Journal of Rural Community Psychology, Vol. E2, No.
and Primary Care Physicians
Michael J. Zvolensky,
George H. Eifert,
Heidi A. Ludwig
SUNY at Buffalo
At present, a communication
"gap" between clinical psychologists and individual service providers may
limit the full use of psychologists’ skills. In this article, we suggest
a number of modalities for improving effective communication between clinical
psychologists and primary care physicians to help physicians better serve
persons in need of mental health care. Furthermore, enhancement of this
communication will enable collaboration between primary care providers
and clinical psychologists to achieve behavior change in persons engaging
in unhealthy disease relevant behaviors (e.g., smoking, poor dieting habits,
drinking and driving, etc.). We first overview the nature of the role primary
care physicians fulfill within the medical system, highlight the logic
behind increasing communication with physicians, and suggest several areas
where communication may be improved.
Improving Communication Between
Psychologists and Primary Care
are increasingly addressing how to maintain quality psychological care
and enhance psychology’s position as a profession within the larger health
care system. These efforts appear to be at least partially in response
to the current general cost-containment efforts in the health care system
and specific funding-related restrictions for mental health services (Eifert,
Schulte, Zvolensky, Lejuez, & Lau, 1997). With the publication of standardized
treatment lists and treatment manuals, psychologists have provided a systematic
effort to communicate that effective psychological interventions are available
for many psychological disorders (Chambless et al., 1996; Sanderson &
Woody, 1995). Although not without controversy and concerns (Zvolensky
& Eifert, 1998), such efforts are commendable because they increase
the likelihood that efficacious psychological care will be delivered and
further establish the role of clinical psychology in the mental health
care system (Barlow, 1996; Craske, 1996; Eifert, et al., 1997). In addition,
clinical psychologists have been instrumental in developing valid and reliable
assessment instruments for the entire spectrum of mental disorders. Clinical
psychologists also have led many scientific efforts to uncover environmental
and personal factors that affect the onset and maintenance of medical problems
such as heart disease, cancer, and chronic pain (Eifert, Bouman, &
Lejuez, in press) among other medical problems (see Blanchard, 1992).
The efforts of clinical
psychologists, however, are still being underutilized within the health
care system because of a lack of communication with other professional
factions in the health care arena, particularly primary care physicians.
Although clinical psychologists realize that their unique skills could
benefit primary care physicians, there have been few systematic efforts
by psychologists in this mental health care area. One reason for this apparent
lack of attention may be due to a limited understanding regarding where
efforts could be focused. As such, our aim is to briefly expand on possible
modalities whereby clinical psychologists could increase communication
and interaction with primary care physicians.
Primary care physicians
comprise a large percentage of active physicians in the United States,
and represent the fields of pediatrics, family and general practice, obstetrics
and gynecology, as well as internal medicine. In fact, there are approximately
241,329 licensed primary care physicians currently working in the health
care system, representing approximately 34% of total licensed physicians
in medicine (Randolph, Seidman, & Pasko, 1997). Primary care providers
are trained to provide comprehensive personal care on continual basis for
a variety of physical ailments across many medical fields. As such, the
main role of the primary care physician includes such tasks as assessing
and treating medical illness, communicating information about diseases,
and successfully managing physical and psychological concerns (Stoeckle,
1987). Given this job focus, primary care physicians come into contact
with a large percentage of clients who not only require medical care, but
also services for psychological problems (Sartorius et al., 1993).
make the primary care physician their first "port of call" for medical
and related services (cf. Mazonson et al., 1996). Additionally, as many
patients have a long-standing professional relationship with their primary
care physician, psychological concerns are often readily expressed to primary
care physicians. For example, patients commonly report that they experience
psychological and emotional distress while in primary care clinics and
practices (Gillin & Byerley, 1990; Goldberg & Stoudemire, 1995;
Walker, Katon, & Jemelka, 1993). Furthermore, there is a growing body
of empirical evidence suggesting that there is a high prevalence of persons
presenting in primary care settings with somatic complaints that disguise
major psychological conditions (Eifert et al., in press).
Although primary care
physicians are well-equipped to deal with medical problems, their formal
training does not involve a systematic analysis of psychological dysfunctions.
As a result, they are typically not in a position to assess and treat mental
health problems appropriately (cf. Clare & Blacker, 1984). Moreover,
because primary care physicians serve large numbers of clients per day,
they do not have the time for comprehensive assessment and treatment of
psychological conditions. Thus, a large percentage of persons with psychological
problems are undetected and therefore untreated (Stoudemire, 1996). For
instance, nearly half of the persons evidencing signs of clinical anxiety
and major depression in primary care settings may not be recognized (e.g.,
Badger et al., 1994; Ormel, et al., 1991; Sturm, & Wells, 1995). Improper
management of somatization problems also may cause additional distress
in a significant number of patients (cf. Eifert, 1992). Additionally, primary
care physicians may be unaware of mental health resources, such as clinical
psychologists, who are available for consultation and referral.
Taken together, these
problems may lead to more "revolving door" clients and unnecessarily elevated
financial cost to the health care system (cf. Simon, 1992). Because inadequate
assessment and treatment of psychological problems increases utilization
of primary care medical services, health care costs could be reduced with
prompt attention to these psychological disturbances - a phenomenon termed
cost offset. This has indeed been the case. Studies conducted with both
Medicaid (Fledler & Wright, 1989) and privately insured patients (Holder
& Blose, 1987) have demonstrated dramatic savings in medical service
utilization across patients receiving psychological intervention. Further,
Mumford, Schlesinger, and Glass (1982), in a review of 34 controlled studies,
found cardiac patients receiving psychological intervention spent approximately
two days fewer in the hospital than untreated patients, recognizing a substantial
cost offset. Unfortunately, many insurance plans do not recognize the importance
of this cost offset, particularly those in which psychological coverage
is managed by an unaffiliated insurer (Fledler & Wright, 1989).
Although these limitations
in mental health service have been addressed by the medical community in
general and psychiatry in particular, with varying degrees of success (e.g.,
Rost, Kashner, & Smith, 1990; Smith, Monson, & Ray, 1986; Smith,
Rost, & Kashner, 1995; Williams, 1984), clinical psychology has devoted
much less effort to address and work toward improving this problem. Interestingly,
while most clinical psychologists will agree with the notion that their
services could benefit primary care physicians, the lack of formal efforts
to work in this area may be due to a lack of clarity regarding where specifically
to focus attention. Thus, in the remainder of the paper, we suggest general
avenues whereby verbal, written, and direct efforts by clinical psychologists
could increase communication and professional interaction with primary
Similar to practicing clinical psychologists, practicing physicians in
the United States are required by their licensing state to maintain an
updated knowledge base of their field. For this purpose, the medical community
has established Continuing Medical Education (CME) credits reflecting the
amount of time spent in post graduate education processes. Clinical psychologists
specializing in specific mental health areas such as substance abuse, anxiety,
and related mood disorders should begin to make more of a systematic effort
to offer information regarding psychological care in the form of CME workshops
and presentations. In this way, primary care physicians can attain a valuable
overview of a specific mental health care area from a psychological perspective
(e.g., assessment of somatization-related problems). In addition, qualified
psychologists could present basic facts regarding the epidemiology, nature,
assessment, and treatment of common psychological problems (such as anxiety
and depression) that affect a patient’s physical and psychological state.
Psychologists could also alert physicians to relevant psychological literature,
assessment and treatment manuals, audio-visual resources, and lists of
professional psychologists in their geographic location who may be useful
resources for consultation.
By discussing clinically-relevant
psychological issues and by alerting physicians to empirically-based treatment
techniques such as those contained in published cognitive-behavioral treatment
manuals, clinical psychologists may increase the chance that persons who
present with mental health problems will receive the best possible care.
Furthermore, such efforts may also enhance the relationship between clinical
psychology and the medical community, particularly if psychiatrists are
also among referral and consultation resources. Additionally, there will
be the opportunity for mutual discussion and reciprocal consultation. Because
it is well established that both psychological and biological factors play
an integral role in health-related behavior and illnesses (Wallston &
Wallston, 1982; Wortman & Dunkel-Schetter, 1987), these inter-professional
communicative efforts will contribute to a more cost-efficient use of health
care services. In a related way, psychologists also may be able to offer
their services at medical conferences in the form of presentations and
symposia. By making formal efforts to increase information regarding mental
disorders available to physicians, they will be in a better position to
deal with persons who present with psychological problems. Further, such
efforts may also facilitate the recognition by physicians and other care
providers that psychologists are qualified experts to consult and a valuable
referral resource for treatment.
Because psychologists are trained as clinical scientists, they have acquired
behavioral repertoires that permit effective written and verbal communication
with various sectors of the population (cf. Phares, 1992). Clinical psychologists
can therefore offer the medical community a valuable resource in the form
of written documentation and information distribution. There have been
too few systematic efforts by psychologists to communicate the application
of research findings regarding psychological care to primary care physicians
in the medical community. For instance, clinical psychologists could write
brief articles for journals and newsletters commonly accessed by primary
care physicians (e.g., American Medical News). In this way, primary care
providers could be alerted to the most current scientifically-based understanding
of how psychological factors affect aberrant psychological and physical
conditions (e.g., McNeil, Zvolensky, Porter, Rabalais, McPherson, &
Kee, 1997). In a similar way, psychologists also may increase the effective
use of psychological care by addressing ways in which medicine and clinical
psychology can work together. Such articles may be more widely read and
accepted if the contributing authors are professionals from psychology
and medicine. Indeed, collaboration between the two factions of the medical
community will likely improve formal communication between the two fields.
Additionally, information pamphlets for specific mental disorders and clinically
relevant books for lay persons may be useful for primary care physicians
to have available in their offices. In this way, clients will have access
to psychological information regarding mental health problems and receive
empirically-based informational resources that could alert them to approach
clinical psychologists for mental health care.
and collaboration. Whereas the aforementioned avenues for increasing
communication have focused primarily on the efforts of psychologists, collaborative
efforts involving both medicine and clinical psychology also may be beneficial.
Advisory boards, for example, whose members could include professionals
from both psychology and the medical community may be a viable endeavor
to promote continual formal discussion and increase communication between
psychology and medicine. For instance, the organizations may help disseminate
cost-efficient self-report instruments developed by psychologists to primary
care physicians for use in practice. In this way, primary care physicians
can communicate via data-based information that is a more reliable informational
source compared to other forms of subjective assessments.
By alerting primary
care physicians to the availability of treatment manuals and other empirically
tested therapies developed by psychologists, physicians could begin to
recognize that efficacious psychological treatments are an effective and
cost-efficient intervention for certain psychological disorders, particularly
when compared to pharmacological agents alone. For instance, psychological
treatments for panic disorder have been shown to produce long-term reductions
in panic-related symptoms, whereas benzodiazepines result in significantly
greater relapse rates and "rebound" panic (for reviews see, Brown &
Barlow, 1992, 1995; Clum, Clum, & Surls, 1993). In this way, it may
be less likely that pharmacological agents will be viewed as the only route
to positive behavior change for problems that are either primarily psychological
or physical in nature (Blanchard & Malamood, 1996; Blanchard &
Schwartz, 1982). Advisory boards, or related formal forums, also may be
able to devise lists of licensed psychologists and psychiatrists by region
and state. These lists of licensed personnel could then be available, on
request, from the established committee for primary care physicians and
other interested physicians and psychologists. Thus, clinical psychologists
could develop "close" working relationships with physicians by working
part- or full-time in a primary care facility. For instance, a clinical
psychologist working in a primary care practice could assess and treat
persons referred for psychological disturbances by the physicians of the
practice. These efforts will streamline professional services for psychological
and physical problems in a single location, thereby creating a biopsychosocial
"team" approach to comprehensive health care that are shown to be effective
and cost-efficient (Bray & Rogers, 1995).
could assist in the training of primary care providers. For instance, all
medical residences of family medicine are required to have a behavioral
medicine component of training and the information from this experience
is later tested on board exams (Society of Teachers of Family Medicine
Behavioral Science Task Force, 1986). Clinical psychologists trained in
behavioral medicine could offer valuable information to these medical trainees
in such areas as communication with patients, and monitoring of pharmacological
intake. Furthermore, didactics combined with a practicum experience as
part of the training that exclusively focuses on behavioral medicine could
be developed. Medical trainees would therefore receive direct experience
and supervision from psychologist. In this way, both psychologists and
physicians will have a better understanding of the nature of their training
and experiences, subsequently leading to more effective future interactions
(e.g., Bray & Rogers, 1995).
Primary care physicians
come into contact with a large percentage of persons in need of psychological
care. Yet, the nature and focus of their position and training does not
permit them to devote extensive time to psychological problems. Although
clinical psychologists are a valuable resource to be used in this area,
an apparent existing information "gap" with primary care physicians seems
to perpetuate inadequate psychological services and increased health care
costs over the long term. The lack of systematic efforts by psychologists
to influence assessment and treatment-related deficiencies in primary care
settings may be due to a lack of information regarding where to work toward
positive behavior change. Our suggestions are an attempt to alert psychologists
to a number of areas where effective communication and interaction between
medical and psychological communities is possible. By focusing efforts
in these areas, psychologists may not only improve services to patients
but would also help clinical psychology, as a discipline, to advance its
position within the mental health care system.
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this article should be addressed to Michael J. Zvolensky, Department of
Psychology, West Virginia University, PO BOX 6040, Morgantown, WV 26506-6040,
Appreciation is expressed
to Barry Edelstein who offered helpful suggestions in the preparation of