Anna Doubeni, MD, MPH, associate professor of clinical family medicine in Family Medicine and Community Health at the Perelman School of Medicine at the University of Pennsylvania, shares with us her thoughts on the emerging educational issues for training primary care providers in integrated behavioral health (IBH), the most promising innovations, and tips for new IBH educational programs
Q: I’d like to start by having you talk about what you think some of the emerging educational issues are for training primary care providers in integrated behavioral health.
ANNA: I think one of the challenges that residents in primary care face, particularly in family medicine, is that we see a lot of patients with mental health needs that are inadequately treated and they end up continuing to come back to us for their primary health care, but also to meet their mental health needs. And yet, we don’t do a great job training residents in the diagnosis, treatment, and triaging of mental health disorders. We often find that we’re working really hard to get patients into mental health care and there are a lot of barriers to that, so our patients end up without proper education and not being able to get the care they really need. That, in the long term, has a huge impact on their medical healthcare, their inability to access healthcare in the right place at the right time, and their inability to follow through on their own self-care management. One thing that’s emerging now is understanding how much a primary care resident needs to learn in the field of mental health.
Q: When you think about trying to design educational programs, can you talk more about how the field can determine the “right amount” of mental health education residents need?
ANNA: I think that’s a really challenging question that isn’t defined clearly in either the literature or in practice. We understand there’s a need for interdisciplinary learning and a need for physicians to learn how to provide care in settings where there are other disciplines they’re interfacing with regularly - including social workers, psychologists, and behaviorists. But how much do residents need to learn about diagnosing mental health disorders and when they should refer to a psychiatrist rather than continuing treatment on their own? That is still an area that isn’t completely defined. I think what ends up driving it now and will end up driving it in the future is the capacity for patients to actually be seen by psychiatrists for medication management and treatment of mental health disorders. Some of that is geographically dependent, and some of that is dependent on the patient’s own willingness to seek care from a different provider at a different facility.
Q: Would you share some of your thoughts on the current landscape of primary care as anchored within larger health systems, and how that may or may not be influencing how we train residents to care for behavioral health needs?
ANNA: There are a lot of things that drive patients to seek care for mental health needs in a primary care practice. Some of it is that mental health is still stigmatized in a lot of ways. Patients don’t want to go to someplace that’s perceived as a place for ‘crazy people’. The other is how systems work: as an example, we still have practices where if a patient misses three appointments, they’re terminated. A lot of our patients in primary care, they’ll miss 3 appointments for all sorts of reasons that have to do with their ability for self-care management and follow through, but they know that they can still come see us. I think one of the biggest educational needs for residents is understanding why patients are or aren’t able to seek mental health care from a psychiatrist or specialist or in a place other than where they’re currently seeking care. I think the other big learning need is actually around how to collaborate with community-based psychiatrists and how to collaborate with other providers if they’re not co-located. We need to know if that’s ideally where a patient should be getting their care and how much responsibility we, as primary care physicians, have to actually counsel, advise, and work with patients to get their care from non co-located community-based psychiatrists.
Q: Looking around the country are there examples of innovative training programs you’d like to highlight and talk a little bit about why they are promising to you?
ANNA: I think the primary model for the integration of behavioral health services in a residency-based setting is working with behaviorists. Some programs have developed their primary care post-doctoral training programs as a way to do integrated behavioral health and co-train primary care physicians with psychologists. That’s putting psychologists who’re used to working in primary care settings into those settings and training residents in how to work with them. They do a lot of dual interviews with the psychologists and residents together with patients, and it’s actually a great way of modeling integrated behavioral health. The way behavioral health is done in a primary care setting is very different from the way it’s done in a psychologist’s office. Our setting at the University of Pennsylvania is very different: we integrate and collaborate with psychiatry by having them supervise a licensed social work counselor who’s embedded into our practice, but that’s very clinically driven. On the educational end, we work with a psychiatrist and we’ve developed a way of actually doing consultative services for patients with mental health needs for whom providers in the practice will continue to provide mental health care, but who need some additional support or understanding from a psychiatrist. At the same time, that provides an educational experience for residents in family medicine to learn about and develop diagnostic and treatment skills as well as knowledge and skills about collaborating with psychiatrists. It’s basically looking at diagnosis, treatment, and triaging and understanding when we really need to refer to ongoing psychiatric care elsewhere and how to get a patient there. We’ve been able to develop, over time, the behavioral health piece with the licensed social work counselor as a key component of the educational experience.
Q: What are some of the challenges we face in training residents within complex health systems where the behavioral health providers might not be co-located with the primary care practice, and some innovative ways to overcome that?
ANNA: I think there are a couple different issues. Part of it is just access itself, and understanding how departments of psychiatry work if you’re in an academic institution or in a health system, and how you get patients in. I think that’s one thing that does require some educational training. The other is how do you communicate? It’s one thing to help a patient gain access, but it’s another to be able to communicate with another provider in a way that actually improves patient outcomes. I think in our current age of communication we’re really in a rapid transition around communication as a society, and there are differences, sometimes generational, of how communication is perceived. I think particularly in the mental health world there’s a significant lack of communication between disciplines of primary care and behavioral health. That lack of communication leads often to a sense that the work can be done in parallel, meaning there’s less of an incentive to communicate. I feel strongly that this is not the best approach to achieve optimum outcomes for patients, so I think it’s crucial to teach and model great communication between disciplines, particularly when it comes to mental care.
Q: Are there any other challenges you’d like to highlight, as an educator, playing a role in shaping residents’ capacity to work in integrated settings?
ANNA: I think this goes not just for behavioral health but for working in all disciplines that lie outside the tradition of medicine. The concept that work can be done in parallel is fairly common. We see that in public health vs medical health, we see it in population health vs individual health, care management vs primary care. I think the biggest challenge, not limited to residents, is helping people understand what connected, coordinated, collaborative care truly means, and how beneficial that can be for a patient. I think it’s also really important for people of all disciplines to understand what is really beneficial about a therapeutic alliance. I think a lot of us, particularly as physicians, feel very strongly that the therapeutic relationship for a patient is with us. I definitely feel that having a therapeutic relationship with a primary provider is of significant benefit for a patient, but we are not the only owners of therapeutic relationships for those patients within healthcare systems. Understanding how we share and collaborate within those therapeutic relationships is a challenge, but it is something that can be taught, and it’s an exciting concept for the future and the development of healthcare infrastructures that understand these concepts.
Q: Imagine yourself speaking to your colleagues around the country who do not yet have any integrated behavioral health training for their residents. Any insights you’d like to share with them on how to start such programming or how to develop and implement curricula or care models?
ANNA: I think one is defining the problem. Is the problem that you need to teach integrated behavioral health? Or is it that your patients need integrated behavioral health because they’re lacking access or because they’re lacking mental health care? How many patients would benefit? How many residents need training? What are your resources? When I approach any sort of clinical program development, as well as curriculum development, I think about the who, what, where, when, and how. Who are your stakeholders? Who needs to learn what? Who is going to benefit from the program? Why are you doing this? What are you actually going to teach? Are you teaching communication or diagnosis and treatment? Are you teaching interdisciplinary learning? Where are these things already happening? If it’s an integrated model, you’ll hope that those things will happen in the setting of primary healthcare delivery for the residents. Then, their educational experience will also be in the place where they provide care for patients. Another question is when? Is this a longitudinal experience? That’s a question we struggled with. Is each resident assigned a patient or five patients, and are the patients followed throughout the course of 3 years in an integrated model? For us, we changed the model as we learned what worked, and ended up linking it to their behavioral health rotation, and had them spend a half day a week within our practice. How is this going to happen? How is the implementation going to go? All your previous questions will go into that.
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