Beyond shadowing residents and providing feedback, psychology fellows accept a wide range of patients for intense, brief, solution-focused psychological care, following a "warm hand-off" from a resident or faculty member in the examining room, said Dr. Vogel, director of behavioral science and psychology at the medical center. Such cases then become the focus of multidisciplinary education and case planning sessions.
In one recent example, a psychology fellow noticed the disengagement of a young mother of a newborn with special needs, something a resident had overlooked in the room.
"She was really quite depressed, and her needs were so paramount she couldn’t attend to the needs of the crying child," said Dr. Vogel.
Beyond assessing the mother for postpartum depression and providing her care, the psychology fellow was able to use the example as a "teaching moment" for the primary care resident comanaging the case.
"We’ve found that case-based teaching works much better than a lecture," said Dr. Vogel.
Bridging the Disciplinary Divide
To be sure, a cultural divide separates medicine and psychology, and each joint training program must find ways to bridge differences in terminology, style, and the structural delivery of care.
Psychologists, especially, are realizing that their softly lit cultural model of long-term therapy in 50-minute sessions may not conform to the increasingly recognized psychosocial needs of large numbers of primary care patients.
"We have to prepare people for the way the world is going to be, not the way the world is now," Dr. Nancy B. Ruddy, a psychologist with Mountainside Family Medicine Residency Program in Verona, N.J., said at a session on integrated training during the annual meeting of the American Psychological Association.
The Genesys model, featured at a different session at the meeting, may be a snapshot of how that world may look.
An evolving focus on mental health in primary care may find psychologists as regular collaborators in community practice, but with a focus that is more immediate, time limited, and problem focused than the care they have historically provided.
"Some psychologists have strong reservations about moving in this direction – and I consider those concerns reasonable, as it is a pretty significant alternative to the traditional model of the psychologist as a provider of individual psychotherapy," said Dr. Robert McGrath, director of a certificate program in integrated primary care in the psychology department at Fairleigh Dickinson University in Teaneck, N.Y.
Others, he said, "are increasingly excited about increasing opportunities for integration."
Family medicine residency programs may also be taking note.
At Genesys, a recent survey of faculty members and primary care residents found a substantial increase in overall satisfaction 2 years into the integrated care program.
On a scale of 0-5, they considered the integrated approach helpful to patients (mean rating, 4.1) and even more helpful to providers (mean rating 4.2), according to pilot data presented at the APA’s annual meeting.
The range of diagnoses referred for psychological care vastly increased, and scores declined on standardized mental health scales administered to 247 patients over 16 months. On the Patient Health Questionnaire (PHQ-9), mean scores declined from 15 to 8.9, while mean scores on the GAD (Generalized Anxiety Disorder scale) declined from 13 to 9.4, Melissa Gray, Ph.D., a graduate of the fellowship program, reported at the meeting.
Who Pays for Integrated Care?
One significant challenge for residency programs remains how to pay for integrated care, especially in a down economy and an era of shrinking reimbursements for even the most traditional types of primary care.
Financial realities are sometimes at odds with a widespread philosophical commitment to whole-person care, and a recent position paper from the American Academy of Family Physicians emphasizes the obligation of every physician to access mental health care for their patients, "whatever the mechanism."
So far, psychologists appear to be taking the lead in developing funding mechanisms for joint training in the primary care specialties.
The Genesys program "took the big jump" to become accredited as a postdoctoral training site by the American Psychological Association, a laborious, expensive, and time-consuming process. As a result, the program can partially cover its costs by billing the Centers for Medicare and Medicaid for some behavioral health services.
"Are we making money? No. Breaking even? Not quite," said Dr. Vogel. But, he added, "People see the value added to the program, and the faculty has become our biggest supporter."
What had long been a healthy partnership, he noted, has become a "great marriage" with the cultivation of an integrated behavioral care model that dovetails with objectives of the National Committee on Quality Assurance and the American Academy of Family Physicians.