Primary-care physicians identify about 40 percent of their patients as needing some mental health treatment, but fewer than 10 percent of these patients actually see a mental health professional, according to research in "Behavioral Health in Primary Care: A Guide for Clinical Integration" (Psychosocial Press, 1997). But as morepsychologists join forces with physicians, the number of patients who receive the help they need may grow.
Meeting that demand are primary-care psychologists, who work with other health-care professionals to offer counseling and behavioral interventions to patients in medical settings. Through such collaborations, physicians involve psychologists to further evaluate and treat patients--often on the same day and sometimes without the patients ever leaving the exam room. In addition to treating mental health disorders such as depression and anxiety, primary-care psychologists can also teach patients behavioral interventions to improve their health.
For example, Alexander Blount, EdD, professor of clinical family medicine and director of behavioral science at the University of Massachusetts Medical School, assisted a patient who visited a physician complaining of insomnia. After the patient's physician evaluated the patient for any possible medical conditions, Blount taught the patient a relaxation exercise that he could do while lying in bed.
"If I am brought in by a physician because a person can't sleep, I need to be able to teach them something that will help them sleep today," says Blount. "I have to be able to add value today, not just meet someone and say, 'I'll see you at three on Tuesday.'"
Why it's hot:
With rising health-care costs and a "broken" health-care system, there's been renewed interest in giving people the tools to maintain their health, says Benjamin F. Miller, PsyD, who this fall began a primary-care psychology postdoctoral fellowship under Blount's supervision. Often these tools take the form of behavioral interventions, such as smoking cessation and exercise programs, which psychologists are uniquely qualified to lead.
"The goal is ultimately to increase [patients'] self-efficacy and send them on their way so that they can manage their own conditions."
He recalls helping a patient develop a weight loss plan that included cutting soda out of her diet. The woman lost seven pounds from this simple act, and the sense of control she gained from the process led her to make other positive changes in her life.
The public, scientists and policy-makers are all increasingly adapting an integrated vision of the mind and body, say policy experts, and health-care practice will have to reflect that reconnection. The end result is healthier people who place less of a burden on the health-care system.
"I see primary-care psychologists as one of the answers to the health-care crisis," says Deborah Seymour, PsyD, associate professor and director of the Behavior Science in Family Medicine program at the University of Colorado Health Sciences Center. "If you look at the number of people who are high utilizers of the medical system, whose high utilization could be reduced with brief psychotherapeutic interventions, the cost savings will be tremendous in terms of decreasing use of services and more effective health care when and where it is delivered."
Large health-maintenance organizations such as Kaiser Permanente already integrate psychologists into primary care, and the federal government has been leading the practice's implementation in its medical centers, says Blount. Department of Veterans Affairs outpatient primary-care centers are all moving toward the practice of integrated primary care, as are U.S. Air Force medical centers worldwide, he adds. Specific psychological interventions have been as effective as medications for depression in several studies and psychological interventions have been shown to be part of evidence-based protocols for several chronic illnesses, including cardiovascular disease, diabetes and traumatic brain injury, according to "Primary Care Psychology," (APA, 2004). And as more research emerges on how patients benefit from integrated primary care, private-sector medical practices are getting on board.
"I get more job requests for people who are trained in this than I have people who are trained to do it," says Susan McDaniel, PhD, professor and associate chair of family medicine and a psychiatry professor at the University of Rochester Medical Center. "There are an awful lot of health-care administrators and physicians who would like to practice this way and are looking for psychologists who have the interest and training."
What you can do:
Typically, primary-care psychologists work in physicians' offices or clinics, though some work in hospitals and medical schools. In the integrated model of primary practice, psychologists work side-by-side with physicians to respond to patient needs as they arise.
"If a patient comes in with a sore throat and the next thing you know, they're crying because their mother just died, we can step in and talk to them," says Seymour. She may also handle emergencies such as people who are acutely suicidal or psychotic.
In a given day, Seymour usually sees a couple of patients in traditional 45-minute therapy sessions, then spends three or four hours examining patients with a physician and offering brief interventions for depression or anxiety. She may spend another hour leading a behavior intervention group on smoking cessation or weight loss or training family medicine residents side-by-side with psychology interns.
"There really isn't a typical day," says Seymour. "I can honestly say that in 15 years, the only boring thing I've done is chart notes."
In educational settings, primary-care psychologists train physicians to recognize and treat psychological disorders, and they can bring another perspective to the traditional doctor-patient relationship. For example, a patient with chronic pain was angry with her physician because the doctor wasn't willing to prescribe as much pain medication as the patient wanted, says Blount. A psychologist met with the two to help with the relationship and also to offer pain-management techniques to supplement medication. Psychologists often consult with patients who have trouble adhering to their medication schedule and offer behavioral and developmental screenings. This allows patients to get extra time with a health-care team, but without asking the physician to assume the entire burden, says Blount.
Salaries for primary-care psychologists are subject to wide regional variance. Those who are part of a private medical practice generally earn more than those at academic health centers, at least early in their careers, says McDaniel. That said, the salary potential for primary-care psychologists is as good as it is for any clinical psychology position, she adds.
The median salary for licensed doctoral-level clinical psychologists in 2003 was $75,000, according to the most recent APA Salary Survey.
How to get there:
Experts recommend that students who are interested in primary-care psychology get as much experience as possible in health-care settings. This may be something they have to seek outside of their graduate programs, as was the case with Megan Kersting, PsyD, program coordinator at the Riverside Urgent Behavioral Care Center in Bellingham, Mass. While in graduate school, Kersting took a part-time job with an emergency services team. She traveled to emergency rooms doing psychological evaluations on patients who presented with mental disorders.
"It was the best education I've had," she says. "It went beyond traditional schooling in that I was able to learn the nuts and bolts of both the medical and mental health industries."
For psychologists who seek internships or postdocs in primary care, the Association of Psychology Postdoctoral and Internship Centers (APPIC) website allows students to select that specialty while searching, and currently returns 89 internships and 32 postdocs. However, Miller cautions that APPIC combines sites that offer only primary-care rotations with those that offer truly integrated, more in-depth programs. He suggests that students carefully research their choices.
McDaniel encourages students to also take advantage of continuing-education opportunities. Each summer, she leads the Medical Family Therapy Institute, a weeklong intensive training program on primary-care psychology. Likewise, Blount heads a 56-hour certificate program in primary care behavioral health with the department of family medicine and community health at the University of Massachusetts Medical School (see resources box.)
McDaniel also recommends that students seek mentors who work in primary care.
"Being mentored by someone who likes doing the work and is experienced in the process helps you position yourself as a psychologist and a full partner in the health-care team," she says.
Pros and cons:
The fast pace and unpredictable workday is a draw for many primary-care psychologists who enjoy the challenge of "never knowing what's going to walk through the door," says Miller.
"I can see 10 new patients a day and never see them again, and that one intervention I have with the patient may be the only time they have an interaction with a psychologist," he adds. "Being able to represent the field is a wonderful [opportunity]."
Seymour is motivated by the opportunity to serve people who would not otherwise access mental and behavioral health services. She once saw a high-level business executive who was referred by his primary-care physician during a routine medical visit for anxiety-related chest pain. Seymour treated him for anxiety and depression.
"He came back later and said, in no uncertain terms, that he never would have sought help if it hadn't walked into his exam room, and that it changed his life," she says.
There are, however, challenges to the field. Although many physicians are grateful for psychologists' services, some are still biased against psychologists and treat them as less than equals, says McDaniel. And even in practices where physicians value their psychologist colleagues, it can be difficult for psychologists to find their niche.
"You have to be comfortable with the role that you aren't [a physician] and not try to be one of them," says Blount. "I often know the medical diagnosis as well or better than the resident I am working with, but I will restrain myself from pronouncing a diagnosis because I want people to always think of me as operating in an area in which I know what I am taking about."
The health-care reimbursement system is another challenge to primary-care psychologists, says Miller.
However, new "health and behavior codes have really opened the gate for primary-care psychology to take off," adds Seymour. "That form of reimbursement was created for primary-care psychologists and is going to allow us to exist and thrive."
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