Journal of Rural Community Psychology

Journal of Rural Community Psychology, Vol. E2, No. 1, 1999

Improving Communication Between Clinical Psychologists and Primary Care Physicians Michael J. Zvolensky, George H. Eifert, Kevin Larkin, West Virginia University Heidi A. Ludwig SUNY at Buffalo   Abstract
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 Clinical
Psychologists and Primary Care Physicians

Clinical psychologists 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

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).

Individuals typically 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 care providers.

Verbal presentations.   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.

Written presentations. 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.

Direct interaction 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).

Psychologists also 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).

Summary

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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Author Note

Correspondence concerning this article should be addressed to Michael J. Zvolensky, Department of Psychology, West Virginia University, PO BOX 6040, Morgantown, WV 26506-6040, USA.

Appreciation is expressed to Barry Edelstein who offered helpful suggestions in the preparation of this manuscript.