Feature

A diabetes patient regularly sees his physician, who notices the man seems depressed. Should she prescribe an antidepressant and monitor his treatment on her own? Or should she work with a psychologist to provide collaborative care?

According to new requirements from the Accreditation Council for Graduate Medical Education (ACGME), a collaborative approach is the answer.

Effective July 1, 2001, ACGME will require that residency programs develop pilot programs to meet several core competency requirements that promote an integrated collaborative approach to care. Residents in all specialties--from surgery to primary care--will be taught teamwork skills and how to partner with other professionals to provide the most effective, as well as cost-efficient, approaches to health care. By 2002, residency programs must demonstrate they are teaching residents to work collaboratively with other professionals before they graduate.

Moreover, upon graduation, residents must "possess knowledge in established and evolving biomedical, clinical and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care," the ACGME rule states. When residency programs undergo accreditation review by ACGME, they will have to document how the new requirements are taught and evaluated in all medical specialties.

"Collaboration is just part and parcel of the competencies any physician should possess," says Marvin Dunn, MD, director of residency review activities for ACGME. "It's good patient care."

APA--and indeed the public--agrees.

"Collaborative care is very effective in meeting patients' needs," says Russ Newman, PhD, JD,APA executive director for practice. "In fact, in a public survey we recently did we found that most people--83 percent--would prefer to see a physician who works collaboratively with a psychologist."

Meanwhile, an APA task force is exploring the other side of the equation: how psychologists' training can better prepare psychologists to work with physicians. That group, known as APA's Primary Care Psychology Curriculum Interdivisional Task Force, expects to have a model curriculum complete later this year.

"The ACGME guidelines insist that medical residents understand the entire system of health care. Psychologists also need to see themselves as part of that system and position themselves that way," says psychologist L. Kevin Hamberger, PhD, professor of family and community medicine at the Medical College of Wisconsin.

Teaching teamwork

The ACGME rule makes official what is already happening in practice, say many psychologists.

"Increasingly, medical residency programs are turning to psychologists, psychiatrists and other mental health professionals," says Dennis J. Butler, PhD, director of behavior sciences for Columbia Family Practice Program, a residency program for family physicians, and associate professor of family medicine at the Medical College of Wisconsin. "This movement is well-established in family medicine residencies and is now beginning to extend into other subspecialty residencies."

But how do you teach collaboration?

A lot of it is training in the nuances of mental health care. "A referral to a mental health professional is significantly different from any other referral a physician makes," says Butler.

For example, a patient with a hernia will be immediately referred to a surgeon. But physicians, and patients alike, need to recognize psychosocial issues exist and different patients will, of course, have different psychological needs.

"Physicians need to learn basic skills such as how to write a referral to a psychologist," Butler explains, "and how to clarify what help they need and how they will interact with the psychologist."

Danny Wedding, PhD, professor of psychiatry at the University of Missouri­Columbia School of Medicine and director of the Missouri Institute of Mental Health, says that most physicians are not yet trained to make appropriate requests to psychologists.

"For example," he says, "primary-care doctors sometimes order psychological tests by name--the MMPI or the Halstead-Reitan Battery--because they are used to precisely ordering medical and laboratory tests from other health-care providers. However, it is much more appropriate for the physician to identify the issue to be addressed."

He notes that physicians' questions such as "Did the patient's recent head injury result in significant cognitive impairment?" or "Is the patient potentially suicidal?" let the psychologist use his or her expertise to decide what instrument or test is appropriate.

At the Medical College of Wisconsin, Butler is already training the next generation of physicians how to provide more collaborative care. For one, he videotapes residents meeting with patients (when consent is given), then reviews the tapes and offers the residents suggestions on how to address mental health issues. Most of the teaching, though, is done through observation and feedback to residents at case meetings, where residents present challenging patients, and psychologists, social workers and medical students discuss possible treatments.

Butler also teaches residents "pre-counseling" through conjoint interviews of residents' patients. The process requires them to listen to patients describe what's wrong, validate their perceptions that a problem may exist, coordinate with other teammates the logistics involved in making referrals and provide feedback and follow-up.

Wedding says this type of training shows why it's so critical for psychologists to occupy key roles in medical schools and on medical staffs.

"Medical students emulate the role models they experience in their training," he says. "If students and residents see their mentors making referrals to psychologists, they will do the same thing when they begin independent practice."

Meanwhile, he says, most primary-care physicians have welcomed the opportunity to collaborate with a psychologist.

"They feel comfortable with the medical aspects of the case, but welcome collaboration on the behavioral aspects, for example, developing a behavior modification program for a patient with diabetes," he notes.

Training psychologists for primary care

Psychologist Susan McDaniel, PhD, a professor of psychiatry and family medicine at the University of Rochester School of Medicine and Dentistry, says the ACGME rule "should offset generations of medical training in which doctors are trained not to trust anyone's judgment but their own."

But she says psychology programs need to do their part, too.

"Both [psychology and medicine] attract people who like to be responsible and in charge, but who don't necessarily know how to work collaboratively and be team members," she says.

McDaniel has a particular interest in the area--she chairs APA's Primary Care Psychology Curriculum Interdivisional Task Force, which is completing a model curriculum for primary-care psychologists. The group is guided by the idea that psychologists should have opportunities for training in primary care throughout the educational continuum--from formal graduate programs through postdoctoral study, and continuing education and training. The proposed curriculum will supplement core education and training in psychology.

So far, the task force has identified the following skills and knowledge that primary-care psychologists should possess:

  • The ability to understand the biological components of health, illness and disease and the interaction between biology and behavior.

  • An understanding of how learning, memory, perception and cognition can influence health.

  • A recognition of the ways emotions and motivation can influence health.

  • An understanding of how social and cultural factors affect health problems, access to health care and adhering to treatment regimens.

  • Knowledge of how to assess cognitive, affective, behavior, social and psychological reactions for all common conditions seen in primary care.

Psychologists who want to partner with primary-care physicians "have to understand the language and world of primary care," adds Newman. "We need to understand the kind of help physicians are looking for and know how to translate that into our language and how to translate what we do so it is understandable and useful to primary-care physicians."

And be available to develop a relationship with a physician, follow up on referrals and suggest being present while physicians and patients meet, says Butler. Patients react more positively if physicians "have a degree of familiarity and respect" for collaborating psychologists, explains Newman.

"The future will hold tremendous opportunities for physicians and psychologists who collaborate," says Wedding. Good news for medical and mental health professionals, even better news for patients.


Marcela Kogan, a writer in Chevy Chase, Md., contributed to this article.

Survey uncovers communication breakdown in the treatment of depression

Many primary-care physicians and their patients may not be communicating effectively when the issue is major depression. A recent survey, commissioned by the National Depressive and Manic-Depressive Association (NDMDA), found that more than three-quarters of people being treated for depression feel their illness isn't under control--and the communication gap may be the root of the problem.

The NDMDA survey involved interviews with 1,001 patients--all taking antidepressants--and 881 primary-care physicians. More than three-quarters of primary-care doctors diagnose depression at least once a week, the survey reports. In fact, 64 percent of the patients surveyed were initially diagnosed by their primary-care doctor. And 84 percent depend on their physician exclusively for treatment information.

So where is the communication breakdown? First, treatment decisions. Seventy-one percent of doctors said they make treatment decisions jointly with their patients. But only 54 percent of patients reported the same. Antidepressants appear to be the most popular treatment choice, the survey says: 97 percent of doctors said they would normally prescribe them for a newly diagnosed patient with major depression.

When asked if they were alerted to antidepressants' possible side effects, most patients (62 percent) said yes. Strikingly, although doctors report that they warn their patients about possible side effects--and patients say they've been told--there's a gap in what doctors say they said and what patients say they heard. For example, 69 percent of doctors say they tell their patients about possible sexual problems related to their medication, but only 16 percent of patients report being told. Similarly, 47 percent of doctors say they warn patients about possible weight gain. Only 16 percent of patients recall hearing this information.

The survey also found that 55 percent of patients stop taking the medication altogether because of side effects.

NDMDA says the lines of communication must be opened. "Both parties need to learn to communicate more effectively about the treatment of depression and antidepressant side effects," their Web site's Call to Action report urges.

Of particular interest to psychologists, the survey reports that four out of five doctors say they would normally prescribe individual therapy. Yet only 32 percent of them say therapy is effective in the treatment of major depression. Perhaps communication lines between primary-care doctors and psychologists need work as well.

--J. DAW