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- [00:00]
Podcast Host
Welcome to advancing health. As healthcare evolves to meet the needs of patients today, providers are finding that breaking down barriers between disciplines, scrapping separate medical training programs in favor of an integrated approach is improving access to care.
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Elisa Adespakwachaga
This is Elisa Adespakwachaga, group vice president at the American Hospital Association. We know that practiced well healthcare is a team sport, yet we still maintain very separate training programs that can sometimes reduce that ability to build team muscle early. I'm very excited to share with you today my conversation with our two guests, Dr. Jeremy Fish, founding director of the John Muir Health Family medicine residency, and Dr. Pilar Corcoran Lozano, behavioral health core faculty and supervising psychologist of the co training program about how they've not only integrated physical and behavioral health in their residency clinic to improve access to care, but but how they've integrated the training programs to truly build teams from day one. So first of all, thank you so much for joining me and sharing your story.
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Dr. Jeremy Fish
Thanks for having us.
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Dr. Pilar Corcoran Lozano
Thanks for having us.
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Elisa Adespakwachaga
Dr. Fish, I'm gonna start with you. As a family medicine physician, you started down this path. You've been a residency director. You thought about, okay, how can we make this better? What made you say, you know what we need? We need clinical psychologists and we need to train them here.
- [01:23]
Dr. Jeremy Fish
Yeah, well, it's been a long journey because I practiced for many years in a county based health system. We did have some behavioral health folks in the residency that I trained at over at Contra Costa. And what I learned was there's a whole lot of care that I'm not a real expert at providing, and yet the need is constant. And I found myself virtually getting kind of quasi psychological support and behavioral health support in ways that I felt very ineffective. And I really didn't find that comfortable for me because I really enjoy as a family physician being able to help people across a full spectrum of needs. And yet I found there often we fell short. So I had some exposure to the model of behavioral health folks being in primary care during my training. Family medicine is unique in that way in that we have behavioral health faculty who are actually teaching us. When I came to John Muir, we really wanted to do something even more advanced. And the reason for that is that I really felt this was a need that was there every time I was in clinic. And so that the residents, every time they're in clinic and they need that help, I wanted them to have that support. And so when we set out to establish an advanced primary care practice in our residency program, the first initiative I really had was to fully establish a partnership with, with the behavioral health educational program. And that's how I met Dr. Corcoran Lozano. She was one of our first students to come into that early iteration of our program. It was initially a kind of mix of LMFTs, licensed marriage and family therapists, as well as PsyD students. We eventually under the leadership of Dr. Heidi Joshi, who was a PsyD expert who had a lot of experience with building PsyD programs that we fully went into the PsyD level program because in many ways they are the highest level skilled across all payers. They can also bill all payers. And so that really kind of solidified that what we needed to do was really build the leaders of the future for primary care behavioral health integration. And so when we established a program at John Muir that has now become our model of co training in this way because we also found, you know, when we're young, when I was younger, I was more open to a lot of different things. And I just think using the youthful energy and the desire, I think the Gen Z and you know, millennials, they really enjoy team based training. They like to rely on other professionals. So I think it really also provided the opportunity for getting the relationships developed early in training where then they would have an expectation of working with behavioral health folks in their careers.
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Elisa Adespakwachaga
I love that. Dr. Lozano, can you tell me a little bit from your perspective, you're coming from a training program that often isn't co located with family medicine residency or physician residency programs. How did you get to this path? As Dr. Fish mentioned, you were one of the early students, but how did you help bring in your own students and adjust them to the workflow of a traditional physician?
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Dr. Pilar Corcoran Lozano
Residency behavioral health providers, mental health providers and family physicians, they're kind of trained in silos. Like we learn about a specific discipline, for example, by reading about it, by seeing videos. And so a big part of my own training was having the opportunity to be in a learning environment that really fostered teamwork, which this residency did. And so it allowed me to be vulnerable. It allowed me to kind of rely on other team members. It allowed me to know the limits of my own knowledge. So that way I could rely on another discipline.
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Dr. Jeremy Fish
Yeah, and I think as you mentioned, really establishing the culture of learning and healthcare, we are always learning, but we don't necessarily do it in a conscious way. And learning to be team members is really tough. I think the key words to use there was making yourselves vulnerable. It is hard to make yourself vulnerable within your profession. It is even more challenging to make yourself vulnerable across professions. And early on, we had some challenges, and yet Dr. Corcoran Lozano saw enough in that to come back. She first came as a doctoral student, returned as a postdoctoral student, and then became a faculty member and now is supervising the faculty. So she's a perfect example of the evolution of the comfort that people get over time in doing this. But it's not easy.
- [06:08]
Dr. Pilar Corcoran Lozano
It's not easy. And it appears, and maybe it seems simple to just be able to work as a team. That sounds wonderful and great. And really, it's a huge cultural shift of putting two different disciplines that are trained vastly different and then putting them together and telling them support this patient.
- [06:30]
Elisa Adespakwachaga
What I love about the work that you've done with this integration, and Dr. Lozano, I'm gonna ask you to talk a little bit about this, because I know this is obviously from the behavioral health side, a huge need. Not that there isn't a need for access to care from every angle, but especially behavioral health needs. How is this integration really driving that ability for all the patients you see in clinic to have access to not only the physical health support they need, but the mental health support they need?
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Dr. Pilar Corcoran Lozano
So one thing that we actually offer in the clinic is what is referred to as warm handoffs. And so these are. We have one of our behavioral health providers sitting in the same exact room as the medical learners, so the medical residents. And so we have our ear open and we're listening to things that are related to possibly behavioral health. And we are a resource for people. And so being in that room allows us to have same day visits with patients many times in this setting, we are the first face related to mental health or behavioral health that a patient may interface. And so there's definitely stigma still related to mental health and behavioral health. And so lessening that stigma by just be like, hey, would you like to talk to Dr. Pilar? She can come in and kind of meet with you. Same day can be very beneficial. And so one is, we're addressing those needs. So we're lessening the barriers, the stigma related to mental health as well. As we're in that visit, we might teach something to that patient. We might talk a little bit about therapy or resources, Give them a skill that they can take home with them. And we can also schedule same day before they leave. They already have an appointment with a mental health provider. They might have met that mental health provider already. So that already lessens the kind of the. The fear maybe that might be like, who am I going to be meeting
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Dr. Jeremy Fish
so yeah, and if I might add to that, because I think it just really is the centerpiece, it took us nearly two years to come up to a joint agreement that warm handoffs would be the key priority, in part because it really brought up that almost everything involved. You know, where is the privacy there? And in a stigmatized industry, privacy is paramount. Right. So you're taking people who have to come in very quickly in a few minutes, are they going to do it inside the same room that the doctor was there? Are we going to put the patient in a different room? So you've got to go, you know, there's workflow issues that have to be addressed. And it was very challenging for them to come in with only a brief like what do I do in a few minutes to establish rapport. That kind of, that's a real primary care challenge. Because often in behavioral health you're spending weeks to months developing that trust. And so what's enough trust in just a few minutes? And that's. We found bringing them into the room right away and then addressing the workflow needs was, was vitally important because if you look at a traditional primary care setting, you're Talking about maybe 10% of patients will actually make their first referral to a behavioral health practice that's not integrated inside of the practice. I mean, it's just profoundly different. The follow through. Right. And so we really wanted to achieve in the, in the realm of 90 to 100% of that first visit. And so it took us a couple years to come to a joint agreement on that. And once we did that, that really established for the residents and the faculty to see the behavioral health folks as a. As a really readily available resource that helped them relieve their stress. Not only is it better care for the patients, but it's actually the mental and behavioral well being of the physicians improves and the staff in the practice because the sense of efficacy, we're doing good work. We're actually helping people because people with unmet mental and behavioral health needs can make very unusual demands on a practice and have behavioral issues that can be very stressful to a practice. So having professionals who really know how to help us manage that is. Is extraordinarily effective. And we saw that particularly during COVID where there were high levels of distress going on. We were so grateful having the behavioral health folks there to help us do the assessments and make sure we could actually do the right thing for these patients.
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Elisa Adespakwachaga
Oh, absolutely. And I think my last question that I want to ask you both to comment on and I'LL start with you, Dr. Fish. You're building an army of residents who think now full spectrum family medicine is not just, you know, family medicine plus ob. It's family medicine plus behavioral health plus ob, plus being part of a team. What lessons are some of your residents telling you they're taking away into their careers? And, you know, now you've graduated a couple of classes, they're starting to demand these things in their attending positions.
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Dr. Jeremy Fish
Yeah, and there's. There's a tension with that because definitely we've gotten feedback from our residents how essential it is, how much they enjoy the partnership that they develop, particularly with the. The co learners. They consider them fellow residents. Right. That they are part of our residency training program. And so those relationships and the depth of those relationships give our residents a great deal of confidence in the care of patients with behavior. So they're very appreciative of the fact that they're very comfortable doing testing like PhQ9 and how to use that sort of assessment around a depressed patient to determine what to do. That there are alternatives to medications, because we face this all the time, where patients, through stigma, don't want to take medicines either, because that medicine means they have a disease they don't want to have. They don't want to necessarily acknowledge that they're depressed or anxious. And so having alternative treatments for those patients where they can work through cognitive behavioral therapy or some other mechanism really helps broaden the comfort of our residents, that there's lots of things we can do for people who are struggling with these challenges. And they tell us, you know, if we were not to have this, they can't imagine what that is like. And so then when they're going on to their careers, this has created a tension point in the, in the systems that they've gone on to work in, where they are saying, hey, Dr. Fish, I'm. I'm at this new place that will go unnamed, and I can't even get a psychiatry consultation. It's just really hard. And so now I'm using all the skills, but, boy, I'm worried I'm going to burn out because everybody's sending me their behavioral health patients. And I said, yes, this is part of the symptoms, and this is part of. Of why we do leadership development, is we want you to learn how to work within your system to say, hey, this does work, because there's a lot of misinformation out there because it's challenging to do this. A lot of health administrators will say, oh, it can't be done. We tried that in 2004, and it didn't work. There's a lot of that in healthcare, and I understand that when something takes two years to get it working well, it's hard for a health system to have that kind of patience to get there. So there's a lot of misinformation that this can't be done. And so part of our mission is to help people understand it can be done. And then part of our training for our residents is you need to be that leader who goes to the meetings and says, here's something we could do that I've seen, because when you have a lived experience of something, you're a much more persuasive and compelling narrative giver on the value of it.
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Elisa Adespakwachaga
Dr. Corcoran Lozano, I'd love to hear your last thoughts on this.
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Dr. Pilar Corcoran Lozano
I think it actually goes down to the need. There's the need for patient care. However, since we're talking about a residency clinic, we are talking about folks that are in training, and there is a need there. There's a need that I am sitting across from a patient in an exam room, and they have feelings and they're crying and they just got a new diagnosis, or maybe they're having a difficult time taking their medications every day. And that could be medications for anything. And so they're sitting there struggling, perhaps, like, how do I communicate with this particular patient? How do I talk to them about medication adherence or asking about what are some of the reasons or barriers for them not to take their medications? And that's just one example. And so we're here for that need to help support and teach these residents. They're able to have these difficult conversations with patients. They're able to actually treat the whole person because they recognize. And something that we really kind of stress here is that we have this thing that is in between our head and our body, and that is referred to as a neck. And that is because our mind and body are connected. We are all whole people, and we're complex. And so it's really about meeting the needs of the learners and the patients. And so also teaching the next generation of psychology trainees, too, on how to do that.
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Elisa Adespakwachaga
Absolutely. Well, I want to thank you both for joining me today for sharing about your program. I love the work that you have put into not saying yes in the face of maybe a few too many no's and continuing to push to bring together the care you knew needed to be provided as a team sport in your clinics. So thank you both for joining me.
- [16:02]
Podcast Host
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