Corrine Giantonio, PhD is a psychologist who has worked for Kaiser Permanente for about 20 years. During 1994, she joined a Kaiser team whose mission was to develop a plan for implementing Integrated Primary Care (IPC), and became the first Behavioral Medicine Consultant (BMC) hired by Kaiser Permanente in Northern California. Dr. Giantonio reported the medical teams there consisted of six primary care physicians, a BMC, a medical assistant for each Primary Care physician, a clinical health educator, a half-time physical therapist and about nine nurses. The mission of this team was to provide for the total medical needs of 20,000 patients.
According to Dr. Giantonio, the role of the psychologist BMC was primarily to be a consultant and educator, as such persons generally did little, if any, psychotherapy. Thus, the BMC served to assess and educate clients, and consult with the physicians and other primary care system staff members with regard to how to handle such patients.
One challenging group of patients are those suffering from panic disorders. Dr. Giantonio noted that such disorders are often overlooked. Dr. Giantonio reported that it had been found that it may take over a dozen primary care physician visits, and six or more emergency room visits before the diagnosis of Panic Disorder was made. She noted that this was both extremely expensive and very inefficient. Dr. Giantonio reported that the purpose of including the BMC on the team was to make "upstream interventions" in cases like this, to get patients the care they need earlier. She stated that after the first emergency room or doctor visit, when a heart attack had been ruled-out, a Behavioral Medicine consult would requested. She reported, "This made it possible for us to get to them much sooner."
Dr. Giantonio noted that the patients have responded positively. She said, "They like the one-stop shopping. It is much more convenient for them. They also like the integrated mind-body approach."
Dr. Giantonio discussed how the Northern California Kaiser system works. It typically begins when a primary care physician comes to suspect that a particular patient has a psychological or stress-related condition. This physician would then make a lateral referral to a BMC or health educator, and often this referral happens within the same day. Dr. Giantonio reported that speed is important here, as "Patients are physiologically motivated, not psychologically motivated. They are often initially reluctant, as they have a lack of awareness about the role of psychological factors. You have to capitalize on their physical distress to move into the biopsychosocial intervention."
Dr. Giantonio reported that when a patient comes in to see a BMC, diagnosis is the first task to complete. Once a diagnosis is made, the psychologist works to increase patient motivation and compliance, educate the remainder of the Primary Care staff about the nature of the condition, and most importantly to "leverage" the physician time.
Dr. Giantonio reported that the great majority of psychological conditions can be treated within the Primary Care system. Dr. Giantonio estimated that perhaps 80% of persons suffering from depression are treated by Primary Care physicians already. As such, it is the de facto mental health treatment in our country. She reported that the great majority of such cases could be treated in a few visits, with some education and medication. She estimated that overall, only about 9% of persons with diagnosable psychological conditions need to be referred to the psychiatrist specialists. These persons who are referred are typically those with the most serious disorders.
Dr. Giantonio noted the dominance of psychologists in the role of Behavioral Medicine Consultants. She noted that "Health psychologists are the only profession who are truly trained in this role." She noted in particular, that her role is very behavioral in nature, and very medical in orientation. In essence, performed no psychotherapy at all.
Dr. Giantonio noted that, "Health psychology training is most consistent with the job itself. It is a difficult learning curve going from a less physiologically related model." She did note that there were some social workers in the system, but they seemed to have a more difficult time making the adjustment than did the psychologists.
Dr. Giantonio noted that one of the more sensitive areas had to do with the role of psychologists in treatment when prescription medication was involved. As psychologists do not at this time have prescription privileges, the role of prescribing must rest solely on the shoulders of the Primary Care physician. However, she noted that the PCPs rely heavily on the psychologists for diagnostic information, as well as for with dealing with patient's motivation and compliance with treatment.
Dr. Giantonio noted that the average Primary Care physician is actually pretty good at recognizing and treating mild to moderate cases of depression. She stated that the PCPs have had much more difficulty though, dealing with diagnosing anxiety and panic disorders.
In contrast, Dr. Giantonio noted that there are some patients with more serious psychological disorders who are more difficult to treat. For example, she mentioned the borderline personality with depression, who might make a suicidal gesture. Dr. Giantonio reported that initially the problem was to deal with the most immediate crisis, which is often done in Primary Care. Following this, there is a referral to psychiatry for psychotherapy. Dr. Giantonio reported that Kaiser has an intensive outpatient team for dealing with severe psychiatric disorders. She reported that while this team operates in a more traditional insight-oriented psychotherapy, the Behavioral Medicine Consultants themselves provide a behaviorally-oriented service.
Dr. Giantonio reported that the goal of this whole system is to leverage the time of physicians. She said, "I save the physicians on my team 3,700 to 4,200 patient visits per year. That's a lot." She reported that one of the consequences of this was that the number of patients that physicians might see would drop from 23 to 30 per day seen at present, down to 17 to 23 per day. She reported that this would allow the physicians to have more quality time for the patients that they did see.
Dr. Giantonio also noted that there has been a differing reaction by physicians to the new model. She stated, "For the biopsychosocially oriented physician, there has been virtually no resistance. They just say, 'I'm so glad to have you here.'" In contrast, she stated that some of the older more traditional "Marcus Welby" kind of physicians have had more difficulty. She said, "I think they are having a grief reaction. They are giving up some of the closeness with their patients." Dr. Giantonio observed that with the BMC on the team, the physician might spend less time talking to the patients about their stress or emotional difficulties.
Dr. Giantonio reported that of the more traditional physicians, "They are very committed to their medical model. These doctors have had more concern about this shift, and their learning curve is steeper. They are having to learn to look at psychology from the very first visit, and this is not the way they were trained."
Dr. Giantonio reported that the outcome of these radical changes is not entirely clear, as there are many different ways to define outcome. She went on to state though that, "Nobody will debate that this is better, more comprehensive care."
Dr. Giantonio reported that one of the parts of this paradigm shift was the changing role of the psychologist in this new system. She stated, "99% of psychologists think of the psychologist as a psychotherapist. The BMC position is changing this point of view. The health psychologist has been used casually in the past, and often they are really just psychotherapists working in the medical setting. The BMC is something different. As what they can do becomes known, they will have a tremendous impact on the field."
Note * Dr. Giantonio advocates the use of the term "Behavioral Medicine Consultant" rather than the term "Behavioral Medicine Specialist
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Integrated Primary Care