Teaching integrated behavioral health in a primary care clerkship

Abstract

Background: Most behavioral health care is actually delivered by primary care physicians. Primary care clerkship students have a unique opportunity to learn about behavioral health and the integrated care model. Integrated care is an effective multidisciplinary model for delivering high quality care.

Purpose: Evaluate the efficacy of a brief curriculum in increasing students’ knowledge regarding common behavioral health issues.

Methods: We designed an interactive, 90-minute curriculum to introduce students to the unique model of integrated care, and to build skills in addressing a number of common behavioral health issues. Each problem is presented from both the medical and behavioral perspective. We evaluated this intervention with a pre- and post-clerkship test assessing knowledge regarding behavioral health care.

Results: There was significant improvement on the overall score and on seven of eight individual questions.

Conclusions: This curriculum is an effective intervention for introducing integrated care and increasing knowledge of several common behavioral problems.

Introduction

Primary care clerkships provide an ideal experience for medical students to learn about both behavioral health and integrated care in primary care. Although students at our institution are required to take a six-week psychiatry rotation, it is important to recognize that most mental health care in the United States is actually delivered by primary care physicians, not psychiatrists (Regier et al. 1993). The annual prevalence for mental health and addictive disorders is high, affecting 28.1% of the population (Regier et al. 1993). In a given year, 5.9% of the population will seek care for these issues from mental health specialists, such as psychiatrists or psychologists, while 6.4% will seek care from general medical physicians (Regier et al. 1993). In addition, 60–80% of patient visits to primary care have psychosocial drivers (Cummings et al. 1997). Consequently, it is imperative for family physicians to be well trained, confident and skillful in addressing behavioral health issues.

Within the United States and internationally, integrated care can be conceptualized in many ways. At our institution, primary care physicians work collaboratively with mental health specialists in a model of integrated care (Strosahl 1996). Integrated care is an innovative system in which behavioral health consultants (psychologists by training) practice side by side with family physicians, co-managing the same patient population. The consultants are trained in a model of care called the behavioral health consultation model (Strosahl 1998; Robinson & Reiter 2007). This model trains the behavioral health consultant to be a ‘generalist’ primary care provider, similar to the generalist family practitioner physicians. Visits are brief (ten to thirty minutes), follow-ups are minimal (0–2 on average), the focus is on improving functioning, and immediate feedback is given to the physician following the consult. While there is extensive collaboration between the physician and the behavioral health consultant, it is clear the physician directs the patient's care. Referrals are made to mental health specialists at local clinics or to other community resources (e.g. self-help groups) when more extensive services are needed. Medical students rotating through our clinic are exposed to behavioral health issues and often train with the behavioral health consultants. Because only a small percentage of students have access to this particular clinical practice, we designed this curriculum to expose all third year clerkship students to behavioral health and the integrated care model.

Table

Practice points

Integrated care is an innovative approach for better delivering effective primary care. A primary care clerkship is an important avenue for teaching students about brief interventions for several common behavioral health problems. Collaborative teaching by medical and behavioral health professionals creates an opportunity to demonstrate the integration of services that can occur in the clinical setting.

In order to promote greater knowledge and confidence in addressing the most common mental health issues seen by primary care physicians, we developed a curriculum for our clerkship students. A family physician and psychologist co-present the material, reflecting the integrated care model of interdisciplinary management of patients. The behavioral health issues covered include anxiety, depression, obesity, low sexual desire in women, and irritable bowel syndrome. Each problem is presented from both the medical and psychological perspective.

This manuscript is designed to discuss whether this unique model of interdisciplinary education is effective in increasing student knowledge regarding common behavioral health issues. The authors propose using this format to introduce students to the concept of integrated care. We describe the key concepts in the curriculum as well as its evaluation.

Methods

Curriculum description

We begin by offering three questions that serve as objectives for the students to consider throughout the 90 minute course:

1. What problems do family physicians face in addressing behavioral health issues?

2. Why is it important that we learn about behavioral approaches to patient care?

3. What are some physician friendly interventions for common behavioral health problems in primary care?

To address the first question, we give a short introduction emphasizing the prevalence of mental health disorders in primary care and the frequency with which family physicians address these problems. Forty-one percent of patients with a mental health disorder receive treatment from any branch of the healthcare system, and 50% of those receive treatment only from their primary care doctor (Wang et al. 2005). Sixty-seven percent of psychiatric scripts are dispensed in primary care (Narrow et al. 1993). In addition, non-psychiatric behavioral issues, such as weight loss, smoking cessation, improving adherence, and adjustment to chronic illness, are universally confronted by primary care physicians.

The integrated care model is described and compared with other models of care that students will likely encounter, such as the traditional model (referral out for mental health care) and the co-located model in which a mental health professional performs standard psychotherapy on location. Factors that can be integrated include location, clinical care, administration/operations, clinical flow, screening, billing, charting, and collaboration.

It is emphasized that integrated care allows for improved biopsychosocial integration with conditions that have physical and psychosocial components (e.g. obesity, chronic pain, diabetes). We underline that the skills and techniques reviewed are adoptable to any general practice, not just those with mental health care specialists. Due to the busy nature of primary care settings, our intention is to educate the students on how they can teach empirically sound strategies to patients in the briefest amount of time possible (30 seconds to two minutes.) We explain to the students that one of the roles of the family practitioner is to be a ‘behavioral health provider.’

We selected the following five behavioral health issues because they are among the most common reasons patients go to see their primary care doctor (McDaniel et al. 2004). See Appendix A for a list of handouts on these topics that we give to students.

Anxiety

The first behavioral health topic we address is anxiety, which is one of the most common mental health condition that can present in primary care (Stanley & Kunik 2005). We stress the importance of making an accurate diagnosis and identifying which anxiety disorder is present, particularly differentiating generalized anxiety disorder, panic disorder, social phobia, and post traumatic stress disorder. We emphasize the medical differential for anxiety symptoms and discuss the extremely high prevalence of co-morbid disorders, including depression and addictions (Wittchen et al. 1994). Once students have correctly identified the diagnosis we proceed with a discussion of medical treatment options. The use of benzodiazepines is a central discussion point, regarding issues of addiction and abuse (Pary et al. 2003).

We emphasize the role of brief cognitive behavioral strategies (self-monitoring, keeping thought records), education about anxiety (fight or flight response, normal vs abnormal anxiety, and how to educate patients on when to see their doctor), the hallmark anxiety characteristic of ‘avoidance,’ and the treatment of skill-building with gradual exposure and response prevention. We discuss the differentiation of relaxation training and mindfulness meditation as treatments for certain anxiety disorders. For example, mindfulness but not relaxation training is indicated for panic disorder due to the ‘observing’ stance engendered by mindfulness and the counterproductive avoidance element of using relaxation with panic (Shearer & Gordon 2006). Students then participate in a guided exercise during which they first experience relaxation training, and then switch to an experience of mindfulness meditation. We created a short script that students can use that is short enough for physicians and students to use at a busy primary care setting (see Appendix B). The student participation in this experience provides a new way of learning the material and helps break the typical monotony of student as listener and teacher as speaker, building in a student as participator approach.

Depression

Students are generally well trained in the diagnosis and treatment of depression, often prior to their primary care rotation. Therefore, we discuss two topics that are likely new educational components: the use of a two-question depression screen and behavioral techniques for treatment. The depression screen is a validated screening instrument that can be used in the busiest practices as a routine, quick, and efficient assessment technique (Kroenke et al. 2003). We have found that students are very receptive to a tool that is time saving and evidence based. When we review options for behavioral treatment of depression, we emphasize behavioral activation as a treatment strategy which recent data show to be effective as antidepressant medication and cognitive-behavior therapy (Dimidjian et al. 2006); it is particularly useful for patients preferring a strictly behavioral approach (Hopko et al. 2003).This treatment systematically increases exposure to positive activities, such as exercise or social contacts (Lejuez et al. 2001).

Low sexual desire in women

Low libido is a surprisingly common complaint among female patients in primary care. We teach the students that the prevalence of this complaint varies with age, with approximately 10% of women below age 49 reporting low desire; this increases to 22% in ages 50–65 years and 47% of those above age 66 (Lewis et al. 2004). After explaining this data, we emphasize the need to rule out medical causes, such as depression, hypothyroidism, pain disorders,and SSRI use. Next, we review the role of hormone replacement therapy in treating low female sexual desire. The evidence for both estrogen and testosterone therapy is presented, including analysis of risks and the need for close monitoring.

Behavioral approaches may be the safest and most effective therapy for this complaint although research is limited. The important role of intimacy as a prerequisite for sexual desire is emphasized (Basson 2001). We educate the students on interventions that increase intimacy, which include frequent nonsexual touching and building in more emotional closeness. We review additional tools, such as keeping a desire log and ‘simmering,’ in which the patient engages in brief but frequent periods of conscious sexual fantasy.

Obesity

We briefly review the epidemiology of obesity in our culture, and discuss various diet and exercise regimens. Patients will often become frustrated by unsuccessful weight loss efforts and inquire about medications or surgery for weight loss. Sibutramine is associated with modest weight loss at one year, with limited evidence for maintenance of weight loss at two years (Arterburn et al. 2004). Orlistat is associated with even more modest weight loss at one year, and major side effects (Davidson et al. 1999). Bariatric surgery produces dramatic weight loss and long term maintenance of weight loss (Lyznicki et al. 2001). We emphasize the significant behavioral changes required to maintain weight loss after bariatric surgery, such as eating very small meals and avoiding calorie dense foods.

After explaining these data, we discuss behavioral approaches to weight loss with a significant emphasis on assessing the patient's readiness to make a lifestyle change, and meeting the patient where they’re at (Prochaska & DiClemente 1983; Miller & Rollnick 2002). We explain that keeping a food diary as self-monitoring is the best predictor of successful weight loss as it greatly increases awareness of eating habits (Boutelle & Kirschenbaum 1998).

Irritable bowel syndrome (IBS)

IBS is a common problem in primary care, affecting about 10 to 15% of the U.S. population (Mertz 2003). Treatment of IBS generally occurs in the primary care setting. Therefore, students should be well versed in pharmacologic and behavioral treatments. First, medical treatments are reviewed, including the role of dietary modification. We then move on to hypnotherapy as a possible treatment option. Most medical students are not familiar with hypnotherapy as a treatment for IBS. Although hypnotherapy for IBS has been well described in several published, placebo-controlled trials since 1984 (Whorwell et al. 1984) with treatment success rates typically ranging from 80–95%, it is often regarded by medical students as a new or unproven therapy. Recent publications confirm that hypnotherapy may be effective in reducing global IBS symptoms and improving quality of life (Gonsalkorale et al. 2002) and may produce benefits lasting up to five years (Gonsalkorale et al. 2003). Teaching patients a home treatment version of scripted hypnosis induction may be equally effective (Palsson et al. 2006). We explain that there are standardized protocols, ranging from 7–12 visits, for teaching patients to control and manage their IBS symptoms, and how we are adapting these as a three-session treatment option in our integrated care program. The treatment protocol can be delivered by either the behavioral health consultant or the physician.

Evaluation of the Educational Intervention

This curriculum was delivered to third year medical students during their family medicine clerkship. During the academic year a total of 84 students, approximately 12–15 per rotation, participated in the family medicine clerkship. To assess the efficacy of this intervention, students completed pre- and post-clerkship assessments regarding their knowledge of common behavioral health issues in primary care (see Appendix C for assessment questions). The Wilcoxon Signed Rank test was used to assess statistical significance between pre- and post-clerkship test scores using SPSS release 11.0.1. All tests were two-tailed with p < 0.05 regarded as significant.

Results

The results of our pre- and post-clerkship assessments have shown marked gains in answering questions correctly. There was a statistically significant improvement in total number of questions answered correctly. At the beginning of the clerkship, students answered an average of 2.5 questions out of 8 correctly. At the end of the four-week clerkship, students answered 5.4 out of 8 questions correctly p < 0.001 (see Figure 1).

Figure 1. Pre-and post-clerkship knowledge, N = 84.

Figure 2 shows the results for individual questions. With the exception of question six (percentage of follow through to see a counselor), all other questions had a statistically significant increase in percentage of students answering correctly with p ≤ 0.001. This reflects the initial low knowledge regarding behavioral health issues, as well as improvements during the seminar and clerkship. The most dramatic improvement in student knowledge scores was in the area of treatment of IBS. Students’ scores went from 1% correct to 42% correct. Clearly, medical hypnosis is a therapeutic approach which is not commonly taught, despite evidenced based research supporting its efficacy (Whorwell et al. 1984; Gonsalkorale et al. 2002, 2003; Palsson et al. 2006). Equally impressive were the gains in the questions regarding the two-question depression screen (from 34% to 83% answering correctly), the most effective treatment for panic disorder (from 7% to 56% answering correctly) and the best predictor of weight loss (from 24% to 70% correct).

Figure 2. Percent of students answering correctly, by question, N = 84.

Discussion

While the field of behavioral medicine is not new to primary care, this model of integrated care (brief visits, co-management, shared medical records) is not yet widely practiced in the U.S. Many students are familiar with the co-located model, as is practiced in most residencies, but very few have been exposed to the burgeoning field of integrated care. It is the authors’ experience that while students have limited interest in traditional psychiatry, they are interested in learning practical ways to deliver behavioral health services within primary care.

Few medical students are exposed to such behavioral interventions as mindfulness meditation and medical hypnosis. Students are initially resistant to these ideas, but most are impressed by research regarding efficacy and potential for application in the primary care setting. Other common issues, such as low libido in women, may initially make some students uncomfortable, but students do appreciate the opportunity to learn effective brief interventions. Many students report this is the first time they have had the opportunity to discuss this topic. Although depression and anxiety are well addressed in other clerkships, behavioral interventions are frequently not emphasized, despite the fact that patients often prefer a behavioral approach. This gives students a wider variety of interventions to better suit their patients’ needs. Similarly, although students are exposed to medical management of obesity and to the stages of change model, most students are not well-versed with behavioral interventions such as self-monitoring.

The study was limited by a design model assessing the same group with pre-and post-clerkship knowledge level. A stronger study design would be to randomize students to the integrated care curriculum (intervention group) versus usual primary care training (control group), and then compare knowledge levels. However, LCME requirements clearly prohibit the use of different curricula for students of the same clerkship course.

Another limitation was the short amount of time to address several important behavioral health issues. The curriculum was only an introduction to these topics and instruction in basic management, as would be instituted in a primary care office. As in other areas of primary care, further training is accrued from various rotations, including the specialized clerkships.

In summary, this 90-minute curriculum introduces primary care clerkship students to concepts in primary care behavioral health which were previously unfamiliar. This initial study suggests that this intervention is effective for introducing the concept of integrated care and helping students gain knowledge on some of the most common behavioral health issues physicians face.

Future directions

In order to further engage students, we are incorporating video clips to illustrate patient presentations of each major behavioral issue covered. Future presentations may include other problems that are amenable to brief behavioral interventions, such as chronic pain, smoking cessation, insomnia, diabetes management, and chronic stress.

Future evaluations will include items assessing students’ skills and attitudes towards behavioral health, as well as knowledge base.

Follow-up at one or two years post-clerkship would assess whether knowledge continues to be retained. To maintain student interest and skill level in both behavioral health and integrated care, other departments will need to incorporate these skills in both their didactic and clinical experiences. Finally, while the behavioral interventions in most integrated care practices will be delivered by behavioral health consultants, it is critical for physicians to develop ‘core competencies’ with behavioral interventions for primary care patients (Strosahl 2005).

Acknowledgements

Sidney R. Baer, Jr. Foundation grant, partially supported Dr. Niemiec's salary and Dr. Margolis’ salary.

The Manuscript was presented at the 2006 STFM Behavioral Science Meeting, 9/16/06, Chicago.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Additional information

Notes on contributors

Kimberly Zoberi

KIMBERLY ZOBERI, MD, is an assistant professor in the Department of Community and Family Medicine at Saint Louis University School of Medicine. She teaches in the required family medicine clerkship and practices in a group setting. Her areas of interest include women's health and behavioral medicine.

Ryan M. Niemiec

RYAN M. NIEMIEC, PsyD, is a clinical psychologist at Saint Louis Behavioral Medicine Institute. He is an assistant professor in the Department of Community and Family Medicine at Saint Louis University School of Medicine. His areas of interest include integrated care and health psychology.

Ronald B. Margolis

RONALD B. MARGOLIS, PhD, is CEO of Saint Louis Behavioral Medicine Institute. He is a professor in the Department of Community and Family Medicine at Saint Louis University School of Medicine. His areas of interest include the business aspects of integrated care and behavioral medicine.

Appendix A

Handouts

To facilitate improved application of learning, we provide multiple handouts for students to take with them. Some handouts are educational for the student on a particular topic and others are to be given to patients. Students are encouraged to keep a folder for use to collect handouts they get from their courses; in feedback, we have heard this has proved to be an invaluable resource for them while they are training and to give to patients when they have their own practice. The following are the typical handouts we include and who the target receiver is and the intended effect:

• Food diary (for weight management patients; self-monitoring food/drink and triggers)

• Thought Records (for depressed and anxious patients; self-guided monitoring of anxious and depressive thoughts/emotions and patterns)

• The 3 C's Technique (for depressed and anxious patients; self-guided managing of thoughts associated with anxiety and depression)

• Mindfulness Practice (for the patient or student, a diagram of the focus and how it helps)

• Overview of the research on hypnosis for irritable bowel syndrome (for the student, four page list of abstracts describing the empirical basis of clinical hypnosis specifically for IBS).

• Presentation slides (for the student, to serve as a reference for their future work).

Appendix B

Relaxation/Mindfulness scripts

Relaxation

Let's begin this experience by purposely bringing our bodies and minds into a state of relaxation. Please close your eyes and allow yourself to breathe slowly, deeply, and comfortably. Feel the slow passing of air through your nostrils. Feel your diaphragm muscle extending and pushing out your abdomen as you breathe deeply. Relax the muscles of your shoulders, your neck, and your face. Feel your body continue to relax as you sink deeper into your seat. Feel the tension fading away with each breath that you take. Now imagine that with each in-breath you are breathing in peace, comfort, and calmness–you’re taking this into your body and mind with each breath … and with each breath out you are letting go of tension, stress, and discomfort.

Mindfulness

Now let's switch to an experience of mindfulness. To be mindful is to be aware of your internal and external experience without judgment, and with a sense of openness, curiosity, and acceptance. Remember, the purpose of mindfulness is awareness, not relaxation. Please open your eyes and begin to notice your present moment experience. Bring your conscious attention to your heart beating and without judging it, just notice it. Notice your hands: do they feel warm or cold, heavy or light, moist or dry, tense, tingling, or numb? Allow whatever sensations you notice to be there without having to change them. Bring your awareness to how you feel emotionally right now: do you feel sad, happy, afraid, or frustrated? Breathe along with the feeling without trying to make it go away, instead just ‘be’ with it.

Appendix C

Pre-and post-clerkship assessment questions

Correct answers to each question are highlighted in bold.

1. What is the LEAST likely cause of low libido in pre-menopausal women?

   • (marital stress, SSRI use, birth control use, low testosterone)

2. What is the most efficacious treatment for IBS?

   • (diet, medication, exercise, hypnosis)

3. Which of the following is an element of the 2-question depression screen?

   • (insomnia, low self-esteem, anhedonia, suicidality)

4. What percentage of antidepressants are prescribed by primary care physicians?

   • (10%, 25%, 50%, 80%)

5. What medical treatment is LEAST indicated for Generalized Anxiety Disorder?

   • (benzodiazepines, cognitive behavioral therapy, relaxation training, SSRIs)

6. What percentage of patients will follow through with a recommendation to see a counselor outside the practice?

   • (10%, 30%, 50%, 75%)

7. Which of the following treatments is most effective in treating Panic Disorder?

   • (relaxation training, mindfulness meditation, deep breathing, benzodiazepines)

8. What is the best predictor of weight loss?

  (starting weight, keeping a food diary, type of diet followed, following an exercise plan)