View Transcript
00:00:00:01 – 00:00:18:12
Tom Haederle
Welcome to Advancing Health. As health care 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.
00:00:18:15 – 00:00:59:05
Elisa Arespacochaga
This is Elisa Arespacochaga, group vice president at the American Hospital Association. We know that practiced well, health care 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 Corps faculty and supervising psychologist of the Code Training Program, about how they’ve not only integrated physical and behavioral health in their residency clinic to improve access to care, but how they’ve integrated the training programs to truly build teams
00:00:59:05 – 00:01:04:12
Elisa Arespacochaga
from day one. So first of all, thank you so much for joining me and sharing your story.
00:01:04:15 – 00:01:05:21
Jeremy Fish, M.D.
Thanks for having us.
00:01:05:23 – 00:01:07:06
Pilar Corcoran-Lozano, PsyD
Thanks for having us.
00:01:07:08 – 00:01:22:28
Elisa Arespacochaga
Dr. Fish, I’m going to 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.
00:01:23:01 – 00:01:43:01
Jeremy Fish, M.D.
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.
00:01:43:04 – 00:02:10:00
Jeremy Fish, M.D.
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.
00:02:10:02 – 00:02:32:19
Jeremy Fish, M.D.
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.
00:02:32:21 – 00:02:54:03
Jeremy Fish, M.D.
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 the Behavioral Health Educational Program. And that’s how I met Dr. Corcoran-Lozano. She was one of our first students to come in to that early iteration of our program.
00:02:54:06 – 00:03:21:15
Jeremy Fish, M.D.
It was initially a kind of mix of LMFTs – license and 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.
00:03:21:16 – 00:03:45:01
Jeremy Fish, M.D.
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.
00:03:45:03 – 00:04:06:12
Jeremy Fish, M.D.
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.
00:04:06:14 – 00:04:34:22
Elisa Arespacochaga
I love that. Dr. Lozono, 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. Fisher 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 residency?
00:04:34:24 – 00:05:04:22
Pilar Corcoran-Lozano, PsyD
Behavioral health providers, mental health providers and family physicians, they’re 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.
00:05:04:23 – 00:05:15:25
Pilar Corcoran-Lozano, PsyD
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.
00:05:15:27 – 00:05:37:29
Jeremy Fish, M.D.
Yeah. And I think as you mentioned, really establishing a culture of learning and health care, 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 word to use there was making yourselves vulnerable. It is hard to make yourself vulnerable within your profession.
00:05:38:02 – 00:06:06:08
Jeremy Fish, M.D.
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 a supervising faculty. So she’s a perfect example of the evolution of the comfort that people get over time in doing this.
00:06:06:09 – 00:06:07:20
Jeremy Fish, M.D.
But it’s not easy.
00:06:07:23 – 00:06:29:14
Pilar Corcoran-Lozano, PsyD
It’s not easy. And it appears, and maybe it seems simple, to just be able to like work as a team. Like 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.
00:06:29:16 – 00:06:57:26
Elisa Arespacochaga
What I love about the work that you’ve done with this integration, and Dr. Lozano, I’m going to 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?
00:06:57:28 – 00:07:19:12
Pilar Corcoran-Lozano, PsyD
So one thing that we actually offer in 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, the medical residents. And so we have our ear open and we’re listening to things that are related to possibly behavioral health.
00:07:19:19 – 00:07:48:10
Pilar Corcoran-Lozano, PsyD
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 might just be like, hey, would you like to talk to Dr. Pilar?
00:07:48:12 – 00:08:13:04
Pilar Corcoran-Lozano, PsyD
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, where in that visit we might teach something to that patient. We may talk a little bit about therapy or resources, give them a skill that they can take home with them.
00:08:13:06 – 00:08:30:14
Pilar Corcoran-Lozano, PsyD
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 fear, maybe, that might be like, who am I going to be meeting? So…
00:08:30:17 – 00:08:52:16
Jeremy Fish, M.D.
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.
00:08:52:18 – 00:09:15:19
Jeremy Fish, M.D.
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? Or 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?
00:09:15:21 – 00:09:47:07
Jeremy Fish, M.D.
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 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
00:09:47:12 – 00:10:17:09
Jeremy Fish, M.D.
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 of 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 really readily available resource, that help them relieve their stress.
00:10:17:13 – 00:10:42:15
Jeremy Fish, M.D.
Not only is it better care for the patients, 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, and have behavioral issues that can be very stressful to a practice.
00:10:42:19 – 00:11:00:27
Jeremy Fish, M.D.
So having professionals who really know how to help us manage that 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.
00:11:00:29 – 00:11:18:25
Elisa Arespacochaga
You know, 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.
00:11:18:27 – 00:11:30:05
Elisa Arespacochaga
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.
00:11:30:08 – 00:11:55:07
Jeremy Fish, M.D.
Yeah. And there’s a 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 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 that they have.
00:11:55:07 – 00:12:16:19
Jeremy Fish, M.D.
So they’re very appreciative of the fact that they’re very comfortable doing testing, like PHQ9 and how to 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.
00:12:16:22 – 00:12:40:06
Jeremy Fish, M.D.
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. So 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.
00:12:40:06 – 00:13:03:23
Jeremy Fish, M.D.
And so then when they’re going on to their careers, this has created a attention point in the in the systems that they’ve gone on to work and where they are saying, hey, Dr. Fish, 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 I’m worried I’m going to burn out, because everybody’s sending me their behavioral health patients.
00:13:03:23 – 00:13:21:00
Jeremy Fish, M.D.
And I said, yes, this is part of the symptoms. And this is part 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.
00:13:21:00 – 00:13:38:22
Jeremy Fish, M.D.
We tried that in, you know, 2004 and it didn’t work. There’s a lot of that in health care. 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.
00:13:38:22 – 00:14:00:05
Jeremy Fish, M.D.
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’ve have a lived experience of something, you’re a much more persuasive and compelling narrative giver on the value of it.
00:14:00:08 – 00:14:03:19
Elisa Arespacochaga
Dr. Corcoran-Lozano, I would love to hear your last thoughts on this.
00:14:03:21 – 00:14:30:24
Pilar Corcoran-Lozano, PsyD
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’re talking about folks that are in training and there’s 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.
00:14:30:24 – 00:14:54:18
Pilar Corcoran-Lozano, PsyD
Or maybe they’re having a difficult time taking their medications every day. And that can 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?
00:14:54:18 – 00:15:20:18
Pilar Corcoran-Lozano, PsyD
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, right? Because they, 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.
00:15:20:21 – 00:15:39:19
Pilar Corcoran-Lozano, PsyD
And that is because we are our mind and body are connected like 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 on how to do that.
00:15:39:21 – 00:15:59:28
Elisa Arespacochaga
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.
00:15:59:28 – 00:16:02:06
Elisa Arespacochaga
So thank you both for joining me.
00:16:02:08 – 00:16:10:18
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.
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