Psychologist Raymond Folen, PhD, chief of behavioral medicine in the psychology department at Honolulu's Tripler Army Medical Center, considers the physical as well as the mental when treating patients. When patients complain of depression, for example, Folen is just as likely to order lab tests of thyroid function as he is to probe their psyches.
The clinical privileges Folen holds in his military setting enable him to perform such tasks, and this may make him somewhat unique among psychologist practitioners. But integration of psychology into primary-care medicine is on the rise. Today more than ever, psychologists are working hand-in-hand with primary-care physicians, says Folen. They're consulting together, embarking on joint research and educating each other about the two disciplines' interplay. And they're working in settings ranging from private practice to hospitals, from specialty clinics to the military.
Just as varied as the settings these psychologists work in are the paths they took to get there. Some stumbled into the field. Others got on-the-job educations. Still others took advantage of specialized training.
No matter how they got there, these psychologists see collaboration as essential to good patient care.
Most patients with mental health problems are now seen by primary-care physicians, says James Bray, PhD, co-editor of "Primary Care Psychology" (APA, 2003) and associate professor of family and community medicine at Houston's Baylor College of Medicine. "When we collaborate, patients get better continuity of care."
Research also shows that patients appreciate collaboration, he adds. And being able to get psychological help to patients in primary-care settings lessens potential stigma, he notes.
The Monitor on Psychology talked with several primary-care psychologists about their paths and current involvement:
Primary-care psychology--which Bray's book defines as a provision of health and mental health services that include prevention of disease and promotion of healthy behaviors--didn't exist when Bray received his doctorate in 1980. Now he can't imagine practicing any other way.
Always interested in behavioral medicine, Bray jumped at the chance to join Baylor's collaboration-minded faculty. Today he runs two clinics--in a private practice and in a community health center for indigent patients--where he works with primary-care physicians. Physicians refer patients for help with everything from depression and anxiety to advice on managing pain, losing weight and adhering to medical regimens.
Bray also squeezes in spur-of-the-moment consultations when physicians need help diagnosing patients or planning treatment. Or sometimes physicians just want to introduce Bray to lessen patients' concerns about seeing a psychologist.
Bray is making sure the next generation won't have to make do with informal training like he did. Instead, psychology interns, graduate students and postdocs come to Baylor for practicum experience and didactic training in primary-care psychology. Family medicine residents get didactic training about psychology and see patients alongside psychologists. Bray even trains medical school faculty, offering experiences ranging from an intensive fellowship to monthly talks.
The Mayo Clinic is "a shopping mall for medicine," says Jonathan Abramowitz, PhD, director of Mayo's obsessive-compulsive disorder and anxiety disorders program and associate professor of psychology at its medical school. And that atmosphere makes collaboration simple.
Having all specialties under one roof makes it easy to rule out physical conditions and get patients the psychological help they need, says Abramowitz, noting that Mayo's electronic record-keeping makes interdisciplinary consultations even easier.
"We've worked very hard to establish lines of communication with other specialties within Mayo so they'll send us patients," he says.
The key is education. Abramowitz is educating everyone from primary-care physicians and emergency-room staff to phlebotomists and magnetic resonance imaging technicians about anxiety.
Say a patient arrives at the emergency room complaining of a racing heart. Thanks to Abramowitz's training, staff can now distinguish panic from heart troubles. They also know how to refer patients without implying they have a potentially stigmatizing disorder.
Abramowitz's colleagues have returned the favor by educating him: To supplement his traditional psychological training and learn more about anxiety's physical causes, he developed his own on-the-job training program by "shadowing" various medical colleagues.
When Susan McDaniel, PhD, began at the University of Rochester School of Medicine and Dentistry in 1982, she taught medical students how to make referrals to area psychologists.
The only problem was psychologists weren't responding. Collaboration wasn't part of training back then, says McDaniel. "There was a 'silo' mentality--they do their thing; we'll do ours."
To solve the problem, McDaniel hired psychologists to practice on-site and established a primary-care family psychology postdoctoral fellowship. McDaniel also trains family medicine residents.
"If physicians can just grab me and introduce me to patients who need help, that goes much farther than making referrals to a faceless person across town or, worse, at a mental health clinic," says McDaniel, now the associate chair of family medicine and a professor of psychiatry and family medicine.
She notes that patients may need help managing depression, anxiety, pain or medical regimens, while physicians may need advice about handling difficult patients.
McDaniel credits her 1998 stint as an APA Practice Directorate-nominated Public Health Service Primary-Care Policy Fellow with teaching her how to promote primary-care psychology. (The program trains leaders to be advocates for improving primary care.) But she credits her medical colleagues for informally training her in actual practice.
Says McDaniel, "You can learn the medical stuff by asking collaborators to teach you and reading articles that give you the latest and greatest."
Collaborating with primary-care physicians can be more difficult in independent practice, says Christina McCann, PhD, of Rochester, N.Y. "It takes more effort when you're not in the same physical space," she says. "Instead of grabbing people in hallways, you have to play phone tag or make sure you get letters written."
But in McCann's field--child and adolescent psychology--the advantages, she says, outweigh any inconvenience.
For one, there's great overlap between psychology and pediatrics in treatment of conditions ranging from learning disabilities to cancer. A teenager who's tired, unmotivated and irritable, for example, may suffer from depression or sleep apnea.
Pediatricians can also provide critical information about families.
"Families often have long-standing relationships with primary-care physicians, so those physicians can provide a wealth of information if I'm just meeting them and trying to understand dynamics," says McCann.
Collaborating also means putting her training into practice. McCann earned a doctorate in health psychology, trained alongside primary-care residents during internship and did a two-year postdoctoral fellowship in primary-care pediatric and family psychology at the University of Rochester.
Lynn Clemow, PhD, got an introduction to medicine before she even went to graduate school: She worked in an emergency room before heading to Louisiana State University for a behavioral medicine program that let her train side-by-side with family medicine residents.
Since earning her doctorate in 1985, Clemow has contributed her psychological perspective to physicians doing research and clinical work on medical concerns as diverse as breast cancer, diabetes and heart disease.
"In primary care, you have to be ready to hit almost all the pitches that come your way," she says. "That variety is interesting and fun."
Today, Clemow is assistant professor of behavioral medicine in psychiatry and medicine at the Columbia University College of Physicians and Surgeons. She's part of a team researching behavioral interventions in cardiovascular care. One study examines the impact of psychosocial intervention and medication on post-heart attack dysphoria; another examines a stress- and anger-management intervention.
The team doesn't just do research. Located in a general medicine department, they also treat patients. Clemow's role is to help patients modify behavioral and psychosocial risk factors and to treat depression, anxiety and, she says, "garden variety stuff you see in any primary-care setting."
Instead of isolating psychologists in their offices to wait for referrals, Hawaii's Tripler Army Medical Center--where Folen works--houses psychologists right in the primary-care clinic.
That helps patients, says Folen, because it eliminates the risk they'll drop out between being referred and being seen. It also helps primary-care providers concentrate on what they do best.
"Physicians on 10-minute schedules aren't going to ask patients how they're feeling because once a patient starts crying their schedule is blown," says Folen. "When we're there, it's safe to ask."
If a physician learns that sudden stomach pain coincided with a breakup, for example, he or she can send the patient to Folen for counseling. Folen will even accompany physicians into their sessions to discuss weight loss or smoking cessation.
Thanks to his position in a federal government setting and specialized training he's had at Tripler--a 300-hour APA-model psychopharmacology course--Folen can also consider physical causes of psychic distress and prescribe some medication.
"[The program] gives trainees a heavy dose, so they can work the bio part of the biopsychosocial model," says Folen. "We want psychologists to be viewed as an essential part of the team. In many cases, we're actually running the team."
Rebecca A. Clay is a writer in Washington, D.C.
Frank, R.G., McDaniel, S.H., Bray, J.H., & Heldring, M., (Eds.). (2004). Primary care psychology. Washington, DC: American Psychological Association.
Gatchel, R.J., & Oordt, M.S. (2003). Clinical health psychology and primary care: Practical advice and clinical guidance for successful collaboration. Washington, DC: American Psychological Association.
James, L.C., & Folen, R.A., (Eds.). (in press). Primary care clinical health psychology: A model for the next frontier. Washington, DC: American Psychological Association.
The Journal of Clinical Psychology in Medical Settings is a quarterly journal published by Kluwer Academic Publishers.
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