Teaching behavioral medicine in a primary care setting

Teaching Behavioral Medicine in a Primary Care Setting An Integrated Approach Mark R. Rosenberg,

M.D., and Susan Hoffman-Wilde,

Abstract: The identification and management of psychosocial complaints is increasingly being recognized as an important function of primary care physicians. Residency programs are slowly incorporating training in behavioral medicine into their curricula. A wide variety of methods for teaching behavioral medicine have been used. This article describes a model in which behavioral medicine education is fully integrated into a primary care setting.

In recent years, behavioral medicine has assumed increasing importance in primary care training. The impetus behind this trend is the recognition that primary care physicians play a critical role in providing care of cognitive and emotional disorders. An estimated 54% of persons with diagnosable mental disorders are seen only in primary care settings [l]. Moreover, between 45% and 50% of patients in a primary care practice have a significant psychosocial problem [2]. Nonetheless, reports of misdiagnosis and inadequate treatment of psychosomatic complaints by primary care physicians frequent the medical literature [3,4]. While there is a clear need for primary care physicians to acquire skills in managing mental health issues, optimal models for the integrated teaching of medicine and behavioral science remain to be defined. A recent survey of primary care residency programs indicates that these programs vary widely in content, sequencing, and degree of integration of behavioral issues into the standard From the Primary Care Training Program, Providence Medical Center (M.R.R., f&H.-W.), and Oregon Health Sciences University (M.R.R.), Portland, Oregon. Address reprint requests to: Mark R. Rosenberg, M.D., Providence Medical Center, 4805 N.E. Glisan Street, Portland, OR 97213.

GeneralHospital Psychiatry

11, 59-62, 1989 0 1989 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010

Ph.D.

medical curriculum [5]. In an excellent overview of mental health training of primary care residents, Burns states that “the design of well-defined replicable training packages for instruction in the diof mental health agnosis and management disorders represents the next frontier for primary care/mental health educators” [6]. The core philosophy of our program is that behavioral medicine is an integral component of internal medicine, rather than a separate subspecialty. Each behavioral skill that is taught is applicable by a physician within the time and space constraints of a primary care office practice. It is recognized that primary care physicians have neither the time nor the expertise to manage the entire spectrum of psychosocial and psychiatric disorders. Ilowever, as Strain points out, “A program that concentrates on communication skills and interviewing exclusively omits essential knowledge” [7]. Our goal is to teach residents a wide range of behavioral medicine techniques, to provide them with knowledge of when each can be used effectively, and to foster the belief that these techniques fall comfortably within the purview of the primary care physician. The behavior medicine program is integrated into the curriculum of the internal medicine residency. Residents do not take a block rotation in behavior medicine. Rather, throughout the training program portions of the behavior medicine curriculum are incorporated as basic components of individual internal medicine rotations. Coordination is insured by having the internal medicine residency assume the administrative and financial responsibility for the behavior medicine program. The director of the primary care training program is

59 ISSN 0163.8343/89/$3.50

M. R. Rosenberg and S. Hoffman-Wilde

both the administrative head and one of the general internal medicine faculty of the behavior medicine team. This position is funded by departmental revenue. Behavior medicine specialists, a psychologist and a psychiatrist, are members of the primary care faculty. They organize the curricular content of the clinics and have major teaching functions. Their salaries are derived from a federally funded primary care training grant. The program emphasizes team teaching by combinations of medical and behavioral professionals. The curriculum is designed to facilitate a gradual incorporation of the principles of behavioral medicine. Basic skills are taught in the first year, and progressively more advanced skills are presented in the second and third years. Teaching formats include: discussion groups, required readings, role playing, and formal and informal patient consultations. Central to the curriculum are the behavior medicine clinics. The clinics provide the residents direct training in applying psychosocial techniques to medical conditions. The goal of this article is to describe the format and curriculum of the behavior medicine clinics. To our knowledge, this is the first description of this integrated training format in the medical literature.

Behavior Medicine Clinics There are three distinct behavior medicine clinics: a stress management clinic, a cardiovascular risk factor modification clinic, and a pain clinic. As is evident, each clinic focuses on an area of medical practice in which behavioral issues and common primary care problems interface. The resident is scheduled to attend specific behavior medicine clinics during rotations with related content. Thus, residents on psychiatry attend stress management clinic; residents on endocrinology, because of the focus on hypertension and hypercholesterolemia, attend the cardiovascular risk factor modification clinic; and residents on rheumatology attend the pain clinic. Residents attend approximately 13 3-hour sessions during each year of their residency. The Behavior Medicine Clinic experience encompasses 117 hours of direct training in behavioral medicine during the residency. The structure of each learning session is similar for all three clinics. Each clinic is facilitated by a general internist teamed with a behavior medicine specialist. The first hour is devoted to didactic teaching, group discussion, and role playing. In preparation for the didactic presentation, the residents are required to read an assigned article. Top-

ics relevant to the medical condition under focus are discussed. Emphasis is placed on the ways physicians can employ psychosocial knowledge to improve the health behavior of their patients. Through modeling and role playing, the residents are taught to use behavioral techniques appropriate to the medical condition being discussed. An example is the use of a review article by Eraker on patient compliance as a foundation for a discussion of factors influencing compliance and ways of anticipating and preventing noncompliance [8]. Then, the residents role play patient and physician to practice interventions that improve compliance. During the next 2 hours, patients are seen by the residents while faculty observe from behind a one-way mirror. In this way, the residents are able to practice new skills and simultaneously gain immediate, structured feedback. We have found it useful to have the resident conduct an initial assessment of the patient, excuse themselves for a brief discussion with faculty about treatment options, and then return to the patient to initiate treatment procedures. If, in an individual patient, a resident is unfamiliar with a needed skill, a faculty member may directly demonstrate the process with the patient either in the company of the resident or with the resident observing through the oneway mirror. By working closely with faculty, residents are encouraged to explore treatment options with which they are unfamiliar. The clinics provide a sequenced learning experience. Basic skills are learned as a PGY-1, and progressively more advanced skills are incorporated in the latter years of the residency. The stress management clinic teaches the preliminary concepts and techniques involved in recognition and treatment of psychiatric and psychosocial dysfunction. The integration of the stress management clinic into the psychiatry rotation emphasizes the importance of precise psychiatric diagnosis and the need for appropriate therapeutic interventions. Examples of first-year basic skills are listed in Table 1. These skills are introduced during the didactic sessions and refined during observed patient visits. The second-year curriculum focuses on modification of caridovascuiar risk. The didactic curriculum includes: l

l

l

Initial assessment Psychologic

of cardiovascular

impact of cardiovascular

Nonpharmacologic management (diet, exercise, alcohol, stress)

disease disease

of hypertension

Teaching Behavioral Medicine

Table 1. Behavior

Medicine

(PGY-I) Principles of effective interviewing Psychosocial assessment

Techniques of tracking behavior Teaching basic coping skills

l

l

Smoking

Functional

Identification and

Psychiatric diagnoses in chronic pain patients

Techniques of enhancing compliance Identification of health beliefs Dealing with denial Negotiating goals

of hypercholesterolemia disease in the elderly

Specific skills that are taught during this PGY-II clinic are listed in Table 1. The third-year curriculum emphasizes chronic pain/somatization disorders. Patients referred to this clinic have pain syndromes refractory to management by their primary care physician. FrequentIy, they are patients who have been “in the system” for years. They are patients who are considered “hateful” because of the frustration, anger, or distress they arouse in the treating physician [9]. Thus, they provide an opportunity for third-year residents to further refine their psychosocial skills, including the identification and treatment of specific psychiatric syndromes that are especially common in this population, e.g., depression, somatization, and borderline personality. New skills learned during the PGY-III year are listed in Table 1. Didactics for this clinic cover: Initial interview of the chronic pain patient (history, functional assessment, treatment goals) The profile of the somatization Coordination

patient

of health care services

assessment

Coordination of health care team

Hypnosis/biofeedback Negotiated prescription of pain medications Appropriate use of psychopharmacologic agents

cation with other treatment edge of disability system)

cessation

Cardiovascular

Pain Clinic (PGY-III)

Patient education

management of psychological issues associated with cardiovascular disease Prescription of nonpharmacologic therapy Progressive relaxation Exercise Diet Cognitive restructuring

Diagnosis of psychiatric disorders

Management

Skills

Cardiovascular Risk Factor Clinic (PGY-II)

Stress Management Clinic

l

Clinics-Representative

(communi-

providers,

knowl-

Nonpharmacologic methods of treatment (hypnosis, biofeedback, cognitive restructuring, increasing activity level) Efficacy of drug therapy One session in the PGY-II cardiovascular risk facclinic illustrates many of the above principles. The first hour consists of a lecture and discussion on the subject “Smoking and Cardiovascular Disease.” A brief lecture reviews epidemiologic data on the health impact of smoking and pathophysiologic abnormalities induced by tobacco use. Role-playing is then used to demonstrate effective techniques for counselling patients about smoking cessation. The last 2 hours of the clinic are spent practicing the newly learned skills with patients who are considering stopping smoking. We have found role playing an extremely useful means of consolidating the skills taught in the behavior medicine clinics. By practicing the techniques with their colleagues and with feedback from the faculty, the residents develop their skills and confidence to a sufficient level to allow effective patient interventions. Exploring the efficacy of a wide variety of behavioral techniques is encouraged. The overall plan of the behavior medicine clinics tor modification

61

M. R. Rosenberg and S. Hoffman-Wilde

is to facilitate the progressive incorporation of behavioral medicine skills over the course of the 3 years of residency. We feel that the skills that are applicable to stress management are basic psychosocial skills that can readily be assimilated by firstyear residents and can then be used as the basis for more advanced learning in the second and third years. A basic psychosocial interview, e.g., is taught in the stress management clinic in order to allow residents to collect information about a patient’s current lifestyle, social support system, activities, health behavior, and sources of stress. By the time they reach their second year, residents have practiced this type of interview sufficiently to be able to quickly assimilate details of a patient’s psychosocial status. They are thus prepared to learn techniques to gather the more specific information required for understanding the health behavior of the cardiovascular patient. This, in turn, gives them the sophistication to effectively interview chronic pain patients. Similarly, basic progressive relaxation is taught in the first year as part of a stress management program. In the second year, specific relaxation techniques that have been found to be useful in the treatment of hypertension are taught. By their third year, the residents have the knowledge and confidence to start using hypnotic techniques in the treatment of chronic pain. Similarly, the clinics are planned to facilitate the assimilation of knowledge and experience regarding mental illness. In the stress management clinic, the fundamentals of psychiatric diagnosis and treatment are emphasized. Over the next 2 years, increasing sophistication is gained. By the time the resident has participated in the pain clinic during their PGY-III year, they are expected, e.g., to reliably differentiate anxiety disorders from depression and to understand the relative merits of cognitive behavioral and pharmacologic therapy in each condition. Additionally, they have learned their own limits and are able to determine if a specific patient can effectively be treated in a primary care setting. The behavioral medicine clinics provide a forum for the integrated learning of medical and behavioral skills. This integration is the primary focus of the program. There are additional goals that we feel are extremely important and shape the content of the clinics. Patient education, the use of the physician-patient relationship as a therapeutic modality, and patient compliance are crucial elements

62

to providing longitudinal health care and are fundamental to the behavioral medicine clinics.

Conclusion Webster, in discussing the problems of teaching behavioral medicine concepts, concluded that psychosomatic medicine needs to be “woven into the overall design of the curriculum” so that “the whole patient (could) become more deeply integrated into the student’s tissues, into the deeper layers of his mind and into his everyday clinical work’ [lo]. This philosophy is reflected in the design of the behavioral medicine clinics. Content that integrates behavioral science and medicine combined with team teaching provide the residents with a forum in which to blend internal medicine with behavioral medicine. This paper was supported in part by a primary care training grant from the Department of Health and Human Services.

References 1. Regier DA, Goldberg ID, Taube CA: The de facto U.S. mental health services system. Arch Gen Psychiatry 36:685-693, 1978 2. Hoeper EW, Nycz GR, Cleary I’D, et al.: Estimated prevalence of RDC mental disorder in primary medical care. Int J Ment Health 8:6-15, 1979 3. Goldberg D: Training family physicians in mental health skills: Implications of recent research. Nat Inst Ment Health, Series DN No. 2, DHHS Pub. No. (ADM) 80-995, 1980 4. Goldberg D: Mental health priorities in a primary care setting. Ann NY Acad Sci 310:65-68, 1978 5. Strain JJ, George LK, Pincus HA, et al.: Models of mental health training for primary care physicians: A validation study. Psychosom Med 49:88-97, 1987 6. Burns BJ, Scott JE, Burke JD, Kessler LG: Mental health training of primary care residents: a review of recent literature (1974-1981). Gen Hosp Psychiatry 5:157-169, 1983 7. Strain JJ, George LK, Pincus HA, et al.: Models of mental health training for primary care physicians: a validation study. Psychosom Med 49:97, 1987 8. Eraker S, Kirscht JP, Becker MH: Understanding and improving patient compliance. Ann Intern Med 100:258-268, 1984 9. Groves JE: Taking care of the hateful patient. N Engl J Med 298:883-887, 1978 10. Webster TG: Learning processes in physician education: integrating psyche and soma. Int J Psychiatry Med 2:67-80, 1971