside the therapy time then therapy can be interminable. It is when the patient starts learning from sources outside the therapy contact that they are ready to terminate. Therapy provided in the primary therapy may not be enough for some but it can also assist the patient to seek the necessary treatment required.

Psychologists may play multiple roles in primary care settings. Jim MacKenzie, Ph.D. of Good Samaritan Hospital of Phoenix and I are working with a multi-disciplinary group, including the Arizona Academy of Family Physicians to establish a working model of Primary Care Mental Care Integration. We are willing to share our work with psychologists in other states interested in this area. For those interested in working with the Primary Care Task Force or a coalition of psychologists in primary, care please contact me.

Jack Wiggins, Ph.D., Psy.D., is a past president of APA and of Division 42. He can be reached at 15817 East Echo Hill Drive, Fountain Hills, AZ 85268, phone: 480-816-4214, E-mail: drjackwiggins@uswest.net

By Jack G. Wiggins, Ph.D., Psy.D.
Chair, Primary Care Task Force

Discuss this and other articles at the IP Chat Discussion Board

Return to Top

			Focus on treatment of chronic diseases is a growing aspect of primary care. The aging of our population has given rise to this populations risk for experiencing one or more chronic health conditions that must be treated and managed. Thus, primary care physicians are being called upon to shift their emphasis from care of acute conditions to treatment and of chronic illness and pain management. This is part of the strategy of the Bureau of Primary Care of the US Health Resource Services Administration. Another part of the strategy is to integrate mental health with primary care. The Bureau of Primary Care has been convening conferences on integrating primary care and mental health in various regions and states for the past year. Some of these programs have been presented through federal/state Agencies for Health Education Centers which are available in every state. Dr. Harriet McCombs, a psychologist and Director of the Mental Health Integration section of the Bureau of Primary Care will be speaking on this topic at the APA convention in San Francisco in Room 250 of the Moscone Center at 12:00-1:50 on Monday, August 27th . One of the major difficulties of primary care physicians (PCP) is making the transition to chronic care is that chronic conditions such as Type II diabetes, chronic obstructive pulmonary disease (COPD), arthritis, etc. require making major life style changes. PCPs, though well trained in treating disease, are poorly equipped to direct life style changes. Without life style changes the patient is likely to continue in pre-conditions modes of behavior, become frustrated, and within three to six months experience a significant degree of depression. This, of course, compounds the treatment tasks presented to the PCP. Behavior modification and teaching coping skills is the stock and trade of psychologists. Therefore, there is a natural affinity for psychologists and PCPs to collaborate in the care of people with chronic conditions. It is ill advised and costly to wait until the patient stricken with a chronic disease has a diagnosable depression to begin the psychological rehabilitation. Stigmatizing people with a psychiatric diagnosis has been a major deterrent to obtaining timely and effective psychological care for people with chronic health problems. The approval of six new procedural codes for treating psychological sequellae of “so-called physical disorders” is long overdue. Even this description misses the point that the psychological aspects of “dis-eases” is an integral part of health and is not just an aftermath of some physiological process. Hopefully, HCFA will assign dollar values commensurate with health enhancement value of these psychological interventions.It is incumbent for HCFA to empower these new approved de-stigmatized treatment codes promptly to implement Surgeon General Satcher’s mental health vision for the future of this nation’s health. It is time to have a psychologist as a Surgeon General to assure the implementation of this integration of mental health and primary care. There are excellent psychologists in the Public Health Service who could fulfill this role with distinction and honor for the health care of the public. Division 42’s Task Force on Primary Care has focused on these issues for the last few years with some success. Our goal has been to educate psychologists about chronic diseases. We created a web site to make research on the psychological aspects of 20 chronic health conditions available to our members. You can log on to this now by going to the Division 42 web site. Until recently, this Primary Care Task Force web site was a orphan without any links to it. Now by going to www.division42.org you can hyper link to the abstracts of psychological aspects of these 20 different chronic health conditions which can be downloaded for your patients. With this accomplished we are now in the process of reconstituting the Division’s Primary Task Force and are seeking volunteers to join with us to further this public health education effort. We need people who keep current in one or more of these health areas to supplement the references that are currently posted. Also we assistance in the posting of these supplementing articles onto the web site to keep it current. If you are willing to do any of these tasks please contact me at your earliest convenience at drjackwiggins@uswest.net. Anyone can send in journal articles they think would be of interest. For the past year we have been looking for ways to develop educational and training opportunities in primary care to back up our assertion that psychology is primary care. Divisions 43 and 12 also have committees focusing on primary care, so this effort is now seen as a multi-divisional interest. It is particularly noteworthy that the psychologists working in Family Physician Residency Training Programs are interested facilitating the training of psychologists in the treatment and management of chronic diseases. The problem is not so much education psychologists about the treatment of chronic conditions but in introducing them into the primary care culture and teaching PCPs and psychologists how to work together in that culture. The 45 minute or even 30 minute consultation is not a format that can be adapted easily to the primary care locale. Even 15-20 minute consultations are a luxury in most settings, including hospital consultations. Psycho-educational approaches plus brief individual interventions are the most user friendly in primary care clinics. The task is to deliver focused interventions addressing the current behaviors in question as collaborative care. A wag has defined collaborations as an unnatural act performed between non-consenting adults. Collaborative working together can enhance the work of a team of doctors, although the short time frame for psychological input may seem like diluting therapy to those who practice using longer time frames. Kirk Strosahl, Ph.D., points out that much can get accomplish in these short primary care consultations. This is because the patient is at a teachable moment due to the focus of the primary care visit and the patient is used to brief consultations in that setting. Furthermore, even if everything is not accomplished in one session, whatever the patient learns in terms of self-management of the condition is more than he or she had before. If patients do not receive this modicum of psychological care they are likely not to receive any at all. Dr. Strosahl is a forceful advocate for delivery for psychological services in primary care setting because it allows the doctors to interact and provide collaborative care where each doctor reinforces the care of the other. It is not parallel treatment by two or more doctors mimicking the “push car” play of young boys. Collaborative care in primary care settings is truly and integrative process of melding the psychological, behavioral and medical acumen for the patient’s benefit. David Burns uses the focused collaborative approach in his treatment of the seriously mentally ill with group treatment methodologies with good effect. Individual psychotherapy can be more effective if the doctor and patient can focus on the same question with same goals in mind. After all, it is what the patient can learn and use outside of the therapeutic contact that determines the effectiveness of the therapy. If the patient becomes dependent upon the learning inside the therapy time then therapy can be interminable. It is when the patient starts learning from sources outside the therapy contact that they are ready to terminate. Therapy provided in the primary therapy may not be enough for some but it can also assist the patient to seek the necessary treatment required. Psychologists may play multiple roles in primary care settings. Jim MacKenzie, Ph.D. of Good Samaritan Hospital of Phoenix and I are working with a multi-disciplinary group, including the Arizona Academy of Family Physicians to establish a working model of Primary Care Mental Care Integration. We are willing to share our work with psychologists in other states interested in this area. For those interested in working with the Primary Care Task Force or a coalition of psychologists in primary, care please contact me. Jack Wiggins, Ph.D., Psy.D., is a past president of APA and of Division 42. He can be reached at 15817 East Echo Hill Drive, Fountain Hills, AZ 85268, phone: 480-816-4214, E-mail: drjackwiggins@uswest.net
By Jack G. Wiggins, Ph.D., Psy.D. Chair, Primary Care Task Force

	Discuss this and other articles at the IP Chat Discussion Board
		Return to Top