Many of your patients really are sick .

Most psychologists are taught to ask questions about a new patient's physical health as part of any assessment. It is important to do much more than a cursory review of physical functioning, especially if the patient is referred from or within a primary care setting. This process involves careful interviewing of the patient and family about relevant health events and current functioning, with particular emphasis on the patient's subjective view of his or her illness. It also involves active collaboration with the patient's primary care physician or nurse practitioner. Although careful health assessment is critical, communication among providers is equally important to avoid unnecessary duplication of effort. In fact, one of the most helpful aspects of practicing in a medical setting is the opportunity for the psychologist to get immediate consultation from the physician concerning the likely impact of medical problems on psychological functioning. For example, information from lung function tests or about staging or prognosis of cancer may be essential in planning psychological services for some patients ( Haley, 1996 ). Close collaboration with a physician, particularly when the focus of treatment is on a physical symptom, can also minimize malpractice risks related to accusations of practicing medicine without a license ( Belar & Deardorff, 1995 ).

Psychologists may be accustomed to helping patients develop confidence and trust in their feelings. However, psychologists may spend so much time focused on thoughts and emotions that they overlook the importance of physical experience. Physical functioning affects individual and family dynamics and vice versa, much more than is acknowledged in most theories of psychotherapy ( McDaniel et al., 1992 ). Although we psychologists often accuse physicians of somatic fixation (overfocusing on the physical and ignoring the psychosocial), we must guard against psychosocial fixation (overfocusing on the psychological experience and avoiding the somatic; McDaniel, Campbell, & Seaburn, 1990 ). For example, it is reasonable to assume that with a man who had a heart attack 2 years ago and now presents with marital difficulties, a detailed medical history is likely to be relevant to the assessment of a relationship conflict. Detailed information about the prognosis of a given illness and its likely effects on the patient's daily functioning should be integrated into the psychologist's treatment plan.

Beyond the realities of any physical limitations or disabilities, illness or accidents serve as wake-up calls to the human psyche. They are reminders of our mortality and, as such, affect a patient and family's functioning and defensive structure. Some people respond to threatened loss by strengthening their emotional and practical resolve: They order their priorities, increase intimacy with those they care about, and do the most with the time they have left. Others go underground with their psychic response to physical events, presenting with child behavior problems, marital problems, work problems, depression, or anxiety. A thorough assessment may reveal these problems to be directly linked to their own or a loved one's illness, disability, or death ( McDaniel et al., 1992 ). For that reason, psychologists need to obtain a thorough physical history for all patients and their close family members, regardless of presenting complaint.

No more Lone Ranger-Join the posse.

Collaboration with other health care providers requires an integrated, biopsychosocial model of patient care ( McDaniel et al., 1992 ). Together with the rest of the health care team, psychologists can provide patients with comprehensive services that avoid artificial distinctions between mental and physical health. Successful collaboration involves the following: developing a collegial relationship with the referring provider, eliciting his or her explanation about the patient's problems, clarifying any questions, and securing his or her support for the psychological treatment.

Joint sessions with the physician or nurse can be particularly useful for initial sessions, particularly for patients who are reluctant regarding referral (especially somatizing patients), for patients who experience a dramatic change in functioning, and for patients for whom the psychological and the physical complications are unusually complex. These sessions can take place either at the physician's or the psychologist's office, depending on each professional's schedule and accessibility. The psychologist should be prepared to spend some of the time scheduled for a session traveling back and forth to the physician's office if the patient would benefit. Even a brief, 15-minute session with both mental and physical health care providers together can be a very powerful experience for patients struggling with health problems.

Arguably the most important trend in the current health care marketplace is increasing levels of integration. The traditional lines separating hospitals, providers, and insurers have begun to blur. There is increasing consumer demand for so-called one-stop shopping in health care services. Only by integrating various aspects of health care can a seamless, coordinated continuum of health care be provided. Organized delivery systems may encompass primary care providers, specialists, ambulatory care centers, homehealth care agencies, and so on. These systems may be owned by or associated with insurance products, grow out of established health maintenance organizations, or be based on provider service networks.

Signposts of this increasing integration include "downsizing of acute care capacity, consolidation of programs and services, development of cross-institutional clinical service lines . . . expansion of the number of primary care physicians, and growth in both primary care and multidisciplinary group practices" ( Shortell, Gillies, & Anderson, 1994 , p. 62). All of these changes are clearly characterized by an increased emphasis on primary care. Furthermore, these patterns of service delivery are based largely on multidisciplinary teams.

These changes provide important opportunities for us psychologists, but in order to participate, many of us need to make significant changes in the way we practice our profession. In particular, participation in the health care system will require the ability to work closely in more flexible ways with other specialists. Participation within primary care delivery-whether as a specialty consultant or as a full team member-depends on developing strong working alliances with other professionals. However, our training has often not equipped us to become team players, given the solo practitioner competitive models of many academic faculties and clinical practices ( Belar, 1995 ).

A number of variables facilitate the development of collaborative interdisciplinary relationships ( Tsukuda, 1990 ). One of the most basic is a working knowledge of other professions' methods of training and their approach to problem conceptualization and inquiry; also important is a respect for their areas of expertise.

Psychologists can take practical and incremental steps toward developing team-based patterns of practice. An early step might be to develop group practices of psychologists. Such groups help render the theoretical diversity within our profession an advantage, rather than a liability, and can relieve psychologists of feeling overwhelmed and burdened by the sense of having to know everything. Another step is for groups to establish informal linkages with primary care physicians. These linkages strengthen referral bases, educate us psychologists about the needs for our services that exist on the front lines of health care, and prepare us to participate in integrated health care delivery systems. These linkages can eventually lead to the development of multidisciplinary primary care practices with psychologists as integral members.

Assessment and enhancement of provider-patient communication is one of the most important roles for the psychologist serving on a health care delivery team. Patients and families learn about the patient's illness and its management from the health care provider. However, numerous studies have documented patients' poor understanding of their medical condition and its treatment (e.g., Johnson et al., 1982 ; Page, Verstraete, Robb, & Etzwiler, 1981 ). In order to be effective, the psychologists must learn about the patient's illness, including what the physician believes the patient and family have been told.

The psychologist's discussion with the patient and family about the illness and its management will often uncover numerous discrepancies between the patient's and the medical provider's perceptions. The psychologist should review these discrepancies with the medical members of the team and devise a plan to correct the miscommunication. The psychologist may meet with the patient and the medical provider to ensure a clearer understanding of patient needs and provider expectations. The psychologist may devise both tools that become part of the clinic's standard practice for assessing patient knowledge and improved methods for ensuring accurate understanding of medical provider recommendations at each clinic visit (e.g., easy-to-understand, written, take-home health care information). In other words, the psychologist can serve as a consultant to a health care team about an individual patient, or the psychologist can serve as a consultant to the health care clinic or system in which the health care team operates. Both are important roles.

Psychotherapy ain't enough.

Psychologists practicing in clinical settings have traditionally thought of themselves as mental health practitioners, with psychological testing and psychotherapy as their major tools of the trade. This model is now considered a limited and limiting formulary. Political and marketplace variables have shaped a new health care environment over the last several years. The opportunities to apply psychology's fund of knowledge to social and public health problems like violence, drug and alcohol abuse, family dysfunction, and community breakdown are increasingly evident to psychologists and policymakers alike. Cutting-edge programs designed to prevent or address these problems are collaborative and systemic in nature. The key words of the emerging health care system, especially at the primary care level, are integration, prevention, outreach, and community-oriented.

In response, psychologists must broaden their roles and contributions to both the private sector and public health care systems. Psychologists must be more visible in the community. If mental health practitioners remain sequestered in private offices while providing traditional services, they risk oblivion. In short, psychotherapy ain't enough.

Psychologists in primary health care settings can and do provide a variety of services and play multiple roles ( Bray, 1996 ; Resnick & Rozensky, 1996 ). These services and roles include clinical and consultation services, education, research, personal and program development, community outreach, policy making, and political advocacy. Capitated reimbursement systems will increasingly provide incentives to primary care practitioners to collaborate with psychologists demonstrating generalist skills and personal and professional flexibility. The range of services psychologists can provide should include the following:

Although other members of the health care team typically take the lead in educating the patient and family about a disease, the psychologist can prove to be an important partner in the design, administration, and evaluation of educational programs. Psychologists are well aware of both the motivational and disruptive role anxiety can have on learning. They understand the importance of shaping behavior and reinforcing successive approximations to new skill acquisition. They appreciate the limits a child's cognitive developmental level will place on what the child learns about an illness and how much responsibility for health care is reasonable to expect from a child and how much should be shared by other family members. Psychologists view the patient in a social context of family, work, and friends and quickly appreciate both the assets and liabilities this social context can present. Once again, the psychologist's role in addressing these issues is valuable and important at both the individual patient level and the health care system level.

Psychologists are experts at assessing and facilitating change in human behavior. Behavior is critical to patient care, whether the illness is acute or chronic and whether the intervention is an invasive medical procedure or an instruction to change lifestyle habits. The treatment of acute illness often requires behavioral interventions for some specified period of time (e.g., taking daily medication for an infection; drinking extra fluids for a cold; using crutches for a broken leg). Chronic diseases typically demand complex, lifelong behavioral interventions (e.g., administering daily insulin injections and testing blood glucose for patients with insulin dependent diabetes mellitus; quitting smoking, reducing fat and salt intake, and increasing exercise for patients with heart disease; avoiding triggers and selecting appropriate medications for patients with asthma). Even invasive medical procedures conducted in an outpatient clinic or in a hospital require a number of patient cooperative behaviors (e.g., venipuncture; placement of a catheter or a nasogastric tube; mammogram procedures). The psychologist can serve as the expert who not only assesses patient behavior, but also designs strategies to enhance cooperative or healthy behavior. This expertise can be offered at the individual level or at the broader level of system design.

Medical illness is associated with more than physical distress; it often generates considerable emotional distress as well ( Kroenke & Mangelsdorff, 1989 ). Disease diagnosis and invasive medical procedures are typically associated with considerable anxiety in both the patient and family. Many individuals actually avoid health care (e.g., refuse screening tests; avoid going to the dentist) because of psychological or medically related fears. Others feel guilty, blaming themselves for the onset of the disease. Others may become depressed as they face physical limitations or a shortened life span. Still others become angry at providers' "incompetence" or at a family member's unwillingness to appropriately care for his or her disease. Once again, the psychologist has a special appreciation for the affect generated by physical disease or dysfunction within the patient and within the family unit. The psychologist can (a) assess the type and extent of this affect and how it affects the patient's health care and (b) devise methods to reduce stress and provide more successful coping strategies.

Patients don't know why they are seeing you unless you tell them.

Most primary care patients with psychosocial problems initially present to their physician with physical symptomatology rather than psychological or behavioral symptoms. Even in cases where patients are aware of psychological problems, such as anxiety, depression, or marital conflict, they frequently want their primary care physician to treat the problem ( Bray & Rogers, 1997 ). Thus, the referring physician and treating psychologist need to consider this context when working together.

A patient may also be reluctant to consult with a psychologist because of negative stereotypes of mental health providers, concerns that the physician is covertly indicating that the patient is "crazy," or fears about talking to a new provider. In some cases, physicians may feel frustrated with their treatment of the patient and the patient may misinterpret that frustration, resulting in feelings of rejection or a sense that the physician does not believe that the symptoms are real. Particularly when patients have physical complaints, the physician and psychologist need to avoid the message that the physical symptoms are not real health problems and are just in the patient's head. A useful therapeutic approach is to have the physician indicate that he or she needs help from a specialist but that the physician will still provide other needed medical care (i.e., the physician is not dumping the patient). An alternative is for the physician to indicate that the problem the patient is currently experiencing is beyond the physician's expertise and thus requires specialty care ( Bray & Rogers, 1997 ).

The psychologist needs to be aware of this context when accepting referrals from a primary care provider ( McDaniel et al., 1992 ). In addition, it is important for the psychologist to negotiate with the primary care provider how he or she (the psychologist) intends to collaborate and what kind of information the provider expects from the psychologist about the patient ( Bray & Rogers, 1997 ). Most primary care physicians expect some type of communication about their patients from consulting doctors ( Rakel, 1995 ). The amount and frequency of such information varies considerably among providers, although a typical format involves a paragraph or two describing the diagnosis, formulation, and treatment recommendations. However, if no follow-up information is provided, primary care physicians are likely to stop making referrals to these providers.

During the first meeting with patients, it is important to clarify their understanding about why their physician referred them to the psychologist. Misconceptions or concerns can be addressed at this time, and reassurance can be offered that the psychologist will be working with their physician to provide optimal treatment for their problems. It is also important to clarify confidentiality issues so that the patient understands and is in agreement with the psychologist and physician sharing information ( Bray & Rogers, 1995 ).

A joint meeting with the patient, physician, and psychologist (usually in the physician's office) may be a means to deal with patients who are resistant to referral ( Bray & Rogers, 1997 ; Dym & Berman, 1986 ). Such meetings have the added benefit of allowing the psychologist to model for the physician the type of rationale for referral that will be well-received by patients in medical settings.

Hurry up.

There are important differences in practice styles between physicians and psychologists ( Bray & Rogers, 1997 ). In a typical outpatient primary care setting, a physician sees at least one patient every 15 minutes. In a similar manner, when patients visit a primary care physician, they are generally presenting with problems for which they seek immediate and concrete solutions. When seeking a consultation from a psychologist or other provider, "physicians are likely to expect clear statements of observed facts and specific intervention recommendations" ( Pace, Chaney, Mullins, & Olson, 1995 , p. 125). Most outpatient psychologists, on the other hand, see individual clients for 45 to 50 minutes. For psychologists who use interpersonal, psychodynamic, or family systems orientations, work with an individual may be viewed as an experiential and personal undertaking focused more on methods and processes than concrete solutions ( Pace et al., 1995 ).

From these premises, areas of culture clash can be anticipated. One of the most striking has to do with the relationship between work and time. Within medical settings, the pace is far more rapid and results are expected far more quickly. Psychologists are likely to experience the perception of time within these settings to be markedly different from that of more familiar environments. Psychologists may find themselves feeling caught by expectations to produce unreasonable outcomes within insufficient periods of time.

There are several basic strategies for managing some of the potential time-related problems that are inherent in physician-psychologist collaborations in primary care settings. Most important is a shift to a problem-focused approach to consultation-at least in one's initial encounters with a patient and early in the development of a relationship with a particular physician. Thus, it is extremely important to focus and clarify the referral question ( Belar & Deardorff, 1995 ). Physicians who are not used to working with psychologists may not be good at this and may make only a general request for consultation or at best write a note such as "Evaluate for possible depression." It may be necessary to talk further with the physician to find out exactly what is expected from the consultation, what specific information is needed, and what working hypotheses are to be confirmed or disconfirmed. It is also important to understand how this information may be relevant for the physician's treatment plan for the patient.

Such clarification provides the framework for a focused consultation that can more quickly provide the answers the physician is seeking. This discussion can also reveal any unreasonable expectations on the physician's part, such as getting a lifelong alcohol abuser to stop drinking so that he or she can have a liver transplant the following month. Psychologists may initially be uncomfortable with providing what may seem like a limited and incomplete assessment. However, recommendations for further exploration of additional areas or for expanded psychological treatments can easily be made in the consultation report. In a similar manner, reports need to be completed quickly-if possible on the day the patient was seen. This style may be different for psychologists used to spending hours laboring over assessment reports.

It is also vital for the psychologist to be aware of and respect the demands on the physician's time. Thus, the psychologist should try to focus his or her own requests for information and background. The physician is likely to be more willing to invest time in discussing patients at length as it becomes clear that this is useful. For example, McDaniel (1995) described conducting occasional conjoint patient visits with a physician colleague. Such conjoint visits are obviously an intensive use of provider time. Opportunities for such innovative and more intensive forms of work are more likely to become available once a strong working alliance is established.

On a similar topic, although many psychologists have been trained to write lengthy and elegant reports, such notes will not be read in medical settings. A standard rule of thumb is that anything longer than a page will not be read. In instances where a longer note is necessary to provide details and documentation, a summary section of about a paragraph will be necessary to summarize the most critical information.

In medical settings, case presentations are also typically brief and to the point. The medical team will not be interested in a 15-minute speculative report; rather, the essential findings, along with specific recommendations, are required.

Don't give any tests you can't carry in a briefcase.

Psychological assessment can represent one of the unique contributions psychologists make in medical settings ( Belar & Deardorff, 1995 ). Physicians and other professionals in health care settings value objective information on patients' depression, cognition, or daily functioning. In fact, over time, physicians may come to view psychological assessment as equivalent to laboratory tests; they may become comfortable in citing the patient's depression score or score on a cognitive screening test as an indication of severity and improvement over time.

In addition to selecting instruments with ideal psychometric features, psychologists should also consider the following variables when selecting assessment instruments for use in medical settings: the acceptability to medical patients, the acceptability to physicians and other health care providers, and the time required for the assessment. Patients in medical settings are likely to be particularly averse to assessments that lack face validity and that strongly emphasize severe psychopathology. Some instruments may also not be appropriate because they are too lengthy, especially if the patient's stamina is poor. In medical settings, patients may be seen with more severe sensory or physical impairments, including deafness, blindness, and paralysis. Some patients may also be too weak or impaired to complete certain tests. In addition, psychologists should be careful that instruments have been appropriately normed and validated on populations seen in primary care settings, such as older adults. Specific suggestions for assessment instruments useful with medical populations have been reviewed elsewhere ( Belar & Deardorff, 1995 ), and adaptations necessary for assessment of older adults with medical problems or sensory impairments are reviewed in several recent sources ( Haley, 1996 ; Kaszniak, 1996 ). Use of brief screening instruments by primary care providers can also enhance the identification of patients who might benefit from referral to the psychologist ( Higgins, 1994 ).

Stand up for what you know, and ask about what you don't know.

Psychologists and primary care physicians have important complementary areas of expertise. The psychologist who begins work in a primary care setting must demonstrate his or her psychological expertise to other health care providers. This expertise should include the ability to offer decisive opinions about behavioral issues in patient care; the psychologist should also be an expert on research findings concerning psychological aspects of health. Particularly in clinical training settings, physicians are accustomed to challenging each other and citing recent research related to patient care; psychologists have much to offer in this type of exchange. In many ways, this ability for a well-informed psychologist to communicate as a peer with the physician is one of the unique contributions psychologists, as opposed to social workers and counselors, make to health care settings. Psychologists should communicate their knowledge while avoiding unnecessary jargon-a courtesy that will likely be returned by experts in biomedicine. Psychologists should not allow themselves to be bullied by the occasional overly brusque physician who may not be accustomed to having a PhD, PsyD, or EdD as a colleague. In most cases, collaboration that is based on mutual respect can be developed.

The psychologist should also demonstrate a willingness to be trained and educated on topics beyond his or her expertise. Physicians do not generally expect psychologists to understand the complexities of medical conditions and the terminology involved. However, if physicians are convinced that the psychologist has something to offer, they are generally willing to explain. Comfort and familiarity with a new setting and vocabulary comes fairly quickly in the context of such two-way relationships.

Although psychologists bring with them generic training in psychological assessment and treatment, they will be most successful in a medical care setting if they can translate their knowledge and expertise into the particular health care setting they are working in. In some cases, this may mean developing an in-depth knowledge about a particular disease or population, whereas in other settings, a broad variety of medical problems are seen across the life cycle. In either case, the psychologist will need to acquire necessary medical information from other members of the health care team and will need to adapt psychological expertise to the special needs and concerns of medically ill or physically compromised patients. It would be a mistake to assume that training and experience in a traditional mental health setting can be immediately and directly translated to the larger medical health care context without appropriate training, supervision, or consultation related to health psychology and medical family psychology. Successful integration into the health care team will require an honest appraisal by the psychologist of the limitations of prior experience and training as well as a willingness to acquire new knowledge and skills and to learn to practice in a context that has different norms than mental health settings. The psychologist who is comfortable admitting ignorance and asking questions will quickly acquire the information needed through conversations, workshops on collaboration, and reading. The psychologist who wishes to appear medically sophisticated and is too embarrassed to ask for translations of medical jargon runs the risk of confusing the patient further and can never be a truly effective member of the health care team.

No specialists allowed-be prepared for anything and everything.

Psychologists working in primary care settings need to be generalists ( Bray, 1996 ). Psychologists can expect to see a tremendous variety of medical and psychological problems that have a broad range of impact and frequently do not fit Diagnostic and Statistical Manual of Mental Disorders criteria. Although it is common for psychologists who are specialists in health psychology or behavioral medicine to focus on a particular medical disorder, such as the psychological aspects of diabetes or obesity, or a particular aspect of psychological practice, such as biofeedback or clinical neuropsychology (e.g., see Blanchard, 1994 ), in many primary care settings such specialization is not an advantage. Patients present with a wide variety of medical problems or with multiple medical disorders. Even patients seen in settings that focus on a specific medical problem, such as diabetes or Alzheimer's disease, often have several complex medical and psychosocial problems. Thus, psychologists in primary care settings must remain aware of advances in a variety of areas and be competent to conduct initial screenings for the full range of psychosocial disorders. Physicians in primary care settings will expect the psychologist to be an expert on the full range of psychosocial and mental disorders. Patients with schizophrenia or with bipolar disorder are commonly seen in primary care settings, and these conditions are often managed by the primary care physician. Thus, the psychologist will commonly be asked to provide a consultation relevant to the adequacy of psychological-psychiatric care delivered by another mental health practitioner.

In medical settings, patients can present with numerous physical and psychological symptoms that psychologists are unprepared for by academic training or life experiences. The diversity of presenting problems in primary care is often overwhelming. Psychologists lacking experience in primary care settings may be poorly prepared for these encounters; thus, experience and training in medical settings are essential.

For example, in medical settings, psychologists will be exposed to medical problems that are commonly discussed or viewed only in the medical office. Patients with amputations, sores, rashes, or coughs will routinely offer these for inspection to the psychologist. Psychologists may also encounter patients who are severely or terminally ill and will have the experience of working with patients who die during the course of treatment. In supervising psychology interns in medical settings, these stressful events are commonly a focus of supervision, and psychologists who are redirecting their practices toward medical populations must expect that the transition may be stressful.

Refer out when necessary.

Whether the psychologist works in a primary care setting seeing a variety of patient problems or in a specialty clinic seeing a particular type of patient, the need to refer will rapidly become apparent. Working as a member of a health care team typically demands relatively rapid consultation about a large number of patients. Rarely does the psychologist have the luxury to do comprehensive psychological assessments that demand multiple test procedures and extensive personal interviews. Rather, the psychologist sees the patient, often for less than an hour, and makes a recommendation. Just as the physician may elect to refer the patient for additional diagnostic studies, the psychologist may elect to refer the patient for more extensive psychological evaluation. For example, the psychologist may be concerned about the cognitive capability of the patient and may refer the patient for a full intellectual assessment. Or the psychologist may be concerned that the patient may have a significant thought or affective disorder and may refer the patient for a more complete personality assessment. Most patients will not need this type of extensive evaluation, but the psychologist must be prepared to evaluate relatively quickly and triage those patients that do.

In a similar manner, the psychologist member of a health care team does not have the time or the training to provide the appropriate psychological treatment for all patients that come to his or her attention. Once again, the psychologist must be prepared to assess relatively quickly what type of intervention the patient needs and identify an appropriate referral to provide that care. Just as the physician may refer a patient to a specialist for a particular medical procedure, the psychologist may refer the patient to a behavioral specialist with expertise in a particular type of care. For example, the overweight, newly diagnosed patient with diabetes may be referred to a psychologist who specializes in weight reduction programs. The patient with a substance abuse problem may be referred to a specialist in the treatment of drug or alcohol abuse. The family of an asthmatic adolescent who is being nonadherent with medical care as a way of expressing angry independence may be referred to a family therapist. In most cases, the psychologist makes an assessment as to whether the psychosocial problems presented can be rather rapidly addressed within the context of the clinic environment over the course of two or three sessions. These cases may be treated within the confines of the health care clinic, whereas more complex cases, which require either more extensive intervention or specialized intervention outside the training and experience of the psychologist, are typically referred elsewhere.

However, the psychologist provides an important link between the psychological specialist to whom the patient is referred and the heath care team. This link occurs at the point of referral when the referring psychologist informs the specialist as to the reasons for the referral. It also occurs later when the patient returns to the health care clinic for routine care and the reasons for the referral are reviewed and any progress is noted. If warranted, additional contact with the specialist to whom the patient was referred may be initiated. At the time of the referral and on subsequent occasions when additional communication with the specialist may occur, issues of patient consent, assent, and confidentiality must be addressed.