Fieldnotes from the Interface
by Scott Meit, Psy.D. and Van Yasek, Ph.D.
Learning Objectives
- Learn how psychologists are integrated into the medical setting.
- Learn important tactics to bridge the gap between psychology and medicine.
The transition from a primarily applied
psychological setting to a medical setting can be difficult, especially
for psychologists not skilled in the interface. Combining more than
25 years of experience in the fields of psychology and medicine, Scott
Meit, Psy.D. and Van Yasek, Ph.D. (medical anthropology) draw on their
direct experience and offer anthropological fieldnotes for psychologists
working in the interface of psychology and medicine.*
SEEING
Physicians and psychologists see the
world/patient through a different lens; neither is implicitly correct
or incorrect.
TIME
The time urgency of physicians can lead
to bad practices – the infamous hallway consult or elevator talk. You
think that you will never do it. Don’t!
EXPECTATIONS
Remember, physicians and psychologists
often differ widely regarding expectations of time, paradigm of care,
conceptualizations and models, language and jargon, and view of the
parameters of the doctor-patient relationship.
CHARTING
Be mindful of how you chart. Some psychologists
entirely integrate psychological notes with physician notes, some have
a special section in the medical record and others keep separate charts.
Be sure your patient and your board know how you chart, that your rationale
is well-defined, and that your patient’s consent is informed.
SUPER SLEUTH MINDSET
Adopt the mindset of a super sleuth.
In your clinical evaluation, first investigate the medical record. Particularly
in medical residencies where continuity is often broken every three
years, the mystery of the patient’s current difficulty has been discovered
before. Often, it’s in there. The average primary care office visit
is less than 15 minutes. Primary care MDs often only look at the last
note and maybe one or two before that. Be a historian.
COMMUNICATION
MDs want feedback; communication is essential.
Primary care physicians see the patient as theirs and you as a consultant.
In all other referrals to cardiology, radiology, and dermatology, they
expect and do get feedback and change their referral patterns when they
do not. Make sure your working arrangement facilitates communication,
such as securing releases, having team meetings, and being present at
morning report.
BREVITY
Be succinct in feedback and answers.
Physicians, in their time urgency, will commonly activate a 60- second
computer chip. If they offered a referral question, what is your answer?
Findings, differential diagnosis, recommendations, treatment plan -
that’s all your medical colleagues want. Save the intriguing narratives
for your scholarly initiatives.
PLAYING YOUR GAME
In your interactions, be particularly
careful not to be tempted into playing “look what you missed.” While
family physicians may not know the first thing about families, may embrace
simplistic thinking, and believe biology is God (McDaniel & Campbell,
1986), don’t you be tempted to go there.
MEDICAL LANGUAGE
Particularly if you’re new to the interface
with medicine, by all means, get a good medical dictionary. If you learn
the language, there will be fewer misunderstandings and you will be
accepted. Psychologists working in medical settings should have at least
a rudimentary understanding of medical terminology, otherwise significant
barriers to effective collaboration may be encountered.
NETWORK
Seek out a network of psychologists who
likewise practice at the interface. They are your peers. Remember, isolation
tempts jeopardy in clinical outcomes, liability, and job satisfaction.
COLLEAGUES OR PEERS
Hopefully MDs are your colleagues. They
are not your peers. Do not seek from a physician what only a psychologist
might provide, such as an opinion on a complex ethical issue. Your ethical
principles and standards of practice are not theirs.
ACCOMMODATE OR SACRIFICE
Anthropologists have long recognized
that it is wise to “do as the Romans do” while knowing that they will
always remain the outsider. Being in no-man’s land provides creative
tension needed to see beyond the bounds imposed by one’s discipline
or work routine. This is a useful, if sometimes uncomfortable, place
to be. Physician culture is conservative and views change agents as
a threat to tradition. They will change very little if at all to accommodate
you. You must learn how to accommodate them without sacrificing personal
and
professional integrity.
ROLE DEFINITION
If you hold yourself aloof from the physician
culture in an attempt to maintain illusory purity, you do yourself no
favors. Likewise, it serves no purpose, and becomes at some point unethical,
to go native. You are not as they are, and over-zealous efforts to get
along will weaken you as a psychologist.
AREAS OF EXPERTISE
Expertise and competence must be recognized.
A primary care health psychologist is not necessarily skilled in every
procedure. For example, you may not be an expert on eating disorders
or pre-surgical screening. With some frequency, you will be asked to
perform procedures beyond your ken. Do as the primary care physician
would. Assess and refer or simply advocate for referral right away to
the appropriate specialist.
PHYSICIAN OR PSYCHOLOGIST
The system will often want to treat you
as a physician when it appears beneficial and remind you that you arenot
one when certain incentive structures are discussed. In parallel, you
will want to be a physician when these incentives are discussed, and
probably will remind others that you are not a physician when call schedules
or higher parking rates for MDs are discussed. You can’t have it both
ways.
THE WHITE COAT
The halls of medicine are filled with
hierarchy and pecking order. Medical students wear short white coats,
residents and attending physicians long white coats, and you probably
don’t wear one at all. You will resent being referred to as an allied
health professional, but you are a participant observer to this melee.
Even so, you will never be fully integrated. Note: Having a white coat
can be quite practical and keep you from getting collared by the head
nurse if you take consults to medical beds in the hospital.
DUAL RELATIONSHIPS
If in a residency program, you will almost
certainly be asked at one time or another to assess or otherwise provide
professional services to a troubled resident. Physicians are often comfortable
in performing an invasive medical exam on a professional and then washing
their hands to attend an administrative meeting with that same person.
Many seem to have difficulty understanding what psychologists mean by
dual relationships and boundaries. Sometimes it may be inferred that
you’re prudish; don’t buy in to that. To informally offer resources
on EAP services or area providers is quite another story and an appropriate
service.
THICK SKIN
If you are teaching medical students
or residents, thicken your skin. It is far safer for medical trainees
to object to your instruction as opposed to the teachings of the attending
physician that they aspire to emulate. Get used to it.
DUE CREDIT
In scholarly or other indices of productivity,
make sure that you document your contributions and that you are properly
credited. Halls of medicine, MD or no MD, credit where credit is due.
*Anthropological Fieldnotes are a time-honored
method of recording data from participant observation and constitute
the best way to record daily experiences, providing a concrete record
of events-in-time, saving us from the revisionist and purely fabricating
tendencies of memory.
REFERENCE
McDaniel, S.H., & Campbell, T.L., (1986)
Physicians and family therapists: The risk of collaboration. Family
Systems Medicine, 4 (1), 4-8.
AUTHORS
Scott Meit, Psy.D., Director, Behavioral
Science Education and Associate Professor, Family Medicine, WV University
School of Medicine, Morgantown, WV; Member, APA Committee on Rural Health;
APA Council of Representatives.
Van Yasek, Ph.D., Research Asst. Professor,
Family Medicine, WV University School of Medicine, Morgantown, WV.
To request additional references, resources,
and a copy of the complete article, please contact Dr. Meit at meits@rcbhsc.wvu.edu
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