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Physician-Psychologist Teamwork: Twelve Years of Practice |
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Professional Practice |
Amy J. Rosenberg, MD and Peggy A. Rothbaum, PhD |
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We read Dr. Bray’s (2002) article, “Collaborative Practice Between Psychologists and Primary Care Physicians” with interest. He clearly explains the value of physician-psychologist collaboration. Similarly, Haley, McDaniel, Bray et al. (1998) stress the importance of physician-psychologist communication and collaboration. Kaintz (2002) presents data on what physicians report that they need from psychologists. She emphasizes for psychologists the role of communication, availability, and relationship building with physicians. As the beneficiaries of a twelve-year collaborative physician-psychologist relationship, we have a developed a partnership that works well (and also works well with other physicians), but may be somewhat atypical from the way in which most psychologists practice. Further, since we are both in private, not institutional practice, it requires extra effort to coordinate our services because our paths do not regularly cross at department meetings or seminars. The purpose of this article is to describe the details of our working relationship. Psychologists seek relationships with physicians as part of marketing their practices and obtaining referrals. It is important to note that although physicians may appreciate referrals from psychologists, and view referrals as a sign of respect and appreciation, these referrals constitute a very small percentage of the physician’s practice. Physicians have high volumes of relatively brief appointments where patients are not generally seen on a predictable and regular basis (e.g. weekly psychotherapy appointments). Thus, in terms of practice building, the main beneficiary of physician-psychologist collaboration is the psychologist. However, physicians and psychologists do share an interest in providing adequate patient care. For this reason many physicians are looking for, but unable to find, psychologists who will collaborate with them in providing care for their patients. Physicians need psychologists who can function within, and add their psychological knowledge, to the medical model of practice. The medical model of practice uses the “S (symptoms)-O (objective)-A (assessment)-P (plan)” model. Thus, the physician begins with a history, which focuses on symptoms. Part of the report of symptoms is inquiring about how the patient feels and having a discussion, not just looking at physical symptoms. This is followed by an examination that may involve laboratory studies: x-rays, blood tests, magnetic resonance imaging (MRI), cat-scans, or other procedures involving a referral. A differential diagnosis, which produces a plan for proceeding with care, is the end result of the process. Often a psychological cause is found during that initial visit. Certainly, if a patient reappears with the same symptoms, there is no apparent medical basis for the symptoms, or the symptoms worsen with no apparent medical basis, there is the possibility that psychological processes such as anxiety or depression are at work. In that case, the physician will consider a referral for psychotherapy. It is at this point that the physician needs a psychologist who can be part of a health care team. The physician needs to know that the psychologist will respond to the patient’s call in a reasonable amount of time. This typically means within a few hours to less than a day. The physician also needs to know that the psychologist will see the patient in a timely manner, and if the patient is at risk psychologically, the patient will be referred to a hospital or emergency room for treatment. If the psychologist suspects any problems needing direct medical intervention such as substance abuse, eating disorders, or failure to comply with medical recommendations, the physician needs to receive this feedback from the psychologist. The physician needs to hear a plan about how the psychologist is going to proceed with the patient’s care. Within a trusting relationship with a psychologist, the physician can then breathe a sigh of relief on at least two levels: the patient is receiving competent care, and the physician did not miss any signs of psychological danger and is thus “covered”. Physicians stay in touch with each other and share information about referrals. Teamwork is the foundation of medical practice. It is done typically by letters, which are dictated by the physician and then typed by staff. However, physicians are often receptive to the fact that many psychologists do not have secretarial help and will be comfortable with verbal updates. Time for lunches and coffee are a luxury that most physicians cannot offer. Physicians get to know how psychologists work by experiencing their work and how readily they are able to adapt to the already functioning system of a busy private medical practice. Similarly, physicians often cannot be interrupted during patient care to come to the phone. Further, when physicians have questions about a particular patient’s psychological status, they need privacy to ask the question. Most medical practices close and break for lunch each day, but the physicians remain in the office making and receiving phone calls. Psychologists who can work within this structure can create an opportunity to create and nurture a relationship with a physician. Briefer, less urgent messages might be left with an office manager, or a chief nurse who can handle them with confidentiality and assure that the physician receives them. When physicians are kept updated on the patient’s progress, it also offers the opportunity to support the psychologist’s work. When the patient is in the physician’s office, the physician can inquire about progress and reinforce the recommendations that the psychologist has made to the patient. It also furthers trust and openness in the relationship between the physician and the patient. The patient perceives that the physician and psychologist are a team, and that the physician cares enough about the patient to stay posted on progress with the psychologist. When psychologists observe something new in relation to the patient’s physical health, and they either contact the physician to discuss it or refer the patient back to the physician, teamwork is again furthered. Conversely, physicians appreciate it when psychologists respect the necessities of medical care for a patient and support that need. For example, anorexic patients need to be weighted whether it makes them feel bad or not. It is also important not to assume that a particular symptom is psychological in nature without allowing the physician the opportunity to rule out any physical causes. Many physicians are eager to learn more about psychology and psychotherapy, particularly as it applies to their own patients. Physicians may have learned about certain psychotherapy concepts in medical school such as splitting, acting out, transference, dissociation, resistance, etc, and may recognize these phenomena when they appear. Further explanation or assistance in managing them may be desired. Some physicians may be less familiar with psychological concepts, but may be interested in learning about them if the explanations are presented in ways that are directly applicable to patient care. Practical tips about recognizing and managing basic psychological phenomena should be included in the discussion so that the physician gets a sense of the usefulness and applicability of psychological knowledge. Physicians who understand splitting and various manifestations of acting out, as well as resistance and transference, can help patients remain with their current psychologist and work these issues through. Educating physicians about the psychological progress of their patients is one of the most important marketing tools there is in terms of establishing physician-psychologist relationships. When a psychologist presents a physician with a plan about a particular patient’s treatment plan, and then updates the physician on the patient’s progress, it is an approximation of laboratory results--the physician has more concrete evidence that the treatment is effective. Further, the physician is afforded the opportunity to ask questions, which builds faith in the psychologist’s interventions and in the actual teamwork. When a patient’s situation is more complex than originally believed, the physician can learn about dissociation, abuse sequelae, learning disabilities, and other topics that may be previously unknown to that particular physician. Making referrals to non-medical professionals is both an important part of physician-psychologist teamwork and physician education. If a patient is referred for a psychological evaluation for something specific, such as suspected dissociative identity disorder (DID), not only does the physician learn about DID, the physician adds a new psychologist to the professional network. The next time the physician needs to make a referral for that specific type of evaluation, a new resource exists. This makes the physician feel part of a team that includes psychologists, and makes the physician appreciative to the original psychologist for providing new information that is helpful to medical practice. Further, physicians refer out to other physicians for specialty care, and will most likely respect a psychologist who does not claim to be able to “do everything”, but needs other psychologists for teamwork. Physicians also appreciate being able to call a psychologist for a specific request that the particular psychologist may not be able to address personally. Examples include “Do you know a psychologist who speaks mandarin Chinese?” or “Do you know a psychologist who specializes in marital treatment?” or “Do you know a psychologist who does adolescent groups?” The psychologist can be a resource for the physician by providing this information and demonstrating reasonable professional limitations and boundaries of expertise. It is also a way of reciprocating for the referrals made by the physician. Likewise, physicians appreciate courtesy and teamwork when psychologists believe that patients need referrals to other physicians. Consulting with the physician and using the existing network of referrals cuts down on duplication of tests and consultations. It also does not undermine the network of professional relationships (which could be a further source of referrals for the psychologist) that the physician may have spent years building. Physicians understand and support patient confidentiality, but have a somewhat different way of handling it. Psychologists require written releases to discuss information about patients; physicians often assume that once a referral has been made, the recipient of the referral is in the professional network and the patient has already agreed to the sharing of information. However, given an explanation, most physicians are willing to wait to until the psychologist acquires a release form signed by the patient, copies it, and forwards to the physician. When given an explanation, the physician does not feel excluded from information which is vital to the patient’s well being, that the psychologist is ungrateful for the referral, or as if the physician is somehow being viewed as not worthy of receiving the information. In summary, there are many advantages to physician-psychologist collaboration. Several other articles by psychologists (Bray, 2002; Haley, McDaniel, Bray et al.; Kainz, 2002) have emphasized the importance of this partnership. For psychologists, the advantages are interesting work and the opportunity for teamwork. Teamwork improves patient care and also provides psychologists with additional backup, second opinions, and professional support. In addition when psychologists can work within the established framework of a busy medical practice there is an opportunity to network with physicians and educate physicians about psychological processes and psychotherapy. This could lead to increased referrals for the psychologist. For patients, the advantages of physician-psychologist collaboration are improved and better coordinated care due to teamwork. Many physicians need, but cannot find, psychologists willing to work within the existing framework of a busy practice. For physicians, the advantages of physician-psychologist teamwork are not necessarily referrals. However, physicians appreciate the improvements in patient care offered by coordinated teamwork with psychologists, opportunities to network with psychologists, and the opportunity to learn more about psychological processes and psychotherapy. Physician-psychologist collaboration requires extra effort in private practice, but has advantages for physicians, psychologists, and patients. References Bray, J.H. (2002). Collaborative practice between psychologists and primary care physicians: Marketing your practice. The Independent Practitioner, 22, 194. Haley, W.E., McDaniel, S.H., Bray, J.H, Frank, R.G., Heldring, M., Johnson, S.B., Go Lu, E., Reed, G.M., and Wiggins, J.G. (1998). Psychological practice in primary care settings: Practical tips for clinicians. Professional Psychology: Research and Practice, 29, 237-244. Kainz, K. (2002). Barriers and enhancements to physician-psychologist collaboration. Professional Psychology: Research and Practice, 33, 169-175. Author Note Amy J. Rosenberg, Westfield Family Practice, Westfield, New Jersey. |
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