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10 Articles in Volume 10, Issue #2
Introduction to a Referred Sympathetic Pain Map
Deconstructing Complex Regional Pain Syndrome
Feedback and Response Regarding ACOEM’s Practice
Psychologists as Primary Care Providers
FDA’s Risk Evaluation and Mitigation Strategies Program
Avoiding Complications From Interventional Spine Techniques
Laser Therapy in the Management of Fibromyalgia
Expanding Ellipsoidal Decompression (EED®) of the Spine
Neurotechnology, Evidence, and Ethics
Sphenopalatine Ganglion Neuralgia Diagnosis and Treatment

Psychologists as Primary Care Providers

Psychologists are trained in advanced skills that intrinsically lend themselves to the management of chronic pain and complex health care problems.

Psychological treatment for chronic pain problems is not new to the practice of pain management. Many of the major Pain Treatment Centers have a long history of employing psychologists as part of a multi-disciplinary team of professionals with a focus on helping patients to learn active behavioral pain management skills. Some of the early Pain Centers were started by psychologists and the early literature focused on the importance of behavioral approaches to pain and associated issues. However, this is rarely acknowledged in the pain literature as the majority of publications in recent years have focused on the use of medications for the treatment of pain problems. While pain medication is important in the treatment of chronic pain, it is only one aspect of the entirety of care for chronic pain patients. Further, many believe the simplistic notion that the psychologist’s role in the treatment of pain problems is to “convince” the patient that their pain problems are “all in their head” and therefore not real. Nothing could be further from the truth and reality in the care of chronic pain patients.

As psychologists, we are presently assessing how our training and skills sets us apart from other mental health providers and what is unique to the training of Doctors of Psychology. This reassessment comes at a time when the health care market is changing and calling for innovation and integration of all health care services.

Common Misconceptions of Psychologist’s Role

The perception of the psychology profession by the lay public, insurers, and other professionals, is still mistaken in the belief that psychology and psychotherapy are a part of the psychoanalytic and disease model. This allows others to define the limits of Doctors of Psychology to a narrow focus of only dealing with diagnosed mental and emotional disorders, thus blurring the distinction between psychologists and other lesser-trained mental health professions. Further, the majority of medically-trained psychiatrists has been limited and focused on the specific provision of psychotropic medications. Nevertheless, there is a critical shortage in the number and availability of psychiatrists even for managing these psychopharmacology issues.

Insurers have traditionally believed that psychological services should be limited in nature and focused on resolving crisis issues with a quick fix primarily to “close the case.” To the insurers, it is of little consequence that the allowed treatment time has not fully assisted the patient in resolving and managing the issues that brought about the crisis. It also ignores the reality of flare-up/relapse planning and longer-term management techniques. A crisis approach, while helpful in some situations, does not adequately address other than the immediate presenting issues. This results in patients returning as “frequent flyers” who are seen as over-utilizing the medical system. Further, some patients need to be managed over time because of the multiple issues they are struggling with in order to just keep functioning. Even when psychologists have provided assistance in developing active self-care skills, some patients do not have the psychological resources to manage their problems over time.

The “medicalization of psychological problems” has been indirectly, and quietly, reduced by the fact that psychologists are providing the appropriate treatments to patients who otherwise would be frequenting emergency rooms and family practice medical clinics. Doctors of Psychology are the de facto primary care psychological providers even though this has never been completely acknowledged by physicians, emergency rooms, and insurers. Outside of medical training programs, psychologists have primarily practiced in isolation and separate from medical care settings. Few are aware of the importance of the “primary psychological care practice settings” of the psychologist’s office. Integrated health care systems, such as Gunderson Lutheran Health Care System in Lacrosse, Wisconsin, have become models for reducing costs primarily because of coordinated and integrated care while, at the same time, improving health outcomes. Such integrated systems are being looked at as potential models for a National Health Care program.

Beyond this, there is a mistaken belief that the provision of psychological services is a costly venture even though there is a great deal of research evidence that points to the importance of early intervention by a psychologist. Such interventions have been shown to reduce overall health care costs, reduce costly hospitalizations, and facilitate medical providers to be better able to provide care to a patient load that involve a number of co-morbid problems, diseases and issues. Ignoring this “evidenced-based practice scientific research” goes against what health care professionals and insurers are citing as the way to reduce health care costs. It also ignores the estimates that up to 80 percent of patients presenting to primary care physicians involve strong psychological issues that would be better handled by psychologists. The actual cost of psychological treatment services is very small when compared with other health care professionals, including costs of hospitalizing patients, or the over-utilization of various diagnostic procedures. Add this to the fact that there are a rapidly decreasing number of physicians going into primary care medicine and, in the long term, the health care system is not going to know what to do with this group of complex patients.

The purpose of this article is to examine the important broad primary care role already being provided by psychologists, together with a discussion on how this role can be expanded in view of the highly specialized and extensive training of a doctoral-level psychologist. This training should be sufficient to allow for official recognition of psychologists specifically as primary care providers (PCP) in the provision of health care services and, in particular, with complex health care and chronic pain patient populations. This article can also be used as a resource to make known and provide education about Doctors of Psychology to the public, insurers, and the medical community.

“Psychologists, who are trained to be both practitioners and scientists, have a long history of working within the medical system.”

Changing Health Care Market

The American Psychological Association, under the leadership of APA President James H. Bay, PhD, has formed a summit of 150 psychologists, along with 30 invited guests, to discuss the expanding role of psychological practice in health care and in the integration of the direct provision of health care services. There is an awareness that the health care marketplace is in the middle of change and it is therefore important for psychology to reassert its lead in designing the models of care.

This is a critical issue for the profession of psychology in the present health care market. In particular is the question of what roles should psychologists undertake at these times. Though these roles have already been defined by the profession, it is critical that we increase the awareness of others about the extent of the special skills that Doctors of Psychology have been trained to do, and are already doing at present. It is important for the health care community to understand the rigorous training and education required of psychologists and how this is significantly different than the training of other mental health professionals.

This discussion on the role of psychologists as primary care providers will also cover the reasons psychologists can step into these expanding roles. Mental health problems are primary issues that present daily to physicians. Suicide is one of the leading causes of death for teens between the ages of 15 to 19 years of age. This is also true for senior citizens with high levels of major depressive disorders, substance abuse, and suicide. A significant portion of patients with serious mental illnesses end up in jails—the new “treatment centers”—and typically are those involved in domestic abuse of spouses and children, and murders. All these complex patients are seen daily in primary care settings. Further, the recent issues involving military personnel returning from a combat setting is significant. Such personnel are experiencing serious mental health issues, traumatic responding patterns, brain injuries, and significant problems in need of multiple interventions in rehabilitation.

Psychologists as Practitioners and Scientists

Psychologists, who are trained to be both practitioners and scientists, have a long history of working within the medical system. This role in both practice and science is unique among mental health professionals and helps in understanding the advanced set of skills possessed by psychologists. Few of the lay public is aware that psychologists have traditionally been part of the training and education of physicians in medical schools. They hold valuable roles not only in training medical students but they have also worked closely with them in clinics and research settings.

What few understand is that some of the important research in medicine is lead by scientists who are psychologists by training. A large component of such research is related to the study of:

  • the brain
  • disability
  • stroke and other rehabilitation issues
  • pharmacology
  • understanding and developing effective approaches to diabetic patients
  • obesity
  • pre-and post-surgical evaluations and complications
  • researching and treating chronic pain patients
  • assessing complex health care problems
  • researching and helping those pa-tients who over-utilize services
  • managing those who do not follow medical advice
  • are involved in research and various issues related to psycho-pharmacology

Research findings from medical schools and universities, though, rarely clarify the role that psychologists play in developing and conducting these studies.

Evidence-based approaches to care in medicine, psychology and the mental health field, in general, have been uniquely developed by psychologists. Most of the other mental health professionals have only been narrowly trained in just a few ways of helping patients. Psychiatry itself has continued to rely only on Freudian psychoanalytic theory and practice. In contrast, a great deal of research has been focused on how cognitive behavioral therapy techniques have been shown to be the most effective methods of intervention for the treatment of a variety of psychological conditions and medical problems. It is a more active approach to treatment that involves both the patient and Doctor of Psychology in examining alternatives, correcting misunderstandings, and focusing on an increase in the patient’s active acquisition of knowledge which can help them maintain and manage their problem issues more positively over time. Other evidence-based approaches developed by psychologists are those related to understanding divorce, and helping families stay together and in dealing with domestic violence in families, abuse of children, and understanding issues related to bullying, school violence, and more.

No other mental health profession has been as involved and focused on such research approaches and how to apply the findings to clinical situations within health care settings while working alongside physicians and other health care providers. In these settings, psychologists have served as primary care providers managing difficult and complex health care problems at the behest of physicians. Such cases require much more time and have to be managed and cared for over time.

In an effort to understand these roles played by psychologists as primary care providers within medical settings, it might be helpful to review what is provided in the clinical, scientific and academic training of psychologists that qualifies them as primary care health care providers.

Comorbid Disorders

The challenge in the present day health care field is that patients present with multiple issues, diseases and disorders that require complex interventional skills. In fact, this is being considered in the development of the new DSM-V diagnostic manual set for publication in 2012. Though we as a society would like to think that patients present with singular problems to which can be applied one type of intervention/technique, this is not representative of the actual patient population that health care providers encounter day to day. It is much like we had hoped that problems could be separated into being either psychological or physical—a reality that research has shown is not possible.

Understanding co-morbid conditions is a more realistic approach to dealing with patients. The concept that a patient should only see their physician with “one problem” for each medical appointment has missed the point that this is not possible with human beings. We are a complex organism that requires professionals to “look deeper” into the person in order to determine the best multi-disciplinary approach that should be considered in any treatment intervention. Many family physicians are aware of this problem and will quickly refer patients with co-morbid problems to Doctors of Psychology.

Disease vs. Problem-focused Solution Model

The discussion about how patients present as complex human beings also addresses the issue of understanding the medical disease model which focuses on symptom presentation and reduction of symptoms. Though medicine and insurers want us all to focus on diagnosed conditions, psychologists have long considered a broader approach to care. A problem-focused model used by psychologists is one that is focused on dealing with the complex issues presented in each case. It is looking beyond the obvious “presenting problem” to one of also understanding the “underlying problems” that may be more important to treatment interventions in these patients. Unless these underlying issues are addressed, the obvious presenting problems will continue to reoccur and manifest themselves as somatic/physical disorders. For example, there is strong evidence in the literature that early childhood sexual abuse will increase the presence of somatic disorders in patients. Many chronic pain disorders have had a history of past sexual abuse.

Integration of Psychology and Medicine

Change is coming to the medical care system for numerous reasons due to both political pressures and the factors that exist in the medical care settings. Most importantly, there is a shortage of physicians and nurses nationally—particularly in primary care Family Practice Medicine —to provide services to an expanding patient population. It is presently difficult for patients to get in to see a PCP physician sometimes for 3-4 weeks or more due to patient load and all the additional tasks expected of primary health care providers. The American Medical Association has projected that by 2025 there will be a shortage of 124,000 physicians, particularly in primary care areas. The American Academy of Family Physicians has projected the need for 3,100 to 4,200 family medicine physicians a year but only approximately 1,100 students are graduating each year from medical school. There is a growing awareness that Family Medicine is going to have to rely more on Master’s Degree Nurse Practitioners and Physician Assistants—along with other non-physician health care providers—just to deal with the demands for basic medical services. The number of physicians being trained to fill primary care roles is lagging substantially behind what will be required.

Beyond this, primary care providers are being required to do more with fewer resources and declining reimbursements. This is complicated by the fact that patients present with an increasingly complex bio-psycho-social-cultural intertwining of issues that requires a more in-depth examination than is possible in the short 5-15 minute contact that most pri-mary care physicians have with patients. In fact, there is a concern that once a universal health care plan is implemented that there will not be enough primary care physicians available to see patients need-ing care.

Family physicians are the primary professionals responsible for the writing of prescriptions for psychotropic medications which are subject to warnings of emotional instability and suicide potential when starting patients on these medications. This is also happening with other medications that are now prescribed for other medical issues. These same “warnings” note that it is important to follow a patient closely for the first few months when new prescriptions are provided to them. Physicians just do not have the time to comply with these recommendations. Many patients are prescribed psychotropic medications because it takes less time with the hope that a focus on “the symptoms of a disease process” will solve all of the patient’s problems. This is happening at a time when society is raising questions about over-prescribing a num-ber of medications.

Psychologists, on the other hand, are the ones who have always provided more expanded contacts with patients in term of time and duration. As such, psychologists have been historically exposed to observing patients who struggle with medications issues in various ways. Physicians frequently consult with psychologists and other prescribing providers about appropriate medication usage and questions about whether or not there might be better avenues for treatment that could be more helpful and have better long-term results. Medications can produce quicker results that may stabilize the situation but mask the real issues and do not necessarily have long-lasting results. A high number of patients—pre-senting to physicians with psychological, psycho-physiologic, complex health care issues, chronic pain and chronic diseases, or chronic need for medication management—could easily be referred for the initial assessment to a Doctor of Psychology if available and fully integrated into the primary care medical environment.

Doctors of Psychology and Primary Care

By integrating the psychological profession within the medical system, the gap between the mind and body can be narrowed. This integration of health care is important since research has pointed to the fact that approximately 80 percent of the patients seen by family physicians are presenting with psychological or other issues that could be equally treated by psychologists.

The traditional role of the Doctor of Psychology has been one of waiting on referrals of patients who would then call for an appointment. However, there is research that a great number of patient referrals are not always followed through by the patient. Further, patients tend not to define their issues as being something that could benefit from the services of a psychologist. This makes them further reluctant to follow up on such a referral. Patients who tend to over-utilize medical services frequently define their issues as somatic in nature and have little understanding how the mind-body connection works. Chronic pain patients can be an exhausting patient group for the primary care providers who struggle with wanting to provide curative services to a patient population that needs multiple levels of on-going care.

“...research has pointed to the fact that approximately 80 percent of the patients seen by family physicians are presenting with psychological or other issues that could be equally treated by psychologists.”

Having a Doctor of Psychology available and integrated into the same medical clinic could help to remove this stigma and result in a better coordination of care and improved outcomes. As in all medicine, the use of triage procedures could be of assistance in several ways:

1. Those patients who present to their physicians with clear psychological issues could be seen briefly by the physician and then immediately screened by a Doctor of Psychology before receiving psychiatric medication.

2. The screening psychologist could then be the one to make decisions, in coordination with the physician, about how to triage patients to various resources for more on-going help. This could include a team of psychologists in the same facility that could then be available to provide more in-depth treatment services.

3. Having several “triage Doctors of Psychology” available on a daily basis to screen patients in the primary care setting would allow for the availability of such professionals throughout the day for seeing new patients. Since they would not be taking on the direct care of patients, they would be immediately available throughout the day. Screen-ing could be accomplished in 25-30 minute segments so more patients could be seen in a day.

4. The new Health and Behavior CPT-Codes were developed with an understanding of the expanding role of psychologists directly in health care. Psychologists have developed a number of evidence-based treatments for a number of medical conditions and a second level of psychologists could be available to follow the patients that require more management and assistance to insure medical compliance and as a way of keeping health costs lower.

5. Issues associated with these groups of patients include, but are not limited to:

  • a. Diabetic issues.
  • b. Obesity issues.
  • c. Chronic pain.
  • d. Pre-surgical patients and screening of patients that would be poor candidates from a rehabilitation standpoint. Screening such patients could help such patients not see surgery as the only solution and direct them to better ways of rehabilitation and management skills. Further, many patients are not appropriate candidates psychologically for surgery and end up being “the failures” of surgical interventions—clogging the medical system even more over time.
  • e. Pain medication that needs to be managed and observed more closely to avoid dependence or abuse issues.
  • f. Chronic illness issues.
  • g. Post-stroke and heart patients that are prone to depression and with poor follow-up, rehabilitation, maintenance issues. Depression is a known risk factor for mortality/ deaths from patients with cardiac problems.
  • h. Psychological issues may not always require a quick response to prescription of medications since, in some cases, that may only prolong the patient’s dependency on long-term use of medication when other, more practical, approaches to care might prove to be more beneficial.

Psychologists see patients more extensively and over time. As a result they are better able to manage some of the issues presented by the patient since the physician cannot spend that much time with a patient and does not see them that often. It is therefore up to the psychologist to coordinate with the physician about what is being observed while the patient deals with issues, adjusts to medications, etc.

Training of Psychologists

To further understand this role of Psychologists as PCPs in health care, it is important to clarify the extensive training and expertise of Doctors of Psychology.

Many people have very little understanding that the education and training of psychologists requires completion of extended and advanced doctoral studies. The title “Doctor” does not mean “physician” as the general public tends to think. The term “Doctor” comes from the Latin meaning “teachers of teachers” or learned professional. The doctorate is the highest terminal degree in a given field and is awarded by universities to signify that the candidate has completed a rigorous educational course beyond a basic college Bachelor’s or Master’s degree that qualifie the individual to be a leader in their particular profession. The PhD degree has a long history dating back to the early training of religious professionals who became Doctors (teachers) of the Church. The first formal PhD degree was awarded in Paris in 1150AD though, in the early 19th century, it took on more meaning—especially in the United States—as being the highest academic doctoral degree awarded by universities across a broad range of fields.

In contrast, the training of the average mental health provider is at a more minimal level. This involves the completion of a basic undergraduate four-year degree program and a one- to two-year master’s degree education taught by doctoral-level professionals.

After their four-year undergraduate degree program, doctoral-level psychologists must complete an advanced graduate level professional education that requires five to seven, or more, years of a graduate psychology program. Beyond this, a supervised internship and post-doctoral Psychologist Resident for an additional year of supervised practice prior to becoming eligible for taking two different licensing exams administered by the State Board of Psychologist Examiners.

To be licensed as a psychologist, the applicant must demonstrate that they have completed clinical and scientific course work in:

  • the biological basis of psychology and brain physiology
  • ethical and legal aspects of practice
  • research and statistics used by scientists
  • psychological theories
  • intervention approaches
  • psychological learning/behavioral theories of intervention
  • the social basis of individual and group behaviors through courses in social psychology
  • extensive training and course work in diagnostic and evaluation issues
  • psychological testing and assessment
  • as well as related course work

The training is extensive and requires a commitment to a long professional course of education and training to be leaders in the behavioral health field. Further, after the completion of all the required course work, and prior to the granting of the doctoral degree (e.g., PhD, PsyD, or EdD), the psychology student is required to establish and conduct a scientific research study—including developing the written study and analyzing and reporting the findings. No other mental health profession is required to have such an extensive and all-inclusive training in the psychological sciences and practical application.

In contrast, psychiatrists must train first as a general medical physician with four years of post graduate training and education, plus a post-doctoral internship in medicine following their undergraduate training. Those who then want to specialize in psychiatry spend three more years working in a hospital where they are trained in the psychiatric aspects of care. Though psychiatrists were previously trained in doing psychotherapy, few these days have this training. As the field of pharmacology has expanded, psychiatry has focused almost exclusively on psychiatric medicines that results in their spending a short period of time, usually 15 minutes, with several patients adjusting and prescribing medications. For the majority of psychiatrists, training in psychological treatment is minimal compared to the more extensive years of training in the provision of psychotherapy, behavioral and psychological services required of doctors of psychology.

Further, there is a shortage of psychiatrists and it is frequently very difficult, and time consuming, to get patients in to see a psychiatrist. They have become the specialists in treating patients in need of psychiatric hospitalization, but they frequently rely on psychologists to provide the psychological therapy services during these hospitalizations. However, once the patient is discharged from the hospital, psychologists are the ones frequently called upon to do the follow-up treatment and provide those services that can prevent relapse of these patients.

Conclusion

Psychological interventions are more complex than is understood by the general public. Though most everyone talks about psychology, much of it is related to pop-psychology with little understanding of the complexity of the issues in the real world. What Doctors of Psychology know and do for patients is not just simply “common sense” but deals with complex patient issues that can overwhelm other practitioners. When crises happen, there is soul-searching about who could have foreseen this issue and why didn’t the patient receive the appropriate psychological assistance. Part of it is that the system has blocked much of this from happening in an open and expanded fashion. Insurers have established barriers to patients needing care by requiring pre-authorizations, limiting the number of treatment contacts, requiring frequent submittal of treatment plans, and other non-compensated mechanisms which complicate care and services. If care is expanded at all, they reduce reimbursements and they employ others with minimal training to interact with professionals so as to place subtle pressure on providers to limit care. These additional mandates on the provider are not reimbursed by the insurers even though they require large amounts of time—sometimes hours—to complete.

Psychologists have always coordinated with physicians and shared information on the management of difficult cases. However, much of it is done in the isolation of the two professions and this does not fully benefit the patient.

The physician and nursing shortage will continue well into the future. All this is happening when “baby boomers” are moving into retirement and are becoming a major population of senior citizens in need of services—in particular, care for chronic pain disorders. Only bold, future-focused measures that look to rely on the training of professionals such as psychologists—already in practice and possessing the extensive training to fill these roles—will allow the health care community to realistically deal with the new challenges in the health care marketplace.

Last updated on: December 27, 2011
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