Psychology trainees work closely with medical staff

Report extols the merits of training psychologists and physicians side-by-side.

By Bridget Murray
Monitor staff

Each day, when doctoral psychology students at a Baton Rouge hospital walk the wards, flagging patients' behavioral health problems, at their side is a resource few clinical psychology students have: a physician.

In a typical day these students might check patients for signs of depression or anxiety, help physicians distinguish between heart problems and panic disorders, or work with diabetic patients who have trouble sticking to their regimen of exercise, diet and medication.

Not only is this co-training with physicians for Louisiana State University (LSU) students unusual, but it's becoming an increasingly well-regarded training model. In fact, it's exactly the sort of training being commended in a new report, 'Interprofes-sional Health Care Services in Primary Care Settings: Implications for the Education and Training of Psychologists.'

Written by psychologists and commissioned by two federal agencies, the report says psychology needs more primary-care training with physicians and other medical staff to keep pace with marketplace trends toward interdisciplinary work and primary-care services. Such training also fits with psychology's expansion from a mental health profession to a behavioral health profession, says psychologist Jean Spruill, PhD, of the University of Alabama, who spearheaded the report with the help of a panel of advisers and APA's Education Directorate.

By working and training together, psychologists and other primary-care providers can provide better patient care, says Spruill. While physicians, nurse practitioners and physician assistants attend to physical problems, psychologists can treat the highly prevalent somatic complaints, like dizziness, pain and fatigue, seen among patients in primary care, she says.

'Without psychologists present, physicians don't recognize mental health problems like depression and anxiety at the rate that they exist in the general population,' says Spruill. 'And when physicians do recognize a problem and make a referral, the patient or client is much more likely to follow through on the referral if the psychologist is right there.'

Emphasizing the value of such collaboration, the report calls on psychology educators to add more team-oriented primary care training to their programs. To guide directors of psychology internships and doctoral programs, it lists barriers to such training, suggests ways to overcome them, and outlines the skills and knowledge students need for primary-care work. It also recommends that psychologists educate physicians and other health professionals about their primary-care skills, lobby politicians for primary-care funding and grants, and develop curricula for psychologists' primary-care training.

Need for training

In pushing for more primary-care training, psychologists should note that primary-care teamwork also cuts costs, says psychologist James Bray, PhD, an adviser on the report and a member of APA's Primary Care Task Force. Working together, health providers less often duplicate one another's services or run expensive tests, says Bray.

If a psychologist finds, for example, that an anxiety disorder is causing a patient's heart palpitations, that might save the physician from sending her for a cardiac catheterization, says Bray, who runs a primary-care training program for psychology doctoral students at the Baylor College of Medicine's family practice center in Houston.

In fact, government attention to the value of interdisciplinary work in primary care was the impetus for the report. In 1997 the Senate Appropriations Committee recommended that disciplines such as psychology, nursing, psychiatry and social work with define their roles in, and training for, primary care-particularly as it's evolving under managed care.

Barriers to primary care

Despite the increasing attention to primary care, programs that provide related training are the exception in psychology. Few of the 43 doctoral programs in clinical health psychology emphasize primary care. And of the more than 500 internship training programs in psychology, only 2 percent offer a major rotation in primary care.

A number of barriers cited in the report help explain the scarcity of such training. Among the most daunting obstacles is a tendency for fields such as psychology, psychiatry, social work and medicine to guard their own turf instead of collaborating, says Spruill. As a result, they sometimes misunderstand one another's approaches, and, in psychology's case at least, lack professionals who can provide interdisciplinary training.

Another barrier is the mistaken notion that physical and mental problems are unrelated, says Bray. Reflecting such thinking, he says, are mental health carve-outs-reimbursement setups that are separate and different from the rest of patients' medical coverage and that are featured in many managed-care plans.

Programs often struggle to secure reimbursement for services provided by their psychology trainees. However, programs can find alternate ways to fund their trainees, says LSU's Phil Brantley, PhD, who notes that the state of Louisiana pays for provider services at the public hospital where his students work.

A new set of skills

According to the report, grants are another way to secure funds for interdisciplinary primary-care training-thus breaking down barriers by familiarizing providers with one another.

For example, grants have funded trainees and enabled psychologist Sheri Pruitt, PhD, to develop an integrated program in behavioral medicine and primary care at the Veterans Administration San Diego Healthcare System, and psychologist Andrew Turner, PhD, of the University of Wyoming, to set up WYO HealthCARE, an interdisciplinary training program for psychologists, social workers, nurse practitioners and physicians.

Together, students from these different disciplines attend semester-long seminars, then spend the summer traveling to Wyoming's most rural reaches and serving the needy.

To guide those providing such training, the report outlines the knowledge and skills needed in clinical, teaching, administrative and teaching roles in primary care. Among the most basic skills recommended are:

o Ability to develop treatment plans for collaborative care.

o Understanding of the medical culture and the language of physicians.

o Willingness to function in different roles, such as team leader, consultant or staff member, depending on patients' needs.

o Familiarity with the bases and medical management of commonly seen problems in primary care, such as depression, substance abuse, diabetes and hypertension.

Such skills will likely be featured in a model curricular guide for primary care being drafted by a joint task force of several APA divisions, chaired by psychologist Susan McDaniel, PhD, a professor of psychiatry and family medicine at the University of Rochester School of Medicine and Dentistry.

Pruitt hopes the guide spurs more psychology programs to cover these skills in their curricula.

'Our students are asking for this kind of training, and we need to provide it.'

APA's Education Directorate has mailed the report to directors of psychology internships and doctoral programs, and anyone can access it through the APA Education Directorate web site (www.apa.org/ed/).





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