I have spent nearly twenty-five years of my career in medical schools and teaching hospitals. I started by devoting three years to training in the Veterans Administration System in the Chicago area. Eventually, I spent a year in a state hospital as the Head of Psychology on a Consultation and Education Service. I then spent seventeen years at Northwestern University Medical School where I served as Chief of Psychiatry Outpatient Services for eight years and Professor and Chair in Psychology for the following nine years. Later, I served as Provost at the University of Missouri where the Dean of the Medical School was also the Director of the Teaching Hospital and he reported to me. Throughout this quarter of a century experience, I have found academic health care centers to be stimulating and exciting settings in which to work. For myself and most professionals involved in patient care, research, teaching, supervision and administration, this environment provided constant challenges and opportunities to improve the lives of individuals from cradle to grave. It is an environment where one can feel personal efforts are important, lives are affected by decisions made and quite dramatic changes and improvements in individuals can be observed. Until recently, most people who worked at the doctoral level in health care settings did so with great enthusiasm. However, the landscape of health care delivery is changing and the excitement I have noted is not nearly so palpable today. It is in the context of this evolving culture that I intend to talk about the history of Psychology?s development and growth in medical centers, our current status and some aspirations for the immediate future.
While the role of psychology in the practice of medicine can be traced from the early Greeks through the Middle Ages and the Renaissance into the modern era (Matarazzo, 1994a), the involvement of psychologists in medical schools is relatively recent. There were a few individuals with a medical school appointment dating back to 1910, but it is only after 1950 that significant numbers appear. In 1953, there were approximately 255 psychologists in medical schools (Mensh, 1953) and this number grew to 583 by 1959, 993 by 1964, 1300 by 1969 and 2,336 by 1976 (Matarazzo, Carmody and Gentry, 1981; Matarazzo, 1994b). Matarazzo (1994a, 1994b) estimated that by 1993, this number increased to over 3,500. Another way to characterize this growth is by decades. In the early 1950's, there were about 2 psychologists per medical school. By 1960, this number more than doubled to 5 psychologists per medical school. In the early 1970's, the number doubled to 10 and by 1980 it had again almost doubled to an average of 19 psychologists per medical school. By the early 1990?s, there was another fifty percent increase so that the average medical school had 28 psychologists. Thus, in a period of about forty years, psychology had grown from averaging about 2 psychologists per medical school to almost 30 psychologists per medical school.
This significant growth in the number of psychologists also was enhanced as the discipline began educating deliverers of clinical services, a phenomena promoted by the Veterans Administration (VA) after World War II. Today, the clear majority of psychologists teaching in medical schools also are rendering needed clinical services, and/or conducting research. For nearly four decades, the VA, in particular, as well as state-supported and even private hospitals, funded positions for psychologists to conduct these activities. The major change occurring today is that psychologists, like physicians, are rendering billable services or conducting funded research that pays their salaries. In a significant number of institutions, psychologists not only generate their entire salary but must provide additional funding that assists in operational costs.
The question facing us today is whether psychology is prepared to move forward in the new world of health care, especially in academic medical centers, or whether our past mistakes and our reticence to be innovative will leave us behind more aggressive and single minded professions.
There can be no doubt that there are striking opportunities to expand psychology's role from a focus on mental health to the broader field of health care. I intend to confine my remarks to five areas that I believe are especially important: the role of psychology in collaboration with other disciplines; interventions psychologists offer; reimbursement for services; education and training, and research.
The Role of Psychology and Its Collaboration With Other Disciplines
The health care world is simultaneously becoming simpler and more complex. This evolution is creating confusion, frustration and even a sense of absurdity for health care professionals (even consumers are experiencing it). On the one hand, managed care is seeking to utilize internists, pediatricians and family practitioners as gatekeepers and to have these practitioners offer the broadest range of services possible. In contrast, never have there been more experienced specialists who offer a myriad of focused treatments that no single clinician or specialty can hope to provide. With many managed care corporations promoting the gatekeeper system, psychologists must adjust to it. This system necessitates that practitioners be members of a team. Psychologists, historically, equated physicians with psychiatrists and spent an inordinate amount of time in competition with them. This history should be forgotten. In the current world, physicians in internal medicine, pediatrics, and family practice are the primary care specialists' the gatekeepers' and are friends of psychologists. Collaboration with these friends means that psychologists accept their role as members of a health care team and surrender the belief that they frequently should lead such a team. An example psychologists may wish to examine occurs in surgery. Anesthesiologists, radiologists, and pathologists are all very important members of a surgical team but they do not often, if ever, lead the team.
It should not be overlooked that many medical specialists (e.g., urologists, neurologists, cardiothoracic surgeons, orthopedic surgeons, etc.) now identify with the historical dilemma of psychologists in hospitals, namely, with the need to have someone refer before one's services become reimbursable. Thus, psychologists now have an opportunity to align themselves with the many specialists who realize the current system is changing the process of how practitioners enter the health care field.
Depending on whether a medical center is located in a rural or urban area and the part of the country in which one practices, this future may already be present. Current trends clearly indicate the following. Psychologists will play an important role in medical schools but a smaller percentage of them will be in tenure track positions. This change in academic appointments is true for all disciplines. However, psychology must address the practice of some medical disciplines that hire psychologists to render clinical services without appointments to an organized psychology faculty. This practice has a long history but it now has dire consequences. If psychologists are not members of a psychology faculty (and many naïve beginning psychologists do not understand this problem), they will not be partners in faculty practices, they will have restricted clinical privileges and they will not have significant input into the actual running of health care services. With patients being given less provider choice, and competition for patients increasing, the potential weakening of psychology's status will surely lead to a second class membership in health care plans. This potentially weak position can only be prevented if colleagues act quickly to organize and reject the system of allowing other disciplines to hire psychologists as adjunct team members. (This problem is made more complex by the fact that academic psychologists have no understanding of this dilemma and, thus, provide little or no education to psychologists in training regarding this extremely important issue.)
A second phenomenon important to psychologists is the rapid development of nursing's role in psychological treatments. Recently, many nurses have obtained master's and doctoral degrees in psychology. In addition, nursing has effectively established the National Institute for Nursing Research (NINR) which is part of the National Institutes of Health. Some of NINR's research focuses on psychological variables. Thus, nursing is a discipline rendering psychological services and conducting funded psychological research. And nurses are increasing the number of practitioners who prescribe medication and admit to hospitals. With increasing competition for both clinical service and research dollars, psychology must plan now how it will better organize itself since other disciplines are utilizing excellent strategies to be centrally involved in health care centers..
In some managed care systems, there are interesting opportunities for psychologists. With carve-outs for behavioral health services (i.e., the funding of independent groups with specific responsibility for behavioral health care), psychologists can develop group practices with a broad number of specialties. These could include pediatric psychologists, family psychologists, rehabilitation psychologists, neuropsychologists, health psychologists and behavioral psychologists (to name only some potential members). Such groups can carefully define their services, aggressively assess outcomes to show the effectiveness of such services (an important factor for viability in managed care) and plan responses to the intense competition developing in health care.
Interventions Psychologists Offer
Over the past decade, the practice of psychology has grown with a significant increase in the number of hospitals granting admitting privileges as well as full Medicare and Medicaid independent diagnosis and treatment reimbursements. The addition of such privileges as certifying disabilities, signing involuntary admission forms, examining patients in hospital emergency rooms, ordering seclusions and restraints, writing behavioral orders and serving as directors of hospitals and clinics have meaningfully broadened psychology?s health care role.
The functions of psychologists have been expanded further through legislation permitting them to perform court evaluations and assessments for forensic insanity.
As psychology continues its move from being a mental health profession to a health care profession, it is necessary to consider two significant changes. First, psychologists need to identify they actually diagnose and treat physical problems (e.g., benign headache, sleep disorders, pain, sexual dysfunction, etc.) and thus must use physical diagnoses codes (The International Classification of Impairments, Disabilities, and Handicaps) (World Health Organization, 1980) is particularly designed for such diagnoses. This requires a change in how psychologists identify treatments in that the profession has traditionally used psychiatric rather than physical diagnoses. Today, in some cases, psychologists actually treat the presenting medical problem (as in the examples I have just mentioned). In other cases, they offer treatment after other medical interventions (e.g., cognitive rehabilitation after tumor removal).
Second, in the case of certain emotional disorders, more psychologists eventually will prescribe medications. With appropriate training, there is no reason why psychologists cannot render this aspect of treatment. Such prescribing already is being done by some psychologists as well as advanced practice nurses, nurse anesthetists, clinical pharmacy specialists, physician assistants, medics, corps men, and others (Washington Report, 1996). The resistance to having psychologists prescribe medications comes from both outside and within the profession. The economic motives for outside resistance are understandable and can be refuted. The difficulties within psychology are more problematic since the resistance comes primarily from groups of individuals who are removed from the health care scene, have little or no experience with the phenomenon they resist, and cite inappropriate data bases for their conclusions.
In the current service environment, psychologists also must be more efficient (not a quality promoted in graduate school). For example, assessment procedures and techniques can be refined to meet the setting in which they are used; and psychologists need to respond quickly to consultations while providing understandable written reports that are immediately available.
Fortunately, many psychologists already have made these changes and offer models to the rest of us.
It cannot be overlooked that emphasis on short-term treatment is paramount in managed care. While there is empirical evidence for the efficacy of a number of short-term treatments, it is reimbursement rather than empirical evidence that is the primary driving force for this emphasis. Many clinicians continue to resist short-term treatments not only because they believe longer-term treatment is more efficacious but also because it is more personally gratifying to the clinician. This phenomenon is equally observable in the legal field where lawyers and judges who participate in alternative dispute resolution acknowledge the system genuinely works (and greatly reduces time and costs to problem resolution) but many of these barristers find it much less gratifying than the tradition of hearing cases in court over extended periods. The issue of reducing or nearly eliminating long-term psychotherapy is serious. However, in the current reimbursement milieu, psychology?s best strategy may be to establish the many shorter effective interventions it delivers. While emphasizing these treatments, psychologists also can take a leadership role in seeking reimbursement for certain longer-term treatments appropriately arguing and demonstrating these are the only interventions that will be effective in specific cases.
Reimbursement for Services
"The relentless economic forces that presently buffet the health care delivery system are exerting a profound impact on the practice of rehabilitation psychology, forcing curtailment of some services, redirection or relocation of others, and prompting practitioners to be innovative in applying existing skills." (Caplan & Berk, 1995, p. 356) This statement applies to almost every specialty in psychology. At the same time, in study after study, whether discussing general medical patients, VA patients or socioeconomically disadvantaged patients, the finding that the availability and use of psychological interventions dramatically reduce both in-patient and out-patient visits and costs is consistent (Cummings, 1991; Cummings, Dorken, Pallack, & Henke, 1993). Even if one eliminates quality of life factors, and focuses solely on the cost of health care, it simply makes sense to provide psychological intervention.
The future of psychology in academic medical settings is dependent on its ability to educate insurers and consumers that its interventions are indispensable because they work and they reduce total health care costs. For example, while participating in Preferred Provider Organizations (PPO?s), perhaps the most popular form of managed care, practitioners find themselves involved in precertification interviews (i.e., the determination of clinical necessity). This requires calling a person who controls entry into managed care and answering questions on how well the intervention, consultation or evaluation to be performed will influence the outcome of the patient?s problem. This is a time consuming and often frustrating process. Even more troubling is frequently a psychologist?s services are rejected even though the referring person, the patient, and the psychologist all know such services are necessary. The obvious point is that psychologists will need to make absolutely clear what the nature of their service is, why it is effective, and what the negative results (including higher health costs) are if the services are not rendered. Further, psychologists will need to educate referrers, usually physicians, as to how to use these same data to make certain referrals are approved.
Education and Training
An effective argument can be made that at the doctoral level, education and training in psychology in research methods, measurement, theory and basic clinical skills are adequate; in some cases, superb. The locus of where advanced clinical and research training occur needs attention. If health psychologists are to offer sophisticated services or conduct research within an environment that they understand, these individuals must be trained in that environment and it is a hospital or medical out patient service. Simply seeing patients in a university counseling service or conducting clinical research in a Psychology Department laboratory is not a sufficient preparation for the demands of today?s health care world. In fact, if psychology is to anticipate changes in the locus of health care services, it needs to add to its training more participation in school based health clinics. The more our discipline identifies itself with the health care world, centers much of its education in milieus where other health care providers are being trained, and makes every effort to complement and add to the training of other disciplines, the better trained and accepted will be the next generation of psychologists.
There also is a need for innovation at the postdoctoral level (Brown, 1996). Such innovation would be especially meaningful if, during the doctoral program, psychologists developed a broad range of treatment skills (e.g., brief intervention techniques, group therapy, family therapy, biofeedback, hypnosis, pain management, play therapy, relaxation techniques, etc.). Then postdoctoral training could span a broad range of problems while allowing specialization in one or two areas (Sheridan et al, 1988). Without such complex training, future psychologists will not have the necessary sophistication and experience either to practice competently or to conduct investigations that are quality contributions to the health care field.
The innovation being suggested can occur in a number of ways. For example, a wonderful array of educational aids now exists. With CD-Roms and the Internet, there are opportunities for students to learn about a broad range of techniques from the leaders in specific fields. With interactive video, they can take live courses from such people. And with the assistance of virtual reality, students can even have meaningful experiences with "patients" where mistakes have no consequences. Finally, psychology must eventually deal with the career ladder problem, a task it has refused to face. While every other profession designates what its doctoral practitioners can do and what lesser-trained individuals can do, psychology has still failed to effectively address this obvious hierarchy.
Research
Psychologists can plan for the future or be a victim of it (a problem the profession knows too well). A significant strength lies in having so many individuals who are scientists-practitioners, a training that not only creates a sense of questioning but encourages individuals to practice with the anticipation of improving the interventions they offer. In medical schools and hospitals, there are frequent reports that all clinicians are spending more time providing service and less time in research and teaching. This is true not only for psychologists but for all physician specialties and for nursing. With these pressures, there is a possibility, if not a reality, that quality research will be significantly reduced in the coming decade. Surely, psychologists can take a lead in helping address this problem. Such leadership will be taxing and require that psychologists appreciate they often are the only members of a hospital team that have formal, sophisticated training in research (rehabilitation is an excellent example). Leadership also obliges psychologists to develop research teams, be primary writers of grants and take responsibility for analyzing data and writing first drafts of articles. Being a research leader in a health care setting is a challenge but such leadership clearly is available to psychology.
Finally, I believe the challenge for Psychology to be a major participant in health care is at a critical juncture. The five areas I have highlighted present our discipline with multiple opportunities to establish an important niche in health care. This comes at a time when managed care has created such chaos that health care will redefine itself. Psychology can follow its familiar pattern of obsessive reflection and debate and other disciplines will simply relegate us to a minor role. There is a genuine danger this will occur. Or, we can assert ourselves as a major health service provider, educating reimbursers and the public that Psychology adds to the quality of health care and reduces costs. This rare and clear opportunity will likely begin to close in 2 to 3 years. We should not let it pass.
Edward P. Sheridan
Sr. Vice President and Provost, University of Houston
